Maple Valley Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Maple Valley, Michigan.
- Location
- 1086 W. Burdickville Road, Maple Valley, Michigan 49664
- CMS Provider Number
- 235588
- Inspections on file
- 20
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Maple Valley Nursing Home during CMS and state inspections, most recent first.
A newly installed boiler heating unit was found to lack manufacturer information and proof of state inspection. The facility could not provide documentation that required corrections identified by a state boiler inspector had been completed, and a final inspection had not been requested.
Surveyors observed multiple failures in food storage, hand hygiene, glove use, and beard net compliance by dietary staff, including unlabeled and undated food, improper hand washing, and repeated use of contaminated gloves during food preparation and service. The dietary manager confirmed staff did not consistently follow required procedures, and facility policies were not adhered to, potentially impacting all residents.
The facility did not establish or implement an effective infection prevention and control program, failed to update related policies, and did not conduct required infection surveillance or investigations. Staff did not use enhanced barrier precautions during high-contact care for a resident with multiple wounds, and an LPN failed to perform hand hygiene during medication administration for several residents, contrary to facility policy.
Three residents experienced delayed meal service when staff received lunch trays before all residents were served, resulting in frustration and hunger for those waiting. One resident, dependent on staff for all ADLs and unable to speak, waited over two hours for a meal, while two others reported being hungry and not having received their lunch. Staff interviews confirmed the delay, and facility policy requires residents to be served before staff.
A resident with COPD reported shortness of breath and requested her inhaler. An LPN administered albuterol without performing or documenting a respiratory assessment or O2 sat before or after administration. The DON confirmed that such assessments are expected, but facility policy did not specify this requirement.
The facility did not ensure that DNR orders for three residents with serious medical conditions were promptly accessible to staff in emergencies. DNR status was not entered in the EMR's code status bar or as a physician's order, and staff had difficulty locating the information, sometimes relying on a paper binder in the DON's office. This resulted in delays in identifying residents' code status during critical situations.
A resident with severe cognitive impairment and multiple psychiatric diagnoses did not receive required monthly CBC monitoring while on clozapine, due to staff failing to obtain blood samples and incomplete task tracking. The DON confirmed that missed lab draws were not reported, resulting in a lapse in monitoring for two months.
A resident with diabetes and other conditions did not have recommended lab draws for A1C and magnesium completed, despite pharmacy and physician agreement. The required A1C lab was missed due to issues with order entry and communication among staff, and there was no documentation that pharmacy recommendations for updated labs were addressed, contrary to facility policy.
A nurse, distracted by multiple residents at the med cart, administered another resident's medications—including Depakote, Seroquel, and vitamin D3—to a resident with a history of hypertension, diabetes, stroke, and depression. This resulted in the resident experiencing lethargy and confusion, in violation of the facility's medication administration policy.
The facility failed to provide up-to-date education and documentation regarding pneumococcal vaccines for two residents, using outdated consent forms and not supplying the most current CDC Vaccine Information Statements. Additionally, a resident did not receive a pneumococcal vaccination despite guardian consent, with no clinical reason documented for withholding it. Facility policies and standing orders were also not updated to reflect current CDC recommendations for PCV15, PCV20, or PCV21.
A facility failed to conduct regular skin assessments for a resident with a history of skin breakdown, leading to unaddressed redness and irritation. Despite the facility's policy requiring weekly assessments, only one assessment was documented shortly after admission. Interviews with staff confirmed the lack of adherence to the policy, resulting in a deficiency in quality of care.
A resident with moderate cognitive impairment sustained a second-degree burn after being served hot soup and left unattended in a reclined position. The soup, held at 173°F, spilled on her upper torso when she attempted to feed herself. Staff interviews revealed improper positioning for eating in bed, and the facility's policy required burn potential assessments, which were not documented.
A facility experienced a deficiency when two former CNAs removed a resident with severely impaired cognition and on hospice care from the premises without authorization or necessary medications. The resident was taken to an unknown location for approximately 16 hours, lacking proper consent or supervision. The incident highlighted lapses in following protocols for resident leave of absence, including the absence of a physician's order and failure in staff communication and oversight.
A resident with moderate cognitive impairment and a history of falls sustained injuries after falling in a common bathroom, highlighting the absence of a completed Fall Risk Assessment and insufficient supervision. Another resident with vascular dementia and a history of wandering eloped multiple times, indicating a lack of effective interventions to prevent elopement and ensure safety.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards by not disposing of expired food in kitchen refrigerators. Six expired containers of juice were found in the reach-in refrigerator, with no received dates labeled on top. The Kitchen Manager acknowledged missing these items during a recent check.
The facility failed to effectively administer its policies and procedures, impacting the well-being of all 22 residents. Key issues included the absence of the NHA during a critical IJ delivery, failure to report and investigate a resident's unauthorized LOA, inadequate staff support and training, and non-compliance with infection control and smoking policies. These deficiencies led to undetected abuse, potential psychosocial harm, and safety risks.
The facility failed to ensure the designated Infection Preventionist completed the required specialized training. The MDS Coordinator, who served as the IP from January 2023 through March 2024, did not finish the necessary training, citing time constraints. The DON and NHA confirmed this deficiency, which was documented in CMS Form #20054.
The facility failed to assess, reassess, obtain consent, and develop care plan interventions for a resident using mobility bars. The resident was unaware of signing a consent, and the use of mobility bars was not documented in the MDS assessments or care plan.
The facility failed to ensure monthly drug regimen reviews were completed and that recommendations were reviewed by a physician for multiple residents. Missing documentation and follow-up indicate a systemic issue in handling MRRs and pharmacist recommendations.
The facility failed to ensure resident rights training for three of seven employees reviewed. The Nursing Home Administrator and a Registered Nurse had not completed the required training within the 12-month period, and an Agency CNA had not completed any training. The Director of Nursing confirmed the lapses in training during an interview.
The facility failed to ensure infection control training for four of seven employees reviewed. The NHA had a future date listed for training, a CNA and the DON did not complete the required Infection Control Annual Inservice, and an agency CNA also did not complete the required training.
The facility failed to ensure that two residents were free from physical restraints imposed for convenience. Both residents had tab alarms used without proper documentation, consent, or physician orders, as confirmed by the Director of Nursing.
