Lahser Hills Care Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Southfield, Michigan.
- Location
- 25300 Lahser Rd, Southfield, Michigan 48034
- CMS Provider Number
- 235320
- Inspections on file
- 30
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lahser Hills Care Centre during CMS and state inspections, most recent first.
A resident with paraplegia and a history of stroke developed a facility-acquired Stage 4 pressure ulcer on the right ischium. Despite a care plan for daily skin checks, documentation failed to accurately record new wounds, and wound care was not consistently documented. Wound evaluations showed the ulcer progressed from unstageable to Stage 4, with the resident attributing its development to prolonged wheelchair use. The DON could not explain documentation discrepancies, and facility protocols for pressure sore assessment and documentation were not consistently followed.
A resident experienced significant and unexplained weight fluctuations due to inaccurate weighing practices, including uncalibrated scales and inconsistent staff procedures. The facility's policy lacked guidance on referencing hospital weights, calibrating equipment, and ensuring consistent weighing methods, resulting in widespread inaccuracies in resident weight records.
The facility did not consistently follow established protocols for antibiotic use, as antibiotics were prescribed for UTIs without documented signs or symptoms and without lab confirmation. The Infection Control Preventionist confirmed that antibiotics were sometimes ordered based only on urinalysis, without culture and sensitivity testing, and could not explain how appropriate antibiotic selection was ensured in these cases.
A resident with multiple chronic conditions and intact cognition was left with a non-functioning clock in their room, despite repeated staff awareness and attempts to address the issue. The broken clock, visible from the resident's bed, was a persistent annoyance, and no maintenance ticket was recorded to resolve the problem, limiting the resident's ability to exercise choice in their environment.
Two residents were found to be using toilet safety frames with cracked and jagged armrests, creating a risk for skin tears. Staff and the DON confirmed the equipment was in disrepair and recognized the potential for injury, while one resident acknowledged the hazard. The facility's policy requires a safe and homelike environment, but the damaged equipment was not identified or addressed prior to the survey.
A resident with a diagnosis of schizophrenia was admitted without the facility notifying the local mental health authority of a significant change in condition, as required by PASARR regulations. The facility's documentation inaccurately reflected the resident's mental health status, and no updated PASARR evaluation was initiated despite ongoing psychiatric assessments and evidence of mental illness. Staff interviews confirmed that no Level II evaluation was completed or submitted.
Two residents with impaired skin conditions did not receive wound care as ordered, with dressings left unchanged for several days despite documentation indicating daily changes. One resident was found with dirty, dated bandages and could not recall care details, while another had an undated, malodorous dressing and reported missed treatments. Facility leadership acknowledged that care and documentation did not meet required standards.
Three residents received antibiotics for UTIs without meeting clinical criteria or having positive culture results. Antibiotics were started based on minimal or non-specific symptoms, such as a single low-grade fever or altered mental status, and in one case, continued even after a negative C&S result. Staff could not provide justification for the antibiotic use or explain the rationale for therapy in the absence of confirmed infection.
A resident with COPD and other comorbidities, who was dependent on continuous oxygen therapy, was left unattended for several hours with an empty portable oxygen tank and was found in respiratory distress with low oxygen saturation and blood pressure. The resident was not provided with the ordered continuous oxygen, resulting in a significant decline in condition and transfer to the hospital for a higher level of care. Facility records did not include an incident report for this event.
A resident with severe cognitive impairment was not timely evaluated for competency, and the facility failed to obtain legal guardianship or ensure proper consent for hospice services. Despite ongoing cognitive decline and the spouse's inability to act as responsible party, no alternative guardianship was pursued, and documentation of consent for hospice and related treatments was incomplete or conflicting.
Two residents developed severe pressure ulcers due to the facility's failure to prevent ulcer formation, document accurate skin assessments, and implement necessary interventions. One resident developed a Stage 4 ulcer requiring antibiotics, while another developed an unstageable ulcer. The facility's records showed missing entries for wound care treatments, and the care plan lacked additional interventions despite high-risk assessments.
The facility failed to implement enhanced barrier precautions (EBP) for two residents with wounds, leading to potential infection spread. One resident had no EBP signage or PPE, and staff provided care without gowns despite an active EBP order. Another resident with a sacral wound was not placed on EBP as per protocol. Interviews with staff, including the DON, revealed a lack of awareness and explanation for these deficiencies.
