Lenawee Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Adrian, Michigan.
- Location
- 200 Sand Creek Highway, Adrian, Michigan 49221
- CMS Provider Number
- 235224
- Inspections on file
- 25
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Lenawee Medical Care Facility during CMS and state inspections, most recent first.
The facility did not maintain required documentation showing that all paid feeding assistants had successfully completed a State-approved training course. Review of facility records showed 12 staff functioning as paid feeding assistants and 9 residents approved for the paid feeding assistant program, but the DON reported that documentation of completed training could only be found for 6 staff. The DON stated that a Life Enrichment Coordinator and several Dining Room Assistants had completed the training and assisted with feeding, yet the facility was unable to locate records verifying their training completion.
Failure to Assess Resident for Self-Administration of Medications: A resident with COPD, HF, anxiety, depression, and a BIMS of 15 was observed during med pass with the RN leaving meds and an inhaler at the bedside, not performing hand hygiene, and allowing the resident to use her inhaler on her own without a documented assessment permitting independent self-administration. The RN also did not provide water to rinse and spit after the inhaler, and the DON stated bedside medication administration was not expected unless an assessment allowed it.
Protected resident information was left visible during medication administration when an RN walked into a resident’s room with the med cart computer screen open and a resident list and daily report face up on the cart. The RN also left meds and an inhaler at the bedside, left the room to get a BP machine, and was observed without hand hygiene before giving meds. The DON confirmed the expectation was to close the screen and not leave resident names visible on the cart.
Delayed Significant Change in Status MDS for a resident enrolled in hospice. A resident with MS and moderate cognitive impairment was enrolled in hospice, triggering an SCSA requirement, but the MDS was completed after the required timeframe. The MDS nurse stated the assessment should have been locked earlier, and the record showed the ARD and completion dates did not meet CMS timing requirements.
Failure to implement a restorative ROM program for a resident with left lower extremity impairment and limited mobility. The resident was observed seated in a wheelchair with the legs extended and the left leg bent outward, while PT and OT discharge summaries recommended restorative services including lower extremity strengthening, passive ROM, AAROM, AROM, and restorative ROM. Staff reported a referral had been made, but the resident was not yet on the restorative program because the caseload was too large and the resident was on a waiting list.
Medication administration errors exceeded the allowed rate when an RN failed to perform hand hygiene, left meds and an inhaler at the bedside while leaving the room, did not provide water for rinsing after the resident self-administered a budesonide-formoterol inhaler, and attempted to apply a discontinued Lidoderm patch instead of the active lidocaine cream order. The DON stated meds should not be left at the bedside unless the resident has an assessment allowing self-administration, and the resident had no such assessment in the record.
Failure to perform hand hygiene during medication administration: An RN entered a resident’s room with medications, handed them to the resident, left the meds and inhaler on the over-bed table, returned with a BP machine, and continued care without hand hygiene before or after these actions. The resident had COPD, HF, AKF, anxiety, depression, and SOB, and the DON stated the expectation was for the medication pass nurse to perform hand hygiene before and after passing medications.
A deficiency occurred when the facility failed to thoroughly investigate and report a substantiated incident of sexual abuse between two cognitively impaired residents, both with multiple comorbidities and requiring one-person assistance with ADLs. Video footage and a CNA witness confirmed that a male resident in a wheelchair repeatedly touched a female resident’s breasts near the nurse’s station before being separated by staff. Despite this, the facility did not interview other residents or staff on the unit about the resident’s ongoing inappropriate sexual comments and behaviors, did not provide staff education related to the incident, and moved the alleged perpetrator to another hallway with other vulnerable female residents. The facility also did not notify law enforcement of the witnessed and recorded sexual abuse, with leadership citing the residents’ cognitive impairment as the reason for not calling the police.
A CNA recorded a video of a resident with moderate cognitive impairment in her room without consent while the resident was on the phone, then shared the video via social media. The resident was unaware of being recorded, and the video was further disseminated, violating facility policy and the resident's right to privacy.
