Maple Manor Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayne, Michigan.
- Location
- 3999 Venoy Road, Wayne, Michigan 48184
- CMS Provider Number
- 235613
- Inspections on file
- 19
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Maple Manor Rehab Center during CMS and state inspections, most recent first.
A resident who developed a pressure ulcer did not have their care plan updated to reflect the wound or the prescribed interventions, despite documented recommendations from a Wound Care Practitioner for specific treatments and preventive measures. The care plan remained outdated and did not address the current skin impairment, and staff confirmed that the necessary updates were missed.
Two residents who required assistance with ADLs were observed with unkempt facial hair and long, dirty fingernails due to staff failing to provide routine shaving and nail care as required by care plans and facility policy. Both residents had intact cognition and expressed a desire for proper hygiene, but staff did not ensure these services were completed or documented, resulting in unmet hygiene needs.
A resident did not receive appropriate care for pressure ulcers, and preventive measures were not consistently implemented to avoid the development of new ulcers. Surveyors observed lapses in pressure ulcer management and insufficient monitoring for residents at risk.
A resident with a urinary tract infection and a supra-pubic catheter received a prescribed course of Macrobid, but their antibiotic use was not recorded on the facility's antibiotic surveillance log. This omission led to inaccurate infection rate calculations for several months, despite facility policy requiring all infections to be tracked and an antibiotic stewardship program to be in place.
A resident with Alzheimer's disease, who had provided consent along with their legal guardian for influenza and pneumococcal vaccines, did not receive either immunization despite being eligible and screened. The Infection Preventionist confirmed the oversight, and there was no documentation of vaccine administration in the medical record, contrary to facility policy.
A resident with Alzheimer's disease who had consented to receive the COVID-19 vaccine did not receive it, despite being screened and found eligible. The facility's Infection Preventionist confirmed that the vaccine was missed and that facility policy required vaccination upon admission.
A resident was discharged with heparin and syringes without proper education on administration, despite having a history of traumatic brain injury. The care plan noted a risk for complications, but no pre-discharge plan was established. Nurse B followed the NP's order to send the resident home with the medication, but did not provide training due to the resident's eagerness to leave. The facility's discharge policy was not followed, as the medication was not included in the discharge instructions.
The facility failed to maintain food safety standards, with undated and expired food found in the kitchen and resident refrigerators. Observations revealed moldy and rotten items, as well as staff personal food improperly stored. The Dietary Manager, CNA, RN, and administration acknowledged the need for proper labeling and removal of expired items to prevent foodborne illness.
The facility's Infection Control Program was found lacking, as the Infection Preventionist did not have a list of reportable diseases and failed to track staff illness call-ins. Additionally, the microbiology summary report, essential for monitoring antibiotic use, was unavailable and not discussed in meetings, indicating a failure to implement the facility's policies on infection surveillance and antibiotic stewardship.
A facility failed to assess a resident for self-medication administration before leaving medications at the bedside. The resident, with multiple diagnoses and a BIMS score indicating cognitive intactness, was observed during medication administration. A nurse left a Lidocaine Patch and a breathing treatment at the resident's bedside without verifying a physician's order for self-administration or bedside medication storage. The medical record lacked a physician's order for self-administration, and the resident's plan of care did not include information on the capacity to self-administer medication.
A facility failed to secure a resident's protected health information, leaving it visible on an unlocked computer screen in a common area. A CNA admitted to not logging off, and the DON confirmed the need for confidentiality. Additionally, a resident was without a privacy curtain for an extended period, leading to dissatisfaction. The Maintenance Director cited staffing issues for the delay, and the DON agreed on the necessity of privacy curtains.
A resident with multiple health conditions, including cerebral palsy and depression, was not consistently assisted with shaving, as required by the facility's care protocols. Despite being scheduled for showers twice a week, records showed that shaving was not performed or documented regularly. Staff interviews confirmed the inconsistency, and the Interim DON could not explain the oversight.
A resident receiving hospice services at the facility was not provided with a clear schedule or documentation of hospice care. The resident's hospice notebook lacked a current calendar and details of services, and there was no evidence of care conference collaboration with hospice providers. The Interim-DON confirmed the hospice care plan was incomplete.