The facility failed to maintain sanitary conditions in the kitchen, with unlabeled bulk flour bins, dried food splatter on rice bins, pooling milk in the cooler, and food debris on the floors. The Dietary Manager confirmed these issues, indicating non-compliance with the 2017 FDA Food Code.
The facility failed to ensure proper administration, documentation, and storage of medications for four residents. Issues included undocumented pain medication, incorrect administration of Klonopin, medications left at the bedside, and an inhaler without a self-administration order.
The facility failed to ensure the safe and secure storage of medications across three medication carts. An RN left a medication cart unlocked and unattended, while an LPN left medications on top of the cart and walked away. Another LPN found an unidentifiable loose pill in a medication cart. The DON acknowledged these issues and confirmed that medications should not be left unattended and carts should be locked when not visible.
A resident with severe cognitive impairment was not treated with dignity and respect when a CNA ignored their requests to use the bathroom, criticized them for spilling a drink, and maneuvered them backward in a geri-chair, contrary to facility protocol.
The facility failed to complete a Level I PASARR evaluation for a resident with mental illness and intellectual disability, resulting in the potential exclusion from necessary care and services. The Social Worker Director admitted the oversight, and the Administrator confirmed the lack of a specific PASARR policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive continuous oxygen therapy as prescribed. Observations showed the resident without proper oxygen supply due to issues with the oxygen concentrator and nasal cannula tubing. Staff interviews revealed inconsistent use of oxygen tanks, contrary to facility policy.
A resident reported severe pain and requested pain medication, but the MAR showed no documentation of administration since the previous night. Despite verbal confirmation from the resident, the MAR lacked proper documentation, and the DON confirmed that nurses had not recorded the administration as required by policy. Delayed documentation raised concerns about potential drug diversion.
A resident with hypertension and hypotension received Midodrine outside of physician-ordered parameters on multiple occasions, and blood pressure documentation was often missing. The DON confirmed that medications should be administered according to orders and that blood pressure should be documented, but this was not consistently done.
A resident was incorrectly administered Klonopin three times per day instead of as needed (PRN) as per the physician's order. The error was identified after family members raised concerns, and the DON confirmed the mistake. The resident's clinical record indicated severe cognitive impairment and diagnoses of failure to thrive and unspecified dementia.
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate. An LPN administered Clopidogrel at the wrong time and gave an unprescribed enteric-coated Aspirin to a resident. The DON acknowledged the errors, which were identified during a medication reconciliation.
Failure to Prevent and Accurately Document Facility-Acquired Stage 4 Pressure Ulcer
Penalty
Summary
A resident with paraplegia, hypertension, and a history of stroke was admitted and later readmitted to the facility. The resident, who was cognitively intact, developed a Stage 4 pressure ulcer on the right ischium while in the facility. The care plan included daily skin checks by CNAs and reporting of abnormalities to nursing staff. However, documentation inconsistencies were noted, including a skin assessment that failed to record any new wounds despite the presence of a pressure ulcer. The treatment administration record showed the application of antifungal cream for a rash, but there was no documentation of wound care for the pressure ulcer during that period. Wound evaluations documented the progression of the pressure ulcer, initially identified as unstageable and later as Stage 4, with ongoing notes indicating the wound was stable or improving. The resident reported that prolonged use of a motorized wheelchair may have contributed to the wound's development. During interviews, the DON was unable to explain discrepancies in documentation and acknowledged that the wound could not have developed in a single day. The facility's policy required thorough assessment and documentation of pressure sores, but these protocols were not consistently followed, resulting in the resident acquiring a facility-acquired Stage 4 pressure ulcer.
Plan Of Correction
F 686 1.) Resident #80 was reassessed by the nurse manager for pressure ulcer prevention to ensure treatments were appropriate and the care plan was updated. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all skin alterations were identified and preventative measures were in place. Licensed nurses and CENAs were re-educated on preventive skin measures, accuracy of completing skin assessments, and documentation. 3.) System change: Nurse managers will witness 5 skin assessments weekly with the nurse to ensure accuracy. Any new areas identified will be documented in the skin assessment. 4.) DON/Designee will audit 5 charts weekly x 12 weeks then monthly x 3 months to ensure appropriate preventive measures are in place, and will complete 5 random skin assessments to ensure accuracy. Any nonadherence will result in 1:1 education. All audits will be taken to the QA committee for review and further recommendations. The DON is responsible for ongoing and sustained compliance.