A resident with severe cognitive impairment and under hospice care was taken out of the facility overnight by two former CNAs without the guardian's permission. The facility failed to notify the guardian and the appropriate authorities in a timely manner, leading to significant distress and concern for the resident's safety. The incident was not reported to the State Agency as required by the facility's policies.
A resident with severe cognitive impairment and multiple medical conditions was taken out of the facility overnight by two former CNAs without the guardian's permission. The facility failed to follow proper procedures for obtaining permission, notifying appropriate parties, and investigating the incident, leading to significant distress and involvement of local law enforcement.
The facility failed to provide written transfer notifications to two residents when they were transferred to the hospital. The Director of Nursing in Training confirmed that the facility did not follow its policy, citing the small size of the building and the practice of notifying residents and their representatives individually.
The facility failed to provide written information to residents or their representatives regarding bed hold policies during hospital transfers, resulting in unawareness of potential expenses. The Director of Nursing in training admitted the facility did not follow its policy and lacked a specific bed hold form.
The facility failed to submit a quarterly MDS assessment for a resident with multiple diagnoses, including dementia and kidney disease. The last assessment was overdue by more than two months, and the LPN responsible discovered that the resident was not scheduled on the EMR scheduler, possibly due to a deletion error.
The facility failed to review, revise, and send PAS/ARR documents for a resident with mental illness and dementia to the local state agency. The required DCH-3878 form was missing from the resident's EMR, and the Social Services Director, recently employed, could not explain the oversight.
A facility failed to develop a resident-centered care plan for a resident with multiple medical diagnoses, including severe allergies and smoking habits. The care plan lacked focus areas, goals, or interventions related to the resident's smoking and severe allergy to bee stings, despite the resident's history of anaphylactic reactions and unsupervised smoking outdoors.
The facility failed to follow a physician's order for a resident requiring [NAME] hose and did not obtain emergency medication for another resident with a severe bee sting allergy, resulting in inadequate care and supervision.
A resident with a history of PTSD was not provided with trauma-informed care, leading to distress from another resident's yelling. The social worker was unaware of the resident's PTSD history and had not conducted an assessment to identify triggers, resulting in inappropriate care plan interventions.
The facility failed to ensure appropriate assessment, measurements, and consent for bedrails for a resident. Observations and record reviews revealed that the resident's bed had mobility bars without documented consent, assessment, or gap measurements. The DON confirmed the requirement for these documents but could not provide them.
The facility failed to coordinate behavioral health services for a resident with severe cognitive impairment and multiple behavioral health diagnoses. Despite recommendations for follow-up consultations, the resident exhibited ongoing violent behaviors and suicidal ideation without appropriate mental health intervention. The lack of a trained social worker and structured procedures contributed to the oversight.
A resident with schizophrenia and chronic kidney disease was mistakenly given Miralax by a nursing assistant in training. The DON had prepared the Miralax and labeled it, but the nursing assistant gave it to the resident without realizing it contained medication. The facility's policy requires prompt physician notification and close monitoring, but these steps were not documented in the resident's medical record.
A resident with multiple diagnoses was on a leave of absence and returned to the facility at 9:48 AM. However, the MAR inaccurately indicated that medications were administered at 8:00 AM. The DON confirmed the error, and there was no documentation of a medication error or notification to the attending physician as required by facility policy.
The facility failed to implement enhanced barrier precautions (EBP) for a resident with open wounds. Despite the resident's ongoing wound treatment, there was no transmission-based precaution (TBP) signage, and a nurse was observed performing wound care without proper PPE. The infection preventionist admitted that staff had not been fully educated on EBP procedures, leading to the deficiency.
The facility failed to offer an influenza vaccine to a resident with moderate cognitive impairment, despite CDC recommendations and the vaccine being due. The last documented administration was over three years ago, and no recent offering was found in the resident's records.
The facility failed to maintain an effective abuse and dementia management training program for three staff members. The NHA and an RN had not completed the required abuse, neglect, and exploitation training within the required 12-month period, and an Agency CNA had not completed the facility's abuse training program. Additionally, the NHA and the same CNA had not completed the required dementia training. The DON confirmed the training lapses during an interview.
A resident with intact cognition and multiple diagnoses was involved in inappropriate social media exchanges with a housekeeping staff member, leading to potential mental and sexual exploitation. The resident's guardian discovered the messages and reported them to the facility. Attempts to contact the staff member were initially unsuccessful, but their identity was confirmed through social media. Facility staff confirmed that such relationships are not allowed.
Lack of Documentation and Final Inspection for Newly Installed Boiler
Penalty
Summary
The facility failed to ensure that its heating, ventilation, and air conditioning (HVAC) system was in compliance with regulatory requirements, specifically section 9.2. During an observation, it was found that a newly installed boiler heating unit lacked manufacturer information and proof of a State of Michigan boiler inspection. The office manager was unable to confirm whether the necessary corrections identified by the state boiler inspector during a previous visit had been completed, and only had limited information about the inspector. Further confirmation from the State of Michigan boiler inspector indicated that the required corrections on the new boiler installation had not yet been completed, and a final inspection had not been requested.
Plan Of Correction
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The boiler was inspected and did not pass. Contractor has made the required repairs and is calling to schedule another inspection as soon as possible. Once the state boiler inspection has been completed, the local building department will perform their inspection. I personally spoke with the state boiler inspector on Friday, as the contractor is not fulfilling his responsibilities of completing this project and scheduling the inspection. The inspector said he would be able to come on Monday, June 30 or July 1, but I have not heard back with a confirmed date or time. I am unable to force the contractor or inspector to get this taken care of in a timely manner, so I do not have firm dates that it will be inspected or approved. Address how the facility will identify other residents having a potential to be affected by the same deficient practice: The residents are not affected by this deficient practice. The boiler is not in use as it is not heating season and operates as designed when needed. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur: This contractor will not be used again in the future. Maintenance Director will ensure any future contractors will complete permits and inspections prior to being paid in the future. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Maintenance director will monitor weekly and maintain communication with contractor to ensure the inspections are completed. Will be discussed at quarterly QAPI meetings.