Failure to Update Care Plan for Pressure Ulcer and Prescribed Interventions
Penalty
Summary
The facility failed to update the care plan for a resident who developed a pressure ulcer while residing in the facility. Observation revealed the resident was awake, alert, and sitting up in bed with some confusion, and had a dime-sized, shallow, crater-like open area on the coccyx covered with dried white cream. The CNA reported the pressure ulcer had developed a couple of weeks prior and that a cream was being applied. The RN confirmed the pressure ulcer was facility-acquired and, upon review of the electronic health record, could not find documentation of a care plan addressing the pressure ulcer. The most recent care plan for skin integrity, last reviewed months earlier, only included a goal for the skin to remain free from breakdown and did not reflect the current skin impairment or prescribed interventions. Progress notes from the Wound Care Practitioner documented the presence of moisture-associated skin damage and a small open area at the coccyx, with specific recommendations for wound care, pressure relief, and dietary interventions. These recommendations included the use of zinc oxide cream, a dry bulky dressing, aggressive off-loading, a foam wedge, a low-air-loss mattress, off-loading heel boots, and a dietitian consult. However, these interventions were not incorporated into the resident's care plan. The Director of Nursing acknowledged that the orders and recommendations were missed and the care plan was not updated, contrary to the facility's policy requiring the interdisciplinary team to develop a relevant care plan after assessment.
Failure to Provide Adequate ADL Assistance for Hygiene and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents who were unable to perform these tasks independently. One resident was repeatedly observed with long, dirty, and untrimmed fingernails as well as unkempt facial hair. The resident confirmed not being offered shaving or nail care, even on scheduled shower days, and expressed a desire for these services, noting that prior to admission, facial hair was kept neat. The care plan indicated the resident required assistance with all ADLs due to generalized weakness, but staff did not ensure the resident was added to the barber list or provided with nail care. Both the unit manager and DON acknowledged that CNAs and nurses were responsible for providing and verifying completion of these ADL tasks on shower days, but this was not done. Another resident was observed multiple times with long fingernails containing visible debris and reported being unable to cut their own nails, preferring them short. The resident's medical record showed a diagnosis of cerebral palsy and a need for substantial to maximal assistance with ADLs, with no documentation of refusals for care. The care plan lacked specific interventions for nail care, and staff interviews confirmed that nails should be trimmed and cleaned according to resident preferences. Facility policy required routine cleaning and inspection of nails during ADL care, but this was not consistently implemented, resulting in the residents' unkempt appearance.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and review of care practices, indicating that residents did not consistently receive the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The report notes lapses in the implementation of pressure ulcer prevention protocols and inadequate monitoring of residents at risk for skin breakdown.
Failure to Accurately Record Antibiotic Use on Surveillance Log
Penalty
Summary
The facility failed to accurately record the use of antibiotics for one resident on the antibiotic surveillance log. The resident, who was admitted with urinary retention and required a supra-pubic catheter, was diagnosed with a urinary tract infection and prescribed Macrobid 100 mg twice daily for 7 days, followed by Macrobid 50 mg once daily for 90 days. Review of the Medication Administration Record confirmed that the resident received the prescribed antibiotics from March through June, but the facility's Infection Control Log did not include the resident's use of Macrobid 50 mg once daily during this period. During an interview, the Infection Preventionist acknowledged that the resident's antibiotic use was overlooked and not included in the facility's antibiotic surveillance log or infection rate calculations for April, May, and June. This omission resulted in an incorrect facility infection rate for those months. The facility's policies require that all resident infections be tracked and that an antibiotic stewardship program be implemented as part of the infection prevention and control program.