Failure to Ensure Accurate Resident Weights Due to Scale and Staff Errors
Penalty
Summary
The facility failed to ensure that resident weights were taken appropriately and verified as accurate according to professional standards of nutritional practice. One resident, who was thin in stature and had a history of loose dentures affecting their ability to chew, was observed with discrepancies in their recorded weights. The resident's electronic medical record showed a significant and atypical weight change of nearly 40 pounds over a two-week period, with weights fluctuating between 183.8 pounds and 144.4 pounds. The initial dietary assessment and hospital records also showed inconsistencies between the hospital discharge weight and the facility admission weight, which were not accurately reconciled at the time of admission. The facility's process for obtaining and documenting weights was inconsistent, with weights being recorded in both standing and sitting positions and by different staff members. There was no clear policy guidance on referencing hospital weights upon admission, calibrating scales, or ensuring consistency in weighing methods. The registered dietician acknowledged that scale discrepancies and staff inconsistencies contributed to the inaccurate weights, and that the issue was not identified until significant weight fluctuations were observed in multiple residents. The Director of Nursing confirmed that two of the facility's standard scales were found to be inaccurate, and that a staff member had been weighing residents incorrectly. These issues led to widespread inaccuracies in resident weight records, which were only discovered after significant fluctuations were noted. The facility's policy did not address the need for scale calibration or specific procedures for addressing weight inconsistencies, contributing to the deficiency.
Failure to Consistently Monitor and Ensure Appropriate Antibiotic Use
Penalty
Summary
The facility failed to maintain a consistent system for monitoring and ensuring appropriate antibiotic use for its residents. Review of infection surveillance records showed that antibiotics were prescribed in multiple cases without meeting established criteria, such as treating urinary tract infections (UTIs) without documented signs or symptoms of infection and without laboratory confirmation. During an interview, the Infection Control Preventionist (ICP) confirmed that McGeer's Criteria was the standard used, but acknowledged that antibiotics were sometimes prescribed based only on urinalysis (UA) results, without obtaining a culture and sensitivity (C&S) to confirm infection or guide antibiotic selection. The ICP also indicated ongoing efforts to educate nursing staff to request C&S testing, but could not explain how appropriate antibiotic selection was ensured when only a UA was performed. Facility policy required review of clinical signs, symptoms, and laboratory reports to determine the need for antibiotics, but this protocol was not consistently followed.
Plan Of Correction
1.) All Residents have the potential to be affected. 2.) A one-time audit was completed on ABT within the last 14 days to ensure they meet McGeer's criteria or have a risk versus benefits completed. The licensed nurses and providers were re-educated on McGeer's criteria. 3.) System change: Mon-Friday during the clinical meeting the ICP/Designee will review ABT to ensure they are meeting McGeer's criteria. 4.) DON/Designee will review 5 ABT weekly x 12 weeks then monthly x 3 months to ensure McGeer's criteria is met or risk versus benefit is obtained. Any non-adherence will result in 1:1 education. All audits will be brought to QA committee for review and further recommendations. The Director of Nursing is responsible for ongoing sustained compliance.
Failure to Provide Working Clock Limits Resident Choice
Penalty
Summary
A deficiency occurred when the facility failed to provide a working clock for a resident who was cognitively intact and had diagnoses including Parkinson's disease, kidney disease, and diabetes. The resident had a clear view of a clock above the door in their room, which consistently displayed the incorrect time and had a non-moving second hand. The resident reported that the clock had never worked since their admission to the room, and although batteries were replaced, the clock would only function briefly before stopping again. The resident found the broken clock to be an annoyance, especially since it was in their direct line of sight. Multiple staff members, including a LPN and a CNA, were aware of the issue and had either attempted to address it by replacing the battery or reported it verbally to maintenance. However, the problem persisted, and there was no record of a maintenance ticket in the facility's system for the clock. The facility's policy states that residents are entitled to exercise their rights and privileges to the fullest extent possible, but the ongoing issue with the clock was not resolved, impacting the resident's ability to exercise choice and self-determination regarding their environment.
Plan Of Correction
F 561 1.) Resident #67 clock was immediately replaced. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all clocks were in working order. Nursing and Maintenance department were re-educated to ensure that clocks were working in their rooms when completing any tasks. 3.) System change: maintenance will complete weekly rounds to ensure clocks are within working order. 4.) Administrator/Designee will review 5 rooms weekly x 12 weeks then monthly x 3 months to ensure that clocks are within working order. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The administrator will be responsible for ongoing sustained compliance.