Failure to Follow Food Safety and Sanitation Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations of improper food storage and handling practices. Surveyors found several food items, such as English muffin breakfast sandwiches and a bag of chicken breast, stored in the refrigerator and cooler without proper labeling or dating. Despite posted instructions to date foods removed from the freezer, staff were unaware of or did not follow these procedures. Additionally, staff could not account for certain food items found in storage, indicating a lack of oversight and adherence to food storage policies. Numerous instances of improper hand hygiene and glove use were observed among kitchen staff and aides. Staff were seen washing their hands for less than the required time, turning off faucets with bare hands, and failing to perform hand hygiene after tasks that could contaminate their hands, such as handling soiled items or touching their face. Staff also repeatedly used the same gloves for multiple tasks, including serving food, preparing meals, and delivering trays, without changing gloves or washing hands between tasks. In some cases, staff placed used gloves on clean prep surfaces, further increasing the risk of cross-contamination. Additional deficiencies included staff not wearing required beard nets while preparing food, despite having visible facial hair, and a lack of posted hand washing instructions at the kitchen sink. The facility's own policies required proper hand washing, glove use, and beard net use, but these were not consistently followed. The dietary manager acknowledged that staff did not change gloves or perform hand hygiene as often as required and was unable to recite the correct hand washing procedure. These failures in food safety and sanitation practices had the potential to affect all residents in the facility.
Failure to Implement Effective Infection Control Program and Precautions
Penalty
Summary
The facility failed to establish and implement an effective Infection Prevention and Control Program (IPCP), as well as to update IPCP policies annually. The Infection Preventionist (IP) was unable to demonstrate infection surveillance for symptomatic residents who had not been diagnosed with an infection and lacked methods for investigating infections. The IP tracked only residents prescribed antibiotics, without documenting symptoms or using established criteria to determine infections. The IP also did not investigate the origin of infections, analyze clusters, or determine the organism and source of infection. Employee illnesses were not tracked prior to January 2025, and there was no correlation monitoring between resident and employee illnesses. The facility's Infection Control Committee (ICC) was not active, and required meetings and policy reviews were not conducted. Several IPCP policies and procedures were outdated and had not been reviewed or updated annually as required. The facility also failed to implement enhanced barrier precautions (EBP) and proper hand hygiene during resident care and medication administration. For one resident with multiple unhealed wounds and a recent surgical amputation, staff did not wear protective gowns during high-contact care activities, despite clear signage and physician orders for EBP. Staff members, including a CNA, RN, occupational therapist, and physical therapist, were observed providing care without the required protective equipment. The CNA was unaware of the reason for EBP signage and could not distinguish between transmission-based precautions and EBP. Additionally, an LPN was observed repeatedly failing to perform hand hygiene before and after administering oral and inhaled medications to multiple residents. The LPN donned gloves without sanitizing hands and did not perform hand hygiene after glove removal or between medication passes, contrary to facility policy. The LPN acknowledged forgetting to perform hand hygiene during medication administration. Facility policies required handwashing before and after medication administration, but these procedures were not followed during the observed medication passes.
Failure to Provide Timely and Dignified Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for three residents by not ensuring timely meal service. During the lunch period, three staff members were observed receiving lunch trays before all residents had been served, contrary to facility policy. Observations and interviews revealed that some residents remained in their rooms without having received their meals well after lunch service had begun. One resident, who was dependent on staff for all activities of daily living and unable to speak due to medical conditions including Huntington's disease and aphasia, was observed expressing hunger and did not receive a meal until over two hours after lunch service started. Another resident with moderate cognitive impairment and a third resident with intact cognition both reported being hungry and not having received their lunch during the observation period. Staff interviews confirmed that the affected residents had not yet received their meals due to staff being occupied with other residents. The Director of Nursing and Dietary Manager both acknowledged that staff should not receive meals before all residents are served, and the facility's policy requires prompt delivery of food to ensure safe, palatable, and high-quality meals. The failure to follow this policy resulted in residents experiencing frustration and helplessness while waiting for their meals.
Failure to Assess Respiratory Status Before and After Inhaler Administration
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), who was cognitively intact, reported feeling short of breath and requested her inhaler. The LPN on duty administered two puffs of albuterol inhaler to the resident in the hallway without performing a respiratory assessment prior to administration. No baseline lung sounds or oxygen saturation (O2 sat) were obtained before giving the medication, and no assessment was conducted after administration to determine the effectiveness of the treatment. Further review of the electronic medication record and medication administration records showed no documentation of a respiratory assessment or O2 sat for the resident on the day in question. The LPN acknowledged that an assessment should have been completed both before and after administering the inhaler. The Director of Nursing confirmed that nursing staff are expected to conduct respiratory assessments for residents reporting shortness of breath and when administering as needed inhaled medications. The facility's policy on medication administered by inhaler did not include instructions for obtaining respiratory assessments before or after administration.
Failure to Ensure Immediate Access to Residents' Code Status in Emergencies
Penalty
Summary
The facility failed to ensure that residents' code status, specifically Do-Not-Resuscitate (DNR) orders, were clearly communicated and readily accessible to staff in the event of an emergency. For three residents with advanced directives, the DNR status was not entered as a physician's order or displayed in the designated code status bar within the electronic medical record (EMR). Instead, the DNR documents were filed under the miscellaneous tab, making them difficult and time-consuming for staff to locate during an emergency. In one instance, an LPN was unable to quickly find the code status for a resident, requiring several minutes to search through the EMR and ultimately referencing a paper binder kept in the DON's office, which was not immediately accessible. The residents involved had significant medical conditions, including Huntington's Disease, vascular dementia, adult failure to thrive, and encephalopathy, and were either totally incapacitated with court-appointed guardians or had signed their own DNR orders. Despite the presence of properly executed DNR documents, the lack of proper documentation and visibility in the EMR and other accessible locations meant that staff could not promptly determine residents' code status. The facility's policy required DNR orders to be documented in the resident's chart for staff awareness, but this was not consistently followed, as observed during staff interviews and record reviews.
Failure to Obtain and Review Required Lab Monitoring for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that laboratory results were obtained and reviewed as ordered to monitor for adverse effects of antipsychotic medications for a resident with severe cognitive impairment and diagnoses including dementia, seizure disorder, and schizophrenia. The resident had active orders for clozapine, which requires regular monitoring with a complete blood count (CBC) with differential every 30 days. However, the electronic medical record showed a gap in laboratory results, with the most recent CBC dated 12/27/2024, and no results for February and March 2025, despite the resident no longer being on hospice and the physician's order to continue monthly monitoring. Interviews revealed that the missed laboratory testing was due to staff failure to obtain the resident's blood sample, with the Director of Nursing stating that when staff are too busy or unwilling, the task is not completed and eventually disappears from the task list without being reported. This resulted in the resident not receiving the required monthly laboratory monitoring for two consecutive months while continuing to receive clozapine and other psychotropic medications.
