Lakeside Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling Heights, Michigan.
- Location
- 13990 Lakeside Circle, Sterling Heights, Michigan 48313
- CMS Provider Number
- 235719
- Inspections on file
- 37
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 44
Citation history
Health deficiencies cited at Lakeside Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cerebral infarction, lymphedema, and polyarthritis, who had a physician order for transfers using a mechanical lift with 2-person assist, was initially moved from bed to wheelchair with the lift. After repositioning in the wheelchair caused the sling to slip out of place, two CNAs were unable to use the sling for the return transfer and instead manually transferred the resident by lifting and attempting to stand them, contrary to the ordered transfer method. The resident reported experiencing pain during this manual transfer and later informed the DON, who acknowledged that the CNAs were expected to follow the resident’s plan of care. A requested transfer policy was not provided to surveyors.
A resident with intact cognition and a history of Schizoaffective Disorder and Alzheimer's repeatedly reported discomfort and inadequate coverage due to being provided with incontinence briefs that were too small. Despite informing staff and the availability of larger briefs in the facility, the resident's preference was not honored, resulting in ongoing discomfort and improper fit. The DON acknowledged the issue and the presence of bariatric briefs, but the resident continued to receive briefs that did not meet their needs.
The facility failed to administer Heparin as ordered for a resident, did not follow hospital discharge instructions for catheter removal and bladder scans for another, and did not complete required vital sign monitoring for a third resident. These deficiencies were due to medication unavailability, overlooked discharge orders, broken equipment, and incorrect order entry in the electronic medical record.
A facility failed to prevent verbal abuse by a CNA towards a resident, leading to feelings of disrespect. The incident began when the CNA insisted on giving the resident a shower despite their refusal, escalating into a verbal altercation with threatening language. The resident, with a traumatic brain injury and multiple fractures, felt disrespected by comments related to their wheelchair use. The CNA resigned after the incident was reported to the administrator.
A facility failed to monitor and timely initiate treatment orders for a new wound on a resident's left baby toe, identified by an LPN. Despite documentation of the wound, no physician or medical staff was contacted for treatment orders, and the resident's MAR and TAR lacked documentation for the wound's treatment. The care plan did not address the new wound, and the Nurse Practitioner did not assess it until eight days later. The Director of Nursing confirmed the nurse should have entered the order into the record, but it was not added, resulting in potential wound deterioration.
The facility failed to maintain comfortable room temperatures, with two resident rooms recorded at 65 and 66 degrees Fahrenheit, leading to resident complaints of cold conditions. The Maintenance Supervisor was unsure of the standard for comfortable temperatures, and the Administrator acknowledged issues with heating units in the area. Facility policy requires temperatures between 71 and 81 degrees Fahrenheit.
The facility failed to provide bed hold policy notifications to three residents during hospital transfers, as required. Interviews and record reviews revealed that the responsibility for issuing these notices was unclear among staff, and the Social Service Director could not locate the necessary documentation. The residents involved had various medical conditions, and one reported not receiving a notice during an emergency transfer.
A resident with multiple medical conditions refused all medications and vital sign checks since readmission, but the facility failed to notify the physician or document these refusals as required by policy. The resident had not had vital signs recorded since August, and the attending physician was unaware of the refusals, indicating a lapse in communication and adherence to care standards.
A resident with moderately impaired cognition was sexually abused by another resident with a history of inappropriate behavior. Despite previous incidents and redirection by staff, the facility did not implement sufficient protective measures, such as separating the residents or providing continuous monitoring, to prevent the abuse.
The facility failed to maintain the carpet in a clean, sanitary, and safe condition, affecting all 58 residents. Observations showed stained, worn, and buckled carpet, with missing spots. Housekeeping staff indicated the need for deep cleaning and replacement, but lacked a floor technician. Residents expressed concerns about the carpet's dangerous condition, with one almost tripping. The DON acknowledged the issue, having tripped on the carpet themselves.
The facility has been without a full-time Activities Director for months, affecting all 58 residents. A resident and an Activities Aide confirmed the lack of activities, especially on weekends. The Regional Nursing Home Administrator acknowledged the absence and mentioned a new hire is expected soon. The facility's policy on activities did not include the role of an Activities Director.
The facility failed to maintain RN coverage for at least 8 consecutive hours daily, as required. Staff postings showed multiple dates without RN coverage, confirmed by interviews with the scheduler and DON. The facility's staffing policy did not address RN coverage requirements.
The facility failed to post and maintain required nurse staffing information, affecting all 58 residents. During a survey, it was found that the facility did not have complete staff posting data for RNs and CNAs. Interviews with staff confirmed the absence of required postings, and the Director of Nursing was unaware of the missing logs. The facility's policy required daily posting of staffing information, but they failed to comply with this requirement.
The facility did not provide adequate meal portion sizes to meet residents' nutritional needs. The Dietary Supervisor served a small piece of baked chicken, estimated at 2 ounces, instead of the required 4 ounces. The RD confirmed the portion was insufficient, and residents reported feeling that the food portions were too small.