Unsafe and Damaged Toilet Safety Equipment Found in Use
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for two residents when their toilet safety equipment was found in disrepair. Observations revealed that the toilet safety frames in the bathrooms of two residents had cracked and jagged armrests, creating an opening with sharp edges where residents would typically place their hands to stand up. One resident acknowledged the risk, stating that the damaged equipment could cut someone using it. Staff, including a CNA, confirmed they had not previously noticed the damage but agreed it posed a risk for skin tears. The Director of Nursing also observed the cracked armrests and recognized the potential for injury. Both residents involved required assistance with transfers and toileting, and one was noted to be cognitively intact and their own responsible party. The most recent skin assessment for one resident showed no current skin tears or new concerns. The facility's policy requires providing a safe and homelike environment, but the presence of damaged and unsafe equipment in use did not meet this standard at the time of the survey.
Plan Of Correction
F584 1.) Resident #15 & #99 bedside commode was immediately replaced. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all bedside commodes were in working order. Nursing, housekeeping, and maintenance departments were re-educated to ensure that bedside commodes were working in their rooms when completing any tasks. 3.) System change: housekeeping will complete weekly rounds to ensure bedside commodes are within working order. 4.) Administrator/Designee will review 5 rooms weekly x 12 weeks then monthly x 3 months to ensure that bedside commodes are within working order. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The Administrator is responsible for ongoing and sustained compliance.
Failure to Notify Mental Health Authority of PASARR Change in Condition
Penalty
Summary
The facility failed to notify the local state mental health authority of a significant change in condition for a resident with a mental disorder, as required by PASARR (Preadmission Screening and Resident Review) regulations. The resident was admitted with a diagnosis of schizophrenia and had a history of psychotic episodes, as well as a documented need for antipsychotic medication. Despite this, the facility's admission Minimum Data Set (MDS) assessment inaccurately indicated that the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability, even though clinical documentation and psychiatric evaluations confirmed the presence of schizophrenia. Further review of the resident's clinical record showed that the only available PASARR documentation was a form completed at a previous facility, which noted both mental illness and dementia diagnoses. There was no evidence that the facility had updated or revised this PASARR documentation or submitted a change in condition to the local mental health agency for evaluation, despite ongoing psychiatric assessments and the resident's intact cognition as indicated by the BIMS score. Interviews with facility staff, including the Social Service Director and the Administrator, confirmed that no Level II evaluation had been completed or initiated since the resident's admission. The deficiency was identified through record review and staff interviews, which revealed a lack of appropriate review and notification regarding the resident's mental health status and PASARR requirements. The facility did not provide additional PASARR documentation or evidence of compliance with notification protocols, and staff responses indicated a misunderstanding of the need for a Level II evaluation in the presence of both mental illness and dementia diagnoses.
Plan Of Correction
F 646 1.) Resident #60, new 77/78, was completed. All residents have the potential to be affected. 2.) A one-time audit was completed on all in-house residents to ensure their PASRR screening was up to date. The SW department was re-educated on PASRR screening by the Regional Clinical Nurse Consultant. 3.) System change: the MDS department will meet with SW weekly to ensure that all new admits, significant changes, and quarterly the PASRR have been reviewed and updated as needed. 4.) The Administrator/Designee will review 5 records weekly x 12 weeks then monthly x 3 months to ensure that PASRR screenings are updated. Any non-adherence will result in 1:1 education. All audits will be submitted to the QA committee for review and further recommendations. The Administrator will be responsible for ongoing sustained compliance.
Failure to Provide Wound Care per Physician Orders and Document Accurately
Penalty
Summary
The facility failed to provide wound care according to physician's orders for two residents with non-pressure related skin conditions. One resident with dementia, type two diabetes, and varicose veins was observed with dirty and unkempt kerlex bandages on both ankles, dated six days prior, despite orders for daily dressing changes. The resident was unable to recall the reason for the bandages or the frequency of changes. Record review confirmed that staff had documented daily dressing changes, but observation indicated this was not done as ordered. Another resident with venous insufficiency, type two diabetes, and chronic pain was found with a left foot wound wrapped in undated kerlex and ace wrap, emitting a strong odor. The resident, who was cognitively intact, reported that the dressing had not been changed for several days, although daily changes with a specific solution were ordered. Staff documentation indicated treatments were completed, but physical evidence and resident interview contradicted this. Facility leadership confirmed that dressings should be dated and changed as ordered, but could not explain the discrepancies in documentation and care.
