Lake Woods Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskegon, Michigan.
- Location
- 1684 Vulcan Street, Muskegon, Michigan 49442
- CMS Provider Number
- 235116
- Inspections on file
- 27
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lake Woods Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, weakness, and impaired mobility was found on the floor yelling in pain and repeatedly stating that her leg was broken, with significant right hip and knee pain and a large skin tear on her arm. Staff moved her from the floor to a wheelchair, later stood her for a more thorough skin check, and then used a stand-and-pivot transfer to bed while she continued to yell out and refused to bear weight on her leg. Facility policy required a licensed nurse to complete a full post-fall assessment, including pain and range-of-motion evaluation and determining the need for emergency treatment, before moving a resident, and specified that the resident should not be moved until this initial evaluation was completed. This assessment was not completed prior to moving the resident, resulting in the cited deficiency.
A resident admitted for orthopedic aftercare and dementia had a hospital After Visit Summary specifying a scheduled post-op orthopedic follow-up, but facility staff did not review and act on this information at admission. The resident’s significant other later reported that the appointment had been missed, and documentation showed the follow-up did not occur until a later date. The MRM, who had been on leave, found no record that the appointment was noted or scheduled by covering staff, and the DON could not determine or document why the original post-op visit was missed.
A resident with significant immobility and multiple risk factors developed a stage 3 pressure ulcer after staff failed to consistently use pressure-relieving devices, did not know the correct settings for a specialty air mattress, and lacked documentation and communication regarding care refusals. The care plan interventions were not reliably implemented, and there was no process to determine the cause of the ulcer or to involve family in managing refusals.
Surveyors found that the facility did not have an active plan to reduce Legionella and other waterborne pathogens, as evidenced by discolored water, lack of regular flushing in soiled utility rooms, spa rooms, janitor sinks, and the laundry room, and incomplete water testing practices. Maintenance staff confirmed that flushing was not routinely performed in these areas, and annual water testing was limited to cold water samples.
Two severely cognitively impaired residents were involved in a physical abuse incident when one resident with a history of wandering entered another's room and was physically assaulted. Despite prior interventions for wandering and confusion, the resident was able to access another room unsupervised, leading to the incident. Staff and witness statements confirmed the abuse occurred before staff intervened.
A resident with congestive heart failure and an active order for digoxin did not have a required digoxin level obtained for over a year, despite a pharmacist's recommendation and an existing physician order for monitoring every six months. The omission was only identified after a surveyor's request, and staff confirmed the lapse in following the monitoring order.
Staff failed to follow established safety practices by transporting a resident in a wheelchair without foot pedals on multiple occasions, despite the resident's medical conditions and facility expectations. Additionally, the facility did not adequately monitor a resident known for pocketing food during meals.
The facility did not maintain complete medical records for two residents, as pharmacist recommendations regarding medication irregularities were missing from their electronic health records. In both cases, the recommendations were either not entered, only available in the pharmacy's system, or not yet uploaded, resulting in incomplete documentation and a failure to meet regulatory requirements.
Surveyors found multiple environmental deficiencies, including unclean spa rooms with bowel movements left in commodes, missing shower tiles, exposed clean linens on open wire shelving, and accumulated dust and debris under equipment and carts. The Maintenance Director was unaware of several of these issues.
A resident with severe cognitive impairment and dysphagia was repeatedly left unsupervised during meals, provided only a single bowl of pureed food and a plastic spoon without a beverage, and struggled to self-feed, resulting in food spillage and prolonged chewing without staff intervention. Staff failed to monitor or assist the resident despite her known history of food pocketing and difficulty eating, and care documentation did not accurately reflect care conferences with the resident's family.
A missing ceiling tile was observed above the door entering the dining area in Terrace Hall, which compromised the maintenance and testing requirements for the automatic sprinkler system as required by NFPA 25. This deficiency was confirmed by the Maintenance Director during inspection.
Surveyors found that delayed egress double doors at the south end lacked the required 15-second delayed egress sign, as confirmed by the Maintenance Director. This failure to properly identify the door as a delayed egress door did not meet regulatory requirements and could impact emergency exiting for 35 occupants.
A battery charger for a wheelchair was found in use within a resident's room, with the battery being recharged overnight while the resident was present. The room did not have the required fire barrier or automatic fire extinguishing system, as confirmed by the Maintenance Director during observation and interview.
Two employees were observed smoking outside on campus grounds at a picnic table near the building, contrary to the facility's policy that only allows smoking inside vehicles. This was confirmed by policy review and interview with the Maintenance Director, indicating a failure to enforce required smoking regulations.
A resident with dementia and mental health issues was involuntarily discharged to a hospital without proper notification or documentation. The facility failed to inform the resident's guardian and the local Ombudsman, resulting in the resident remaining in the hospital without a clear plan for return or alternative placement.
A resident with dementia and mental health issues was sent to the hospital for aggressive behavior and was not allowed to return to the facility, violating the bed-hold policy. The facility failed to complete necessary discharge paperwork or initiate involuntary discharge procedures, leaving the resident without a home to return to.
A medication cart was left unlocked and unattended in a hallway, compromising the security of controlled substances stored within. An RN acknowledged the oversight, citing a delay in the oncoming nurse's arrival. Interviews with staff confirmed the expectation to lock carts when unattended, aligning with facility policies requiring double lock security for controlled substances.
A facility failed to protect a resident's medical records, leaving an e-MAR visible on a medication cart without staff supervision. Staff interviews revealed inconsistent practices in securing computer screens, with some relying on ineffective methods. The DON confirmed the expectation to hide screens, aligning with the facility's HIPAA policy.
A resident with dementia and depression exhibited increased agitation and combative behaviors after abrupt discontinuation of Zyprexa. The facility failed to update the care plan or implement new interventions, leading to physical aggression towards staff and other residents. Another resident was physically assaulted, but due to insufficient supervision and lack of reliable witnesses, the incident could not be verified. The facility's inaction and lack of documentation contributed to the deficiency in protecting residents from abuse.
A resident with severe cognitive impairment was left unsupervised outside a facility for approximately three hours while waiting for a day center bus that never picked her up. The resident, who was not recommended for outdoor independence, was observed by multiple staff members but was not assessed or assisted back inside. The incident was not reported until nine days later, highlighting a lack of supervision and communication among staff.
A resident with a history of aggressive behavior pushed another resident, resulting in fractures to her right radius and femoral neck. The incident occurred in a dining area, and the aggressive resident admitted to acting out to leave the facility. The injured resident, who was severely cognitively impaired, required hospitalization for her injuries.
The facility failed to properly assess, monitor, and treat pressure ulcers for three residents, resulting in significant deterioration of their conditions. One resident's wounds worsened due to inadequate repositioning and lack of communication, another experienced progression of wounds due to inconsistent care and delayed treatment, and a third developed new unstageable pressure ulcers without prompt treatment or proper documentation.
The facility failed to follow standards of care for five residents, leading to unaddressed medical concerns, incomplete wound care treatments, improper medication administration, and inadequate post-fall neurological assessments. These deficiencies were identified by surveyors and involved multiple residents with chronic conditions and cognitive impairments.
A resident with multiple diagnoses, including COPD and muscle weakness, was moved from her room of three years following an incident with her roommate. Despite expressing a strong desire to return to her original room, the facility did not accommodate her request, leading to feelings of frustration and distress.
