Majestic Care Of Flushing
Inspection history, citations, penalties and survey trends for this long-term care facility in Flushing, Michigan.
- Location
- 540 Sunnyside Drive, Flushing, Michigan 48433
- CMS Provider Number
- 235132
- Inspections on file
- 34
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Majestic Care Of Flushing during CMS and state inspections, most recent first.
Two residents who required assistance with ADLs were found to have long, soiled fingernails due to the facility's failure to provide routine nail care. One resident with multiple medical conditions and contractures had neglected nails despite care plan notes about scratching and skin breakdown risk, while another resident with dementia and arthritis had unclean nails and no documentation of recent nail care. Staff acknowledged nail care should occur during showers, but records did not confirm this was done.
A resident with a coccyx pressure ulcer did not receive wound care as ordered, with observations revealing a dressing unchanged for several days despite staff documentation indicating daily care. The resident reported infrequent dressing changes and was seen scratching the wound, leading to bleeding. Nursing staff had initialed wound care as completed without performing the task, and there was no documentation of care refusal.
A resident in need of pain management did not receive safe and appropriate pain management services, as the facility failed to provide the necessary care to address the resident's pain.
Surveyors identified multiple deficiencies in kitchen sanitation and equipment maintenance, including unclean food preparation tools, malfunctioning dishwashing equipment, and inadequate cleaning of kitchen fixtures. Staff interviews revealed inconsistent adherence to cleaning schedules and a lack of clear responsibility for maintaining sanitary conditions.
Surveyors found that the facility failed to implement a comprehensive infection prevention and control program, with staff not performing hand hygiene, missing hand sanitizer dispensers, and soiled equipment. The infection control nurse was unfamiliar with surveillance processes, and infection data was incomplete or inconsistent. In one case, a resident with a wound infection was not included in surveillance records or treated, and another resident's potential bed bug exposure was handled by maintenance staff instead of nursing, with no proper documentation or follow-up. Covid-19 cases were not consistently tracked or reported, and there was no evidence of outbreak investigation or health department notification.
The facility did not properly implement or document its Antibiotic Stewardship Program, as shown by incomplete infection surveillance records, missing laboratory data, and lack of documentation for antibiotic use in four residents. Several residents received antibiotics without clear evidence of infection, appropriate assessments, or monitoring, and staff were unable to explain or justify antibiotic choices due to missing or incomplete records.
A resident's bathroom was found with a large hole in the baseboard, a cracked toilet, and unsanitary conditions, while an environmental tour revealed widespread issues such as soiled linens on the floor, corroded sinks, missing emergency equipment, dirty vents, and unclean common areas. These deficiencies resulted in an unsafe, unsanitary, and uncomfortable environment for all residents and staff.
Multiple residents, all dependent on staff for ADLs and with significant medical needs, were left without accessible call lights or experienced long delays in staff response, leading to unmet toileting and personal care needs. Family members and residents reported staff inaction, and observations confirmed residents were left soiled, exposed, or unable to summon help, resulting in distress, skin irritation, and embarrassment.
Multiple residents who were dependent on staff for ADLs did not consistently receive showers, grooming, or hygiene care as required by their care plans. Observations and interviews revealed missed showers, unwashed hair, body odor, dirty nails, and soiled clothing, with staff citing workload and staffing shortages as reasons for missed care. Documentation did not reflect resident refusals, and residents expressed dissatisfaction and embarrassment over the lack of personal care.
Multiple residents reported significant delays in call light response, missed showers, and untimely incontinence care due to inadequate staffing. Staff interviews and facility records confirmed frequent call-ins, inability to secure coverage, and reliance solely on internal staff, resulting in unmet ADL needs and resident frustration.
Three residents experienced missed showers and inadequate personal hygiene due to the facility's failure to follow or revise ADL care plans. Residents reported infrequent bathing, unkept appearances, and dissatisfaction with care, while records showed a lack of individualized scheduling, incomplete documentation of preferences, and no recorded refusals despite missed showers.
A resident with dementia, dysphagia, and depression, who required assistance with ADLs and had impaired cognition, was repeatedly found in bed with no accessible activities and expressed ongoing boredom. Despite a care plan indicating preferences for independent activities, board games, and music, only limited group activities were documented, and there was no activity cart or consistent provision of materials of interest. The resident's environment lacked accessible engagement, and basic needs such as access to the TV and glasses were not met.
A resident with severe cognitive impairment, a history of falls, and multiple comorbidities was observed ambulating and toileting without staff assistance, despite care plan interventions requiring supervision and help with these activities. The resident was left unsupervised, stood from a wheelchair without brakes locked, and exposed themselves to the hallway while attempting to use the bathroom. Staff did not consistently follow care-planned interventions, resulting in unassisted ambulation and toileting for the resident.
A resident with multiple respiratory and cardiac conditions was found with a CPAP mask, tubing, and head strap that were visibly soiled with brown buildup over several days. Despite orders and documentation indicating weekly cleaning, the equipment remained dirty, and the resident reported it was not being cleaned. Staff confirmed the equipment was dirty, demonstrating a failure to provide appropriate respiratory care.
Two residents reported receiving cold, unappetizing meals that did not meet their stated preferences, with one resident also lacking regular access to fresh water. Multiple residents at a council meeting unanimously described ongoing issues with food quality, meal delivery delays, and unfulfilled menu choices, with staff interviews and observations confirming these deficiencies.
Three residents with recent amputations or surgical wounds did not receive timely or adequate wound assessment, monitoring, or treatment. One resident's surgical site was not assessed for two weeks, leading to infection and further surgery. Another resident's amputation site was not assessed or monitored until several days after admission, and care plan interventions were incomplete. A third resident's toe amputation wound was not consistently treated or documented, with no physician order in place despite ongoing wound care.
A resident with a PEG tube did not receive proper assessment and monitoring of the insertion site, resulting in a reddened, painful area that was noticed by family rather than staff. There was no documentation of PEG site care or assessment, no physician order for PEG care upon admission, and the resident's admission weight was not obtained until five days after arrival. Enteral nutrition orders were delayed, and the resident initially received a different formula than indicated. Facility policies for enteral feeding and weight monitoring were not followed.
A resident with multiple medical conditions did not receive several prescribed medications on time due to delays in pharmacy delivery, lack of emergency medication drops, and incomplete use of backup medication supplies. The DON confirmed that some medications were not administered as ordered and that the facility did not obtain medications from local pharmacies while waiting for contracted pharmacy deliveries.
A resident with multiple health conditions was admitted to a facility with pressure ulcers that were not documented by staff. Despite hospital records indicating the presence of these ulcers, the facility's initial assessment failed to identify them, leading to a deficiency in care. The facility's policy on wound prevention was not adequately followed, resulting in a lack of proper documentation and intervention for the resident's pressure ulcers.
A resident with end-stage renal disease did not receive scheduled dialysis treatments due to coordination issues at the facility, leading to her being sent to the ER with hallucinations and confusion. Despite attempts to arrange dialysis, the facility failed to monitor the resident's condition adequately, resulting in a five-day lapse in treatment. The facility's policy for monitoring postponed dialysis was not followed, as no weight or lab work was conducted to assess the resident's kidney function.