A resident with a history of right femur fracture and Multiple Sclerosis, dependent for transfers, was injured when a CNA attempted a transfer alone using a sit-to-stand lift, contrary to the care plan requiring two-person assistance. The resident's leg gave out during the transfer, resulting in a fall and subsequent femur fracture, which was confirmed after ongoing pain and further imaging.
A resident's personal property was misappropriated when a CNA removed and discarded colored pictures from the resident's room without permission, leading to the resident's distress. The facility's investigation confirmed the incident, which was reportedly due to competition between CNAs.
Missing Documentation of State-Approved Training for Paid Feeding Assistants
Penalty
Summary
The facility failed to maintain records of successful completion of a State-approved paid feeding assistant training course for 6 of 12 staff members functioning as paid feeding assistants. Surveyors reviewed facility lists showing 12 staff designated as paid feeding assistants and 9 residents approved for the paid feeding assistant program. During an interview, the DON stated the facility could only locate documentation of completed State-approved training for 6 of the 12 paid feeding assistants. The DON identified specific staff, including the Life Enrichment Coordinator and multiple Dining Room Assistants, who had reportedly completed the paid feeding assistant training and had assisted residents with feeding, but the facility was unable to locate documentation verifying that these individuals had completed the required training. No additional clinical details or medical histories of the 9 residents approved for the paid feeding assistant program were provided in the report, and the deficiency centers on the absence of required training documentation for staff who assisted with feeding.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess one resident, R121, for permission to self-administer medications safely and independently. R121 was admitted with diagnoses including COPD, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. Her most recent MDS showed a BIMS score of 15 out of 15, and she required minimum assistance with showering, personal care, dressing, and putting on footwear, although that section of the assessment was not completed at the time. During a medication pass observation, an RN removed medications from the cart, left the computer screen open with resident information visible, and did not perform hand hygiene before handling and giving medications to R121. The RN left the medications and inhaler on the over-bed table and stepped out of the room to get a blood pressure machine. After returning and obtaining a BP of 151/92, the RN allowed R121 to state that she used her inhaler on her own, then handed her a blood pressure pill without observed hand hygiene before returning to the cart or before giving the medication. The inhaler was Budesonide-Formoterol Fumarate Inhalation Aerosol, ordered for COPD with instructions to rinse the mouth after use, but no water was provided for rinse and spit. R121 stated nurses usually stayed in her room while she took medications and that she could not always take them all at once. Record review did not show an assessment authorizing self-administration, and the DON stated the nurse should not leave medications at the bedside unless there was an assessment permitting self-administration and should provide water to rinse and spit after inhaler use.
Protected Resident Information Left Visible During Medication Administration
Penalty
Summary
The facility failed to protect personal, private, and confidential information for one resident, R121. R121 was admitted with diagnoses including chronic obstructive pulmonary disease, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. The most recent MDS showed a BIMS score of 15 out of 15 and indicated the resident needed minimum assistance with showering, personal care, dressing, and putting on footwear, though that section was not completed at the time referenced in the report. During an observation, an RN was seen pulling medications from the medication cart to administer to R121 and walked into the resident’s room with the medications while leaving the computer screen open with R121’s personal and protected information visible. The screen also showed a list of resident names and a daily report face up on the cart. The RN did not perform hand hygiene before handing medications to the resident, left medications and an inhaler on the over-bed table, left the room to get a blood pressure machine, and later returned to give the blood pressure medication without observed hand hygiene before accessing the cart or after handing the medication to the resident. The DON stated the expectation was to close the computer screen before leaving the medication cart unattended and that the same expectation applied to leaving the resident list face up on the cart.
Delayed Significant Change in Status MDS for Resident Enrolled in Hospice
Penalty
Summary
The facility failed to complete a Significant Change in Status MDS assessment timely for one resident. The resident was admitted and later readmitted to the facility with a diagnosis that included Multiple Sclerosis, and the Significant Change in Status MDS reflected moderate cognitive impairment on the BIMS and that the resident received hospice services. The MDS had an ARD of 2/5/26 and was completed on 2/19/26. Record review showed the resident was admitted to hospice services on 1/30/26, and the MDS nurse reported that the significant change in status occurred on that date when the resident enrolled in hospice. In a follow-up interview, the MDS nurse stated the Significant Change in Status MDS should have been locked by 2/12/26. The CMS LTC Facility Resident Assessment Instrument 3.0 User’s Manual states that an SCSA is required when a terminally ill resident enrolls in hospice, with the ARD within 14 days of the hospice election and the MDS completion date no later than 14 days from the ARD and no later than 14 days after the determination that the criteria were met.