The facility failed to notify responsible parties after falls for two residents, leading to delays in medical intervention and care. One resident, moderately cognitively impaired, fell unwitnessed, and another, severely cognitively impaired, was observed with extensive facial bruising. Notifications to the physician and family were not made promptly as required by facility policy.
The facility failed to implement policies for reporting a resident-to-resident incident involving two residents. One resident, with multiple health issues, reported threats and yelling from her roommate, which were not documented or addressed by the staff. The facility's response to a related complaint was inadequate, and the incident was not properly reported as per policy.
The facility failed to revise care plans for two residents, one after a fall and another with worsening pressure ulcers, despite clear indications and staff acknowledgment that updates were necessary.
A resident with difficulty in walking and muscle weakness did not receive scheduled showers on two consecutive days, leading to frustration. The staff failed to document the refusal of the shower, and the Unit Manager acknowledged the oversight.
The facility failed to prevent an elopement for a resident with severe cognitive impairments, resulting in the resident leaving the facility unnoticed and sustaining minor injuries. Additionally, the facility failed to complete post-fall assessments for another resident with extensive facial bruising, delaying necessary evaluations and notifications.
The facility failed to follow physician orders for a resident's suprapubic catheter care, including not cleansing the site with soap and water, not changing dressings, not emptying the drainage bag every shift, and not irrigating the catheter as required. The resident reported a foul odor from the catheter site, and multiple instances of missing documentation were noted in the Treatment Administration Record.
A resident with multiple health issues, including pressure ulcers and diabetes, reported receiving cold food and staff not reheating it despite requests. The Dietary Manager was aware of the complaint but had not followed up, leaving the issue unresolved.
The facility failed to ensure that a resident with a left above-the-knee amputation received necessary follow-up appointments and adjustments for his prosthetic leg, resulting in pain and frustration. Despite the resident's complaints and the physical therapy plan indicating the need for adjustments and staff assistance, there was no evidence that the facility staff were trained to assist the resident with the prosthetic leg or that the resident's guardian was involved in the therapy plan of care.
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks for their care. Incidents involving altercations, rough transfers, and threats were not properly documented, compromising the residents' safety and well-being.
A facility failed to maintain clean medical equipment at the bedside for a resident with a feeding tube, resulting in the potential use of unsanitary devices. Despite acknowledging the issue, the DON did not remove the unclean items, which remained at the bedside during subsequent observations.
The facility failed to ensure that the designated Infection Preventionist (IP) completed specialized training in infection prevention and control before assuming the role. The current IP, an RN Unit Manager, had taken over the role a few months ago and was still in the process of completing her IP certificate, having not yet taken the final test for certification.
Failure to Complete Full Post-Fall Assessment Before Moving Resident With Suspected Fracture
Penalty
Summary
The deficiency involves the facility’s failure to complete a full post-fall assessment before moving a resident who had sustained an unwitnessed fall and was complaining of severe pain. The resident was an elderly female with dementia, weakness, difficulty walking, and a need for assistance with personal care. On the night of the incident, staff heard the resident yelling and found her on the floor in her room. She repeatedly stated that she felt like she had broken her right leg and that her right knee and hip hurt. Staff documented that they were unable to perform range of motion without causing pain, and that the resident exhibited repeated troubled calling out, loud moaning or groaning, crying, facial grimacing, and could not be consoled, distracted, or reassured. A 13-centimeter skin tear on the right arm was identified, cleaned, and bandaged, and pain medication was administered. Despite the resident’s significant pain and statements that she had broken her leg, staff moved her multiple times before completing a full assessment as required by facility policy. According to interviews, the RN and CNAs lifted the resident from the floor into a wheelchair, then later stood her up to complete a more thorough skin assessment, and subsequently used a stand-and-pivot transfer to move her into bed, during which she did not want to bear weight on her leg and yelled out in pain. The facility’s fall management policy required that when a resident is found on the floor, a licensed nurse complete an initial sequential assessment—including full body inspection, pain assessment, active and passive range of motion, neurological evaluation if indicated, vital signs, and evaluation for emergency treatment—and that the resident not be moved until this initial evaluation was completed. The policy also emphasized minimizing movement and stress on a suspected fracture and guarding or splinting the injured area before moving. These required steps were not followed before the resident was moved from the floor and subsequently transferred, leading to the cited deficiency.
Failure to Schedule and Maintain Post-Op Orthopedic Follow-Up Appointment
Penalty
Summary
The facility failed to ensure services were provided according to professional standards of practice when staff did not arrange a scheduled post-operative orthopedic follow-up appointment for one resident. The resident was admitted with diagnoses including orthopedic aftercare and dementia, and the local hospital’s After Visit Summary dated 12/3/2025 documented a post-op visit with an orthopedic specialist scheduled for 12/12/2025 at 1:45 PM. The resident’s significant other later reported concern that this follow-up appointment had been missed, which was documented in the Interdisciplinary Documentation on 12/12/2025, noting that the orthopedic office would need to be contacted and a new post-op follow-up appointment made. Further review of the resident’s record showed that the follow-up orthopedic visit did not occur until 12/24/2025. The Medical Records Manager stated that she had been on leave at the time of the resident’s admission and that another staff member was covering her duties. She reported that the After Visit Summary should have been reviewed at admission and necessary follow-up appointments scheduled, but her logs contained no documentation that the post-op appointment was noted or scheduled at that time. The DON reported being uncertain why the resident missed the original post-op appointment and was unable to find documentation explaining how it was missed.
Failure to Prevent and Manage Pressure Ulcer Due to Inconsistent Pressure Relief and Documentation
Penalty
Summary
A deficiency was identified when a resident with multiple risk factors, including diabetes mellitus, muscle weakness, muscle wasting, abnormal posture, and dementia, developed a stage 3 pressure ulcer on the left heel. The resident was largely immobile, unable to move his neck upright, and could only move his right arm and hand. During care observations, staff elevated the resident's left foot on a pillow but did not use any other pressure-relieving device for the foot, despite a pressure-relieving boot being available at the bedside. The resident's specialty air mattress was found set on 'firm,' and staff were unaware of the correct settings for the mattress or how to adjust it appropriately. The facility did not provide the mattress manual or clarify the correct settings when requested by the surveyor. The DON confirmed the pressure ulcer was facility-acquired and could not identify the cause. There was no documentation or process in place to determine the cause of the pressure ulcer, and the facility's policy did not address this. The care plan noted the resident sometimes refused care, but there was no documentation of refusals related to pressure relief prior to the ulcer's development, nor any evidence of communication with the resident's guardian or brother regarding refusals. The care plan included interventions such as using an alternating pressure mattress and a pressure-relieving boot, but these were not consistently implemented or documented as refused. Additionally, staff did not have clear expectations or documentation practices for reapproaching the resident after refusals or for involving the guardian or family members to assist with compliance. The lack of consistent use of pressure-relieving devices, unclear mattress settings, and insufficient documentation and communication regarding care refusals contributed to the resident developing a stage 3 pressure ulcer.