A facility failed to serve food at the preferred temperature, leading to dissatisfaction among residents. A resident reported the food was cold and unappealing, and observations showed staff serving meals with food cart doors open. A Registered Dietician confirmed the food was below the preferred temperature, and the facility's policy on serving hot foods was not followed.
The facility failed to serve meals on time, leading to resident dissatisfaction. Breakfast and lunch were served significantly later than the scheduled times due to insufficient kitchen staffing. Residents complained about hunger and the consistent lateness of meals.
A survey revealed multiple sanitation and food safety deficiencies in the kitchen of an LTC facility. Observations included a soiled trash can, improper thawing of pork chops, undated food items, and unsanitary conditions such as grime buildup and a mold-like substance in the ice machine. Additionally, the dish machine's temperature log was not maintained, and equipment like the ventilation hood lights and garbage grinder were non-functional.
The facility failed to manage its operations effectively, leading to deficiencies in maintaining a safe environment and equipment. The carpet in hallways remained stained and unsafe, and there was a lack of documentation and awareness regarding the mechanical lift's repair status. The Nursing Home Administrator was unavailable, leaving no documentation on these issues, and no Quality Assurance activities were documented to address them.
The facility failed to implement an active water management plan, lacking team member lists and water flow diagrams, and did not conduct required inspections. Additionally, staff did not consistently don and doff PPE for residents on enhanced barrier precautions, as observed in multiple instances. Interviews revealed a lack of awareness and adherence to infection control protocols, increasing the risk of infections.
The facility failed to respond promptly to call lights for four residents, resulting in significant delays in care. One resident waited over 13 minutes for pain medication, while another experienced prolonged waits in soiled conditions. A third resident reported waiting up to an hour and a half for hygiene assistance, and a fourth resident's call light was ignored for 30 minutes despite needing help with a mechanical lift. The facility lacked documentation on call light response times, and staff did not adhere to the policy requiring prompt response to call lights.
The facility failed to provide adequate activities for four residents, leading to dissatisfaction and boredom. One resident expressed having nothing to do but ride in circles in their wheelchair, while another wandered the facility seeking bird-watching opportunities. A third resident reported a lack of engagement in activities for months, and a fourth noted the absence of an activities director and weekend activities. The Activities Aide confirmed working alone during weekdays without weekend coverage, highlighting staffing and scheduling challenges.
The facility failed to provide a 14-day stop date for PRN antianxiety medications or adequate documentation to justify their use beyond 14 days for two residents. One resident with anxiety and rheumatoid arthritis had Alprazolam orders without a stop date, while another nonverbal resident with severe cognitive impairment had a Xanax order without a stop date. The facility's policy requiring a 14-day limit on PRN orders was not followed.
A facility failed to maintain essential equipment, leading to safety hazards and discomfort for residents. One resident was injured by a damaged wheelchair, while another faced issues with an unstable mechanical lift and ill-fitting wheelchair cushions. Additional maintenance oversights included a broken dresser and inadequate shower pressure, highlighting a lack of attention to resident needs and safety.
The facility failed to provide a mechanical lift for two residents, leading to unsafe conditions. One resident, with muscular dystrophy, was unable to get out of bed for days, requiring fire department assistance. Another resident, with cerebral infarction, faced manual lifting by staff, which was dangerous. Staff interviews revealed a lack of documentation and awareness about the lift's repair status.
A facility failed to report an abuse allegation involving a resident attempting to touch another resident inappropriately. The incident was observed by staff but was reported to the State Agency 14 days later due to the administrator's absence and the DON's uncertainty about the reporting process. Facility policy requires immediate reporting, but this was not followed.
The facility did not provide the necessary written transfer notification to a resident and the Ombudsman when a resident was transferred to an acute care hospital due to a worsening bruise that developed into a wound. The EMR lacked documentation of the transfer notification, and the facility's administrative staff could not produce the required documentation during the survey.
A resident with respiratory issues was observed with an oxygen concentrator running but the nasal cannula was on the floor, and no active physician's order or care plan for oxygen was documented. The resident had diagnoses including Acute Respiratory Failure and COPD, and their MDS assessment indicated moderately impaired cognition. The facility's policy requires a baseline care plan, which was not implemented.
A resident with encephalopathy and type 2 diabetes experienced multiple falls without updates to their fall care plan. Despite having moderately impaired cognition and requiring supervision for ADLs, the care plan's last intervention was dated months prior. Interviews with staff confirmed the lack of updates, which contradicted the facility's policy requiring care plan revisions after status changes.
A resident in an LTC facility did not receive consistent, scheduled showers as per their preference and facility policy. Despite requiring maximal assistance with bathing due to medical conditions, the resident only received four baths in a month, with no showers documented. The resident expressed frustration over the lack of personal cleanliness, and the DON acknowledged the difficulty in accommodating the resident's preferred shower time.
The facility failed to schedule follow-up appointments for a resident with a fracture and hip replacement, leading to missed chemotherapy treatments. Additionally, another resident with respiratory issues had no active physician orders for oxygen, despite being observed with an oxygen concentrator running and reporting difficulty breathing.
