Hoyt Nursing & Rehab Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Saginaw, Michigan.
- Location
- 1202 Weiss St, Saginaw, Michigan 48602
- CMS Provider Number
- 235056
- Inspections on file
- 23
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hoyt Nursing & Rehab Centre during CMS and state inspections, most recent first.
The facility did not update its emergency preparedness policy after upgrading its backup generator, leaving staff with outdated instructions to use extension cords and red outlets for backup power, which no longer reflected the facility's current emergency power capabilities.
A remote annunciator for the emergency generator was installed in the back building electrical room, rather than in a location readily observed by operating personnel. This placement could result in generator alarms and conditions going unnoticed by staff, as confirmed by observation and interview with the maintenance director.
Exit and directional signs were not properly displayed or configured, with the emergency exit sign outside the Saginaw Room Dining space set up incorrectly. This left the North side of the facility without an emergency exit from resident spaces, and the exit configuration did not match the emergency placards in the corridors. These issues were confirmed by the maintenance director during the survey.
Surveyors found that a shower room door across from the 100 nurse station was an open grate type, which would allow smoke, heat, and fire to pass into the emergency egress corridor. This was confirmed by the maintenance director during the inspection, indicating non-compliance with smoke resistance requirements for corridor doors.
A resident with severe physical disabilities and cognitive impairment was physically assaulted by a new roommate with a history of aggression, resulting in a black eye and facial contusions. The incident occurred after a room transfer decision made by the IDT without proper assessment of compatibility or family notification, and in the absence of a formal bed transfer or supervision policy. The abuse was not witnessed by staff and was only discovered during routine care.
A resident with a history of sepsis and multiple chronic conditions experienced an elevated temperature and pulse, which were reported to a nurse by a CNA. The nurse failed to perform an assessment, document the change, or notify a physician for over four hours, only administering Tylenol later in the day. The resident was subsequently found unresponsive and died, with staff interviews and records confirming that required protocols for assessment and escalation were not followed.
A resident with severe cognitive impairment and a legal guardian was assigned a new roommate without prior notification to the responsible party, as required. After the roommate change, the resident was found with a black eye and facial bruising, and reported that the new roommate had made contact with his eye. The facility administrator confirmed that the responsible party was not notified before the change, and there was no specific policy in place for such notifications.
The facility failed to obtain informed consent for psychotropic medications for four residents, as required by their policy. The deficiency was identified through record reviews and interviews, revealing that psychotropic medications were administered without documented consents. The social work designee admitted to relying on verbal agreements instead of written consents, and the Social Services Director confirmed the lack of adherence to the facility's procedure for obtaining consents. This resulted in the administration of psychotropic medications without the necessary informed consents.
A resident with a Stage 2 pressure injury on the coccyx was readmitted with the wound progressed to Stage 3. The facility failed to follow its wound management policy by missing a weekly assessment and photograph of the wound. The DON acknowledged the oversight, stating that while treatment was given, the required documentation was not completed.
A resident admitted with multiple diagnoses did not receive necessary hydration for five days due to the facility's failure to input hospital discharge orders for free water flushes. The omission occurred because the order was in a separate document, which was overlooked. Interviews revealed that the admitting nurse should have inputted the orders or contacted the physician if the order was missing. The facility's policy requires documentation of total free water intake, which was not followed.
The facility failed to ensure timely call light responses, adequate communication access, and respect for residents' preferences and dignity. Residents reported long waits for call light responses, lack of access to personal phones, and unmet food preferences. Additionally, unsanitary conditions were observed, such as soiled bedding and unemptied urinals, contributing to residents' dissatisfaction and feelings of neglect.
Two residents in the facility did not receive adequate assistance with Activities of Daily Living (ADL). A resident with a history of stroke and muscle weakness had overgrown toenails and was not receiving showers as per their care plan, while another resident requiring 1:1 meal assistance was left without help, resulting in an untouched lunch tray. These deficiencies highlight lapses in care coordination and adherence to care plans.