A resident with mental health issues attempted suicide twice due to inadequate supervision at an LTC facility. Despite requiring 1:1 supervision, the facility failed to provide continuous monitoring, leading to two incidents where the resident attempted strangulation. Staff interviews revealed miscommunication and a lack of clear policies to address suicidality.
The facility failed to provide adequate pressure ulcer care for three residents, leading to wound deterioration and infection. A resident's coccyx wound worsened due to inconsistent treatment orders and lack of proper care, resulting in sepsis. Another resident had a foot dressing that was not dated or initialed, and a third resident's heel protectant boots were not used as ordered, with dressings also lacking proper documentation.
Two residents in a LTC facility sustained injuries due to inadequate supervision and failure to follow post-fall assessment protocols. One resident, an active exit seeker, was startled by staff, resulting in a fall and head injury requiring emergency treatment. The facility did not document required neurological assessments post-fall. Another resident with dementia fell and fractured his hand while visiting another resident's room, against facility guidance. The care plan lacked increased supervision measures, contributing to the incident.
The facility failed to maintain an accurate infection control program, with inconsistencies in tracking infections and outdated policies. Discrepancies were noted in infection counts and antibiotic use, with some infections treated without meeting criteria. The infection preventionist was unaware of the need for education on infection increases, and the DON confirmed outdated policies and lack of audits on antibiotic stewardship.
The facility failed to provide scheduled showers for four residents, leading to a deficiency in ADL care. A resident with a self-care deficit due to obesity and amputation missed scheduled showers without documentation. Another resident with physical limitations reported missing showers due to staff shortages. Two residents refused showers multiple times, but no alternative bathing options were documented. The facility's ADL policy was not adhered to, indicating a failure to prevent deterioration in residents' abilities.
A facility's medication error rate exceeded 5% when an LPN was unable to administer pantoprazole and Entresto to a resident due to unavailability in the medication dispensing machine. Despite ordering the medications the previous day, they were not delivered by the pharmacy, leading to an 8% error rate.
The facility failed to properly label and secure medications, resulting in several deficiencies. An unlocked medication cart was found unattended with loose medications, and expired or undated medications were discovered in various locations. Facility policies on medication storage and administration were not followed, increasing the risk of decreased efficacy and potential drug diversion.
The facility failed to maintain sanitary conditions in the kitchen, with staff not adhering to hygiene practices like wearing hair and beard nets. Observations showed food debris on floors, improper food storage, and inadequate cleaning. A cook used the same gloves for multiple tasks without washing hands, and structural issues like an unfinished doorway and open drain were noted, posing health risks to residents.
The facility failed to maintain an effective vaccination program for four residents, with issues including missing consents, unadministered vaccines despite signed consents, and outdated policies. Interviews revealed that the infection preventionist lacked access to the vaccination database, and the DON acknowledged the need for better processes. An LPN could not explain why a resident did not receive vaccinations despite signed consents.
The facility failed to maintain essential equipment, including beds and wheelchairs, in safe condition, affecting multiple residents. A resident nearly fell due to an unstable bed, while another faced frustration with a non-functional bed remote. A wheelchair with loose wheels and a cracked overhead light fixture were also reported but remained unaddressed until surveyor intervention. The maintenance staff and administration were unaware of these issues, highlighting a lack of communication and systematic checks.
The facility failed to ensure dignified care and timely call light responses for several residents, leading to prolonged incontinence and frustration. Residents reported extended wait times for assistance, with some experiencing exposure and lack of privacy. A CNA refused to assist a resident, citing workload, further highlighting the facility's deficiencies in maintaining resident dignity and care.
A resident's Tramadol medication was misappropriated due to discrepancies in the controlled substance log and MAR. The facility's failure to accurately document and reconcile medications led to one pill being unaccounted for. The nurse involved was suspended pending further investigation.
A resident experienced a fall resulting in fractures to the right hand, which was not reported to the State Agency as required. The resident was found with an ice-wrapped hand and transferred to the ER, where fractures were confirmed. The facility's DON confirmed the failure to report the injury, violating the facility's Abuse Prevention Program.
A resident with dementia and severely impaired cognition sustained an injury of unknown origin, resulting in fractures to the hand. The facility failed to conduct a thorough investigation, as required by its policies, by not obtaining witness statements from staff who observed the incident. This oversight led to a deficiency with the potential for undetected abuse or neglect.
Two residents with PICC lines in an LTC facility were found to have non-occlusive dressings and lacked initial measurements upon admission. The facility's policy of weekly dressing changes was not followed, and there were discrepancies in documentation and untimely monitoring orders. The management acknowledged these deficiencies.
The facility failed to obtain informed consents for psychotropic medications for two residents, leading to the administration of potentially unnecessary medications. One resident received an antipsychotic for eight weeks without proper consent from her guardian, while another was given multiple psychotropic medications without any signed consents. The facility's policy did not address informed consents, contributing to the oversight.
A facility failed to adhere to professional standards in medication administration and documentation for two residents. One resident had a discrepancy in the controlled substance log for Tramadol, with a missing pill unaccounted for. Another resident was offered Melatonin without a proper order, and the nurse involved backdated entries in the medical record. The nurse had a history of medication administration violations, and facility policies were not followed, resulting in inaccurate documentation.
The facility failed to complete yearly PASSAR and Level II evaluations for three residents, resulting in a lack of yearly follow-up and documentation. The Social Work Director and Director of Nursing acknowledged the issue and mentioned access problems with the OBRA system. The facility's PASSAR/Level II Screening Policy was requested but not provided during the exit interview.
Failure to Provide Routine Nail Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that routine nail care was provided for two residents who required assistance with activities of daily living (ADLs). One resident, with a history of bipolar disorder, anxiety, contractures, heart disease, neuropathy, and a recent finger fracture, was observed to have long, discolored, and jagged fingernails on a contracted hand. The care plan noted the resident's risk for skin breakdown and a tendency to scratch, but did not include specific interventions for nail care or alternative plans to address nail maintenance. The resident expressed concern about the condition of his nails, noting they were curling under, and agreed to have them trimmed when offered by staff. Documentation did not reflect consistent nail care assistance as part of his ADL support. Another resident, diagnosed with dementia, arthritis, gout, heart failure, and other chronic conditions, was observed with long, unclean fingernails and stated she needed her nails done. The care plan indicated that nail care should be provided on bath days and as necessary, but review of shower documentation showed the last shower occurred a week prior, with no record of nail care being completed. Staff confirmed that nail care was expected to be performed during showers, but there was no evidence this was done. The facility was unable to provide a nail care or shower policy upon request during the survey.