Failure to Implement Pharmacy Recommendations and Timely Lab Orders
Penalty
Summary
The facility failed to ensure timely review and implementation of Medication Regimen Reviews (MRRs) and pharmacy recommendations for one resident. The resident, who had diagnoses including diabetes mellitus type II, bipolar disorder, and anxiety, was cognitively intact as indicated by a perfect score on the Brief Interview for Mental Status (BIMS). A pharmacy consultation recommended lab draws for A1C and magnesium levels, which the physician agreed to and signed. However, a review of the resident's medical records, medication and treatment administration records, and progress notes from October through December revealed that no labs were ordered or drawn, and there was no documentation of these labs being completed. Further review showed that a physician order for routine A1C labs was entered, but the required A1C lab for September was not scheduled or drawn, despite the last A1C being completed in March. The Director of Nursing (DON) acknowledged that lab draws were missed due to issues with order entry duration and communication lapses among travel nurses, resulting in the oversight. Additionally, a subsequent pharmacy consultation again requested updated lab values, but there was no evidence that this was addressed. Facility policy requires timely correction and documentation of pharmacy recommendations, which was not followed in this instance.
Significant Medication Error Due to Nurse Distraction
Penalty
Summary
A medication error occurred when a nurse administered another resident's medications to Resident #10, who had diagnoses including hypertension, diabetes, stroke, and depression, and was assessed as cognitively intact and independent with most activities of daily living. The incident took place during a medication pass when multiple residents were present at the medication cart, asking questions, which distracted the nurse. As a result, Resident #10 received Depakote 125 mg, Seroquel 50 mg, and vitamin D3 25 mcg, which were not prescribed to her. Following the administration of the incorrect medications, Resident #10 became lethargic and experienced confusion, as reported by both the resident and documented in the medical record. The facility's incident report confirmed the error and noted a change in the resident's condition, specifically lethargy for the majority of the shift. The facility's medication administration policy emphasized the importance of verifying the right resident and right medication, and cautioned against interruptions during medication passes, but these procedures were not followed at the time of the incident.
Deficient Pneumococcal Vaccine Education, Consent, and Administration
Penalty
Summary
The facility failed to properly educate residents or their representatives on the currently available and CDC-recommended pneumococcal vaccines for two individuals. In both cases, the immunization consent forms signed by the residents' representatives did not specify which Vaccine Information Statement (VIS) was provided, nor did they include information about the PCV15, PCV20, or PCV21 vaccines. Instead, the forms referenced outdated recommendations and vaccines, such as PCV13 and PPSV23, which are no longer recommended for routine use among adults aged 65 and older. There was also no documentation in the electronic medical records by the physician or Infection Preventionist regarding any discussions or education provided about the benefits or risks of pneumococcal vaccination. Additionally, the facility did not administer a pneumococcal vaccination or document any clinical reasons for withholding it for one resident, despite the legal guardian having provided consent for the vaccination more than two months prior. The resident's medical record lacked any documentation of contraindications or clinical considerations for not administering the vaccine. The Infection Preventionist confirmed that the vaccination had not been given and that the process was still ongoing, with no further explanation or documentation provided. The facility's vaccine consent forms and immunization policies were also found to be outdated, referencing vaccines and recommendations that are no longer current according to the CDC. The standing orders and immunization policy documents did not reflect the most recent guidance, which recommends the use of PCV15, PCV20, or PCV21 for adults at risk. The most current VIS, which includes updated recommendations, was not provided to the residents or their representatives, resulting in a lack of informed decision-making regarding pneumococcal vaccinations.
Failure to Conduct Regular Skin Assessments
Penalty
Summary
The facility failed to conduct regular skin assessments for a resident, leading to a deficiency in quality of care. The resident, who was admitted with diagnoses including ischemic cardiomyopathy and type two diabetes, had a documented history of skin breakdown and redness in skin folds. Despite this, the facility did not perform weekly skin assessments as required by their policy. The resident and her guardian reported consistent redness and irritation in her skin folds, which the facility did not address. Interviews with facility staff revealed that skin assessments were supposed to be conducted weekly and documented in the Treatment Administration Record (TAR) and the electronic medical record (EMR). However, the only documented skin assessment for the resident was on 10/26/24, shortly after admission, with no further assessments recorded. The Director of Nursing confirmed the lack of documentation and acknowledged the resident's history of skin issues, indicating a failure to adhere to the facility's skin integrity policy.
Resident Burned by Hot Soup Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent a serious burn injury to a resident who was served hot soup and left unattended. The resident, who had moderate cognitive impairment and was drowsy at the time, attempted to feed herself and spilled the soup, resulting in a second-degree burn on her upper torso. The soup was served at a temperature of 173 degrees Fahrenheit, which was hot enough to cause burns. The resident was found in a reclined position with the soup spilled on her abdomen, and the incident was reported by a Certified Nursing Assistant (CNA) who had left the tray unattended. Interviews with staff revealed that the resident was not positioned correctly for eating in bed, as she was reclined at approximately 45 degrees instead of being upright. The facility's Director of Nursing (DON) confirmed that the tray table should have been moved to the side, and the resident should have been placed in an upright position to prevent such accidents. The facility's policy on burns required an assessment for burn potential on admission and quarterly, but no such assessment was found in the resident's electronic medical record prior to the incident.
Unauthorized Removal of Resident by Former CNAs
Penalty
Summary
The deficiency reported by surveyors involved the facility's failure to prevent the unauthorized removal of a resident, Resident #9 (R9), from the facility by two former terminated Certified Nurse Aides (CNAs). The incident occurred on 9/18/23 when the former CNAs took R9 out of the facility to an unknown location for approximately 16 hours without authorization or necessary medications, including hospice medications and a thickening agent for R9's prescribed therapeutic diet. Despite being on hospice services and having severely impaired cognition, R9 was taken out without proper consent or supervision, posing a risk of serious harm or death. The facility's staff, including the former Director of Nursing (DON) and Registered Nurses (RNs), failed to follow protocols for residents going on a leave of absence, which required authorization from the responsible party or guardian. The facility's lack of oversight and communication led to a situation where R9's whereabouts were unknown for an extended period, causing distress to R9's guardian and raising concerns about the resident's safety and well-being. Additionally, the facility did not have a physician's order for R9's leave of absence, indicating a lack of proper documentation and adherence to established procedures.