A resident with limited range of motion and mobility needs did not receive restorative services as per physician orders. Despite having a care plan for restorative therapy, there was no documentation of participation in the program. The resident, who was cognitively intact and experienced occasional pain, expressed a desire for exercise to maintain and improve mobility. The Director of Nursing was unaware of the issue, and the facility's policy on providing restorative programs was not followed.
The facility did not ensure a timely physician response to Pharmacist Medication Regimen Reviews (MRR) recommendations for a resident. Despite pharmacy progress notes indicating irregularities, the complete MRR and physician follow-up were unavailable. The DON suggested the MRRs might be in a binder, but they were not provided, and a policy for MRRs was not received before the survey ended.
Failure to Follow Ordered Mechanical Lift Transfer for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s ordered transfer method and provide safe transfer assistance. A cognitively intact resident with diagnoses including cerebral infarction, lymphedema, and polyarthritis was admitted on 9/4/25 and required staff assistance with ADLs. The resident had an active physician order dated 1/22/26 specifying transfers with a named mechanical lift and 2-person assist. On 3/23/26, two CNAs transferred the resident from bed to wheelchair using the mechanical lift. After the resident was in the wheelchair, they were readjusted, which caused the sling to slip too far up the resident’s back, making it unusable for the return transfer to bed according to the CNAs. When it was time to transfer the resident back to bed, instead of using the ordered mechanical lift, the two CNAs decided to perform a manual transfer. The resident reported that the CNAs, one on each side, lifted them from the wheelchair and attempted to stand them on their feet, which caused pain that the resident stated they communicated to the CNAs. One CNA stated they were unable to reposition and connect the sling due to the resident’s size and confirmed that a manual transfer was performed. The other CNA reported that the resident was informed of the manual transfer, appeared agreeable, and was able to bear some weight, and stated the resident did not complain of pain. The resident later reported the incident to the DON, who acknowledged that the CNAs should not have transferred the resident in that manner and that they were supposed to follow the plan of care. A transfer policy was requested from the facility during survey but was not provided by the end of the survey.
Failure to Honor Resident's Incontinence Brief Size Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's preference for incontinence brief size, despite repeated requests and clear evidence that the provided briefs were too small and uncomfortable. The resident, who had diagnoses of Schizoaffective Disorder and Alzheimer's but was cognitively intact, reported that the briefs did not cover the thigh or buttocks area, were too tight, and caused discomfort. The resident stated they had informed staff about the issue, but was told that the current size was all that was available. Observations confirmed that the briefs were stretched thin and did not fit properly, and the resident continued to be placed in briefs that were too small over several days. Further review of the facility's supply showed that larger briefs were available in the storage room, but the correct size was not provided to the resident. The Director of Nursing acknowledged the existence of bariatric briefs for larger residents and noted that shipments had been delayed, but staff had purchased appropriate sizes as needed. The resident's care plan documented the need for assistance with incontinence care, and the facility's admission contract guaranteed reasonable accommodation of resident needs and preferences. Despite this, the resident's preference for a larger brief was not honored, resulting in discomfort and inadequate care.
Failure to Follow Physician Orders for Medication, Catheter Care, and Vital Signs
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with a history of traumatic secondary hemorrhage, seroma, and high cholesterol, Heparin doses were missed on 18 occasions due to the medication being unavailable. Documentation showed that staff did not notify the physician of the missed anticoagulant doses, as required by facility policy. The resident reported that the facility frequently ran out of Heparin, and the Director of Nursing (DON) confirmed the missed doses and lack of physician notification. Another resident, admitted with urinary retention and nephritis, was re-admitted after a hospital stay for a urinary tract infection. Hospital discharge instructions required discontinuation of an indwelling catheter and a trial of voiding with bladder scans and specific documentation. These orders were not followed, as the catheter was not discontinued, bladder scans were not performed, and there was no documentation of the required procedures. The DON and a registered nurse acknowledged that the discharge orders were overlooked, and it was revealed that the facility's bladder scan machine had been broken for months. A third resident had physician orders for regular vital sign monitoring, which were not completed as required. The electronic medical record did not prompt staff to take vital signs due to incorrect order entry, and the last recorded vitals were from the resident's admission several months prior. Staff confirmed that vital signs were not taken as ordered, and the DON stated that vital signs should be completed per physician orders and on admission for baseline.
Failure to Prevent Verbal Abuse by CNA
Penalty
Summary
The facility failed to prevent verbal abuse by a staff member towards a resident, resulting in the resident feeling disrespected. The incident involved a verbal altercation between a Certified Nurse Assistant (CNA) and a resident, where the CNA insisted on giving the resident a shower despite the resident's refusal. The situation escalated when the CNA used threatening language, implying harm, which was witnessed by another staff member. The resident, who had a traumatic brain injury and multiple bone fractures, reported feeling disrespected by the CNA's comments, particularly those related to their use of a wheelchair. The incident was reported to the facility's administrator, who confirmed the details of the altercation and the threatening language used by the CNA. The CNA voluntarily resigned after suspecting termination. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury or intimidation, which includes verbal abuse. The report highlights the failure of the facility to protect the resident from verbal abuse, as required by their policy.