Plan Of Correction
F 684 1.) Resident #6 and #13 were re-assessed by the wound nurse and no acute issues noted. All residents have the potential to be affected. 2.) A one-time audit was completed to ensure that all dressing changes were completed as ordered. Licensed nurses were re-educated on completing dressings as ordered. 3.) System change: the nurse managers during rounds will spot check wound care dressings to ensure they are completed as ordered. 4.) The DON/Designee will observe 5 dressing changes weekly x 12 weeks then monthly x 3 months to ensure they are completed as ordered. Any nonadherence will result in 1:1 education. All audits will be brought to the QA committee for review and further recommendations. The Director of Nursing will be responsible for ongoing and sustained compliance.
Failure to Prevent Unnecessary Antibiotic Use
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary antibiotic therapy, as required by regulations. For one resident, antibiotics were prescribed for a urinary tract infection (UTI) based on a single low-grade fever recorded ten days prior, with no culture and sensitivity (C&S) test performed and no clear documentation of infection criteria being met. Another resident received antibiotics for a UTI despite only exhibiting altered mental status, with no C&S ordered and documentation indicating that antibiotic stewardship guidelines were not followed. In both cases, the infection control preventionist (ICP) and the director of nursing (DON) could not provide justification for the antibiotic use or explain the rationale for the chosen therapy in the absence of confirmed infection. A third resident was started on antibiotics for a UTI based on an abnormal urinalysis, with the C&S later returning negative for infection. Despite this, the resident continued to receive the full course of antibiotics. The ICP acknowledged that antibiotics should have been discontinued once the negative C&S result was received but could not explain why this did not occur. In all three cases, documentation indicated that infection criteria were not met, and antibiotics were administered without appropriate clinical justification or supporting laboratory evidence.
Plan Of Correction
F 757 1.) Resident #40, #85, and #86 were assessed by the nurse manager and no acute issues noted. 2.) A one-time audit was completed on ABT within the last 14 days to ensure they meet McGreer's criteria or have a risk versus benefits completed. The licensed nurses and providers were re-educated on McGreer's criteria. 3.) System change: Mon-Friday during the clinical meeting the ICP/Designee will review ABT to ensure they are meeting McGreer's criteria. 4.) DON/Designee will review 5 ABT weekly x 12 weeks then monthly x 3 months to ensure McGreer's criteria is met. Any non-adherence will result in 1:1 education. All audits will be brought to the QA committee for review and further recommendations. The Director of Nursing will be responsible for ongoing sustained compliance.
Failure to Provide Continuous Physician-Ordered Oxygen Therapy
Penalty
Summary
A resident with a history of chronic kidney disease, COPD, altered mental state, type II diabetes, and alcohol abuse, who was receiving hospice services and was oxygen-dependent, was not provided with continuous physician-ordered respiratory care. The resident had an order for humidified oxygen at 3L/min via nasal cannula every shift due to COPD. On the day of the incident, the resident was left unattended in the dining room for several hours with an empty portable oxygen tank and was found lethargic, slumped over a table, with a soiled brief and a dry, bloody mouth. The humidity bottle for the concentrator in the resident's room was also empty. Nursing staff discovered the resident in distress after being alerted by a nursing student. Upon assessment, the resident's oxygen saturation was found to be critically low at 80%, and blood pressure was also significantly decreased. The nurse returned the resident to their room and placed them on the concentrator at the ordered flow rate, but the oxygen saturation only improved to 86% after increasing the flow to 5L/min. The resident exhibited signs of hypoxia, including altered mental status, inability to eat or swallow, and increased confusion. The hospice nurse was contacted, and it was determined that the resident required transfer to the hospital for a higher level of care. Facility records revealed that there was no incident or accident report addressing the event involving the empty oxygen tank and resulting respiratory concerns. Interviews with staff and the physician confirmed that the resident should have been receiving continuous oxygen therapy as ordered. Facility policy on oxygen administration requires verification of physician orders and ensuring proper functioning of oxygen equipment, which was not followed in this case.