Fall and Elopement Risks Due to Inadequate Supervision and Assessments
Penalty
Summary
The report details multiple deficiencies identified during the survey of a long-term care facility. One significant deficiency involved a resident (R24) who sustained a fall resulting in injuries due to the facility's failure to implement appropriate interventions to prevent falls. R24, a resident with moderate cognitive impairment and a history of falls, was found on the floor after falling in the women's common bathroom. Despite being identified as a moderate fall risk with poor safety awareness, R24 did not have a completed Fall Risk Assessment during their stay at the facility. The incident highlighted a lack of proper supervision and intervention to prevent falls for residents at risk. Another deficiency outlined in the report pertained to a resident (R17) with vascular dementia who eloped from the facility multiple times, posing a risk of falls and injury. R17's cognitive intactness and history of wandering behaviors were not adequately addressed by the facility, leading to instances where R17 attempted to leave the facility and engage in potentially unsafe behaviors. The lack of effective supervision and interventions to prevent elopement for residents with wandering tendencies was evident in this case.
Expired Food in Kitchen Refrigerators
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by not disposing of expired food in kitchen refrigerators. During an observation at 10:00 a.m. on the specified date, six expired containers of juice were found in the reach-in refrigerator, with expiration dates as far back as February 2024. None of the juice containers had a received date labeled on top. The Kitchen Manager acknowledged that he had recently checked the refrigerators for expired foods but had missed these juices. This failure to properly date and dispose of expired food items is a violation of the FDA Food Code 2017, which mandates that ready-to-eat, time/temperature control for safety food held for more than 24 hours must be clearly marked with the date by which it should be consumed, sold, or discarded.
Deficient Administration and Oversight in LTC Facility
Penalty
Summary
The facility failed to administer its policies, practices, and procedures effectively and efficiently, impacting the well-being of all 22 residents. The Nursing Home Administrator (NHA) was not present during the delivery of an Immediate Jeopardy (IJ) regarding resident abuse, despite being informed earlier by state surveyors. Additionally, the facility administration did not report and investigate an unauthorized leave of absence (LOA) of a resident, resulting in the resident's location being unknown for approximately 16 hours without necessary medical supplies and equipment, including hospice medications. This led to undetected abuse and potential psychosocial harm to the residents. The facility administration also failed to provide adequate support, training, and oversight to the staff. The former Director of Nursing (DON) reported a lack of communication and support from the administrative staff, who were often absent from the facility. The DON also mentioned that the new social worker was overwhelmed and not properly trained, leading to missed mental health services for a resident with violent behaviors and self-harm statements. Additionally, the MDS Coordinator/Former Infection Preventionist (IP) was terminated abruptly, further indicating a lack of effective management and support. The facility administration did not ensure that the IP completed the required specialized training in infection prevention and control, placing the entire facility population at risk for infectious disease outbreaks. The administration also failed to implement the Smoking Policy and Procedure for two residents, compromising the safety of residents, visitors, and staff. Furthermore, the administration did not maintain an effective abuse and dementia management training program, resulting in an Immediate Jeopardy when a resident was taken from the facility without the guardian's knowledge and a resident-to-resident altercation occurred. The facility's policies and procedures were not reviewed and updated as required, contributing to these deficiencies.
Failure to Ensure Infection Preventionist Completed Required Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) completed the required specialized training in infection prevention and control. The MDS Coordinator, who served as the IP from January 2023 through March 2024, did not finish the necessary training despite starting the certification process. During an interview, the MDS Coordinator admitted to struggling with the certification process and ultimately did not complete it. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed that the MDS Coordinator did not have the required certification and cited time constraints as her excuse for not completing the training. On the day of the scheduled Infection Control (IC) meeting, the MDS Coordinator was observed leaving the facility abruptly, indicating she had been terminated and would not participate in the meeting. The current IP, who received her certification in March 2024, was training under the MDS Coordinator until her departure. The facility's failure to ensure the MDS Coordinator completed the required IP training resulted in a deficiency, as verified by the DON and NHA. This deficiency was documented in the CMS Form #20054, which mandates that facilities must have a qualified IP with completed specialized training before assuming the role.
Failure to Assess and Obtain Consent for Mobility Bars
Penalty
Summary
The facility failed to assess, reassess, obtain consent, and develop care plan interventions for a resident. An observation was made of the resident in her room sitting in her wheelchair, with two side rails/mobility bars on the upper half of each side of her bed. The resident stated she was not aware of signing a consent for the mobility bars. The physician's order indicated the use of mobility assist bars, but the resident's Minimum Data Set (MDS) admission assessment and subsequent quarterly assessments lacked any indication of the use of a bed rail or mobility bar. Additionally, the resident's care plan did not include an intervention for the use of mobility bars or an assessment/reassessment for their use.
Failure to Complete and Document Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRRs) were completed and that recommendations were reviewed by a physician for five residents. Specifically, for Resident #20, the facility was unable to find the pharmacist's recommendations and the physician's response for the months of October and November 2023. Similarly, for Resident #21, the facility could not locate the pharmacist's recommendations and the physician's response for the months of November 2023 and January 2024. Resident #6 also had missing pharmacist recommendations and physician responses for multiple months, including September, October, December 2023, and February 2024. For Resident #4, the facility did not document any reports to the attending physician or Director of Nursing (DON) for several months, despite the pharmacist making recommendations. The DON was unable to locate the pharmacy recommendations and stated that the protocol was to upload these records to the resident's electronic medical record (EMR). The facility also failed to provide a policy regarding MRRs when requested by the surveyor. This lack of documentation and follow-up indicates a systemic issue in the facility's handling of MRRs and pharmacist recommendations.