Plan Of Correction
ELEMENT #1: ACTION TAKEN: Resident #26 will have a review of positioning devices, and the alternating pressure mattress will be set per manufacturer guidelines. The resident person-centered plan of care will be reviewed to ensure interventions are in place and utilized to promote wound healing and prevent further pressure injury development. Updates will be made to the person-centered plan of care as needed based on this assessment. ELEMENT #2: IDENTIFICATION OF OTHER RESIDENTS: Residents residing at Lake Woods have the potential to be affected. The resident's person-centered plan of care will be reviewed to validate interventions are in place and utilized to promote wound healing and prevent pressure injury development. Updates will be made to the person-centered plan of care as needed based on this assessment. ELEMENT #3: MEASURES TAKEN: Lake Woods will provide reeducation to licensed nursing staff and certified nursing assistants by 5/26/2025 prior to the next day worked in the case of the leave of absence, vacationing employee. The educational agenda will include application of person-centered interventions, with examples provided of various interventions for utilization to prevent worsening or the development of pressure injuries. The education will include the location of the resident's preference of settings for their alternating pressure mattress to ensure it is followed. ELEMENT #4: MONITORING: The Director of Health Care Services and/or designee will conduct rounds 3-5 times per week for 4 weeks on varying shifts to evaluate the education provided and inspect for the implementation of care planned interventions, including a review of the alternating pressure mattress settings, to prevent worsening or the development of pressure injuries. The Director of Health Care Services will compile a report of this audit for review and recommendation by the Quality Assurance Performance Improvement Committee monthly times one (1) month and periodically thereafter. The Director of Health Care Services will assume responsibility for sustained compliance.
Failure to Maintain Water Management Program and Routine Flushing
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens in its plumbing system. During a facility tour, surveyors observed multiple instances of discolored water and lack of regular flushing in various areas, including soiled utility rooms, spa rooms, janitor sinks, and the laundry room. In several locations, water from fixtures was brown or black before running clear, and some fixtures had not been flushed for extended periods, as evidenced by evaporated water in a commode basin and dust accumulation on unused shower equipment. Maintenance staff confirmed that flushing was not routinely performed in these areas, with a focus only on vacant rooms. Further interviews with maintenance and facility directors revealed that the facility's water management practices were insufficient. Annual testing for free chlorine was only conducted on cold water samples, with no testing performed on the hot water systems that service residents. Additionally, a review of the facility's own risk assessment document indicated that regular flushing of low-flow pipe runs and infrequently used fixtures was required, but this was not being implemented. No specific residents or staff were identified as directly affected in the report.
Plan Of Correction
ELEMENT 1 ACTION TAKEN: The facility will conduct a review of the plan to reduce the risk of legionella and other opportunistic pathogens of premise plumbing. An audit will be completed by 5/26/2025 of hot and cold water fixtures regardless of room vacancy. Fixtures that have not been flushed will be at that time, including the one in the soiled utility room near the salon. The hopper and the mop sinks hot and cold water fixtures in the soiled utility room near room 40 will be flushed by 5/26/2025. The shower in the corner of the spa room will be deep cleaned by 5/26/2025 and repairs will be made to rectify the flow of water to ensure flushing of the fixture can be completed. A repair will be made by 5/26/2025 to apply the cold handle to the sink in the janitors closet, and once repaired the faucet will be flushed. The hot water faucet on the same sink will be flushed. A repair to the handle of the hot water line in the laundry room will be made by 5/26/2025, and once repaired the faucet will be flushed. The facility will complete a free chlorine test of hot water by 5/26/2025, any abnormal results will be rectified. ELEMENT 2 IDENTIFICATION OF OTHER RESIDENTS: All residents residing in the facility have the potential to be affected. All residents will be reviewed for waterborne illness. The health care practitioner will be notified of any residents identified to have signs or symptoms for further medical assessment and treatment. ELEMENT #3 MEASURES TAKEN: Members of the Water Management Committee, to include the Administrator, Director of Health Care Services, Infection Prevention, Environmental Services and Maintenance staff will be reeducated by or prior to 5/26/2025 to the next day work in the case of a leave of absence or vacationing employee related to water management plan and services to reduce the risk Legionella and other opportunistic pathogens of premise plumbing, and water quality measures and disinfectant residual practices. ELEMENT #4 MONITORING: The Nursing Home Administrator and or designee will conduct an audit through observation of Environmental Services and or Maintenance staff flushing faucets throughout the facility, regardless of room vacancy 3-5 times a week for four weeks and periodically thereafter. The water management plan will be reviewed under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, the Administrator, or designee(s), will audit as adherence to the policy and procedure to prevent Legionnaires Disease potential sources weekly for four (4) weeks. A summary report of the findings will be provided to the QAPI Program/Committee for review. The Administrator will assume responsibility for attained and sustained compliance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents' rights to be free from physical abuse. One resident with severe dementia and a history of wandering entered another resident's room and mistakenly got into his bed. The second resident, also severely cognitively impaired, was observed by staff with his hands on the first resident's shoulders and then making contact with an open hand to the side of her face. Witness statements from staff and a housekeeper confirmed that the second resident pinned the first resident to the bed and slapped her on both sides of her face before staff intervened. The first resident was upset but did not sustain visible injuries. Prior to this incident, the first resident had a documented history of wandering into other residents' rooms and had previously been involved in another physical altercation after entering a different resident's room. Interventions such as 15-minute checks and a companion during evening hours had been implemented due to her increased confusion and wandering behaviors. Despite these measures, the resident was able to enter another resident's room unsupervised, leading to the physical abuse incident. Both residents involved were severely cognitively impaired, with documented diagnoses of dementia and other neurological conditions. The first resident's care plan noted altered mobility, poor safety awareness, and a need for redirection due to wandering. The second resident had no recall of the incident and was also noted to be confused. The failure to adequately supervise and prevent the first resident from entering other residents' rooms resulted in a situation where she was physically abused by another resident.
Plan Of Correction
ELEMENT #1: Action Taken: Resident #58 and Resident #60 will have a review of the person-centered plan of care review to mitigate further resident to resident interactions. ELEMENT #2: Identification of Other residents: Lake Woods strives to establish clinical and psychological support practices for our residents that limit the opportunity for avoidable interactions. Residents residing in the facility that are identified as having wandering behavior will be identified through a review of MDS section E0900 and will have a review to their person-centered plan of care interventions to mitigate risk of avoidable resident to resident occurrences. Root cause analysis will be completed, and any opportunities that are identified will be care planned. ELEMENT #3: Systemic Changes: Lake Woods will consistently follow Policies and Procedures Protecting our residents from abuse and mistreatment. All staff will be reeducated by 5/26/2025 or prior to their next day worked in the event of a leave of absence or vacationing employee, regarding the abuse and neglect protocols. Specific examples of possible interventions will be included in the education that may reduce the risk of other resident to resident interactions from occurring. The reeducation will include an Abuse prevention overview including a review of policies entitled; Abuse Suspected Abuse Investigations; Abuse Prevention Overview; and Resident to Resident Interactions. ELEMENT #4: Monitoring: The Director of Health Care Services and/or designee will review the implementation of interventions to mitigate the risk of an avoidable event 3-5 times a week for four weeks enquiring with staff to evaluate understanding and implementation of interventions to prevent high risk events. The Director of Health Care Services or designee will provide a report to QAPI for one (1) month. The Administrator assumes responsibility for attained and sustained compliance.
Failure to Obtain Timely Digoxin Level per Physician Order
Penalty
Summary
A 79-year-old resident with diagnoses including congestive heart failure and osteoarthritis was admitted to the facility and had an active physician's order for digoxin 125 mcg daily, along with an order for a digoxin level to be obtained every six months. The pharmacist's medication regimen review on 4/3/25 noted that the last digoxin level was obtained on 4/12/24 and recommended that a new level be obtained immediately and then every six months thereafter, due to the medication's narrow therapeutic window. However, a review of the resident's medical record from 4/12/24 to 5/1/25 revealed no evidence that a digoxin level had been obtained or ordered in response to the pharmacist's recommendation. When the surveyor requested documentation of the digoxin level or an order for it, it was discovered that the order was only written after the surveyor's inquiry. Interviews with clinical staff confirmed that the digoxin level had not been ordered as recommended, despite other laboratory recommendations from the same pharmacy review being followed. The DON also confirmed that the last digoxin level was obtained over a year prior and could not explain why the six-month interval order was not followed.