Failure to Obtain Guardianship and Proper Consent for Cognitively Impaired Resident on Hospice
Penalty
Summary
The facility failed to timely evaluate the competency of a resident with impaired cognition and did not obtain legal guardianship or ensure proper consent for hospice services. The resident, who had diagnoses including chronic kidney disease, COPD, altered mental state, type II diabetes, and alcohol abuse, was noted to have fluctuating and eventually severely impaired cognition. Despite documentation of forgetfulness, confusion, and inability to answer questions, the resident remained listed as their own responsible party, and no advanced directives or guardianship were established for an extended period. Social service notes indicated ongoing discussions with the resident's spouse about guardianship, but no action was taken to complete the process, even after the spouse expressed inability to care for the resident and requested assistance with guardianship paperwork. The facility did not pursue alternative guardianship options or seek a formal competency evaluation when the spouse failed to complete the necessary documents. Additionally, there was a lack of documentation regarding who consented to hospice services and related medical decisions, with conflicting and incomplete records about consent forms and responsible parties. Interviews with facility staff revealed uncertainty about policies and procedures for guardianship, competency evaluations, and hospice consent. The spouse reported feeling uninformed and pressured regarding hospice consent and had not been in contact with the resident for an extended period. The facility's own policy required social workers to assist with legal matters such as guardianship and to help residents determine decision-making preferences, but these actions were not completed in this case.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the formation of pressure ulcers and did not document accurate skin assessments or implement necessary interventions for two residents, R903 and R904. R903, who was admitted with encephalopathy, diabetes, and dementia, developed a Stage 4 pressure ulcer on the right ischium, which became infected and required antibiotics. The facility's records showed inconsistencies in wound care documentation, with missing entries in the Treatment Administration Record (TAR) and Medication Administration Record (MAR), indicating that prescribed treatments were not consistently administered. The Director of Nursing (DON) acknowledged the discrepancies and the need for proper documentation. R904, admitted with alcohol-induced chronic pancreatitis, depression, and calorie malnutrition, initially had no skin conditions but later developed an unstageable pressure ulcer on the coccyx. The resident's Braden Scale score indicated a high risk for pressure ulcers, yet the care plan did not include additional interventions beyond those initially set. The facility's records showed missing entries for wound care treatments, and the Wound Nurse was not informed of the resident's increased risk or nutritional concerns until after the wound developed. An order for an air loss mattress was placed but not included in the care plan. The facility's policy on pressure ulcer prevention was not followed, as residents were not adequately assessed for risk, and interventions were not introduced at the earliest possible time. The DON admitted that further attempts could have been made to prevent the development of pressure ulcers and that treatment orders should have been administered as prescribed. The lack of timely and appropriate interventions contributed to the residents acquiring severe pressure ulcers, highlighting deficiencies in the facility's wound care management and documentation practices.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to enhanced barrier precautions (EBP) for two residents, resulting in the potential for the spread of infection. For one resident, identified as R903, there was no EBP sign posted on the door, and the only personal protective equipment (PPE) available in the room was a box of gloves. No isolation cart or PPE supplies were observed inside or outside the room. Despite having an active physician order for EBP due to wounds, staff members, including a CNA and an LPN, were observed providing care without wearing isolation gowns. Interviews with various staff members, including the assigned nurse, unit manager, infection control nurse, and the director of nursing (DON), revealed a lack of awareness and explanation for the absence of EBP signage and PPE supplies. The DON mentioned that PPE is usually stored at the nurse station, but none was found there. The staff's failure to adhere to EBP protocols during hygiene and wound care activities was evident, as they did not use the required gowns. For another resident, identified as R904, the facility's protocol to place residents with pressure wounds on EBP was not followed. The resident had a documented fragile area on the sacrum, but there was no order for EBP when treatment was initiated. The DON confirmed that an order should have been placed, but it was not found in the resident's record. This oversight further highlights the facility's failure to implement its infection prevention and control program effectively.
Sanitary Conditions in Kitchen Not Maintained
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour. The bulk flour bin was found without a label identifying its contents, which Culinary Specialist T attributed to a recent cleaning that removed the label. Additionally, two bulk rice bins had dried food splatter on their lids and exterior surfaces. The milk cooler had pooling milk at the bottom, and various areas of the kitchen floor were observed with food debris and spills, including a large spill of a white granular substance in front of the stove, food debris behind the trash can next to the coffee maker, a pile of spilled thyme spices next to the spice rack, and food debris underneath the racks in the dry storage room. Dietary Manager S confirmed the presence of the food debris and stated that staff are supposed to mop every night but evidently had not done so adequately. These observations indicate non-compliance with several sections of the 2017 FDA Food Code, including sections 3-302.12, 4-602.13, 4-601.11, and 6-501.12. The lack of proper labeling, cleaning, and maintenance of food storage containers and kitchen surfaces could potentially affect all residents consuming food from the kitchen. The Dietary Manager acknowledged the issues but did not provide an immediate solution or explanation for the lapses in maintaining sanitary conditions.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered, documented, and stored according to professional standards of practice for four residents. For one resident, R215, the facility did not document the administration of pain medication (Oxycodone with Acetaminophen) on the Medication Administration Record (MAR) despite the resident experiencing severe pain and the medication being pulled from the supply. Additionally, a packaged medication was found on R215's tray table, indicating improper storage and handling of medications by the nursing staff. Another resident, R265, was administered Klonopin three times per day instead of as needed (PRN) as per the hospital transfer records. The error was attributed to a nurse incorrectly entering the medication order into the system. This led to the resident receiving unnecessary doses of a psychotropic medication, which concerned the resident's family members, including a licensed pharmacist. For resident R11, medications were left at the bedside, and the resident was unaware of what the medications were or how long they had been there. This was against the facility's policy that required nurses to ensure residents took their medications before signing off on the MAR. Similarly, resident R95 had a Fluticasone-Salmeterol inhaler at the bedside without a provider order for self-administration, which was also against the facility's medication administration policy.