Failure to Timely Initiate Wound Care Orders
Penalty
Summary
The facility failed to monitor and timely initiate treatment orders for a new wound on a resident's left baby toe, which was identified on 01/07/2025. Despite the wound being noticed and documented by an LPN, there was no indication that the physician or medical staff was contacted for wound care treatment orders. The resident's Medication Administration Record (MAR) and Treatment Administration Records (TAR) did not show any documentation for treatment of the left baby toe or foot. The resident's care plan also did not address the new wound, and the Nurse Practitioner did not document an assessment of the left baby toe or foot until 01/15/2025, eight days after the wound was first identified. The Director of Nursing confirmed that the nurse should have entered the order into the record, but no order or treatment was added into the physician orders or onto the January MAR or TAR. The facility's policy requires accurate documentation of wound assessments and treatments, but this was not followed in this case. The lack of timely treatment and documentation resulted in the potential for wound deterioration, as the wound care orders were not initiated until after the resident was seen by the wound care Nurse Practitioner on 01/15/2025.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable room temperatures in two resident rooms, resulting in resident complaints of cold conditions. On the morning of January 21, 2025, the air temperature in one resident's room was measured at 66 degrees Fahrenheit, and the resident was observed in bed with a blanket pulled over his head. Another resident's room was measured at 65 degrees Fahrenheit, and the resident expressed feeling cold. A nearby vacant room was found to have a temperature of 48 degrees Fahrenheit. During an interview, the Maintenance Supervisor was uncertain about the facility's standard for comfortable ambient air temperature, initially suggesting anything under 60 degrees was too low, then reconsidering to under 70 degrees, but ultimately was unsure. The Administrator was unaware of the issues in one of the rooms but acknowledged that the other room was in an area with vacant rooms and broken heating units. The facility's policy stated that temperatures in common resident areas should be maintained between 71 and 81 degrees Fahrenheit.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a bed hold policy notification for three residents during their transfer to a hospital, as required by regulations. The deficiency was identified through interviews and record reviews, which revealed that the facility did not issue written notices specifying the duration of the bed-hold policy to the residents or their representatives. The Director of Nursing stated that the responsibility for bed holds lies with the Business Office and Social Work, while the Nursing Home Administrator indicated that nurses should provide the bed hold policy upon the resident's departure, or communicate it by phone the next day in emergency situations. However, the Social Service Director, who recently assumed the role of contacting families for bed holds, was unable to locate the bed hold notice for one of the residents. The residents involved in this deficiency included one with altered mental status and metabolic encephalopathy, another with muscular dystrophy, chronic kidney disease, and high blood pressure, and a third with diabetes and high blood pressure. The records showed that these residents were transferred to the hospital for various medical reasons, but there was no documentation of bed hold notifications being provided. One resident, who was transferred in an emergency, reported not receiving a bed hold notice. The facility's policy requires that a written notice be given at the time of transfer, but this was not adhered to, leading to the deficiency noted in the report.
Failure to Notify Physician of Resident's Refusal of Care
Penalty
Summary
The facility failed to notify the physician of a resident's refusal of vital signs and medication, which is a deficiency in meeting professional standards of quality. The resident, identified as R904, was observed in bed and appeared pleasant and conversant, with no signs of distress. R904 had a history of multiple medical conditions, including muscular dystrophy, chronic kidney disease, and diabetes mellitus, and was dependent on staff for various activities of daily living. Despite these needs, the facility did not record any vital signs for R904 since August 17, 2023, and failed to take vital signs upon the resident's readmission on September 3, 2024. The facility's records indicated that R904 had refused all medications since readmission and frequently refused care, medications, and treatments since July 8, 2023. The attending physician was not informed of these refusals, as evidenced by the lack of documentation in the physician's progress notes. The Director of Nursing confirmed that the facility's policy required documentation of refusals and physician notification, which was not adhered to in this case. The facility's policy on residents' rights regarding treatment and advance directives outlined specific documentation and notification procedures that were not followed, contributing to the deficiency.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident with moderately impaired cognition who was sexually abused by another resident with a history of inappropriate sexual behavior. The abusive resident had been observed attempting to touch other residents inappropriately on multiple occasions prior to the incident. Despite these observations, the facility did not implement sufficient protective measures to prevent the abuse from occurring. The facility's investigation revealed that the abusive resident had been redirected multiple times by staff for inappropriate behavior, including attempts to touch other residents and staff. However, the facility did not provide adequate evidence of protective interventions to prevent further incidents. The abusive resident's room was located directly across the hall from the victim's room, and the facility failed to take timely action to separate the two residents or provide continuous monitoring to ensure the victim's safety.
Facility Fails to Maintain Safe and Clean Carpet Conditions
Penalty
Summary
The facility failed to maintain the carpet throughout the building in a clean, sanitary, and safe condition, affecting all 58 residents. Observations revealed that the carpet on the 200 unit was stained, worn, and had missing spots next to the walls. Further inspection showed large stains and buckling in some areas. Interviews with housekeeping staff indicated that the carpet needed a deep clean and replacement, but there was no floor technician available, and the owner had been informed about the issue. The Maintenance Director confirmed the lack of staff to operate the carpet cleaning machine and mentioned that replacing the carpet would be costly. Residents expressed concerns about the carpet's condition, describing it as dangerous and dirty, with buckling and unraveling in several places. One resident reported almost tripping while using a walker. The Director of Nursing acknowledged the issue, having personally experienced tripping on the carpet. A review of the facility's policy on providing a safe and homelike environment highlighted the requirement to ensure a safe physical layout that does not pose a safety risk, which the current carpet condition failed to meet.