A resident developed an unstageable pressure ulcer on the left heel due to the facility's failure to implement a comprehensive pressure ulcer prevention and skin management program. Despite the resident's inability to reposition herself and the presence of a starting pressure ulcer on the right heel, preventive interventions were not included in the care plan until after the wound developed. The physician's progress notes lacked documentation of the left heel ulcer, indicating a gap in wound assessment and management.
A resident with Multiple Sclerosis and contractures experienced a decline in range of motion due to the facility's failure to implement a comprehensive restorative nursing program. The resident, dependent on staff for all activities, received inconsistent and inadequate passive range of motion exercises, leading to worsening contractures and unnecessary pain. Observations revealed a lack of specific exercises and repetitions in the care plan, and staff documentation was inaccurate, often reflecting time spent in the room rather than on exercises.
A facility failed to ensure safety and supervision for several residents, leading to multiple deficiencies. A resident was given a shower with an improperly sized sling, risking injury. Another resident was dropped off at the wrong medical facility due to inadequate transportation procedures. A third resident, deemed unsafe to smoke, was found smoking in his room, violating the facility's non-smoking policy. Additionally, a resident's wander guard was not properly documented or checked, posing an elopement risk.
A nurse in an LTC facility prepared a Heparin injection for a resident using an incorrect needle size, initially selecting a 1 and 1/2 inch needle meant for intramuscular injections instead of the appropriate size for subcutaneous administration. The error was identified before the injection was administered, highlighting a gap in the nurse's knowledge despite previous competency assessments.
The facility failed to maintain a comprehensive infection control program, as evidenced by improper hand hygiene practices during care. A nurse did not wash hands between glove changes during wound care for a resident with multiple health conditions. Another nurse failed to perform hand hygiene before and after administering medications, including to residents under enhanced barrier precautions. These actions violated the facility's hand washing policy and highlighted deficiencies in infection prevention and control.
Failure to Update Emergency Power Loss Policy After Generator Upgrade
Penalty
Summary
The facility failed to update its Emergency Preparedness policies and procedures following an upgrade to the emergency backup generator. Although the generator was enhanced to cover the power load of the entire facility, the written policy still instructed staff to use extension cords and red outlets to provide backup power only to certain resident rooms and treatment areas. This outdated information did not reflect the current capabilities of the upgraded generator. During a record review and interview with the maintenance director, it was confirmed that the utility power loss policy had not been revised to align with the new generator system. The continued reference to outdated procedures in the policy could cause confusion among staff during a power outage emergency, as the instructions no longer matched the facility's actual emergency power resources.
Emergency Generator Annunciator Not Readily Observable
Penalty
Summary
The facility failed to ensure that the remote annunciator for the emergency generator was installed in a location that is readily observed by operating personnel, as required by NFPA 99 standards. During an observation, it was found that the new emergency generator annunciator was placed in the back building electrical room, rather than in a more visible area. This placement could result in alarms and generator conditions going unnoticed by facility staff. The deficiency was confirmed through an interview with the maintenance director at the time of observation. No specific residents or patient medical histories were mentioned in the report, and the deficiency was identified through direct observation and staff interview.
Deficient Exit Signage and Egress Configuration
Penalty
Summary
Exit and directional signs in the facility were not displayed in accordance with regulatory requirements, as observed during a survey. Specifically, the emergency exit sign outside the Saginaw Room Dining space had an incorrect emergency egress configuration, resulting in the North side of the facility lacking an emergency exit from resident spaces. Additionally, the exit configuration did not match the emergency placards displayed in the corridors. These findings were confirmed through an interview with the maintenance director at the time of observation. This deficiency could affect 35 occupants in the event of an emergency evacuation, as noted in the report.