Failure to Ensure Safe and Secure Storage of Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications across three medication carts. During an observation, a Registered Nurse (RN) left a medication cart unlocked, unattended, and out of sight while administering medications to a resident. This action was in direct violation of the facility's policy, which mandates that medication carts must be closed and locked when out of the nurse's sight. Additionally, a Licensed Practical Nurse (LPN) left previously pulled medications on top of the cart and walked away, and on a separate occasion, dropped two pills on the floor and placed them back on top of the cart before walking away to administer other medications. Both actions were acknowledged by the LPN as improper and against the facility's policy, which states that no medications should be kept on top of the cart and that loose medications should be disposed of immediately. Further inspection of another medication cart revealed an unidentifiable loose pill in a blue plastic container. The LPN acknowledged the presence of the loose pill and disposed of it, in accordance with the facility's policy on medication storage. The Director of Nursing (DON) was informed of these observations and acknowledged that medications should not be left unattended and that medication carts should be locked when not visible to the nurse. The DON also confirmed that loose medication pills should not be present in the medication carts.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect. On the morning of 4/29/24, a resident (R19) with severe cognitive impairment was observed sitting in a geri-chair in the dining room. R19 announced twice that they needed to go to the bathroom, but the Certified Nursing Assistant (CNA) D told them to wait until they were done eating and did not respond the second time. After R19 finished eating, CNA D noticed that R19 had spilled their drink and had food debris on their shirt. CNA D then maneuvered R19 in the geri-chair by pulling them backward through the dining room to the shower room, which is against the facility's protocol for moving residents in geri-chairs. The resident's clinical record indicated that R19 had diagnoses of dementia, schizoaffective disorder, and major depressive disorder, with a Brief Interview for Mental Status (BIMS) assessment showing severely impaired cognition. The care plan for R19 included supervision and assistance during meals, especially near the end. The Director of Nursing (DON) confirmed that residents should always be pushed facing forward in a geri-chair and had no explanation for the observed actions. The facility document titled 'Right of Resident in Michigan Nursing Facilities' emphasizes the right of residents to a dignified existence and self-determination, which was not upheld in this instance.
Failure to Complete PASARR Evaluation
Penalty
Summary
The facility failed to ensure a Level I Preadmission Screening (PAS) and Annual Resident Review (ARR) for Mental Illness/Intellectual Disability/Related Conditions was completed accurately and sent to the local community mental health for a Level II OBRA evaluation for a resident. The resident, who was admitted and readmitted with diagnoses including schizophrenia, adjustment disorder with mixed anxiety and depressed mood, and psychotic disorder with delusions and hallucinations, had a comprehensive Minimum Data Set (MDS) assessment with the PASRR section left blank. The Level I Screening form indicated the resident had a current diagnosis of mental illness, had received treatment for mental illness, and had been prescribed antipsychotic or antidepressant medications within the last 14 days. However, there was no evidence that a Level I evaluation had been completed by the facility. During an interview, the Social Worker Director (SWD) admitted that the Level I evaluation had been overlooked. The Administrator confirmed that there was no specific policy on PASARR but stated that the facility followed Federal Regulations regarding PASARR. This oversight resulted in the potential for the resident to be excluded from receiving necessary care and services appropriate to meet their mental health and intellectual disability needs.