Absence of Full-Time Activities Director
Penalty
Summary
The facility failed to employ a full-time Activities Director, a deficiency that potentially affects all 58 residents. During an interview, a resident reported that the facility has been without an Activities Director for months, resulting in a lack of activities, especially on weekends. The Regional Nursing Home Administrator confirmed the absence of an Activities Director and mentioned that a new hire is expected to start soon. An Activities Aide, who has been working alone in the activities department, corroborated this information, stating they have been in the role for the past year, both part-time and full-time, after previously serving as a receptionist and a certified nursing aide. Additionally, the facility's policy on activities did not mention the role of an Activities Director.
Inadequate RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, which is a requirement for adequate coordination of care. This deficiency was identified through a review of daily staff postings, which revealed multiple dates across January, March, June, and July where RN coverage was not provided. Interviews with the scheduler and the Director of Nursing (DON) confirmed the inconsistency in RN coverage, particularly when the DON joined in March. The facility's policy on Nurse Staffing Posting Information did not address the requirement for RN coverage, contributing to the deficiency.
Failure to Post and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to record and post necessary staffing information as required by regulatory guidance, which had the potential to affect all 58 residents. During a survey, it was found that the facility did not have staff posting data showing the number and hours of the staff working, particularly for RNs and CNAs. The survey team requested staff postings for specific periods, but the facility was unable to provide complete records. The facility's policy required daily posting of nurse staffing information, including the facility name, current date, resident census, and the total number and hours worked by nursing staff per shift. However, the facility did not consistently track or maintain these records. Interviews with facility staff, including the Unit Manager and the Regional Nursing Home Administrator, confirmed the absence of required staff postings. The Director of Nursing, who started in March 2024, was unaware of the missing logs. The facility's policy stated that nurse staffing information should be readily available and maintained for a minimum of 18 months. Despite this, the facility failed to provide complete staffing records for the requested periods, indicating a lack of compliance with their own policy and regulatory requirements.
Inadequate Meal Portion Sizes
Penalty
Summary
The facility failed to provide residents with meal portion sizes that met their nutritional needs, specifically regarding protein intake. During an observation, the Dietary Supervisor was seen preparing lunch trays with a small piece of baked chicken, approximately 2 1/2 inches by 2 1/2 inches, which was estimated to weigh around 2 ounces. This portion size was confirmed by the Registered Dietitian (RD) to be insufficient, as the diet spreadsheet indicated that a 4-ounce portion was required for a regular diet. A group of residents also reported that they felt the food portions were too small, leading to inadequate food intake.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for one resident and a group of seven confidential residents, leading to dissatisfaction during meals. On multiple occasions, a resident expressed dissatisfaction with the food, stating it was cold and unappealing, which resulted in them not eating most of it. During an observation, staff were seen serving lunch trays to residents' rooms with the food cart doors left open, which likely contributed to the food being served at inadequate temperatures. A Registered Dietician (RD) checked the temperature of a random food tray and found the baked chicken, cooked mixed vegetables, and orzo pasta to be significantly below the preferred temperature of 165 degrees Fahrenheit. The RD acknowledged the temperature issue, although they noted the chicken tasted good. The surveyor also taste-tested the meal and found it to be lukewarm, negatively impacting the food's palatability. The facility's policy on food preparation, which emphasizes serving hot foods hot, was reviewed and found to be inconsistent with the observed practices.
Delayed Meal Service and Resident Dissatisfaction
Penalty
Summary
The facility failed to serve meals in a timely manner and in accordance with the scheduled mealtimes, leading to resident dissatisfaction. The documented meal times were breakfast from 7:30 am to 8:30 am and lunch from 11:30 am to 12:30 pm. However, on the morning of July 14, 2024, kitchen staff were observed preparing to start breakfast service at 9:15 am, and breakfast trays were still being delivered at 10:30 am. Dietary Aide K attributed the delay to insufficient staffing, with only one or two staff members available to manage meal preparation and delivery. Additionally, lunch trays were observed being delivered at 3:07 pm, well past the scheduled lunch time, prompting complaints from residents about hunger and late meals. A confidential group of residents confirmed that meals were consistently served late, not aligning with the facility's documented meal times.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. A trash can near the handwashing sink was found without a liner and heavily soiled with a mold-like substance. The handwashing sink near the ice machine contained food debris and lacked paper towels. Additionally, raw pork chops were improperly thawed in a sink with water, reaching unsafe temperatures, and were left unattended for an extended period. Several food items in the kitchen's walk-in cooler and reach-in refrigerator were opened and undated, violating food safety standards. The kitchen's physical environment was also found to be unsanitary. The flooring throughout the kitchen had a heavy buildup of grime and food debris, and the dry storage room had food debris under the racks. The ventilation cover above the clean dishware rack was soiled with dust. The dish machine's temperature log had not been updated since earlier in the month, and staff were unsure how to monitor the machine for adequate sanitation. The interior lights for the ventilation hood were non-functional, and the garbage grinder was broken and full of old food, attracting gnats. The ice machine in the pantry was observed with a black mold-like substance on the interior sides of the ice bin. The Facilities Director confirmed the presence of the mold-like substance and noted that the cleaning solution used did not reach the sides of the machine. These observations indicate a failure to adhere to the 2017 FDA Food Code, which outlines necessary cleaning and maintenance practices to prevent contamination and ensure food safety.