Non-Compliant Corridor Door Allows Smoke Passage
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors protecting corridor openings were capable of resisting the passage of smoke, as required by NFPA 19.3.6.3. Specifically, during an inspection, it was found that the shower room door located across from the 100 nurse station consisted of an open grate design. This type of door would allow smoke, heat, and fire to transfer from the shower room into the emergency egress corridor, compromising the intended fire and smoke barrier. The deficiency was confirmed through an interview with the maintenance director at the time of observation. The report does not mention any specific residents or their medical conditions being directly involved or affected at the time of the deficiency. The finding was based solely on the physical observation of the door and its non-compliance with regulatory requirements for smoke resistance.
Failure to Prevent Resident-to-Resident Abuse Following Inappropriate Room Assignment
Penalty
Summary
A resident with severe physical disabilities, including bilateral lower limb amputations and upper extremity contractures, was subjected to physical abuse by another resident. The abused resident was totally dependent for all care and had a history of vascular dementia, bipolar disorder, depression, and schizophrenia. The incident resulted in the resident sustaining a black eye and facial contusions. The resident was unable to defend himself due to his physical limitations and required assistance for all activities of daily living. The facility failed to prevent the abusive incident, which occurred after a room transfer placed the aggressive resident as a roommate with the vulnerable resident. The aggressive resident had a history of verbal aggression and was known to be manipulative, with staff and social services noting concerns about his behavior. The decision to pair these two residents was made by the interdisciplinary team, but staff later acknowledged that it was not a good fit. There was no evidence that the family of the vulnerable resident was notified of the new roommate, and the facility lacked a formal bed transfer policy. Staff interviews revealed that the incident was not witnessed, and the injury was only discovered during routine care. The facility also lacked a supervision policy for monitoring resident safety, and there was no documentation of a behavioral assessment or increased supervision for the aggressive resident prior to the incident. The event was reported to the police, and both residents exhibited physical signs consistent with an altercation. The facility's failure to properly assess roommate compatibility, notify families, and implement appropriate supervision contributed to the occurrence of resident-to-resident abuse.
Failure to Assess and Respond to Change in Condition Leads to Resident Death
Penalty
Summary
A deficiency occurred when a nurse failed to perform a timely, complete, and accurate assessment of a resident who experienced a change in condition. The resident, who had a complex medical history including sepsis, pneumonia, acute respiratory failure, heart failure, and other chronic conditions, was dependent on staff for activities of daily living and was on oxygen and a feeding tube. On the day of the incident, a CNA reported to the nurse that the resident had an elevated temperature of 101°F and a pulse of 110 at 9:00 a.m. Despite this report and the resident's history of sepsis, the nurse did not conduct a physical or cognitive assessment, nor did she document any such assessment in the medical record between 9:00 a.m. and 5:35 p.m. The nurse delayed any intervention for over four hours, only administering Tylenol at 1:17 p.m. for the increased temperature, without notifying the physician or considering hospital transfer. Interviews confirmed that the nurse acknowledged not performing an assessment or contacting the physician, despite facility policies requiring such actions in response to changes in condition. The Director of Nursing and other staff corroborated that the nurse did not act on the reported vital sign changes and failed to follow established protocols for assessment and escalation. Later that day, the resident was found unresponsive and cold to the touch, with no pulse, and a code blue was called. Despite resuscitation efforts, the resident died. The facility's policies and job descriptions clearly outlined the expectation for timely assessment and physician notification in the event of a change in condition, which were not followed in this case.