Failure to Provide Wound Care as Ordered and Inaccurate Documentation
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with multiple medical conditions, including a pressure ulcer on the coccyx. Physician orders specified daily cleansing of the coccyx wound with normal saline, application of collagen wound filler, and comfort foam, to be changed every day and as needed. However, during observation, the resident's wound dressing was found to be dated four days prior, shriveled, and appeared to have not been changed as required. The resident reported that the dressing was changed about once a week, and was observed scratching the wound, causing bleeding. Review of the Medication Administration Record/Treatment Administration Record showed that staff had initialed daily completion of wound care, including on days when the dressing had not been changed. Interviews with nursing staff and the Director of Nursing revealed that some nurses had documented completion of wound care without actually performing the dressing change. There was no documentation in the progress notes to indicate that the resident had refused care on the days in question. The facility's wound care policy was requested but not provided prior to the survey exit.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Maintain Sanitary Kitchen and Equipment Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not ensure that kitchen equipment and fixtures were in good working condition. During a kitchen tour, surveyors observed multiple instances of unclean food preparation equipment, including kitchen knives with dried food, a can opener with a black dried substance, plates with food particles, and a steam table with crumbs and dried food. Additional observations included a professional oven and microwave with dried food residue, and utensils with broken pieces and dried batter. The kitchen's cleaning schedules indicated that these items were supposed to be cleaned daily or weekly, but the observed conditions did not align with these schedules. Surveyors also found that the large dishwasher was malfunctioning, spraying hot water onto the floor and staff due to a loose water shield and damaged curtains, with no safety mats in place despite their availability. The three-compartment sink was leaking water from the faucet, and maintenance staff were unaware of the issue. The walk-in cooler fan covers were covered in black dust and dirt, and there was no documentation or set schedule for their cleaning. The floor drain under the cook's sink was filled with dirt, dust, and food items, and the milk cooler had dried milk residue both inside and on the floor. Metal pans with significant wear were found on the clean pan rack, and the cleaning of walk-in fan covers was delayed for several days after initial observation. Interviews with dietary and maintenance staff revealed a lack of awareness or adherence to cleaning responsibilities and schedules. Staff acknowledged that certain equipment should be cleaned after each use or weekly, but these practices were not consistently followed. Maintenance staff also indicated that they relied on dietary staff to notify them about cleaning needs for certain equipment, such as the walk-in cooler fan covers, rather than following a set schedule.
Failure to Implement Comprehensive Infection Control Program
Penalty
Summary
The facility failed to implement and operationalize a comprehensive infection prevention and control program, as evidenced by multiple observations and interviews. Surveyors observed that hand hygiene practices were not followed by staff, including dietary and nursing assistants, who did not use hand sanitizer or wash hands before leaving residents' rooms after delivering food or providing care. Hand sanitizer dispensers were missing from some resident rooms, and staff were seen touching contaminated surfaces and moving between residents without performing hand hygiene. Additionally, soiled room divider curtains and lack of accessible hand hygiene equipment were noted. The infection control (IC) program lacked accurate and complete outcome and process surveillance. The IC nurse was unfamiliar with the facility's surveillance processes, could not explain discrepancies in infection data, and was unaware of the water management plan. Infection surveillance documentation was incomplete, with missing summaries and analyses, inconsistent line listings, and lack of documentation for some infections. For example, a resident with a wound culture positive for infection was not included on the line list and did not receive documented treatment. Another resident's infection was listed twice with conflicting information, and there was no documentation of whether infections met McGeer criteria. Covid-19 cases were not consistently tracked or reported, and there was no evidence of health department notification or outbreak investigation. The facility also failed to respond appropriately to a staff report of potential bed bugs. When aides reported possible bed bugs in a resident's bedding, the maintenance director, who lacked clinical credentials, conducted a skin assessment instead of nursing staff. No nursing skin assessment or follow-up documentation was found in the resident's medical record. The pest control company was called and then canceled by the maintenance director without proper investigation or documentation. Staff were not informed of the incident during shift reports, and there was no clear policy or procedure for handling such situations. Overall, the facility's infection control program was disorganized, with inadequate documentation, lack of staff education, and insufficient monitoring of both residents and staff for infections.
Failure to Implement and Document Comprehensive Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize a comprehensive Antibiotic Stewardship Program, as evidenced by incomplete documentation, lack of analysis, and insufficient monitoring of antibiotic use for four residents reviewed for antimicrobial treatment. Infection control documentation for January 2025 did not include a summary or analysis of infections, and the Monthly Infection Surveillance Report was missing critical information, such as whether infections met McGeer’s Criteria for 15 out of 31 cases. The infection control nurse (IC RN K) was unable to explain missing data or confirm the appropriateness of antibiotic treatments due to incomplete records and lack of laboratory results. For one resident treated for a UTI, the line listing omitted the date antibiotic treatment was started, did not specify if the infection was facility or community acquired, and lacked laboratory testing results. The IC nurse could not explain why certain organisms were not documented or confirm if the prescribed antibiotic was appropriate, as sensitivity data was missing. Another resident was treated for a UTI, but the facility lacked a culture and sensitivity report, and the infection was incorrectly classified as community acquired when it was actually facility acquired. The IC nurse could not evaluate the appropriateness of antibiotic treatment due to missing documentation and assessments. Additional deficiencies included a resident started on two antibiotics after a podiatry visit without any progress notes, assessment, or documentation of infection signs and symptoms. The IC nurse and DON were unable to provide documentation or rationale for the antibiotic orders, with the DON indicating antibiotics may have been prescribed prophylactically. Another resident was prescribed a prolonged course of antibiotics without documentation of the infection being treated, the organism involved, or monitoring of ongoing antibiotic use. The resident was not included in the infection control line listing, and the facility could not provide supporting documentation for the extended antibiotic therapy.
Widespread Environmental Deficiencies Compromise Facility Safety and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents and staff, as evidenced by multiple observations throughout the building. One resident was found to have a bathroom with a large hole in the baseboard exposing cement and debris, a cracked toilet base, and an unknown brown substance around the toilet. The resident expressed concern about potential falls due to the bathroom's condition. Additional issues in the same bathroom included missing baseboards and exposed cement block above the hand sanitizer dispenser. During an environmental tour, numerous deficiencies were identified in various areas of the facility. These included clean linen and gowns on the floor, soiled vents blowing onto uncovered clean linen, corroded sink drains, uncovered suction equipment, dead sewer flies, soiled gloves on the floor, missing emergency pull cord light, missing shampoo dispenser handle, dusty vents, and unlabelled body wash. Other areas had stained or bowing ceiling tiles, holes in air vent grates, hazardous chemicals at bedsides, damaged privacy curtains, exposed wood and scratched walls, soiled sinks, missing tiles, clutter, and dirty equipment. The resident activity room and laundry room were also found to be unclean, with debris, cobwebs, soiled blinds, and standing water present. The facility's job descriptions for the Housekeeping Supervisor and Maintenance Director require them to ensure a clean, orderly, safe, and attractive environment, as well as efficient functioning and upkeep of the building. However, the observed conditions indicate a failure to meet these responsibilities, resulting in an environment that is not safe, sanitary, or comfortable for residents, staff, and the public.