Failure to Implement Restorative ROM Program
Penalty
Summary
The facility failed to implement a restorative maintenance program for one resident who had been admitted with diagnoses including a non-pressure chronic ulcer of the left thigh with necrosis of muscle, a displaced intertrochanteric fracture of the left femur, and a left artificial knee joint. The admission MDS dated 2/1/26 showed the resident scored 8 out of 15 on the BIMS and had lower extremity impairment on one side that interfered with daily functions or placed the resident at risk of injury in the last 7 days. On 3/17/26 and 3/18/26, the resident was observed seated in a wheelchair in the room, watching TV and later minimally self-propelling with the arms. On both observations, the wheelchair footrests were elevated to approximately seat level height, the legs were extended, and the left leg was bent laterally at the knee. Therapy documentation showed the resident was discharged from PT and OT on 2/18/26, with recommendations for restorative services including lower extremity strengthening, passive ROM, active assisted ROM, active ROM, and restorative ROM. In interviews, the Therapy Director and RN reported a referral had been made for restorative services, but the resident was not yet on the restorative program because the caseload was too large and there was a waiting list; staff also stated the facility had two restorative aides plus one as-needed aide and about 25 residents on restorative services at the time.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent when two medication errors were observed during 30 medication administration opportunities for one resident, resulting in a 6.67 percent error rate. The resident involved had diagnoses including COPD, heart failure, acute kidney failure, anxiety, depression, shortness of breath, and pain in both shoulders, and the most recent MDS showed a BIMS score of 15. During observation, an RN did not perform hand hygiene before giving the resident medications, left the medications and inhaler on the over-bed table while leaving the room to obtain a blood pressure machine, and did not provide water for the resident to rinse and spit after self-administering Budesonide-Formoterol inhalation aerosol. During the same medication pass, the RN also pulled a Lidoderm 4% patch to apply to the resident’s shoulders even though the record showed that the patch had been discontinued the prior evening and a new order had been written for Lidocaine 4% external cream instead. The resident stated nurses usually stay in the room during medication administration and that she was not offered water to rinse and spit after using her inhaler. The DON stated the expectation was to verify the medication order, check allergies, and triple-check the medication against the order and resident, and confirmed that if an order was discontinued the nurse should notice it and that medications should not be left at the bedside unless the resident had an assessment allowing self-administration.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was not followed during medication administration for one resident. During observation, the RN pulled medications from the medication cart and went into the resident’s room without performing hand hygiene. The RN handed the resident her medications without hand hygiene, then left the medications and inhaler on the over-bed table while leaving the room to get a blood pressure machine. The RN returned with the BP machine, again without performing hand hygiene, and took the resident’s vital signs with a BP of 151/92. The resident was admitted with diagnoses including COPD, pain in both shoulders, heart failure, acute kidney failure, anxiety, depression, and shortness of breath. The most recent MDS showed a BIMS score of 15 out of 15 and indicated the resident needed minimum assistance with showering, personal care, dressing, and putting on footwear. During interview, the DON stated it was the expectation for the medication pass nurse to perform hand hygiene before and after passing medications.