Failure to Provide Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure continuous oxygen was provided per physician orders for a resident with severe cognitive impairment and multiple diagnoses, including dementia, schizoaffective disorder, and major depressive disorder. The resident was observed multiple times without proper oxygen supply, either due to the oxygen concentrator not being plugged in or the nasal cannula tubing being obstructed or disconnected. On one occasion, a CNA was seen transporting the resident without an oxygen tank, relying on an oxygen concentrator that required a power supply to function. Additionally, the resident was observed with the nasal cannula tubing wrapped around an oxygen tank but not attached to the resident, indicating a failure to provide the necessary continuous oxygen therapy. Interviews with staff revealed that oxygen tanks were not consistently used for residents on continuous oxygen therapy, with one LPN stating that the tanks would run out of oxygen quickly. The Director of Nursing confirmed that oxygen tanks should be used when transporting residents but had no explanation for why this protocol was not followed. The facility's policy on oxygen administration emphasized the importance of providing continuous oxygen and having a reserve oxygen tank available, but these guidelines were not adhered to in the case of the resident in question.
Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure all controlled substances were accounted for and accurately documented for a resident. On 5/1/24, the resident reported severe pain and requested pain medication before allowing any treatment. The resident had an active order for Oxycodone with Acetaminophen, but the Medication Administration Records (MAR) showed no documentation of the medication being administered since 10:07 PM on 4/30/24. Despite the resident's verbal confirmation of receiving the medication, the MAR lacked proper documentation, and the Director of Nursing (DON) confirmed that the nurses had not recorded the administration as required by policy. Further investigation revealed discrepancies in the documentation of controlled substances. The DON provided an Individual Resident's Controlled Substance Record indicating that the medication was pulled from the supply at specific times, but the MAR did not reflect this administration. The midnight nurse later added documentation to the MAR, but the process of delayed documentation raised concerns about the potential for drug diversion. The facility's policy on medication administration required immediate recording of administered medications, which was not followed in this case.
Failure to Administer Blood Pressure Medications According to Physician-Ordered Parameters
Penalty
Summary
The facility failed to administer blood pressure medications according to physician-ordered parameters for a resident with diagnoses of hypertension and hypotension. The resident received Midodrine, a medication used to treat low blood pressure, outside of the specified parameters on multiple occasions. Specifically, the resident's Medication Administration Records (MAR) showed instances where Midodrine was administered despite the resident's systolic blood pressure (SBP) being greater than 120 mmHg, which was against the physician's orders. Additionally, there were several instances where the resident's blood pressure was not documented at all, making it impossible to determine if the medication should have been administered or held. The Director of Nursing (DON) confirmed that nurses should administer medications according to physician-ordered parameters and that there should be a space to document blood pressure on the MAR. However, a review of the resident's March and April MARs revealed missing blood pressure documentation, and in some cases, the medication was held without documented justification. The facility's policy on medication administration requires obtaining and recording vital signs as necessary prior to medication administration, which was not consistently followed in this case.
Incorrect Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident received psychotropic medication as ordered. The resident, who was admitted for physical therapy and nursing care, was observed in a catatonic state. Family members, including a licensed pharmacist, expressed concerns about the administration of Klonopin three times per day, which was not noted in the hospital transfer records. The hospital records indicated that Klonopin was to be administered as needed (PRN), not on a scheduled basis. The resident's clinical record showed a diagnosis of failure to thrive and unspecified dementia without behavioral disturbances, and the resident was severely cognitively impaired. The Director of Nursing (DON) confirmed that the scheduled order for Klonopin was entered incorrectly and should have been PRN, as per the physician's order. The physician recalled that the order was intended to be PRN due to behavioral concerns when taking the resident's vitals. The facility's policy on controlled substance medication orders was reviewed, which requires accurate documentation and adherence to the prescribed orders. The discrepancy between the intended PRN order and the scheduled administration led to the deficiency in the resident's care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, resulting in a total error rate of 6.25%. During a medication administration observation, an LPN administered Clopidogrel (Plavix) 75 mg to a resident at 9:00 AM, despite the medication being ordered for 7:00 PM. Additionally, the LPN administered Aspirin Enteric Coated (EC) 81 mg, which was not ordered by the provider. These errors were identified during a medication reconciliation of the physician's orders, which confirmed the discrepancies in the administration times and the type of medication given. The Director of Nursing (DON) was informed of the findings and acknowledged the errors. The facility's policy on medication administration requires reviewing and confirming medication orders prior to administration, verifying the medication three times, and ensuring the correct dosage and schedule. The observed actions of the LPN did not adhere to these guidelines, leading to the medication errors for the resident involved.
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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