Failure to Administer Consented Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide influenza and pneumococcal immunizations to one resident who had both the capacity and consent, as well as legal guardian consent, to receive these vaccines. The resident, who had Alzheimer's disease, was admitted to the facility and was screened and determined eligible for both vaccines. Despite signed and dated consents for both immunizations in January 2025, there was no documentation that either vaccine was administered. The Infection Preventionist confirmed that the vaccines were not given and acknowledged the oversight, stating that the resident should have received them. Facility policy required that influenza vaccines be offered annually between October 1st and March 31st, and that pneumococcal vaccines be offered unless medically contraindicated or previously administered, with completed records to be filed in the medical record.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to provide the COVID-19 vaccine to one resident who had consented to receive it, as identified through interview and record review. The resident, who had a diagnosis of Alzheimer's disease, was admitted to the facility and, along with their legal guardian, signed a consent form for the COVID-19 vaccine in January 2025. Despite being screened and determined eligible for vaccination, there was no documentation that the vaccine was administered. The Infection Preventionist confirmed that the facility's policy required screening, education, and provision of the COVID-19 vaccine upon admission, but acknowledged that the vaccine was missed for this resident without excuse. This deficiency was identified during a review of the facility's Infection Prevention Control Program and the resident's electronic health record, which showed a lack of documentation for the COVID-19 vaccine despite completed consent and eligibility.
Inadequate Discharge Planning for Anticoagulant Medication
Penalty
Summary
The facility failed to ensure adequate discharge planning for a resident, identified as R400, who was discharged with a bottle of heparin and syringes without proper education on administration. The resident, who had a history of traumatic brain injury and other medical conditions, was not previously on this medication. The hospital social worker reported that the resident was discharged without any explanation on how to use the medication, which is typically administered by a nurse. The resident's care plan indicated a risk for complications related to anticoagulant therapy, but there was no evidence of a pre-discharge plan being established with the resident or their representatives. The progress notes from the day of discharge did not include any instructions on the anticoagulant, and the discharge instructions provided to the resident did not mention the medication or how to administer it. Nurse B, who was involved in the discharge, admitted to not providing training on the medication due to the resident's eagerness to leave and later updated the progress note to reflect the discontinuation of heparin, which was not initially documented. Interviews with facility staff revealed that Nurse B was following the Nurse Practitioner's order to send the resident home with the anticoagulant if they were not walking. However, Nurse B expressed discomfort with this decision, fearing potential bleeding complications. The Director of Nursing confirmed that Nurse B was following the NP's order. The facility's policy on discharge summary required reconciliation of medications and documentation of discharge instructions, which was not adhered to in this case.
Deficient Food Safety Practices in Kitchen and Resident Refrigerators
Penalty
Summary
The facility failed to maintain proper food safety standards in the kitchen and resident refrigerators, as observed during a survey. In the kitchen walk-in cooler, there were undated and moldy food items, including bell peppers and mixed salad, as well as a tub of white onions and a box of sour cream without expiration dates. The kitchen freezer contained a staff member's personal item, a frozen bottle of red pop, which was not supposed to be there. In the pantry, an opened bottle of honey was found with an expired date. The Dietary Manager acknowledged that all items should be labeled, dated, and expired items discarded. Further observations in the North and South unit resident refrigerators revealed numerous unlabeled and undated food items, including personal staff lunches, drinks, and expired food items such as a rotted orange and expired frozen yogurts. Both the Certified Nursing Assistant and Registered Nurse present during the observations agreed that staff food should not be stored in resident refrigerators and that all items should be labeled and expired food removed. The Nursing Home Administrator and Director of Nursing were unsure of which department was responsible for maintaining the unit refrigerators, but agreed with the need for proper labeling and removal of expired food to prevent foodborne illness. The facility's policies on food safety and storage were reviewed, highlighting the requirement for labeling, dating, and monitoring refrigerated food.
Inadequate Infection Control Program and Surveillance
Penalty
Summary
The facility failed to establish a comprehensive Infection Control Program, as evidenced by several deficiencies noted during a review with the Infection Preventionist (IP) and the Interim Director of Nursing (I-DON). The IP was unable to provide a list of diseases that are required to be reported to state and local health departments. Additionally, the IP did not review or track the staff call-in log, which documents reasons for staff absences, including illness. This lack of documentation and tracking could hinder the facility's ability to monitor potential infection outbreaks among staff and residents. Furthermore, the facility did not have the microbiology summary report available, which is crucial for monitoring antibiotic usage and preventing overuse or inappropriate use. The report, which includes results of cultures and antibiotic susceptibility patterns, was not received or discussed during infection control meetings, as confirmed by the Medical Director. The facility's policies on Antibiotic Stewardship and Infection Surveillance were not effectively implemented, as they require tracking of employee infections and utilization of data from staff reports of symptoms, which was not being done.