Failure to Ensure Resident Dignity and Timely Assistance with Call Lights and Toileting
Penalty
Summary
Surveyors identified multiple failures by facility staff to honor residents' rights to dignity, self-determination, and communication. Several residents, all dependent on staff for activities of daily living (ADLs) due to complex medical conditions such as heart disease, kidney disease, cognitive impairment, and mobility limitations, were observed without accessible call lights or experienced extended call light response times. In some cases, residents were unable to reach their call lights, were unaware of their location, or reported that staff did not respond in a timely manner. Family members corroborated these accounts, with one family member stating they had to provide incontinence care themselves due to staff inaction. Resident Council meeting notes further documented widespread complaints about delayed call light responses, with reports of waits exceeding an hour and staff not meeting residents' needs. Additional deficiencies were observed in the provision of toileting and personal care. One resident, dependent on staff for toileting and personal hygiene, was left soiled and told to wait for assistance until after eating, despite having both urinary and fecal incontinence. The resident was observed attempting to eat without adaptive equipment, with food spilled on their clothing and a strong odor of bowel movement present. Staff were unable to identify who delivered the food tray or provide timely incontinence care, contrary to the resident's care plan, which required routine checks and assistance with toileting and eating. Another resident was observed with their pants down, exposed to the hallway while attempting to access the bathroom independently, indicating a lack of timely staff assistance with toileting and a failure to maintain the resident's dignity and privacy. These incidents, supported by resident interviews, observations, and care plan reviews, resulted in residents experiencing fear of abandonment, anger, skin irritation from prolonged exposure to urine and feces, and embarrassment.
Failure to Provide Consistent ADL Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs), including bathing, grooming, and hygiene, for multiple residents who were dependent on staff for these services. Several residents did not receive scheduled showers or bed baths as documented in their care plans, with records showing missed showers on specific dates and no documentation of resident refusals. Observations and interviews revealed residents with unwashed hair, body odor, dirty or untrimmed nails, and soiled clothing, indicating a lack of consistent personal hygiene care. Residents expressed dissatisfaction and distress regarding the lack of assistance with ADLs. Some reported that showers were not given regularly, and that staff would often tell them to wait for the next shift or only provide a quick wash with a wet cloth. Staff interviews confirmed that showers and other ADL tasks were sometimes missed due to staffing shortages or workload, and that not all residents' preferences or needs were being met as outlined in their care plans. In several cases, there was no documentation of refusals or alternative care provided when showers were missed. The affected residents had significant medical histories and cognitive impairments, making them reliant on staff for daily care. Observations included residents with dried food and wet spots on clothing, long and dirty fingernails, unshaven facial hair, and unchanged or soiled clothing. These findings were corroborated by both staff and resident interviews, as well as review of care plans and ADL task sheets, which consistently showed gaps in the provision of required personal care services.
Failure to Provide Adequate Staffing for Resident ADL Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the Activities of Daily Living (ADL) needs of residents, as evidenced by multiple resident complaints and staff admissions. During a Resident Council meeting, all sixteen residents present unanimously reported a shortage of staff, resulting in delayed call light responses, missed showers, and untimely incontinence care. Residents described waiting extended periods—sometimes up to two hours—for assistance, with some staff turning off call lights without providing the requested help or telling residents to wait until the next shift for care. Several residents reported having to wait so long for assistance that they experienced incontinence or had to seek help at the nurse station themselves. Interviews with residents further corroborated these issues, with consistent reports of insufficient staff, poor attitudes among aides, and a lack of empathy. Residents described staff as being overworked, with some aides refusing to adjust their routines to meet residents' immediate needs. Night shift staffing was particularly problematic, with reports of residents not receiving water, being left unattended for long periods, and staff failing to return after initially responding to call lights. Some residents also noted that showers were infrequent and dependent on which aide was working, and that some aides were not adequately trained to provide proper shower care. Staff interviews and facility records confirmed the staffing challenges. The staff scheduler acknowledged frequent call-ins and an inability to secure adequate coverage, as the facility does not use agency staff and relies solely on internal staff. The Nursing Home Administrator admitted to ongoing staff turnover and issues with staff performance, including some staff hiding or not doing their work. The facility's call light audits only tracked response times, not whether the requested service was actually provided. Observations by the surveyor also noted staff complaints about being short-staffed. The facility's own policies and job descriptions require sufficient staffing and competency in ADL care, but these standards were not being met, as evidenced by the consistent resident and staff reports.
Failure to Follow and Revise ADL Care Plans for Bathing and Hygiene
Penalty
Summary
The facility failed to follow and/or revise care plans for Activities of Daily Living (ADL) related to bathing and personal hygiene for three residents. Observations and interviews revealed that residents experienced missed showers and unkept appearances, including body odor, without documented refusals or individualized care plans reflecting their preferences. For example, one resident was observed to have body odor on multiple occasions and reported that showers were not given regularly. The care plan indicated staff assistance for sponge baths twice weekly and as needed, but did not specify individualized days or whether a sponge bath was the resident's preferred method of bathing. Shower records showed only four showers in a 30-day period, and there was no documentation of refusals in the progress notes. Another resident reported inconsistent assistance with bathing and hygiene, stating that some staff were helpful while others were not, and that there were staffing shortages on certain shifts. The care plan called for staff assistance with showers twice weekly and as needed, but again lacked individualized scheduling or documentation of resident preferences. Shower records indicated missed showers on specific days, with no documented refusals. A third resident expressed dissatisfaction with receiving only quick bed washes instead of showers, which he did not like. The care plan included staff assistance for showers and instructions to reapproach and document refusals, but only two showers were recorded in a 30-day period, and no refusals were documented in the progress notes.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful activities to meet the needs of a resident, resulting in complaints of boredom and having nothing to do. Observations revealed that the resident was often found resting in bed with the television on but with the volume off and the remote out of reach. The resident expressed feeling bored and stated there was nothing to do. Interviews with the Activity Director indicated that while some one-on-one activities and food-related group activities were offered, there was no activity cart available to provide a variety of in-room activity choices. Documentation showed that only four activities were provided in the past 30 days, and the resident's care plan indicated a preference for self-directed and independent activities, as well as board games and country music, but there was little evidence these preferences were being met. The resident had diagnoses including dementia, dysphagia, and depression, required assistance with activities of daily living, and had impaired cognition. Despite these needs, the resident's care plan interventions, such as providing materials of interest and assistance to activity functions, were not consistently implemented. Multiple observations confirmed that the resident's environment lacked accessible activities, and basic needs such as access to the television and glasses were not addressed, contributing to the resident's ongoing complaints of boredom.