Deficiencies in Facility Maintenance and Equipment Management
Penalty
Summary
The facility failed to effectively manage its daily operations, resulting in deficiencies related to the maintenance of the facility's environment and equipment. Specifically, the facility did not address the unsafe condition of the carpet throughout the hallways, which remained stained despite cleaning efforts. The Housekeeping/Laundry Supervisor acknowledged the need for carpet replacement and indicated that the issue had been communicated to the owner. Additionally, the facility did not maintain or timely replace resident care equipment, as evidenced by the lack of documentation and awareness regarding the mechanical lift's repair status. The Maintenance Supervisor and Director of Nursing were unable to provide details or documentation about the lift's repairs or the duration it was unavailable. The Nursing Home Administrator, who was on vacation, left the facility without documentation or information regarding the mechanical lift repairs or carpet plans. During a Quality Assurance review meeting, it was found that there were no documented QA activities related to the worn carpet or mechanical lift repairs in the Quality Assurance Binder. The facility's policy on providing a safe and homelike environment was not adhered to, as the facility failed to ensure that residents could receive care and services safely due to these unresolved issues.
Deficiencies in Water Management and PPE Use
Penalty
Summary
The facility failed to implement an active water management plan to reduce the risk of Legionella and other opportunistic pathogens in its plumbing system. During the survey, it was found that the Water Management binder lacked a list of team members and a water flow diagram. The policy outlined daily, weekly, and quarterly inspections, but there was no evidence of these being conducted. The kitchen dish machine had a heavy buildup of lime scale, and the dish machine log had not been completed since early July. Interviews with the Maintenance Supervisor, Director of Nursing/Infection Preventionist, and Administrator revealed a lack of involvement and awareness regarding the water management program, and no evidence of testing was provided by the end of the survey. The facility also failed to ensure proper donning and doffing of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). For three residents, staff were observed not wearing the required PPE during care activities. One resident reported that staff only wore gloves when emptying a catheter bag, and another resident stated that staff never wore gowns, only gloves. Interviews with staff, including a CNA and an LPN, confirmed the absence of PPE outside the residents' rooms and a lack of adherence to PPE protocols. The Director of Nursing stated that staff were expected to wear PPE when providing care to residents on EBP. The facility's infection prevention and control program policy, reviewed and revised in March 2024, emphasized the need for staff education and competence in resident care procedures. However, observations and interviews indicated that staff did not consistently follow the established procedures for infection control, particularly in relation to the use of PPE for residents on EBP. This failure to adhere to infection control protocols increased the risk of communicable diseases and infections among residents.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to respond to call lights in a timely manner for four residents, leading to significant delays in care. Resident R50's call light was activated for over 13 minutes before being addressed, during which time they requested a pain pill. R50 reported that it sometimes takes 30 minutes to an hour for their call light to be answered. R49 expressed that it takes 20 to 30 minutes for their call light to be initially answered, and they have experienced waiting in soiled conditions for 2 to 3 hours. R49's call light logs were unavailable for review. Resident R24 reported waiting up to an hour and a half for their call light to be answered, particularly when needing assistance with hygiene. R24 described a pattern of staff turning off the call light without providing the needed help, causing frustration and distress. R24 was cognitively intact and able to accurately report the time they waited. The facility did not have call light logs available for R24, indicating a lack of documentation on response times. Resident R9's call light was activated for 30 minutes while a CNA was observed using their cell phone at the nurse's station. R9 required assistance with a mechanical lift to get out of bed and had informed staff of their need two hours prior. CNA E turned off R9's call light without providing assistance, stating they informed the assigned aide. The facility's policy requires all staff to respond to call lights, but this was not adhered to, resulting in prolonged wait times for residents.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide adequate activities to meet the needs of four residents, as observed during a survey. Resident 9 expressed dissatisfaction with the lack of activities, stating that there was nothing to do except ride in circles in their wheelchair. Resident 19 was observed wandering around the facility, expressing boredom and a desire to bird watch, but no activities were provided. Resident 20 reported that they used to be offered activities but had not been engaged in any for the past few months, relying on their family for leisure materials. Resident 32 mentioned the absence of an activities director and a lack of weekend activities, expressing a desire for off-site trips. The Activities Aide, working alone Monday through Friday, confirmed the lack of weekend coverage and the challenges in providing a comprehensive activities program. The facility's policy states that activities should support residents' choices based on their assessments, care plans, and preferences, aiming to enhance their physical, mental, and psychosocial well-being. However, the facility's current staffing and scheduling limitations have resulted in a failure to meet these standards, as evidenced by the lack of activity notes for the residents in question.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide a 14-day stop date for PRN antianxiety medications or adequate documentation to justify their use beyond 14 days for two residents. Resident 21, who was admitted with diagnoses of anxiety and rheumatoid arthritis, had physician orders for Alprazolam without a stop date. Despite having intact cognition, as indicated by a Brief Interview for Mental Status score of 15/15, the orders lacked the necessary stop date. Interviews with the Social Service Director and the Director of Nursing revealed that there was an expectation for all PRN anti-anxiety medications to have a 14-day stop date unless otherwise noted, but this was not implemented. Resident 44, who was nonverbal and had severely impaired cognition due to conditions such as encephalopathy, depression, and vascular dementia, also had a PRN order for Xanax without a stop date. The facility's policy on the use of psychotropic medications, which requires a 14-day limit on PRN orders unless justified by a physician, was not followed. Interviews with the Social Service Director and other staff indicated a lack of adherence to this policy, as there was no documentation justifying the continued use of the medication beyond the 14-day period.