Failure to Ensure Resident Rights Training
Penalty
Summary
The facility failed to ensure the provision of resident rights training requirements for three of seven employees reviewed. Specifically, the Nursing Home Administrator and a Registered Nurse had not completed the required resident rights training within the 12-month period, with their last training completed on 2/1/23. Additionally, an Agency Certified Nurse Aide had not completed any resident rights training. During an interview, the Director of Nursing stated that she was responsible for annual training and competencies and that the facility conducts training based on the calendar year. The DON also mentioned that the agency staff should have completed the training through their agency, but confirmed that the Agency CNA had not completed specific training for this facility. The facility's Resident Abuse, Neglect, Mistreatment, or Misappropriation Prevention Program mandates that all staff and volunteers be in-serviced upon employment and at least annually thereafter regarding Resident's Rights.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to ensure the provision of infection control training for four of seven employees reviewed for infection control training. Specifically, the Nursing Home Administrator had a future date listed for training completion, indicating it had not been done. A Certified Nurse Aide (CNA) and the Director of Nursing (DON) did not complete the required Infection Control Annual Inservice. The DON was noted to have been the preventionist for years but no documentation or certificate was provided to confirm her training. Additionally, an agency CNA also did not complete the required Infection Control Annual Inservice. These deficiencies were identified during a review of staff education records and competencies on 4/25/24.
Failure to Ensure Residents Were Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents, R15 and R20, were free from physical restraints imposed for purposes of convenience. R15, who had diagnoses including dementia, anemia, kidney disease, and constipation, was observed with a tab alarm clipped to the back of her shirt while sitting in a reclining chair. The review of R15's electronic medical record (EMR) found no physical order, signed consent, or restraint assessment, despite the care plan indicating the use of a tab alarm. R15's responsible party was listed as a guardian, but there was no documentation of consent from the guardian for the use of the restraint. Similarly, R20, who had diagnoses including dementia, aphasia, and cerebral infarct, was observed without a tab alarm clipped to his shirt on multiple occasions, despite the care plan indicating its use. The review of R20's EMR also found no physical order, signed consent, or restraint assessment. R20's responsible party was his spouse, but there was no documentation of consent for the use of the restraint. The Director of Nursing confirmed that all alarms need a consent from the resident or guardian, a physician order, and should be care planned and reassessed quarterly, which was not done in these cases.
Failure to Report Unauthorized Leave of Absence Timely
Penalty
Summary
The facility failed to ensure an unauthorized leave of absence (LOA) was reported timely to the facility administrator and State Agency (SA) for one resident. Resident #9, who had severe cognitive impairment and was under hospice care, was taken out of the facility overnight by two former CNAs without the guardian's permission. The guardian was not informed until the following morning, causing significant distress and concern for the resident's safety. The progress notes revealed that the resident was taken out of the facility at 6:07 PM, and attempts to contact the guardian were made later that night but were unsuccessful. The resident returned the next morning, and the facility staff, including the Director of Nursing (DON) and Nursing Home Administrator (NHA), were unaware of the resident's absence until they arrived at work. The facility's failure to notify the guardian and the appropriate authorities in a timely manner was a significant oversight. Interviews with the staff indicated a lack of clarity and communication regarding the resident's leave. The former DON admitted to not notifying the NHA immediately due to previous instructions not to bother them. The NHA confirmed that the incident was not reported to the SA as required by the facility's policies. This incident highlights a breakdown in the facility's procedures for managing and reporting unauthorized absences, especially for residents with severe cognitive impairments and under hospice care.
Failure to Investigate Incident of Abuse/Neglect
Penalty
Summary
The facility failed to investigate an incident of abuse/neglect involving a resident with severe cognitive impairment and multiple medical conditions, including Huntington's disease and aphasia. The resident was taken out of the facility overnight by two former CNAs without the permission of the resident's guardian. The guardian was not informed until the following morning, causing significant distress and concern for the resident's safety and well-being. The progress notes and interviews with staff and the guardian revealed that the facility did not follow proper procedures for obtaining permission for a leave of absence (LOA) and failed to notify the appropriate parties in a timely manner. The resident's responsible party was not contacted until after the resident had already left the facility, and multiple attempts to reach the former CNAs and the guardian were unsuccessful. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were unaware of the resident's absence until the next morning, and local law enforcement was eventually involved. The facility's policies on abuse investigation and incident/accident reporting were not followed. There was no documented investigation summary of the incident, and the State Agency (SA) was not notified. The NHA and DON confirmed that the incident was not properly discussed in Quality Assurance and Performance Improvement (QAPI) meetings, and no appropriate corrective action was taken. The failure to investigate and report the incident as required by facility policy and regulatory standards constitutes a significant deficiency in the facility's handling of abuse/neglect allegations.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to notify two residents in writing about the reasons for their transfers to the hospital. Resident 18 was transferred to the hospital on 7/7/23 and returned to the facility on an unspecified date, but there was no written notification of the transfer provided to her. Similarly, Resident 20 was transferred to the hospital on 6/19/23 and returned to the facility on an unspecified date, also without receiving written notification of the transfer. The facility's policy requires written notification of transfers to be provided to residents and their representatives, but this was not followed in these cases. During an interview, the Director of Nursing in Training confirmed that the facility did not follow its transfer notification policy, citing the small size of the building and the practice of notifying residents and their representatives individually. The facility's policy, reviewed on 1/30/24, mandates that written notice of pending involuntary transfers or discharges be provided to residents, with additional copies filed in the resident's chart and sent to relevant parties. The policy also requires documentation of the transfer or discharge in the resident's medical record and communication of appropriate information to the receiving healthcare institution or provider.
Failure to Provide Written Bed Hold Information
Penalty
Summary
The facility failed to ensure written information was provided to residents or their representatives regarding bed hold policies during hospital transfers or therapeutic leaves. Specifically, three residents (R18, R20, R24) were transferred to hospitals on various dates, and in each case, there was no Bed Hold Authorization form completed in their Electronic Medical Records (EMR). This resulted in the residents and their representatives being unaware of potential expenses related to reserving their beds during their absence from the facility. Interviews and record reviews revealed that the facility did not follow its policy regarding bed holds and transfers. The Director of Nursing in training acknowledged that the facility did not have a specific bed hold form and admitted that they typically notify residents or their representatives individually. The facility's policy, revised in 2002, mandates informing residents of their rights and obligations during temporary absences, but this was not adhered to in the cases reviewed. The lack of proper documentation and notification represents a significant deficiency in the facility's compliance with regulatory requirements.