Plan Of Correction
ELEMENT #1: Action Taken: Resident #36 had a Digoxin lab level drawn on 5-13-2025. ELEMENT #2: Identification of Other residents who may have the potential to be affected: All residents residing at the facility that receive Digoxin have the potential to be affected and will be identified through an order listing report. An audit will be completed to validate a lab has been completed as ordered. Any discrepancies identified will be reviewed with the health care provider. ELEMENT #3: Systemic Changes: Licensed Nursing Staff will be reeducated by 5/26/2025 or prior to their next date worked in the case of the leave of absence or vacationing employee, regarding expectations of following a physician order. Education will include a review of pharmacy recommendations and the facilities process of reviewing them with the provider, the process of ordering labs per provider orders based on the recommendation, and ensuring the labs are completed. ELEMENT #4: Monitoring: The Director of Health Care Services and/or designee will audit medical records with individuals who had pharmacy recommendations to complete labs 3-5 times per week for 4 weeks to verify the labs were completed based on the physician orders. The Director of Health Care Services will provide a summary of the audit to the Quality Assurance Performance Improvement Committee monthly for one (1) month and periodically thereafter. The Director of Health Care Service will assume responsibility for attained and sustained compliance.
Failure to Ensure Safe Wheelchair Transport and Resident Monitoring
Penalty
Summary
The facility failed to prevent accident hazards by not ensuring safe transportation of a resident in a wheelchair and by not adequately monitoring another resident known for pocketing food. Specifically, a 61-year-old resident with multiple diagnoses including unsteadiness, difficulty walking, dementia, and muscle weakness was observed being pushed in a wheelchair without foot pedals by staff on two separate occasions. The resident's care plan indicated that staff could assist with wheelchair propulsion as needed, and facility staff interviews confirmed that the standard practice is to use foot pedals when pushing residents in wheelchairs. However, both direct observation and staff statements revealed that this protocol was not followed, and the facility did not have a written policy addressing this issue, relying instead on orientation materials and standard practice. Additionally, the report notes that the facility failed to monitor a resident known for pocketing food during meals, though the detailed findings focus primarily on the wheelchair transport issue. Staff interviews and a review of orientation materials confirmed that the expectation is 'No Pedals, No Push,' yet this was not adhered to in practice. The lack of a formal written policy and repeated non-compliance with established safety practices contributed to the deficiency.
Plan Of Correction
Element #1 ACTION TAKEN: Resident #34 will have a review of their person-centered plan of care for Locomotion with revisions made based on the review to ensure safe transportation occurs while in a wheelchair. Wheelchair foot pedals were provided to Resident #34. Resident #42 will have a review of their person-centered plan of care to ensure safe monitoring is provided during meals and reflected on the plan of care with revisions made based on the review. Element #2 IDENTIFICATION OF OTHER RESIDENTS: Residents residing at the facility requiring assistance for wheelchair mobility have the potential to be affected and will be identified through the care plan item listing report for locomotion. Identified residents will have a review of their person-centered plan of care for Locomotion with revisions made based on the review to ensure safe transportation occurs while in a wheelchair. An audit will be conducted to validate residents requiring assistance for wheelchair mobility have foot pedals available for use. Residents that pocket food have the potential to be affected and will be identified through care plan review. The resident's person-centered plan of care will be reviewed to validate interventions are in place and utilized to promote safety monitoring during meals. ELEMENT #3: SYSTEMIC CHANGES: Lake Woods will provide reeducation to all staff by 5/26/2025 or prior to the next day worked in the case of the leave of absence, vacationing employee. The educational agenda will include the standard of practice while providing locomotion assistance in the wheelchair with the utilization of the foot pedals. Licensed nursing staff and certified nursing assistants will receive reeducation that residents who pocket food require supervision at meals, and the importance of offering fluids during meals. Examples will be provided when residents may decline assistance and examples of interventions for staff utilization to encourage the residents to accept assistance. ELEMENT #4: MONITORING: The Director of Health Care Services and/or designees will observe staff on various shifts as they provide assistance to residents with locomotion while in their wheelchair, including utilization of foot pedals 3-5 times a week for four weeks and periodically thereafter to evaluate effectiveness of the education that was provided. An additional observation will be completed during various mealtimes to ensure staff are providing monitoring of residents that are known to pocket food. This audit will be conducted 3-5 times a week for four weeks and periodically thereafter. The Director of Health Care Service will compile a report of this audit for review and recommendation by the Quality Assurance Performance Improvement Committee monthly times one (1) month and periodically thereafter. The Director of Health Care Services will assume responsibility for sustaining compliance.
Incomplete Documentation of Pharmacist Recommendations in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by federal regulations. For one resident, who had diagnoses including depression and diabetes, pharmacist medication regimen reviews identified potential medication irregularities on three separate occasions. However, the corresponding pharmacist recommendations and documentation regarding these irregularities were not present in the resident's medical record. The recommendations were either not entered, only available in the pharmacy's computer system, or awaiting upload despite being signed by the physician weeks prior. For another resident with diagnoses including congestive heart failure and osteoarthritis, a pharmacist medication regimen review also identified a potential medication irregularity. The pharmacist's recommendation related to this irregularity was not found in the resident's medical record. Although the facility was able to provide a copy of the recommendation from the pharmacy's computer system upon request, it was not included in the resident's official medical record at the time of the survey. Interviews with facility staff confirmed that the pharmacist recommendations for both residents were not present in the residents' medical records. In some cases, recommendations were only stored in the pharmacy's system or had not yet been uploaded to the electronic health record, resulting in incomplete documentation. This lack of timely and accurate recordkeeping interfered with the ability to ensure informed decisions and continuity of care for the affected residents.
Plan Of Correction
ELEMENT 1 ACTION TAKEN: Resident #26 pharmacy recommendations from 8/6/2024, 11/4/2024, and 4/3/2025 are in the medical record. Element #2 Identification of other Residents: Each resident residing in the facility has the potential to be affected. Pharmacy recommendations conducted at the facility in the last 30 days will be completed to validate the recommendations are in the residents' medical record. Element #3 Measures Taken: Reeducation will be provided to the Director of Health Care Services and Health Information Manager by 5/26/2025 or prior to the next day worked in the /case of the leave of absence, or vacationing employee. The educational agenda will include the requirement of all pharmacy recommendations, including recommendations made to nursing, to be uploaded in the medical record in a timely manner once completed. Element #4 Monitoring Measures Taken: The Nursing Home Administrator and/or Designees will conduct an audit of medical records 3-5 times a week for four (4) weeks and periodically thereafter to ensure pharmacy recommendations, including those made to nursing, are in the medical record in a timely manner once completed. The Nursing Home Administrator will provide a summary of the audit to the Quality Assurance Performance Improvement Committee monthly for one (1) month and periodically thereafter. The Nursing Home Administrator will assume responsibility for attained and sustained compliance.