Failure to Provide Supervision and Assistance with Toileting and Ambulation
Penalty
Summary
The facility failed to follow care-planned interventions and provide adequate supervision and assistance with toileting for a resident with severe cognitive impairment, a history of falls, and multiple comorbidities including dementia, visual loss, and chronic kidney disease. Observations revealed that the resident was left unsupervised in their room, stood up from their wheelchair without locking the brakes, and ambulated independently to their closet and bathroom on multiple occasions. The resident was also observed to change their socks and slippers and propel themselves in the wheelchair without staff assistance. During one incident, the resident exposed themselves to the hallway while attempting to use the bathroom unassisted, and the wheelchair rolled and struck the bathroom door, creating a potential hazard. Record review indicated that the resident had several unwitnessed falls in recent months and required staff assistance for activities of daily living, including ambulation, transfers, and toileting, as documented in their care plan. Despite these interventions being in place, staff did not consistently provide the required supervision or assistance, resulting in the resident performing activities independently that should have been assisted. Interviews with staff confirmed the resident's poor safety awareness and cognitive impairment, further emphasizing the need for adherence to care-planned interventions.
Failure to Maintain Clean CPAP Equipment for Resident
Penalty
Summary
A resident with diagnoses including obstructive sleep apnea, heart failure, and chronic obstructive pulmonary disease was observed with visibly soiled CPAP equipment over multiple days. The CPAP nasal mask, tubing, and head strap all had significant brown buildup, and the resident reported that nobody cleaned the equipment. The resident required assistance with activities of daily living and had impaired cognition. Despite physician orders specifying weekly cleaning of the CPAP tubing and documentation indicating the cleaning was completed, the equipment remained dirty upon repeated observations. Record review confirmed that the treatment administration record was marked as completed for the required weekly cleaning, yet the equipment was still visibly soiled. Staff acknowledged the presence of brown buildup and that the equipment was dirty, indicating a failure to provide safe and appropriate respiratory care as ordered. The deficiency was identified through direct observation, resident interview, and review of medical and treatment records.
Failure to Provide Palatable and Timely Meals per Resident Preferences
Penalty
Summary
The facility failed to provide palatable, appetizing, and per-preference meals at safe and appropriate temperatures for multiple residents. One resident, who is bed bound, alert, and dependent on staff for all ADLs, reported receiving cold and unappetizing food, missing items on her meal tray, and not receiving her preferred or required foods, such as oatmeal and caffeine-free beverages. She also reported receiving food with egg shells and experiencing significant delays in meal delivery, sometimes receiving meals hours late. Review of her care plans indicated she had specific dietary needs and preferences, which were not consistently honored by the facility. Another resident, who is thin and has missing teeth, reported that his meals were usually cold and tasteless, and he did not regularly receive fresh water, prompting him to keep bottled water at his bedside. Observations confirmed that his meal trays were cold and flavorless, and that he relied on bottled water due to inconsistent water delivery. During a Resident Council meeting, multiple residents unanimously expressed dissatisfaction with the food, citing issues such as poor taste, lack of variety, untimely meal delivery, unfulfilled menu preferences, and staff not respecting resident choices. These findings were corroborated by interviews with staff and direct observation of meal service.
Failure to Assess, Monitor, and Treat Surgical Wounds
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and intervention for wounds in three residents with recent amputations or surgical wounds. One resident was admitted with a right below the knee amputation (RBKA) and had no documented assessment or monitoring of the surgical site for 14 days after admission, despite hospital discharge instructions requiring daily inspection. The initial skin assessment did not mention the surgical wound, and subsequent assessments lacked details such as measurements, presence of staples or sutures, and peri-wound condition. There were no physician orders or care plan interventions addressing wound monitoring until two weeks post-admission, by which time the wound had dehisced and become infected, ultimately requiring further surgery. Another resident with a right above the knee amputation (AKA) did not have the surgical site assessed or monitored until three days after admission, and wound monitoring orders were not initiated until the fourth day. The admission skin assessment failed to mention the surgical site, and the care plan did not include specific interventions from the hospital discharge instructions, such as the use of a stump shrinker or showering guidelines. The resident reported that nurses checked the incision every other day, but documentation and orders did not reflect consistent monitoring from admission. A third resident with a left great toe amputation had an open wound that was not consistently assessed or treated according to physician orders. The skin assessment was completed four days after admission, and there was no order for wound dressing or treatment for the left great toe, despite wound care being observed and the resident expressing concern about inconsistent dressing changes. Documentation showed only weekly measurements by the wound nurse, and the care plan lacked specific interventions for the wound. Interviews with staff confirmed that wound assessment and monitoring were not routinely performed as required, and there was confusion regarding wound care orders.
Failure to Assess and Monitor PEG Tube Site and Timely Obtain Admission Weight
Penalty
Summary
A deficiency occurred when a resident with a percutaneous endoscopic gastrostomy (PEG) tube did not receive proper assessment and monitoring of the tube insertion site. During an observation, the resident was found with a reddened, raised area at the PEG site, which had gone unnoticed by nursing staff. The family reported that they had placed a dressing on the site themselves after noticing the area looked sore, and expressed concerns that nurses were not checking the site. The dressing was undated, and the resident indicated pain when the area was examined. Record review revealed that there were no physician orders for PEG site care upon admission, and no documentation of assessments or care of the PEG site in the resident's medical record. The facility's policy required daily checks and documentation of the enteral retention device and surrounding skin, but this was not followed. Additionally, the resident's admission weight was not obtained until five days after admission, despite policy requiring weights to be taken upon admission. The registered dietician and DON confirmed the delay in obtaining the weight and the lack of documentation for PEG site care. Further review showed that enteral nutrition orders were not in place until 24 hours after admission, and the resident received a different enteral formula than what was indicated on the hospital discharge summary until the correct product arrived. The DON acknowledged that the nurse failed to enter the tube feeding order on the day of admission and that documentation of PEG site assessments was missing. The facility's documentation practices did not capture the required ongoing assessment of the PEG site, and the initial nursing admission assessment did not include a skin assessment of the PEG insertion site.
Failure to Provide Timely Pharmaceutical Services Resulting in Missed and Late Medications
Penalty
Summary
The facility failed to provide timely pharmaceutical services for one resident, resulting in late and missed medication doses. The resident, who was admitted with diagnoses including aphasia following a stroke, right-sided hemiplegia, and gastrostomy status, required extensive assistance with activities of daily living but had intact cognition. Record reviews revealed multiple instances where medications were either documented as not given, left blank, or marked with a '9' on the medication administration record. Specific medications affected included atorvastatin, amantadine, famotidine, metoprolol, and heparin, with several doses either missed or not properly documented as administered. Interviews with the DON revealed that medication orders not submitted before a certain time would not be included in the next delivery, and the contracted pharmacy did not provide emergency drops for new admissions. The DON also stated that medications should be available in the backup supply, but was unable to provide a backup medication list when requested. Additionally, the DON indicated that the facility did not obtain medications from local pharmacies while waiting for deliveries from the contracted pharmacy. The pharmacy contract reviewed by surveyors required 24-hour emergency delivery for new or changed prescriptions, but this was not consistently followed, leading to the deficiency.