Failure to Submit Quarterly MDS Assessment
Penalty
Summary
The facility failed to submit a quarterly Minimal Data Set (MDS) assessment for one resident (R15) within the required timeframe. R15, who was admitted to the facility with diagnoses including dementia, anemia, kidney disease, and constipation, was dependent on staff for various activities of daily living. The last MDS assessment for R15 was completed on 10/11/23, and the next assessment was due on 2/10/24. However, no updated MDS assessment was found, and the facility could not provide one during the survey. This indicates that the quarterly MDS assessment was overdue by more than two months at the time of the survey on 4/25/24. During an interview, the Licensed Practical Nurse (LPN) responsible for MDS assessments stated that she uses the electronic medical record (EMR) scheduler and the Resident Assessment Instrument (RAI) tool to keep track of assessment due dates. Upon checking the EMR, the LPN discovered that R15 was not scheduled on the scheduler, which she attributed to a possible deletion error. The LPN acknowledged that R15's quarterly MDS assessment was overdue and expressed the need to start the assessment immediately. The facility was unable to provide a policy for MDS assessments when requested by the surveyor.
Failure to Complete and Send PAS/ARR Documentation
Penalty
Summary
The facility failed to ensure that the Preadmission Screening (PAS)/Annual Resident Review (ARR) documents were reviewed, revised, and sent to the local state agency for a resident with mental illness and dementia. The resident, who was admitted with diagnoses including dementia with behavioral disturbance, depression disorder, and bipolar disorder, had an Annual Minimum Data Set (MDS) assessment indicating mild cognitive impairment. Despite the PAS/ARR Level I screening marking the resident as having a current diagnosis of mental illness or dementia and receiving treatment for the same, the required DCH-3878 form was not completed or sent to the local Community Mental Health Services Program (CMHSP). This oversight was discovered during a review of the resident's Electronic Medical Record (EMR). The Social Services Director, who had been recently employed and in her position for only three weeks, was unable to explain the missing form for the resident. The deficiency was identified through an interview and record review, revealing that the facility did not comply with the requirement to send the necessary documentation to the local CMHSP. This failure potentially excluded the resident from receiving necessary care and services appropriate to meet their mental health needs. The Social Services Director acknowledged the oversight but could not provide an explanation due to her recent employment and limited time in the position.
Failure to Develop Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop a resident-centered care plan for a resident with multiple medical diagnoses, including depression, bipolar disorder, paraplegia, and pressure ulcers. During an interview, the resident confirmed that the facility was treating his wounds, which were still open and undergoing treatment. However, there was no transmission-based precaution signage outside the resident's room to alert staff of the enhanced barrier precautions required due to the open wounds. Additionally, the resident's care plan did not include focus areas, goals, or interventions related to his smoking habits or his severe allergy to bee stings, despite the resident's history of anaphylactic reactions to bee stings and his unsupervised smoking outdoors. The resident was observed to have a lock box in his room, which he did not use, and kept his cigarettes and lighter in his jacket pocket. The resident's progress notes indicated that he had been smoking outdoors unsupervised and had received cigarettes and vape pens from his brother. The Director of Nursing (DON) was unaware of the resident's severe allergy to bee stings and the lack of emergency medication orders to counteract an anaphylactic reaction. The care plan was not updated to reflect the resident's allergy and smoking habits, leading to a deficiency in providing a comprehensive, resident-centered care plan.
Failure to Follow Physician Orders and Provide Emergency Medication
Penalty
Summary
The facility failed to follow a physician's order for a resident diagnosed with dementia, aphasia, and cerebral infarct. The resident was observed multiple times without the prescribed [NAME] hose while seated during the day. Interviews with staff, including a Registered Nurse (RN) and the Director of Nursing (DON), revealed that the staff were unaware of the resident's need for the [NAME] hose, and the order remained active in the electronic medical record (EMR) without being followed or discontinued if no longer needed. Another resident, who was cognitively intact and had a history of severe allergic reactions to bee stings, was observed smoking outside the facility unsupervised. The resident's medical records indicated an allergy to bee stings, but there was no physician order for emergency medication to counteract an anaphylactic reaction. Interviews with the RN and DON confirmed that they were unaware of the resident's need for such medication, and the resident was not provided with the necessary emergency medication or supervision while outdoors. The facility's failure to follow physician orders and obtain necessary emergency medication for residents demonstrates a lack of adherence to medical directives and inadequate resident care. The deficiencies were identified through observations, interviews, and record reviews, highlighting lapses in communication and oversight among the facility's staff.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to mitigate triggers that may cause re-traumatization for a resident (R6) who has a history of PTSD suspected from childhood sexual abuse. R6 expressed concern about another male resident who constantly yells out, which scares her. Despite this, the facility's social worker, who started three weeks prior, was unaware of R6's PTSD history and had not conducted a social service assessment to identify potential triggers. The care plan interventions for R6 were deemed inappropriate by the social worker, who acknowledged the need for more effective interventions. R6's medical records indicated diagnoses of dementia with behavioral disturbance, major depressive disorder, and bipolar disorder. Her care plan included a history of severe chronic bipolar disorder and PTSD, with interventions to provide a calming environment. However, the facility's trauma-informed care policy and procedure were not followed, as the social worker had not assessed R6 for trauma exposure or developed a plan of care to address her symptoms. The facility's policy required training for all employees on trauma-informed care, which was not evident in this case.
Failure to Ensure Proper Assessment and Consent for Bedrails
Penalty
Summary
The facility failed to ensure appropriate assessment, measurements, and consent for bedrails for one resident (R5). On 4/23/24, an observation revealed that R5's bed had two side rails/mobility bars, and R5 was unaware of having signed a consent for them. A review of R5's electronic medical record (EMR) showed no evidence of consent, gap measurements, or assessment for the mobility bars. The Director of Nursing (DON) confirmed that consent and assessment were required but could not provide the necessary documentation by the time of the exit on 4/25/24. R5's physician order dated 2/22/23 indicated the use of mobility assist bars, but the complete EMR lacked documentation of consent, assessment, re-assessment, and gap measurements. Additionally, R5's Minimum Data Set (MDS) admission assessment and subsequent quarterly assessments did not indicate the use of bed rails or mobility bars. The facility's policy on bed rails, dated 4/23/24, required a comprehensive assessment, medical need determination, and informed consent, none of which were documented for R5.