Environmental Deficiencies in Spa and Linen Areas
Penalty
Summary
During a facility tour with the Maintenance Director, surveyors observed several environmental deficiencies. In the spa room near the activities area, there was a strong odor and a bowel movement left in the commode, with clean folded towels stacked next to the sink. The shower floor in the same room had approximately a dozen one-inch square tiles missing near the front, and a piece of trash identified as a gold tooth filling was found on the floor. The Maintenance Director was unaware of these issues and could not identify if any resident was missing a tooth filling. In the clean linen room, the bottom rack of the linen cart was open wire shelving, leaving clean linens exposed to contamination, and there was an accumulation of trash, dust, and dirt under the cart, which was rarely moved. In another spa room at the end of the hall, a bowel movement was found in the commode and smeared on the padded cover for the plumbing under the sink, and dust was observed on unused equipment and the shower fixture.
Plan Of Correction
ELEMENT 1 ACTION TAKEN: The spa room near the activities center was deep cleaned and the area of the floor where there were missing tiles will be repaired by 5/26/2025. The floor in the clean linen room was cleaned. A solid surface shelf was installed on the bottom shelf of the clean linen cart in the clean linen room. The spa room at the end of the hall was deep cleaned including the padding of the plumbing pipe under the sink that was also sanitized. ELEMENT 2 IDENTIFICATION OF OTHER RESIDENTS: The facility will conduct a resident council meeting by 5/26/2025 where residents will have the opportunity to express any concerns related to their living environment. Any identified concerns will be addressed through the resident grievance process. ELEMENT 3 MEASURES TAKEN: All staff will receive reeducation by or prior to 5/26/2025 or the next day worked in the case of a leave of absence or vacationing employee related to the standards of providing a safe, functional, sanitary, and comfortable environment to ensure satisfaction of the living environment is maintained for residents, staff, and visitors. ELEMENT 4 MONITORING: The Nursing Home Administrator and or designee will conduct an audit through observation during rounds in the facility 3-5 times a week for four weeks, and periodically thereafter. The observations will be of various areas and rooms throughout the facility to ensure a safe, functional, sanitary, and comfortable living environment is maintained. Examples of locations to audit are shower rooms, resident rooms, storage rooms, linen closets, dining rooms, etc. A summary report of the findings will be provided to the QAPI Program/Committee for review. The Administrator will assume responsibility for attained and sustained compliance.
Failure to Supervise and Assist Cognitively Impaired Resident During Meals
Penalty
Summary
An 84-year-old resident with severe cognitive impairment, vascular dementia with behavioral disturbance, affective mood disorder, insomnia, and dysphagia was observed during multiple lunch periods to be left unsupervised while eating. The resident, who was on a pureed diet with regular liquids and had a history of pocketing food, was provided with a single bowl of mechanically altered food and a plastic spoon, but no beverage was initially given. Staff were not present in the immediate area to monitor or assist the resident, despite her difficulties with self-feeding, including being unable to use the spoon effectively, resorting to eating with her fingers, and accumulating food on her hands, clothing, and the table. The resident was also observed chewing the same bite of food for extended periods, with staff only intervening after concerns were raised about food pocketing and lack of fluids. Documentation indicated that the resident required only setup or clean-up assistance for eating, but direct observation showed significant challenges with self-feeding and a lack of timely staff intervention. The care plan and dietary orders were not effectively implemented, as the resident was not consistently provided with beverages and was not adequately monitored for safe eating practices, despite known risks such as food pocketing. Additionally, there was a discrepancy in care conference documentation, with staff reporting that a care conference with the resident's son had not occurred as documented, raising concerns about care coordination and communication.
Sprinkler System Maintenance Deficiency Due to Missing Ceiling Tile
Penalty
Summary
A deficiency was identified when a ceiling tile was found missing from the drop ceiling grid in Terrace Hall above the door entering the dining area. This observation was made during a facility inspection and confirmed by interview with the Maintenance Director. The missing ceiling tile compromised the maintenance and testing requirements for the automatic sprinkler system as outlined by NFPA 25, specifically impacting the system's ability to function as intended due to the absence of a heat collector in that area. The report documents that the facility failed to ensure the sprinkler system was maintained in accordance with required standards, as evidenced by this physical deficiency.
Plan Of Correction
Element #1 The ceiling tile missing from the drop ceiling grid located on Terrace Hall above the door entering the dining room was replaced. Element #2 The ceiling tile missing from the drop ceiling grid located on Terrace Hall above the door entering the dining room was replaced. A facility-wide audit was conducted to identify and replace any additional missing drop ceiling tiles. Element #3 The EVS manager and/or designee will audit twice weekly to validate there are no missing drop ceiling tiles. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee monthly, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Missing Delayed Egress Signage on Exit Doors
Penalty
Summary
A deficiency was identified when surveyors observed that the delayed egress double doors located at the south end of the facility did not have the required 15-second delayed egress sign. This observation was made during a walkthrough and was confirmed through an interview with the facility Maintenance Director at the time of the observation. The lack of proper signage on the delayed egress doors means that the doors were not in compliance with the requirements for special locking arrangements as outlined in the applicable codes. The report specifically notes that the door was not identified as a delayed egress door, which is necessary for proper emergency exiting procedures. The deficiency could potentially affect 35 occupants in the area if emergency exiting is required.
Plan Of Correction
Element #1 Signage was added to the emergency egress door that indicates 15 second egress. Element #2 Signage was added to the emergency egress door that indicates 15 second egress. A facility-wide audit was conducted to validate all egress doors have appropriate signage. Element #3 The EVS facility manager will monitor egress doors twice weekly to assure signage remains. The EVS Manager will report findings of missing signage immediately to the Administrator. And will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee monthly, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Failure to Provide Fire Barrier Protection in Hazardous Area
Penalty
Summary
The facility failed to ensure that hazardous areas were protected by a fire barrier with a 1-hour fire resistance rating or an automatic fire extinguishing system as required. Specifically, a battery charger for a wheelchair was observed in use within a resident's room located in B hall. The battery was being recharged during night hours while the resident was present in the room. This practice was confirmed through an interview with the facility Maintenance Director at the time of observation. The deficiency was identified during an observation on April 29, 2025, at approximately 11:31 AM. The report notes that the area where the battery charging occurred did not meet the required fire safety standards, as the room was not separated by the necessary fire barrier or equipped with an automatic fire extinguishing system. The finding was based on direct observation and staff interview, with no mention of corrective actions or follow-up steps included in the report.
Plan Of Correction
Element #1 The power chair battery charger for room 10 was removed from the resident room and relocated to a non-resident care area for overnight charging. Element #2 The power chair battery charger for room 10 was removed from the resident room and relocated to a non-resident care area for overnight charging. A facility-wide audit was conducted to identify additional power wheelchairs that would require charging in the facility. All staff will be re-educated on the requirement for power chairs to be charged in non-resident care areas by 5/26/25 or prior to their next day worked in the case of the leave of absence or vacationing employee. Element #3 The EVS manager and/or designee will audit twice weekly to validate power chairs are being charged in the designated, non-resident care areas. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee monthly, times one, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Noncompliance with Smoking Policy by Facility Staff
Penalty
Summary
Facility staff failed to adhere to established smoking regulations as required by 19.7.4. During an observation, two employees were seen smoking outside on the campus grounds at a picnic table near the building, which was not in accordance with the facility's smoking policy that only permits smoking inside personal vehicles. This noncompliance was confirmed through a review of the facility's smoking policy and an interview with the Maintenance Director at the time of the observation. The deficiency was identified as potentially affecting 26 occupants in the event of a fire, as the required smoking regulations were not fully implemented or enforced.