Failure to Notify Responsible Party of Roommate Change Resulting in Resident Injury
Penalty
Summary
The facility failed to notify the responsible party of a resident prior to a roommate change, which resulted in a new roommate being moved into the resident's room without prior notification. The resident involved had severe cognitive impairment, a legal guardian, and multiple medical diagnoses including vascular dementia, bipolar disorder, depression, schizophrenia, and bilateral lower limb amputation. Following the roommate change, the resident was observed with a black eye and facial bruising, and an incident report documented that the resident stated another resident made contact with his eye, while the other resident denied the action. Both residents involved had cognitive impairments, with one having a BIMS score indicating severe impairment and the other slight impairment. The Nursing Home Administrator acknowledged that there was no specific policy for bed or roommate changes and that the facility relied on regulatory guidance and interdisciplinary team meetings to make such decisions. The administrator admitted that the responsible party for the resident was not notified of the roommate change, which was a failure on the facility's part. Facility documentation and state guidance both require notification of the resident's representative prior to any room or roommate change, but this was not done, leading to the incident and subsequent injury.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medications used to treat mood and behavior disorders for four residents. The deficiency was identified through observation, interviews, and record reviews, revealing that informed consents were not obtained prior to the initiation or change in dosage of psychoactive medications. The facility's policy requires that residents do not receive psychotherapeutic medications unless needed to treat a specific condition, with documented target behaviors and ineffective non-pharmacological interventions. Additionally, informed consent from the resident or responsible party, along with education regarding potential side effects, is required. For Resident #101, the Medication Administration Record (MAR) showed multiple psychotropic medications prescribed without documented consent. The social work designee admitted to not obtaining written consents, relying instead on verbal agreements, and acknowledged the absence of consent forms in the medical records. Similarly, Residents #102, #103, and #104 had psychotropic medications administered without updated consents for medication changes or new medication initiations. The Social Services Director confirmed the lack of consents and the failure to follow the facility's procedure for obtaining them. The report highlights that the facility's process for managing psychotropic medications was not followed, as evidenced by the absence of consent documentation in the residents' medical records. The interviews with the social work designee and Social Services Director revealed a lack of adherence to the facility's policy, resulting in the administration of psychotropic medications without the necessary informed consents. This deficiency indicates a systemic issue in the facility's handling of psychotropic medication consents, affecting the care and treatment of the residents involved.
Failure to Adhere to Wound Management Policy
Penalty
Summary
The facility failed to adhere to its wound management policy for a resident who was admitted with a Stage 2 pressure injury on the coccyx. Upon readmission from the hospital, the wound had progressed to a Stage 3 pressure injury. The facility's policy required weekly documentation and photographic assessment of pressure ulcers, but a weekly assessment was missed between 10/28/2024 and 11/11/2024. This oversight was acknowledged by the Director of Nursing (DON), who confirmed that while treatment was administered, the necessary documentation and photographic evidence were not completed. The resident, who is of advanced age and has diagnoses including age-related physical debility, reduced mobility, cerebral infarction, and hypertension, was noted to have moderately impaired cognition with a BIMS score of 12. The failure to conduct a weekly assessment and take a picture of the wound as per the facility's policy resulted in a missed opportunity to monitor the wound's progression accurately. This lapse in protocol potentially contributed to the worsening of the resident's pressure injury, as noted by the DON during an interview.
Failure to Provide Adequate Hydration for Resident on Enteral Nutrition
Penalty
Summary
The facility failed to provide adequate hydration for a resident receiving enteral nutrition feedings, resulting in the resident not receiving appropriate hydration for five days. The resident was admitted with several diagnoses, including Hypomagnesemia, Atrial Fibrillation, Gastrostomy Infection, Dysphagia, Anxiety, and a Solitary Pulmonary Nodule. Upon admission, the hospital discharge orders included a recommendation for free water flushes every four hours, but this order was not inputted into the facility's system. Consequently, the resident did not receive the necessary hydration from the time of admission until five days later when the Registered Dietitian completed an initial assessment and added the free water flush order. Interviews with facility staff revealed that the omission of the free water flush order was due to it being in a separate document from other discharge medications, which was overlooked. The Clinical Care Coordinator stated that the admitting nurse should have inputted the enteral nutrition orders based on the hospital discharge summary, and if the free water flushes were not listed, the nurse could have contacted the physician to obtain the order. The facility's policy on enteral nutritional feeding requires the physician's order to include the total amount of free water intake to be consumed in 24 hours, which was not followed in this case.