Deficiencies in Equipment Maintenance and Resident Safety
Penalty
Summary
The facility failed to ensure that essential patient equipment was in safe operating condition, leading to potential hazards and discomfort for several residents. One resident was observed with blood seeping from a bandage on her arm, which was attributed to cracked and worn wheelchair armrests that exposed sharp plastic edges. Despite the resident's complaints to staff about the discomfort and injury caused by the wheelchair, the issue was not addressed until it was brought to the attention of the surveyor. Another resident experienced multiple issues with their power wheelchair and the facility's mechanical lift. The resident reported discomfort and improper seating due to an ill-fitting air cushion, which caused them to slide out of the wheelchair frequently. The mechanical lift used for transfers was described as unstable and worn, with chipped paint and a loose anchor post, raising concerns about its safety. Despite these issues being known to staff, including the unit manager and CNAs, no corrective actions were taken to address the equipment's condition. Additional deficiencies were noted in the facility's maintenance of resident rooms and equipment. One resident's dresser was in disrepair, with missing and collapsed drawers, which had been reported to maintenance staff months prior without resolution. Another resident faced issues with their room's shower pressure and was told to purchase their own clock batteries, as the facility did not provide them. These maintenance oversights contributed to an environment where residents' needs and safety were not adequately prioritized.
Failure to Provide Mechanical Lift for Residents
Penalty
Summary
The facility failed to ensure the availability of a total assistance mechanical lift for two residents, resulting in their inability to safely get in and out of bed as desired. Resident R2, who has muscular dystrophy and anxiety disorder, was unable to get out of bed for four consecutive days in June 2024 due to the facility's lift being out for repairs. The fire department was called to assist R2 back into bed when the lift was unavailable. Interviews with staff, including the Maintenance Supervisor and the Director of Nursing, revealed a lack of documentation and awareness regarding the lift's repair status and duration of unavailability. Resident R9, who has cerebral infarction, hypoxia, and morbid obesity, also experienced issues due to the lack of a functioning mechanical lift. R9 reported that approximately two weeks prior, the facility did not have a working lift, which prevented them from attending a family event. Staff attempted to manually lift R9, which was deemed dangerous by the resident. The facility's policy on providing a safe and homelike environment was not adhered to, as the residents could not receive care and services safely due to the lift's unavailability.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation in a timely manner to the State Agency (SA) for one resident involved in an incident. The incident involved a resident, R45, who was observed by staff attempting to touch another resident, R4, inappropriately on the chest. This incident occurred on June 11, 2024, but was not reported to the SA until June 25, 2024, which is 14 days after the incident took place. The Director of Nursing (DON) acknowledged during a phone interview that all abuse investigations should be reported to the Abuse Coordinator and the SA promptly. However, the incident was delayed in reporting because the administrator was on vacation, and the DON was unsure of the reporting process in their absence. The facility's policy mandates that such incidents should be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury. The failure to adhere to this policy resulted in the delayed reporting of the incident.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide the required written transfer notification to a resident and the Ombudsman when the resident was transferred to an acute care hospital. The deficiency was identified during an interview and record review, where the resident confirmed they were recently hospitalized due to a worsening bruise that developed into a wound. A review of the resident's census indicated hospitalization and subsequent return to the facility. However, the Electronic Medical Record (EMR) lacked documentation of the written transfer notification. Upon request, the facility's corporate administrative staff could not provide the written transfer notification or the Ombudsman monthly notification list by the time of the survey exit.
Failure to Implement Respiratory Care Plan for Resident
Penalty
Summary
The facility failed to implement a care plan for a resident requiring respiratory care. The resident, identified as R15, was observed on multiple occasions with an oxygen concentrator running, but the nasal cannula was found lying on the floor instead of being used by the resident. Despite the resident reporting difficulty breathing, there was no active physician's order for oxygen, and no care plan for oxygen or respiratory care was documented in the resident's medical record. R15 was admitted with diagnoses including Acute Respiratory Failure, Pneumonia, Adjustment Disorder with Anxiety, and Chronic Obstructive Pulmonary Disease. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition. During an interview, the MDS/Registered Nurse acknowledged that all orders should be transcribed and care plans written for each resident, but this was not done for R15. The facility's policy requires a baseline care plan to be developed and implemented for each resident, which was not adhered to in this case.