Plan Of Correction
Element #1 The facility smoking policy was reviewed and acknowledges the facility will not provide a designated outdoor smoking area on facility property. Staff are permitted to smoke in their vehicle. Element #2 All staff will be re-educated on the smoke free facility policy and procedures by 5/26/25 or prior to their next day worked in the case of the leave of absence or vacationing employee. Element #3 The EVS manager and/or designee will audit four to six times weekly to validate staff adherence to the smoke free facility policy and smoking only off premises or in their personal vehicles. The EVS facility manager will report recommendations and audit findings to the Quality Assurance Performance Improvement Committee Monthly times one, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Failure to Notify and Document Involuntary Discharge
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the local Ombudsman about a facility-initiated discharge. The resident, a male with a history of dementia, bipolar disorder, and other mental health issues, was sent to a hospital following an incident where he exhibited aggressive behavior towards staff. Despite the transfer, the facility did not provide the necessary discharge paperwork to the resident or his guardian, nor did they inform the Ombudsman as required by their policy. The Nursing Home Administrator and Director of Nursing admitted during interviews that they did not complete the necessary transfer paperwork for the resident. They confirmed that they informed the resident's guardian via telephone that the resident was sent to the hospital and would not be allowed to return to the facility. This lack of documentation and formal notification resulted in the resident remaining in the hospital for an extended period without a clear plan for his return or alternative placement. The facility's failure to follow its own policies and procedures for involuntary discharges was further highlighted by the local Ombudsman, who was unaware of the resident's situation. The Ombudsman noted that the facility did not check the appropriate boxes on the discharge forms to indicate whether the resident would return, nor did they send the required monthly discharge list to the state. This oversight contributed to the resident's prolonged hospital stay and lack of placement options.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, a male with dementia, bipolar disorder, and other mental health issues, was sent to the hospital due to aggressive behavior, including hitting staff. Despite the resident's guardian being informed of the transfer, the facility did not complete or provide any discharge paperwork, nor did they initiate involuntary discharge procedures. This resulted in the resident being involuntarily discharged without a home to return to, as the facility refused to readmit him. The incident involved a series of actions and inactions by the facility's staff and administration. After the resident exhibited aggressive behavior, the facility's administration, including the Nursing Home Administrator and Director of Nursing, decided not to allow the resident to return. They communicated this decision to the hospital but failed to provide the necessary documentation or follow proper discharge procedures. The resident's guardian was informed via phone, but no formal paperwork was completed, leaving the resident in the hospital for an extended period without placement options.
Medication Cart Security Breach
Penalty
Summary
The facility failed to secure one of its medication carts, specifically the Harbor Medication Cart, which was observed to be left unlocked and unattended in a hallway outside a resident's room. This observation was made on the morning of October 22, 2024, at 07:55 AM. The cart's lock was visibly in the unlocked position, indicated by a red/orange dot, and there were no staff members within visual range of the cart, although residents were present in the hallway. This situation resulted in the controlled substances stored in the cart being secured by only a single lock, contrary to the requirement for a double lock system for controlled substances. During the incident, an Agency Registered Nurse (RN) returned to the cart and acknowledged the oversight, explaining that she was assisting with medication administration due to the oncoming nurse's delay. Interviews with other nursing staff, including a Licensed Practical Nurse (LPN) and another RN, confirmed that it is standard practice to lock medication carts when unattended, except in emergencies. The Director of Nursing also affirmed that nurses are expected to lock their carts when leaving them. The facility's policies on medication storage and controlled medication security, revised in 2021 and 2016 respectively, were reviewed and confirmed the requirement for medication carts to be locked or attended by authorized personnel, and for controlled substances to be stored under double lock.
Failure to Safeguard Resident Medical Records
Penalty
Summary
The facility failed to safeguard the confidentiality of medical records for one resident, resulting in the potential for unauthorized access to personal health information. During an observation, a computer screen on the Harbor Medication Cart was left open, displaying the resident's electronic Medication Administration Record (e-MAR) with personal and health identifying information visible to passersby. No staff were present near the medication cart at the time, and an Agency RN later returned, acknowledging the oversight and explaining that she was assisting due to a staffing delay. Interviews with staff revealed inconsistent practices in securing computer screens. An LPN mentioned that she allows her computer to go to sleep when away from the cart, but acknowledged that this does not effectively hide the information if the cart is disturbed. Another RN described using a method to hide the screen, which displays a message if the mouse is moved, to protect resident privacy. The DON confirmed that nurses are expected to hide their screens when leaving the medication carts. The facility's HIPAA policy requires closing computer programs before leaving computers, indicating a failure to adhere to this policy in practice.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident #4, who was admitted with dementia and major depressive disorder, exhibited wandering and exit-seeking behaviors. Despite being on Zyprexa for depression, the medication was abruptly discontinued without proper documentation or rationale, leading to increased agitation and combative behaviors. The facility did not update Resident #4's care plan to address these changes, nor did they implement new interventions to manage his behaviors effectively. Resident #4's behaviors escalated, including physical aggression towards staff and other residents. He was observed wandering into other residents' rooms, becoming combative when redirected, and even physically assaulting a staff member. Despite these incidents, the facility did not conduct a comprehensive assessment or medication review, nor did they increase supervision or update the care plan to protect other residents. The facility's failure to address Resident #4's escalating behaviors and provide adequate supervision resulted in Resident #5 being physically assaulted by Resident #4. The facility's investigation into the incident revealed that Resident #5 had been punched by Resident #4, resulting in bruising. However, due to insufficient staff supervision and lack of reliable witnesses, the facility could not verify the incident. The facility's policy on abuse prevention was not adequately followed, as there was no increased supervision or updated care plans for behaviorally challenged residents. The facility's inaction and lack of documentation contributed to the deficiency in protecting residents from abuse.
Resident Left Unsupervised Outside for Hours
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in the resident being left unsupervised outside. The resident, who was severely cognitively impaired with a BIMS score of 6, was left outside the facility waiting for a day center bus that never picked her up. The resident was outside for approximately three hours without supervision, during which time she reported feeling hot and her scalp was warm. The resident's care plan indicated that outdoor independence was not recommended due to her cognitive and physical impairments. On the day of the incident, the resident was wheeled outside by a staff member who observed the day center bus pull into the parking lot. However, the staff member did not verify that the resident was successfully picked up before leaving for a meeting. Multiple staff members observed the resident outside but did not assess her needs or offer assistance to bring her back inside. The resident did not have access to a call light or a personal cell phone to request help, and she was not vocal about needing assistance. The incident was not reported or investigated until nine days later when the day center notified the facility after a grievance was filed by the resident's responsible party. The facility's investigation revealed that the resident was visible to staff during the time she was outside, but there was no documentation of any staff assessing her needs or offering assistance. The facility lacked policies for transportation and resident handoff, and staff education on these processes was initiated following the incident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in significant injuries. Resident #2, who was severely cognitively impaired, was pushed by Resident #1, leading to a fall that caused fractures to her right radius and femoral neck. The incident occurred near the front lobby/dining room area when Resident #1, who was mildly cognitively impaired and had a history of aggressive behavior, pushed Resident #2 because she was in his way. Prior to the incident, Resident #1 exhibited increasing aggressive behaviors, including verbal aggression towards staff and other residents. Despite these warning signs, the facility did not effectively manage or mitigate the risk posed by Resident #1's behavior. On the day of the incident, Resident #1 was observed to be agitated and aggressive, and he admitted to pushing Resident #2 because he wanted to leave the facility. Following the incident, Resident #2 was assessed and found to have sustained significant injuries, requiring hospitalization. The facility's failure to adequately address Resident #1's escalating behaviors and protect Resident #2 from harm constitutes a deficiency in ensuring resident safety and preventing abuse.