Failure to Document Pressure Ulcers Upon Admission
Penalty
Summary
The facility failed to properly assess and monitor a resident with pressure ulcers upon admission, leading to a deficiency in documenting these ulcers. The resident, a 56-year-old female with multiple health conditions including necrotizing fasciitis, end-stage renal disease, and bilateral above-knee amputations, was admitted with pressure ulcers that were not identified by the facility staff. Despite a progress note from the hospital indicating the presence of pressure ulcers on the coccyx and right ischium, the facility's initial skin assessment did not document these conditions. Further review revealed discrepancies in the facility's documentation and assessment of the resident's skin condition. The Unit Manager noted only a bruise and self-inflicted scratches during the initial assessment, missing the pressure ulcers that were later identified by hospital staff when the resident was sent to the ER. The facility's policy on wound prevention emphasizes the need for evidence-based interventions for residents at risk of pressure injuries, but this was not adequately followed in this case, resulting in a failure to document and address the resident's pressure ulcers upon admission.
Failure to Provide Timely Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident, resulting in the resident being discharged to the emergency room with hallucinations and confusion. The resident, a 56-year-old female with end-stage renal disease and other significant health issues, was admitted to the facility with orders to receive hemodialysis three times a week. However, upon admission, the facility encountered difficulties arranging dialysis appointments due to the resident's previous non-attendance at the dialysis center, leading to a lack of available chair time. Despite attempts to coordinate dialysis, the facility did not succeed in securing treatment for the resident during her stay from September 12 to September 17. Interviews with facility staff revealed a lack of follow-up and monitoring, as the resident did not receive any dialysis treatments during this period. The Director of Nursing and other staff members acknowledged the oversight, noting that the resident's cognitive state did not initially appear to change, which contributed to the delay in sending her to the emergency room. The resident's condition deteriorated, leading to hallucinations and confusion, prompting the facility to eventually send her to the emergency room on September 17. The emergency room visit was necessitated by the resident not having received dialysis for five days, as confirmed by the nephrologist. The facility's policy required ongoing monitoring and medical management if dialysis was postponed, but this was not adequately implemented, as evidenced by the lack of weight monitoring and lab work to assess kidney function during the resident's stay.
Failure to Maintain Resident Safety Leads to Suicide Attempts
Penalty
Summary
The facility failed to maintain the safety of a resident who had a history of mental health issues, resulting in two suicide attempts by strangulation. The resident, diagnosed with Alcoholic Cirrhosis of the Liver, Paranoid Personality Disorder, and Alcohol-induced persisting Dementia, was admitted to the facility and required close supervision due to his mental health condition. Despite this, the facility did not provide adequate supervision, as evidenced by the absence of a designated 1:1 sitter on certain shifts, which contributed to the resident's ability to attempt suicide twice. The first suicide attempt occurred when the resident was found with strings tied tightly around his neck, which had to be cut off by a nurse. Despite being sent to the emergency room for evaluation, the resident returned to the facility without new orders and was placed on 1:1 supervision. However, the facility failed to ensure continuous 1:1 supervision, as there was no specified sitter for the resident on the 2nd and 3rd shifts on a subsequent day. This lack of supervision allowed the resident to attempt suicide again by wrapping a phone charger cord around his neck. Interviews with staff revealed confusion and miscommunication regarding the assignment of 1:1 sitters, and a lack of a clear policy to address suicidality and subsequent procedures. The facility's failure to implement and maintain appropriate interventions and supervision for the resident's safety led to the citation of past non-compliance.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent the deterioration of wounds for three residents, leading to significant health issues. Resident #74, who was admitted with a pressure ulcer on the coccyx, did not receive the prescribed wound care treatment consistently. The treatment orders were not followed, and there was confusion between two different wound care treatments. The wound care practitioner had ordered Triad cream, but the facility also had an order for Allevyn, which was not completed on several occasions. This inconsistency and lack of proper wound care led to the worsening of Resident #74's wound, resulting in infection and sepsis. Resident #290 had a dressing on the right foot that was not dated or initialed, which is against nursing standards of practice. The dressing was observed to be dried onto the wound, indicating that it was not changed as required. This oversight in wound care documentation and management could potentially lead to further complications for the resident. Resident #292 had bilateral foot dressings that were not dated or initialed, and the resident was not wearing heel protectant boots as ordered. The care plan indicated the need to elevate heels, but the specific order for heel protectant boots was not included in the care plan or Kardex. This lack of adherence to physician orders and care plan documentation contributed to inadequate wound care management for Resident #292.
Inadequate Supervision and Documentation Lead to Resident Injuries
Penalty
Summary
The facility failed to provide adequate supervision and post-fall assessments for two residents, leading to significant injuries. Resident #84, who was an active exit seeker and oriented only to self, attempted to leave the building unauthorized. During this attempt, he was startled by a staff member, tripped, and sustained a head injury that required emergency medical treatment, including stitches. Despite the facility's policy requiring neurological assessments post-fall, no such evaluations were documented for Resident #84 following his return from the hospital. Resident #17, who had a history of dementia and severely impaired cognition, sustained fractures to the third and fourth metacarpals of his right hand after a fall. The incident occurred while Resident #17 was visiting another resident in her room, contrary to the facility's guidance to visit in more public areas. The Director of Nursing confirmed that there were no witness statements from staff regarding the incident, and the care plan for Resident #17 did not include increased supervision or measures to prevent him from entering other residents' rooms. The facility's failure to adhere to its fall management policy and ensure proper documentation and supervision contributed to the injuries sustained by both residents. The lack of a comprehensive post-fall assessment for Resident #84 and the absence of preventive measures in Resident #17's care plan highlight deficiencies in the facility's management of resident safety and accident prevention.
Inaccurate Infection Control Program and Outdated Policies
Penalty
Summary
The facility failed to maintain an accurate infection control program, as evidenced by inconsistencies in tracking infections within the resident population. In January 2024, there were discrepancies between the number of infections highlighted on the mapping, the line listing, and the summary, with some infections not meeting antibiotic criteria yet being treated with antibiotics. Similar inconsistencies were noted in February, March, and April 2024, with infections being placed on antibiotics without meeting criteria and discrepancies in infection counts across different records. Additionally, the facility's infection control policies were outdated, with some not having been revised since 2016 or 2018, and there was a lack of education provided to staff regarding infection control procedures. Interviews with the infection preventionist and the Director of Nursing (DON) revealed a lack of awareness and action regarding the increase in infections, particularly urinary tract infections (UTIs). The infection preventionist, who had recently taken over the role, was not aware of the need for education in response to the infection increase. The DON confirmed that the infection control policies were not current and that there were no audits or education on antibiotic stewardship. The mapping, line listing, and summaries did not match due to the absence of a consistent infection preventionist, as the previous one had been incapacitated, leading to a piecemeal approach to infection control management by the DON and regional consultant nurses.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for four residents, leading to a deficiency in the care of activities of daily living (ADL). Resident #8, who has a self-care deficit due to morbid obesity and a below-the-knee amputation, did not receive scheduled showers on two occasions, with no documentation explaining the missed showers. Similarly, Resident #51, who requires assistance due to physical limitations and cerebral palsy, reported missing a scheduled shower, attributing it to staff shortages. The task list and progress notes for Resident #51 also lacked documentation for missed showers on two scheduled days. Resident #17 and Resident #20 both refused showers on multiple occasions, but there was no documentation of alternative bathing options being offered. Resident #17's care plan required staff assistance for showers twice a week, yet there was no record of why the resident refused or if alternatives were provided. Resident #20 also refused showers on several days, and the facility did not offer a bed bath or alternative day, as indicated by the shower sheet documentation. The facility's ADL policy states that care and services should be provided to prevent deterioration in residents' abilities, but the lack of adherence to scheduled bathing routines indicates a failure to meet this standard.