Failure to Assess Resident for Self-Medication Administration
Penalty
Summary
The facility failed to assess a resident for self-medication administration before leaving medications at the bedside. The resident, who was admitted with multiple diagnoses including congestive heart failure, hypertension, and COPD, was observed during medication administration. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. During the observation, a registered nurse left a Lidocaine Patch and a breathing treatment at the resident's bedside upon the resident's request, without verifying a physician's order for self-administration or bedside medication storage. The medical record review revealed no physician's order for the resident to self-administer medication or to keep medication at the bedside. Additionally, the resident's plan of care did not include any information on the capacity to self-administer medication. An evaluation for self-administration of medication indicated the resident preferred to use the facility's nursing services, and the section for self-administration was left blank. The Interim-DON confirmed the lack of a physician's order and the absence of a completed evaluation demonstrating the resident's capability or desire to self-administer medication.
Privacy and Confidentiality Deficiencies in Resident Care
Penalty
Summary
The facility failed to properly secure protected health information for a resident, resulting in the potential for unauthorized disclosure, access, and modification. During an observation, a hallway computer screen was found unlocked with the electronic health record of a resident visible to multiple staff and visitors. A Certified Nursing Assistant (CNA) was logged into the computer and admitted to leaving the screen unlocked to answer a call, acknowledging the mistake of not logging off. The Director of Nursing confirmed that staff should log out or close the screen when leaving an EHR screen to protect confidential patient information. Additionally, the facility failed to provide a privacy curtain for a resident, leading to dissatisfaction and a lack of privacy. The resident expressed concern about the absence of a privacy curtain, which was confirmed by observations over two days. The Maintenance Director acknowledged receiving a work order for the curtain two weeks prior but had not completed the installation due to staffing issues. The Director of Nursing agreed that each resident bed should have a privacy curtain to maintain privacy. The facility's policy on confidentiality emphasizes the right to secure and confidential personal and medical records.
Failure to Provide Consistent ADL Assistance for Resident
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a resident who was dependent on staff for personal care. The resident, who was admitted with multiple diagnoses including athetoid cerebral palsy, hypertension, and major depression, was observed with facial hair stubble on multiple occasions, indicating a lack of regular shaving. The resident expressed a desire to be shaved and noted that staff only assisted with shaving sporadically. The facility's policy was to shave male residents on the days they received showers, but records showed that shaving was not consistently documented or performed. Interviews with staff, including a Certified Nursing Aide (CNA) and the Interim Director of Nursing (DON), confirmed that the resident was scheduled for showers twice a week, during which shaving was supposed to occur. However, documentation revealed that shaving was not completed or recorded on several occasions. The Interim DON acknowledged the lack of documentation and was unable to provide an explanation for the oversight. This deficiency in care was observed and confirmed during the surveyor's visit, highlighting a failure to adhere to the facility's care protocols for dependent residents.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to coordinate hospice services for a resident, resulting in a deficiency. The resident, who was admitted with multiple diagnoses including a benign neoplasm of the left kidney, type 2 diabetes, and chronic obstructive pulmonary disease, was receiving hospice services. However, the resident was unable to explain the disciplines or frequency of the hospice services provided and did not have a visible hospice service calendar in their room. The resident's medical record indicated they were receiving hospice services, but the plan of care did not specify the frequency or schedule of these services. During interviews, it was revealed that the hospice information, including a calendar of visits and services, should have been documented in a hospice notebook at the nurse's station. However, the notebook for the resident contained a blank hospice calendar and lacked details on the services and their schedule. The Interim-Director of Nursing confirmed the absence of a current hospice calendar and acknowledged that the hospice care plan was incomplete. Additionally, there was no documentation of care conference collaboration with hospice services, indicating a lack of coordination and communication between the facility and hospice providers.
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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