Failure to Properly Assess, Monitor, and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, monitor, and treat pressure ulcers for three residents, resulting in significant deterioration of their conditions. Resident R48, who was admitted with multiple pressure ulcers, expressed concerns about her wounds and lack of communication from staff. Observations revealed that R48 was not repositioned adequately, and there were no positioning devices in her room. The Director of Nursing (DON) could not locate complete documentation of R48's wound sizes or stages on admission, and there was no clear plan for pressure relief or follow-up care, leading to the worsening of her wounds over time. Resident R23, admitted with a stage 2 pressure sore and other significant health issues, experienced a progression of his wounds due to inconsistent wound care and failure to implement recommended treatments. The facility did not document several dressing changes, and the recommended pressure-relieving boots were not provided in a timely manner. The DON admitted to stopping the use of the boots without proper documentation or rationale, and the wounds worsened significantly as a result. Resident R37, who had bilateral below-knee amputations and other serious health conditions, developed new unstageable pressure ulcers on his back and right thigh. Despite the resident's complaints of foul odor and lack of dressing changes, the facility failed to initiate treatment orders or a short-term care plan promptly. The wounds were not thoroughly assessed, and there was a lack of proper documentation and follow-up care, leading to the deterioration of the resident's condition.
Failure to Follow Standards of Care and Incomplete Assessments
Penalty
Summary
The facility failed to follow standards of care for five residents, leading to several deficiencies. One resident, who had chronic kidney disease and muscle weakness, complained of swollen ankles for 2-3 weeks without receiving an assessment or evaluation from her physician. Despite notifying the Nursing Home Administrator (NHA) multiple times, there was no documentation indicating that the facility addressed her concerns until the surveyor intervened. Another resident, who had idiopathic aseptic necrosis of the toes, reported that his daily dressing changes were not being performed as ordered. The Treatment Administration Record (TAR) showed multiple instances where the wound care treatments were not documented as completed, and the facility failed to provide assurance that the treatments were being administered as prescribed. Additionally, a resident with diabetes mellitus potentially experienced a serious medication error when an LPN signed out insulin that was reportedly administered by the night shift nurse, contrary to facility practice. The Director of Nursing (DON) confirmed that this practice was inconsistent with the facility's procedures. The facility also failed to complete neurological assessments for two residents after falls. One resident, who had metabolic encephalopathy and unsteadiness, experienced an unwitnessed fall, and the neurological assessments were missing documentation at several intervals. When the resident had another fall, the assessments were not restarted as required. Another resident, who had heart failure and dementia, had neurological assessments initiated after a fall, but the assessments were abruptly stopped and not completed. The facility's policy required continuous monitoring following unusual occurrences, but this was not adhered to in both cases. These deficiencies highlight significant lapses in the facility's adherence to care standards, including failure to address medical concerns promptly, incomplete wound care treatments, improper medication administration practices, and inadequate post-fall neurological assessments. These actions and inactions directly contributed to the deficiencies identified by the surveyors.
Failure to Honor Resident's Room Choice
Penalty
Summary
The facility failed to honor the resident's choice, resulting in feelings of frustration and distress for a resident. The resident, who has multiple diagnoses including Chronic Obstructive Pulmonary Disease, muscle weakness, and is on hospice, was moved from her room of three years to another room following an incident with her roommate. The resident expressed a strong desire to return to her original room, but staff did not accommodate her request, citing concerns about potential future roommates. The resident's responsible party also communicated the resident's preference to the social worker, but the resident remained in the new room against her wishes. Interviews with the resident, her responsible party, and staff revealed that the resident was initially agreeable to the temporary room change but later expressed a clear preference to return to her original room. Despite this, the facility did not facilitate the move back, leading to the resident feeling that she had to stay in the new room to avoid further trouble. The resident's belongings were still in the original room, and she expressed concerns about the potential for having a worse roommate if she returned. The facility's actions did not support the resident's right to self-determination and choice, as required by regulations.
Failure to Notify Responsible Parties After Resident Falls
Penalty
Summary
The facility failed to notify the responsible party after resident falls for two residents, resulting in the physician and family/guardian not being informed of changes in the residents' conditions. Resident #135, who was moderately cognitively impaired, fell to the floor unwitnessed on 4/23/2024, and neither the physician nor the family was notified. This was confirmed by a Corporate Consultant who acknowledged that the notifications should have been made as per the facility's policy. The facility's policy requires prompt notification of the family and healthcare practitioner following a fall with potential for injury, which was not adhered to in this case. Resident #58, who was severely cognitively impaired but independent for ambulation, was observed with extensive facial bruising on 5/13/2024. The Electronic Medical Record revealed that new bruising was noted on 5/10/2024, but the medical provider and responsible party were not notified until three days later. This delay in notification was confirmed by the Director of Nursing and Corporate Consultant, who acknowledged that the nurse did not complete the notifications as expected. The facility's policy mandates prompt notification of the medical provider and responsible party in such cases, which was not followed, leading to a delay in medical intervention and care.
Failure to Report Resident-to-Resident Incident
Penalty
Summary
The facility failed to implement policies and procedures for reporting a resident-to-resident incident involving two residents, R7 and R26. R26, who has multiple diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, and Phantom Limb Syndrome, reported that R7 threatened and yelled at her in the dining room. Despite R26 informing the staff multiple times about the threats, no action was taken, and no incident was documented in R26's Electronic Medical Record (EMR) between 5/09 and 5/14/24. The facility's policy requires thorough investigation and proper reporting of any suspected abuse, neglect, or mistreatment, which was not followed in this case. R26's Responsible Party (RP) also reported that R7 was vaping in their shared room, which exacerbated R26's health issues. The RP's complaint highlighted that R7 frequently yelled at R26 and disrupted her sleep. The facility's response to the RP's complaint did not address the vaping or the verbal abuse adequately. During an interview, the NHA confirmed witnessing the incident in the dining room but did not document it in R26's record. The NHA admitted that a note should have been documented and that the residents were separated after the incident. R7, who has diagnoses including Post-Polio Syndrome, Bipolar Disorder, and Alcohol Abuse, was noted in her EMR to have been aggressive towards R26, causing R26 to cry. R7's behavior included yelling, throwing items, and being under the influence of substances. Despite these observations, the incident was not properly documented or reported in R26's records. The facility's failure to document and report the incident as per their policy resulted in a deficiency in ensuring the safety and well-being of the residents involved.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for two residents, resulting in significant oversights in their care. Resident #136, who was admitted with diagnoses including heart failure, difficulty walking, and dementia, experienced a fall on 3/15/2024. Despite the incident, no updates were made to the resident's care plan to address the increased risk of falls. Interviews with various staff members, including a corporate consultant, RN, and the Director of Nursing, confirmed that the care plan should have been updated immediately following the fall, but no such revisions were found in the resident's records. Similarly, Resident #23, who was admitted with a stage 2 pressure sore and at risk for developing additional pressure sores, did not have their care plan updated despite the development and worsening of multiple wounds. The resident's skin assessments and physician assistant documentation revealed the progression of existing wounds and the emergence of new ones, yet the comprehensive care plan remained unchanged. The short-term care plan for wound and skin issues was also not updated in a timely manner, further indicating a failure to appropriately revise the care plan in response to the resident's deteriorating condition.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide a resident with scheduled showers, resulting in the resident experiencing frustration. The resident, a [AGE] year-old male with diagnoses including difficulty in walking, muscle weakness, and a need for assistance with personal care, was scheduled to receive showers every Wednesday and Saturday evening. On 5/11/24, the resident did not receive his scheduled shower as staff claimed they did not have time, and the same occurred on 5/12/24 despite staff promising to provide the shower. The resident expressed his frustration to the Unit Manager, who acknowledged that staff are supposed to report and document any refusals of showers. However, there was no documentation in the progress notes indicating that the resident refused a shower on 5/11/24.