Deficiencies in Call Light Response, Communication Access, and Resident Care
Penalty
Summary
The facility failed to ensure that residents' call lights were available, within reach, and answered in a timely manner. This deficiency affected multiple residents, including one who reported that their call light was often not answered for hours, leading to difficulties in receiving assistance. Another resident was unable to reach their call light due to physical limitations, and it was observed to be out of reach on multiple occasions. The facility's policy stated that call lights should be answered within 15 minutes, but this was not consistently adhered to, as evidenced by resident complaints and observations. Additionally, the facility did not provide adequate access to communication devices for residents. One resident reported not having a phone available for personal use, which was confirmed by staff who were unable to locate a portable phone for resident use. This lack of access to communication devices hindered residents' ability to maintain contact with family and friends, contributing to feelings of isolation and frustration. The facility also failed to honor residents' food preferences and maintain a clean and dignified environment. One resident expressed dissatisfaction with not receiving their preferred food items, such as eggs, despite having no dietary restrictions. Another resident's bedding was found to be soiled with drainage from a wound, and their urinal was not emptied in a timely manner, leading to unsanitary conditions. These failures in providing personalized care and maintaining cleanliness further contributed to residents' dissatisfaction and feelings of being treated without dignity and respect.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for two residents, resulting in unmet care needs. Resident #9, who has a history of stroke, dysphagia, and muscle weakness, was found with severely overgrown toenails and had only been receiving showers once a week, contrary to their care plan. The resident's medical record indicated they required extensive assistance with ADLs, yet they had not seen a podiatrist since admission, and their shower schedule was not updated to include a second weekly shower. This oversight led to discomfort and potential hygiene issues for the resident. Resident #47, who required 1:1 assistance during meals, was observed with an untouched lunch tray, indicating they had not been assisted with their meal. The CNA responsible for Resident #47 was occupied with another resident and was unaware that the resident had not eaten. The DON was informed of the situation and instructed the kitchen to prepare a new meal. This incident highlights a lapse in ensuring that residents with specific assistance needs are adequately supported during meal times.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to implement a comprehensive pressure ulcer prevention and skin management program for a resident, resulting in the development of an unstageable pressure ulcer on the resident's left heel. The resident, who was admitted with diagnoses including Hemiplegia, Hemiparesis, Hypertension, Atrial Fibrillation, and Mood Disorder, required staff assistance with Activities of Daily Living (ADLs). Despite the presence of a starting pressure ulcer on the right heel noted on May 1, 2024, and subsequent orders for wound care, there was no mention of a left heel pressure ulcer in the physician progress notes until later. The wound was identified as unstageable and in-house acquired, with various stages of slough, eschar, and drainage documented over time. The Unit Manager acknowledged noticing a reddened circle on the resident's left heel on May 1, 2024, which began to spread by May 7, 2024. The resident was unable to reposition herself in bed, and interventions such as 'heels up' were implemented only after the wound developed. The care plan lacked interventions for the prevention of pressure ulcers until after the wound's appearance. Additionally, there was no documentation indicating that the wound had been assessed by the physician, highlighting a gap in the facility's pressure ulcer prevention and management practices.