Failure to Update Fall Care Plan Interventions
Penalty
Summary
The facility failed to update the fall care plan interventions for a resident following multiple falls. The resident, who was observed with bruising on their forehead, reported a recent fall. A review of the resident's incidents and accidents from April to July revealed multiple falls, yet no new interventions were added to the care plan after these incidents. The last intervention on the care plan was dated in April, despite the resident experiencing several falls thereafter. The resident, admitted with diagnoses including encephalopathy and type 2 diabetes, had moderately impaired cognition and required supervision for all activities of daily living. Interviews with the MDS/RN and the DON confirmed that the care plan had not been updated with new interventions following each fall, contrary to the facility's policy. The policy requires the care plan to be reviewed and revised as necessary when a resident experiences a status change, with the interdisciplinary team collaborating on intervention options.
Failure to Provide Scheduled Showers for a Resident
Penalty
Summary
The facility failed to provide consistent and scheduled showers for a resident who required assistance with activities of daily living (ADL), specifically bathing care. The resident expressed a desire to receive regular showers, stating that they were not being provided as scheduled, which was twice a week. The resident reported feeling upset and frustrated due to the lack of showers, as personal cleanliness was important to them. A review of the resident's ADL bath logs indicated that they received only four baths in a one-month period, with six instances where the activity did not occur, and no explanation was provided. Additionally, there was no documentation of any showers during the 30-day period, and the baths that were provided did not align with the resident's preference for evening or night showers. The resident's medical history included limb amputation, peripheral vascular disease, stroke, anxiety, and depression, requiring maximal assistance with toileting and bathing/showers. The Director of Nursing acknowledged the resident's concerns and mentioned the difficulty in accommodating the resident's preferred shower time. The facility's policy on Activities of Daily Living, implemented in November 2022, stated that care and services should be provided based on the resident's comprehensive assessment and consistent with their needs and choices. However, the facility did not adhere to this policy, resulting in the resident's dissatisfaction with their bathing care.
Failure to Schedule Follow-Up Appointments and Ensure Oxygen Orders
Penalty
Summary
The facility failed to set up follow-up appointments for a resident, resulting in a delay of care. The resident, who had a fracture in their left knee and a left hip replacement, was observed with a swollen knee and a surgical dressing on the hip that had not been changed since the previous month. The resident reported missing four chemotherapy treatments since admission. The medical record indicated the need for follow-up with orthopedic and oncology physicians, but no appointments were scheduled until much later. The receptionist, responsible for scheduling, was unaware of the need for these appointments until recently, and the Director of Nursing was not familiar with the resident's situation. Additionally, the facility failed to ensure appropriate physician orders were in place for oxygen for another resident. This resident, with a history of acute respiratory failure, pneumonia, and COPD, was observed with an oxygen concentrator running but the nasal cannula on the floor. The resident reported difficulty breathing, and upon checking, there were no active physician orders for oxygen. The facility's policy required oxygen to be administered under physician orders, except in emergencies, but this was not followed. The MDS/RN indicated that all orders should be transcribed and care plans written, but this was not done for the resident's oxygen needs.
Failure to Provide Restorative Services for Resident with Limited ROM
Penalty
Summary
The facility failed to provide restorative services to a resident with limited range of motion and mobility needs. The resident, who was observed in a power wheelchair with a bent right arm and a tightly closed right hand, expressed a desire for exercise and range of motion therapy to maintain and improve mobility. Despite having physician orders for restorative therapy to maintain upper extremity strength and range of motion, the resident reported not receiving any restorative therapy or being enrolled in a therapy program. The resident's care plan indicated they were on a restorative program with specific exercises outlined, but there was no documentation in the electronic medical record of participation in a restorative exercise program. The resident's Minimum Data Set assessment revealed a history of limb amputation, peripheral vascular disease, stroke, anxiety, and depression, requiring varying levels of assistance with daily activities. The resident was cognitively intact and experienced occasional pain. During an interview, the Director of Nursing was unaware of the resident not receiving restorative services and stated that the issue would be addressed. The facility's policy on Activities of Daily Living emphasized the provision of maintenance and restorative programs to assist residents in achieving the highest practicable outcomes, which was not adhered to in this case.
Failure to Ensure Timely Physician Response to MRR Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to Pharmacist Medication Regimen Reviews (MRR) recommendations for a resident. The medical record review revealed pharmacy progress notes indicating irregularities on specific dates, but the complete MRR and pharmacy recommendations with physician follow-up were not available. An email request for these documents was made, but the facility was unable to provide them. The Director of Nursing (DON) indicated that the MRRs might be in a binder in the office, but they were not sure why they were not provided. Additionally, a policy for MRRs was requested but not received before the survey concluded.
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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