Medication Error Rate Exceeds 5% Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors observed for a resident, resulting in an 8% error rate. The errors were identified during a medication administration observation involving a Licensed Practical Nurse (LPN) and a resident. The LPN noted that the medications pantoprazole (Protonix) 40mg and Entresto 24-26mg were not available in the facility's medication dispensing machine, despite having ordered them the previous day. The LPN mentioned that the pharmacy typically delivers medications at night and confirmed that the order had been placed, but the medications were still unavailable. The resident's Medication Administration Record (MAR) indicated that pantoprazole was to be administered once daily for acid reflux, and Entresto was to be given twice daily for heart failure, both starting from earlier in the month. The MAR entries for the date in question directed to see progress notes, which confirmed the unavailability of both medications. This lack of medication availability and administration as prescribed contributed to the facility's medication error rate exceeding the acceptable threshold.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications, leading to several deficiencies. During an observation, a medication cart was found unlocked and unattended in the hallway, with a half-eaten sandwich and a bottle of water on top. The drawers of the cart were accessible, except for the narcotic drawer, and contained loose medications. A Licensed Practical Nurse (LPN) admitted to leaving the cart to inform management of the state surveyor's presence. Additionally, another LPN identified loose tablets in a different medication cart, and there were no antibacterial wipes available for cleaning the glucometer, which was placed back into the cart after use. Further observations revealed expired and undated medications in the facility. In the East med room, a bottle of Tuberculin was found opened without a date, and a resident's latanoprost eye drops were undated and half full. On the North Hall medication cart, several medications, including Timolol and Brimonidine eye drops, and insulin vials, were either expired or lacked open and use-by dates. The facility's policies on medication storage and administration were not adhered to, as medications were not properly labeled or stored, increasing the risk of decreased efficacy and potential drug diversion.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination and foodborne illness risks for all residents consuming food from the kitchen. Observations revealed that the kitchen staff did not adhere to proper hygiene practices, such as wearing hair and beard nets, as required by the facility's policies. Specifically, a dietary aide refused to wear the necessary hair and beard nets and was subsequently sent home. Additionally, the kitchen floors were observed to have food droppings and debris, and the griddle had burnt-on food residue from previous meals. The dishwasher room was also noted to have debris on the floors and overflowing trash cans. The facility's food storage practices were found to be inadequate, with improperly labeled and stored food items in the coolers. An opened box of apple juice without an open date and a container of tea past its expiration date were found in the refrigerator. The kitchen's cleaning schedule was not consistently followed, as evidenced by the presence of unswept floors and dirty countertops, despite staff signing off on completed cleaning tasks. The kitchen manager acknowledged that the cleaning procedures were not being followed by the newer, younger staff, and that there was a significant buildup of lime on the dishwasher surfaces. Further observations highlighted improper glove use by kitchen staff during meal preparation and service. A cook was seen using the same pair of gloves for multiple tasks without washing hands in between, including handling food and opening storage areas. Additionally, structural issues were noted, such as an unfinished kitchen doorway with exposed drywall and metal, and an open drain under the sink without a cover. These deficiencies indicate a lack of adherence to professional standards for food safety and sanitation, posing a risk to the health and safety of the residents.
Deficiency in Vaccination Program
Penalty
Summary
The facility failed to maintain an effective vaccination program for four residents, as identified during a survey. Resident #59 had a signed consent for a pneumococcal vaccination, but the vaccine was never administered. Additionally, the consent form indicating refusal of the Pneumovax-23 vaccine lacked a date. Resident #72's records showed no consent or administration of influenza and pneumococcal vaccines. Resident #74 had consents signed for pneumococcal, influenza, and COVID-19 vaccinations, but none were administered. Resident #86's records lacked both immunization consents and any administered vaccines. Interviews with facility staff revealed gaps in the vaccination process. The Director of Nursing (DON) acknowledged that the infection preventionist did not have access to the State Agency Vaccination Database, which hindered the vaccination process. The DON admitted that immunizations should be offered upon admission and consents obtained at that time. An LPN was unable to explain why Resident #74 did not receive vaccinations despite signed consents. The facility's policies on influenza and pneumococcal vaccines were outdated, lacking current CDC recommendations, which contributed to the deficiencies.
Deficient Equipment Maintenance in Resident Rooms
Penalty
Summary
The facility failed to maintain essential resident equipment in safe operating condition, affecting multiple residents. In one instance, a resident in room 42A reported nearly falling due to a bed that did not lock properly, which had been an ongoing issue for weeks. The resident had previously fallen and bruised her shoulder due to the bed's instability. Despite the resident and her family notifying the staff, the issue remained unresolved until the surveyor's intervention. Additionally, another resident in the same room experienced frustration as their bed would not adjust up or down due to a malfunctioning remote control, which was not addressed until the surveyor's report. In room 63A, a resident's wheelchair was found to have loose wheels, which the resident had reported but remained unfixed until the surveyor's involvement. The resident expressed distress over the situation, and the staff was unaware of the issue until it was brought to their attention by the surveyor. Similarly, in room 3B, an overhead light fixture was cracked, posing a potential hazard, and had been in this condition for over a month without being addressed, despite the resident's report to the staff. The facility's maintenance staff and administration were unaware of these equipment issues, as there was no record of maintenance requests for the affected rooms. The Maintenance Director, who had been in the position for only two weeks, confirmed that they were not informed of these concerns until the surveyor's report. The Director of Nursing was also unaware of the equipment issues contributing to a resident's fall, as the fall report did not mention any bed-related problems. The Nursing Home Administrator could not provide an equipment policy, indicating a lack of systematic checks and communication regarding equipment maintenance.
Deficiencies in Resident Dignity and Call Light Response
Penalty
Summary
The facility failed to ensure resident rights pertaining to dignified care for several residents, resulting in multiple deficiencies. One resident, who was cognitively intact, reported being left wet due to untimely call light responses and the call light being out of reach. The resident expressed frustration over the situation, which was confirmed by a Licensed Practical Nurse who observed the call light was not properly placed. Another resident, also cognitively intact, reported waiting two to three hours for call light responses, which was particularly distressing due to their dependency on staff for mobility and personal care needs. Additional residents reported similar issues with call light response times, leading to prolonged periods of incontinence and frustration. One resident described waiting for hours to be assisted with a bedpan, while another reported that staff would turn off the call light at night and not return. The facility's failure to ensure timely call light responses was further highlighted during a confidential group meeting, where multiple residents shared experiences of extended wait times and feelings of neglect. The facility also failed to maintain privacy and dignity for a resident with severe cognitive impairment. This resident was observed exposed in their room with the door open, while staff attended to a roommate behind a curtain. The lack of privacy was not addressed until several minutes later when a staff member covered the resident. Additionally, a resident was observed being denied timely assistance for a change before a meal, with a CNA expressing frustration and refusing to assist, citing workload as a reason. These incidents collectively demonstrate a significant lapse in maintaining resident dignity and timely care.
Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic pain medication for a resident, resulting in discrepancies in the documentation of controlled substances. During an inspection of the North Hall medication cart, a discrepancy was found in the controlled substance log for a resident's Tramadol 50 MG. The facility was dispensed 30 pills, but the count was inaccurate, with one pill unaccounted for. The controlled substance form showed inconsistencies in the number of pills remaining, particularly on 5/17/2024, when the count decreased by two pills instead of one. This discrepancy was not caught during the routine narcotic count conducted at the beginning and end of each shift. Further review of the Medication Administration Record (MAR) from 5/15/2024 to 5/21/2024 revealed that Tramadol was documented as administered only three times, while the narcotic sheet indicated it was given eight times. This inconsistency suggests that facility nurses were not accurately documenting medication administration. The Director of Nursing (DON) confirmed that the MAR and narcotic sheet should match, but the investigation revealed that the missing Tramadol pill was still unaccounted for, and there was no documentation of it being wasted. The facility's policies on controlled substances and medication administration require accurate documentation and reconciliation of medications at each shift change. However, the failure to adhere to these policies led to the misappropriation of a resident's medication and inaccuracies in the controlled substance log. The nurse involved in the discrepancy was identified and suspended pending further investigation, highlighting the need for improved oversight and adherence to established procedures.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source to the State Agency for a resident, resulting in a potential for undetected abuse or neglect. The incident involved a resident who was assisted to the Central unit by another nurse after visiting another resident and experiencing a fall. The resident was found sitting in a wheelchair with an ice-wrapped right hand, and the tip of the right finger was bent upward. The resident was transferred to the emergency room, and upon return to the facility, X-ray results indicated fractures to the third and fourth metacarpals, with a cast noted on the right hand up to the arm. An interview with the Director of Nursing confirmed that the injury was not reported to the State Agency, as required by the facility's Abuse Prevention Program, which mandates immediate notification of such incidents to the appropriate authorities.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation for an injury of unknown origin involving a resident with dementia and severely impaired cognition. The resident was admitted with diagnoses including dementia with other behavioral disturbances and had a BIMS score indicating severe cognitive impairment. On a specific date, the resident was found with an injury to the right hand after visiting another resident. The injury was severe enough to require an emergency room visit, where fractures to the third and fourth metacarpals were diagnosed, and a cast was applied. The Director of Nursing confirmed that the investigation into the incident did not include witness statements from staff, despite the presence of staff who could have provided information. The facility's policies on abuse prevention and investigation require comprehensive steps, including interviews with involved staff and witnesses, which were not followed. This oversight resulted in a deficient practice with the potential for undetected abuse or neglect and unmet care needs for the resident.
Deficient PICC Line Management in LTC Facility
Penalty
Summary
The facility failed to provide care and services according to its policy and standards of clinical practice for two residents with Peripheral Inserted Central Catheter (PICC) lines. For Resident #290, the PICC line dressing was observed to be non-occlusive and dated 5/8, despite the resident being admitted on 5/10. The dressing had not been changed during the resident's stay, contrary to the facility's policy of weekly dressing changes. Additionally, there were no initial measurements of the PICC line upon admission, and the orders for PICC line monitoring and dressing changes were delayed by several days. Similarly, Resident #292's PICC line dressing was also non-occlusive, and flex tape was used in an attempt to secure it. The resident's medical records lacked documentation of initial measurements upon admission, and the dressing was not changed despite its condition. The facility's policy requires weekly dressing changes and initial measurements of arm circumference and catheter length upon admission, which were not adhered to in these cases. The discrepancies in documentation and untimely monitoring and dressing change orders were acknowledged by the facility's management.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for the use of psychotropic medications for two residents, leading to the administration of potentially unnecessary medications. Resident #60 was administered Paliperidone, an antipsychotic medication, for eight weeks without proper consent from her court-appointed guardian. Although verbal consent was reportedly obtained, there was no documentation to support this claim, and the consent form was not completed until eight weeks after the medication was ordered. The facility's policy on psychotropic management did not address the requirement for informed consents, contributing to the oversight. Resident #84 was administered multiple psychotropic medications, including two antipsychotics, an antidepressant, and Alzheimer's medication, without any signed consents. The resident was admitted to the facility from a hospital and was noted to be alert and oriented to self only. Despite the facility's efforts to work with the resident's daughter to obtain guardianship, no consents were documented for the medications administered. This lack of documentation and consent raises concerns about the appropriateness of the drug regimen and the potential for adverse side effects.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to administer and document medications per professional standards of practice for two residents, resulting in a discrepancy with narcotic medication and erroneous medication documentation. For Resident #58, a discrepancy was found in the controlled substance log for Tramadol, where one pill was unaccounted for. The log indicated that two pills were deducted on a specific date, although only one was administered. This discrepancy was confirmed by a count of the remaining pills, and the Director of Nursing (DON) acknowledged that the medication was still unaccounted for after an investigation. For Resident #293, the issue involved the attempted administration of Melatonin without a proper order. The resident refused the medication, and it was later discovered that the nurse involved had backdated entries in the medical record to justify the administration. The Medication Administration Record (MAR) showed discrepancies in the timing of the medication order and administration, and the nurse's documentation did not align with the actual events. The DON confirmed that the nurse had attempted to backdate the MAR entry and had documented the medication as given on an incorrect date. The facility's internal investigation revealed that the nurse involved, Nurse V, had a history of medication administration violations, including gross negligence and administering medication without proper orders. Despite being deemed competent in medication administration, Nurse V continued to demonstrate a lack of adherence to professional standards. The facility's policies on administering medications and documentation in medical records were not followed, leading to inaccurate and untimely documentation of medication administration.
Failure to Complete Yearly PASSAR and Level II Evaluations
Penalty
Summary
The facility failed to complete yearly PASSAR and Level II evaluations for three residents, resulting in a lack of yearly follow-up and documentation. Resident #602, admitted with diagnoses including Depression and Anxiety, had a comprehensive Level II evaluation due by March 11, 2022, but the most recent documentation was from May 17, 2023, without any other correspondence for 2023. Resident #604, with diagnoses including Dementia and Depression, had a PASSAR dated March 15, 2021, but no corresponding SAR (78) document. The Social Work Director (SWD) and Director of Nursing (DON) acknowledged the lack of up-to-date documentation and mentioned issues with access to the OBRA system as a contributing factor. Resident #603, with diagnoses including Major Depressive Disorder and Schizophrenia, had a PASSAR/Level II assessment dated October 28, 2022, but no documentation for 2023 and 2024. The SWD confirmed the absence of up-to-date assessments for this resident as well. The facility's PASSAR/Level II Screening Policy was requested but not provided during the exit interview.
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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