Inadequate Restorative Nursing Program Leads to Resident's Decline
Penalty
Summary
The facility failed to implement a comprehensive restorative nursing program for a resident with multiple medical conditions, including Multiple Sclerosis, functional quadriplegia, and contractures. The resident was dependent on staff for all activities of daily living and had impaired range of motion in both upper and lower extremities. Despite being cognitively intact, the resident experienced a decline in range of motion and worsening contractures due to inconsistent and inadequate passive range of motion exercises. The facility's documentation was inaccurate, and the resident expressed discontentment with the care provided, indicating that exercises were only performed upon request. Observations and interviews revealed that the facility did not have a dedicated restorative CNA, and the staff did not perform specific passive range of motion exercises as part of the resident's care plan. The documentation in the electronic medical record was inconsistent, with an average of only 4.35 minutes of range of motion exercises documented daily, and often recorded as the total time spent in the resident's room rather than the actual time spent on exercises. The lack of specific joint exercises and repetitions in the care plan contributed to the resident's decline in range of motion. Interviews with the therapy director and nursing staff highlighted a lack of coordination and communication regarding the resident's restorative care needs. The therapy director confirmed that the resident had experienced a decline in range of motion since admission, but there was no formal process for therapy staff to refer or recommend restorative nursing interventions. The facility's failure to provide detailed and purposeful passive range of motion exercises, along with inadequate documentation and communication, resulted in the resident's unnecessary pain and increased risk for further decline.
Multiple Safety and Supervision Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure a safe environment for Resident #14 during a shower, as observed on June 13, 2024. The resident, who was non-ambulatory and required assistance with all activities of daily living, was transferred using a Hoyer lift with a sling that was too small for his size. This resulted in the resident almost sliding out of the shower chair multiple times, causing him to yell in pain. The staff struggled to manage the situation, indicating a lack of proper guidance and assessment for the appropriate sling size, as no documentation or instructions were available for the staff. Resident #51 experienced an unsafe transportation incident when she was dropped off at the wrong medical facility for an appointment. The contracted transportation company failed to follow the correct procedure, leading to confusion and potential distress for the resident. The facility did not have a comprehensive process or procedure in place to ensure the safe transportation of residents, nor did they provide adequate training or instructions to the transportation drivers, increasing the likelihood of similar incidents occurring in the future. Resident #67 was found smoking in his room, which is against the facility's non-smoking policy. Despite being deemed safe to smoke in previous assessments, a recent evaluation revealed that the resident was unsafe to smoke due to tremors and burns on his fingers. The facility failed to update the resident's care plan to reflect his smoking status and did not adequately supervise or control the possession of smoking materials, leading to a dangerous situation. Additionally, Resident #43's wander guard was not properly documented or checked for functionality, posing a risk of elopement for the resident with severe cognitive impairment.
Medication Administration Error with Heparin Injection
Penalty
Summary
The facility failed to ensure the safe administration of a subcutaneous injection for a resident, leading to the potential for significant medication errors. During a medication administration task, a nurse prepared a Heparin injection for a resident using an incorrect needle size. The nurse initially selected a 1 and 1/2 inch needle, which is typically used for intramuscular injections, instead of the appropriate needle for a subcutaneous injection. This error was identified when the nurse was questioned about the needle size before administering the injection. The nurse demonstrated a lack of knowledge regarding the appropriate needle size for subcutaneous versus intramuscular injections, as evidenced by their inability to recall the correct needle lengths for each type of injection. Despite having been deemed competent in injections in November 2023, the nurse's actions during this incident indicated a gap in their understanding. The resident involved had an active physician order for Heparin to be administered subcutaneously every eight hours, and the incorrect preparation of this medication posed a risk of decreased efficacy and potential side effects.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to implement a comprehensive infection control program, as evidenced by the lack of accurate tracking and surveillance of infections among residents. During an interview with the Infection Control Registered Nurse (RN C), it was revealed that the facility did not maintain documentation of tracking residents with potential infections or those with infectious organisms not receiving antibiotics. This deficiency was further highlighted by the observation of improper hand hygiene practices by staff members during care procedures. Specific incidents included a nurse performing wound care on a resident with multiple health conditions, including a pressure ulcer, without washing hands between glove changes. Additionally, another nurse failed to perform hand hygiene before and after administering medications to residents, including those under enhanced barrier precautions. These lapses in hand hygiene were contrary to the facility's hand washing policy, which mandates hand hygiene before and after glove use, and contributed to the overall failure in infection prevention and control.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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