Failure to Prevent Elopement and Complete Post-Fall Assessments
Penalty
Summary
The facility failed to prevent an elopement for a resident with severe cognitive impairments, resulting in the resident leaving the facility unnoticed by staff. The resident, who had a high risk of wandering, was found outside the facility in a stranger's car. The incident occurred because a staff member deactivated the exit alarm without ensuring the door was secured, allowing the resident to exit unnoticed. The resident was outside for over an hour before being found and returned to the facility, during which time he sustained minor injuries. Additionally, the facility failed to complete post-fall assessments for another resident who was found with extensive facial bruising. The resident, who was severely cognitively impaired, had an unwitnessed fall, and the initial assessment did not include a neurological evaluation or a fall assessment. The incident was not documented properly, and the medical provider and responsible party were not notified until three days later. The delay in initiating the required assessments and notifications indicated a failure in shift-to-shift reporting and adherence to facility policies. The deficiencies highlight significant lapses in the facility's supervision and response protocols, particularly in monitoring residents with cognitive impairments and ensuring timely and appropriate post-fall assessments. These failures could have led to serious physical outcomes for the residents involved.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to follow physician orders for the care and management of a resident's suprapubic catheter. The resident, who was cognitively intact and had a history of bilateral below the knee amputations, traumatic brain injury, heart failure, and neuromuscular dysfunction of the bladder, reported that staff were not changing his dressings as required. During an observation, an LPN was seen using a partially open pack of gauze moistened with Normal Saline instead of cleansing the area with soap and water as per the physician's orders. The Treatment Administration Record (TAR) indicated that the catheter site should be cleansed with soap and water and covered with a drain sponge every evening shift, but this was not consistently documented as done on several days in April and May 2024. Additionally, the TAR showed that the catheter drainage bag was not emptied and recorded every shift as required, with multiple instances of missing documentation in April 2024. Furthermore, the order to irrigate the catheter with Acetic Acid Irrigation Solution was not marked as completed on several AM shifts in April and May 2024, with no corresponding progress notes explaining the omissions. The resident also reported a foul odor coming from the catheter site, indicating potential issues with infection control. The lack of adherence to the prescribed catheter care regimen, including the failure to cleanse the site with soap and water, change dressings, empty the drainage bag, and irrigate the catheter as ordered, highlights significant lapses in the facility's catheter care and management practices. These deficiencies were observed and documented by surveyors, confirming the facility's failure to provide appropriate catheter care for the resident.
Failure to Provide Palatable Food
Penalty
Summary
The facility failed to provide palatable food for a resident, resulting in the potential for poor nutrition and poor wound healing. The resident, a [AGE] year-old female with multiple diagnoses including pressure ulcers, diabetes mellitus, and lymphedema, expressed concerns about receiving cold food. Despite informing staff, the resident reported that they did not have time to reheat her food, leading her to leave meals uneaten. The Dietary Manager acknowledged the complaint and had completed a resident concern form but had not followed up with the resident. The issue remained unresolved as staff continued to neglect reheating the resident's food upon request.
Failure to Ensure Follow-Up and Assistance with Prosthetic Leg
Penalty
Summary
The facility failed to ensure that a resident with a left above-the-knee amputation received necessary follow-up appointments and adjustments for his prosthetic leg, resulting in pain and frustration. The resident expressed that the prosthetic leg caused discomfort and that he stopped using it because it hurt. Despite the resident's complaints and the physical therapy plan indicating the need for adjustments and staff assistance, there was no evidence that the facility staff were trained to assist the resident with the prosthetic leg or that the resident's guardian was involved in the therapy plan of care. The resident's therapy was discontinued at his request without any documented reason or involvement of his guardian to advocate for him. The Director of Nursing (DON) acknowledged that the resident had a follow-up appointment scheduled for adjustments, but the facility failed to provide transportation for the appointment. The DON attempted to reschedule the appointment but did not provide any additional information on whether the resident should continue using the prosthetic leg or receive further adjustments. The resident's legal guardian was not aware of the ongoing issues with the prosthetic leg and expressed willingness to assist the facility in addressing the resident's needs. The lack of follow-up and staff training led to the resident's pain and frustration with the use of his prosthetic leg.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in the potential for providers not having an accurate and complete picture of the residents' stay. For Resident 137, the facility's investigative documentation for an incident on 2/8/24 revealed that a CNA found Resident 137 with an open area on his eyebrow after an altercation with another resident. However, the incident was not documented in Resident 137's medical record, and the progress notes did not mention the possible cause of the laceration. Additionally, the Skin Assessment form did not indicate the reason for the assessment, whether it was routine or post-incident. Interviews with LPNs and the NHA confirmed that all incidents should be documented in the resident's medical record, but this was not done in this case. For Resident 5, the facility failed to document concerns raised by the resident about rough transfers and being molested by another resident. Despite the resident's complaints and a facility-reported incident on 5/13/24, there were no progress notes documenting these concerns on that date. The progress notes for 5/14/24 mentioned multiple concerns that met criteria for reporting to the State Agency but did not specify the actual concerns. This lack of documentation could lead to a failure in addressing the resident's safety and well-being. For Resident 26, the facility did not document an incident where the resident's roommate threatened and yelled at her in the dining room. The resident was relocated to another room for the night, but there was no documentation of the incident in the resident's Electronic Medical Record (EMR) between 5/09 and 5/14/24. Interviews with the resident, her responsible party, and the NHA confirmed the incident occurred, but it was not documented as required. This failure to document incidents accurately and completely could compromise the resident's safety and care.
Failure to Maintain Clean Medical Equipment at Bedside
Penalty
Summary
The facility failed to maintain clean and sanitary medical equipment at the bedside for one resident, resulting in the potential use of an unsanitary medical device. The resident, who has a feeding tube and receives 26 to 50% of their total calories through it, was found with a graduated vessel and a large syringe on the nightstand next to their bed. The vessel, dated 3/30/24, contained a sticky substance, and the undated syringe had an off-white substance in the barrel and tip, indicating it had not been cleaned after the last use. Despite acknowledging that the unclean medical equipment should have been discarded, the Director of Nursing did not remove these items, and they remained at the bedside during subsequent observations on 5/14/23 and 5/16/24.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) completed specialized training in infection prevention and control before assuming the role. According to the Centers for Medicare and Medicaid Services (CMS) Infection Prevention, Control & Immunizations pathway, the IP is required to complete this training prior to taking on the responsibilities. During an interview, the Director of Nursing (DON) confirmed that there was no employee with the required specialized training. The current IP, a Registered Nurse (RN) Unit Manager, had taken over the role a few months ago and was still in the process of completing her IP certificate, having not yet taken the final test for certification.
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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