Failure to Thoroughly Investigate and Report Substantiated Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and appropriately respond to an alleged and substantiated incident of sexual abuse between two cognitively impaired residents. One resident (R2), with CHF, stroke, traumatic brain injury, dysphagia, major depression, hypertension, bipolar disorder, weakness, and unsteady gait, had a BIMS score of 7 indicating moderate to severe cognitive impairment and required one-person assistance with ADLs. Another resident (R3), with CHF, adjustment disorder, vascular dementia without behavioral disturbance, unsteady gait, and gait abnormalities, had a BIMS score of 3 indicating severe cognitive impairment and also required one-person assistance with ADLs. Camera footage and staff observation documented that R3, while in his wheelchair near the nurse’s station, touched R2’s face, rubbed her back, and then repeatedly touched both of R2’s breasts before being separated by a CNA. The facility verified the incident by reviewing the hallway camera footage and obtaining a witness statement from the CNA who intervened, confirming that R3 touched both of R2’s breasts. However, the investigation was limited to these immediate observations and did not include interviews with other residents on the same household regarding R3’s inappropriate behaviors, comments, or touching of female residents. The record also did not show interviews with other staff working on that household about R3’s prior or ongoing inappropriate behaviors or comments toward female residents or staff, despite staff later reporting that R3 was flirty with female residents and staff, made sexually suggestive comments, and had been “a little hands on” with staff. The facility moved R3 from one alert hallway to another where other vulnerable female residents lived, but records showed no evidence of staff education related to this sexual abuse incident, even though this was not the first time R3 had exhibited inappropriate behaviors and comments. The facility did not contact law enforcement regarding the witnessed and video-recorded sexual abuse, with the Nursing Home Administrator stating that police were not called because both residents were cognitively impaired and providing no other explanation. The record review and interviews confirmed that the facility failed to conduct a thorough investigation, failed to interview potentially affected residents and staff, failed to provide education to staff regarding the incident, and failed to report the substantiated sexual abuse to the police as required by regulation.
Resident Privacy Violated by Unauthorized Video Recording
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) recorded a video of a resident in her room without her knowledge or consent. The resident, who had diagnoses including Parkinson's Disease, vascular dementia, and major depressive disorder, was moderately cognitively impaired according to her most recent assessment. The video was taken from behind the resident while she was sitting in her wheelchair, watching television, and talking on the phone. The CNA then turned the camera on herself at the end of the video. The resident was unaware that she had been recorded and, when asked, stated her feelings about being recorded would depend on the circumstances, but she had no knowledge of this specific incident. The video was sent via social media messenger to another CNA, who shared a social media account with a third party, allowing the video to be further disseminated. Facility investigation confirmed that the video was recorded and shared without the resident's awareness, violating the facility's policy prohibiting photography or video recordings on the property and the resident's right to privacy. The CNA involved admitted to recording the video as a form of personal documentation related to workplace allegations, not for any resident care purpose.
Failure to Follow Transfer Care Plan Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent for transfers and had a history of right femur fracture and Multiple Sclerosis, was not transferred according to their care plan. The care plan and Kardex specified that two-person assistance was required for transfers using a sit-to-stand lift. However, a CNA attempted the transfer alone, relying on outdated information from a report sheet that did not reflect the updated care plan requirements. During the transfer, the resident's right leg gave out, and although the wheelchair was locked, it moved backward, causing the resident's legs to slide out and resulting in the resident being lowered to the floor and landing hard on their buttocks. The resident immediately began experiencing significant pain in the right thigh, which persisted and worsened over the following days. Initial x-rays did not reveal a fracture, but ongoing pain and subsequent imaging confirmed a femur fracture with callus formation, necessitating surgical intervention. The incident was further complicated by the resident's continued reports of severe pain during movement and care, as documented in multiple progress notes and medication administration records. The failure to follow the care plan for transfer assistance directly led to the resident being injured during the transfer process.
Misappropriation of Resident's Personal Property
Penalty
Summary
The facility failed to protect the personal property of a resident, leading to feelings of sadness and potential mistrust. The resident, who was cognitively intact, had colored pictures on her wall that were created by a favorite CNA. Another CNA, without the resident's permission, removed and discarded these pictures, which upset the resident. The incident was observed by the resident's family member, who noted a possible competition between the two CNAs as a reason for the removal of the pictures. The facility's investigation, which included reviewing camera footage, confirmed that the CNA entered the resident's room when she was absent and discarded the pictures. The CNA admitted to removing the pictures, claiming they caused the resident distress. The social worker and nursing home administrator were informed, and the incident was reported and substantiated as misappropriation of property.
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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