Failure to Coordinate Behavioral Health Services
Penalty
Summary
The facility failed to coordinate behavioral health services for a resident with severe cognitive impairment and multiple behavioral health diagnoses, including recurrent major depressive disorder, dementia, and delusional disorders. The resident was observed multiple times sleeping in a dark room and exhibited violent behaviors and suicidal ideation. Despite a consultation with a community mental health provider recommending follow-up, no follow-up occurred within the specified timeframe. The resident continued to display severe behavioral symptoms, including suicidal statements, over several months without appropriate mental health intervention. The resident's electronic medical record revealed numerous instances of suicidal ideation and violent behavior, yet there was a significant delay in follow-up consultations with the community mental health provider. The facility's Director of Nursing (DON) admitted that the lack of a trained social worker contributed to the oversight. The new social worker, who was inexperienced and overwhelmed, failed to manage the resident's behavioral health needs effectively. This lack of coordination and follow-up led to the resident's continued distress and unsafe behaviors. Interviews with staff, including Certified Nursing Assistants (CNAs) and the Social Services Director (SSD), confirmed the resident's ongoing behavioral issues and the facility's failure to provide necessary behavioral health services. The facility did not have a behavioral health policy available for review during the survey, further indicating a lack of structured procedures to address such critical needs. The deficiency highlights the facility's failure to ensure the resident received the necessary behavioral health care and services, as required by regulations.
Failure to Ensure Licensed Personnel Administered Medications
Penalty
Summary
The facility failed to ensure that licensed personnel administered medications to a resident. Resident #12, who has diagnoses including schizophrenia and chronic kidney disease, was mistakenly given Miralax by a nursing assistant in training. The Director of Nursing (DON) had prepared the Miralax in a thickened liquid and labeled it with the resident's first name. The nursing assistant, unaware that the cup contained medication, gave it to Resident #12, who consumed it quickly before it could be retrieved. The DON confirmed that CNAs are not permitted to administer medications and could not recall if the attending physician had been notified after the error. The facility's policy on medication error reporting requires prompt notification of the attending physician, implementation of physician's orders, and close monitoring of the resident for 24 to 72 hours. However, a review of Resident #12's electronic medical record did not show any physician communication or evidence of increased monitoring following the error. Additionally, the Medication Administration Record did not contain an order for Miralax at the time of the incident. The Medication Related Incident Report was signed by a physician approximately 11 days after the error occurred.
Inaccurate Medication Administration Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident diagnosed with Huntington's disease, aphasia, dysphagia, contracture of an unspecified hand, and alcohol abuse. The resident was on a leave of absence from the facility and returned at 9:48 AM. However, the Medication Administration Record (MAR) inaccurately indicated that medications were administered at 8:00 AM, which was not possible as the resident was not present in the facility at that time. The Director of Nursing (DON) confirmed that the medications were not administered at 8:00 AM and should not have been marked as such in the MAR. The facility's policy requires that medication errors be documented in the resident's clinical record and reported to the attending physician. However, there was no documentation of a medication error or evidence of notification to the attending physician in the resident's electronic medical record (EMR). The DON was unable to provide further insight into why the administration of the resident's medications was inaccurately documented or identify the nurse responsible for the error.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with open wounds. Resident #21, who was admitted with medical diagnoses including depression, bipolar disorder, paraplegia, and pressure ulcers, had wounds that were still open and undergoing treatment. Despite this, there was no transmission-based precaution (TBP) signage outside the resident's room to alert staff of the need for EBP. Additionally, a registered nurse was observed performing wound care without wearing proper personal protective equipment (PPE). The infection preventionist acknowledged the need for EBP for the resident but admitted that staff had not been fully educated on the procedures, leading to the lack of proper precautions and signage. The deficiency was further highlighted by the facility's own policy, which mandates the implementation of EBP for the prevention of transmission of multidrug-resistant organisms (MDROs). The policy, dated 4/5/24, was not followed, as evidenced by the absence of TBP signage and the improper use of PPE during wound care. The infection preventionist's admission that staff education was incomplete underscores the facility's failure to adhere to its own infection control protocols, thereby compromising the safety and care of the resident.
Failure to Offer Influenza Vaccination
Penalty
Summary
The facility failed to ensure that an eligible resident was offered influenza vaccines as recommended by the CDC. Resident #20, who has diagnoses including cerebral infarction, dementia, and aphasia, was admitted to the facility with a BIMS score of 8, indicating moderate cognitive impairment. A review of the resident's vaccination history revealed that the last dose of the seasonal influenza vaccine was administered on 10/30/20, and the status for eligible vaccinations indicated that the seasonal influenza vaccine was due. Interviews with the Current Infection Preventionist and the Director of Nursing in training confirmed that there was no documentation of an influenza vaccine offering for the resident in the previous three years. The CDC recommends routine annual influenza vaccination for all persons aged 6 months and older who do not have contraindications, ideally offered during September or October. However, the facility failed to document any offering or administration of the influenza vaccine to Resident #20 for the past three years, despite the resident being eligible and the vaccine being due. This deficiency was identified through interviews and record reviews conducted by the surveyors.
Failure to Maintain Effective Abuse and Dementia Management Training Program
Penalty
Summary
The facility failed to maintain an effective abuse and dementia management training program for three out of seven staff members reviewed for annual training. Specifically, the Nursing Home Administrator (NHA) and a Registered Nurse (RN) had not completed the required abuse, neglect, and exploitation training and competency evaluation within the required 12-month period, with their last training completed on 2/1/23. Additionally, an Agency Certified Nurse Aide (CNA) had not completed the facility's abuse training program. Furthermore, the NHA and the same CNA had not completed the required dementia training, with the NHA's last training also completed on 2/1/23. The Director of Nursing (DON) confirmed that the facility conducts training based on the calendar year and acknowledged that the agency CNA should have had training completed by the agency but did not have specific training for this facility. The facility's policy on Resident Abuse, Neglect, Mistreatment, or Misappropriation Prevention Program mandates that all employees and volunteers receive information, training, and ongoing in-services about appropriate interventions for dealing with aggressive or catastrophic reactions of residents, how to report allegations without fear of reprisal, recognizing signs of burnout, frustration, and stress that may lead to abuse, and what constitutes abuse, neglect, and misappropriation of resident property. The policy also requires that all facility staff and volunteers be in-serviced upon employment and at least annually thereafter regarding Resident's Rights, including freedom from abuse, neglect, mistreatment, and misappropriation of property. The failure to adhere to these training requirements was identified during an interview with the DON and a review of staff education records and competencies on 4/25/24.
Failure to Protect Resident from Exploitation
Penalty
Summary
The facility failed to protect a resident from potential mental and sexual exploitation by a staff member. The resident, who has intact cognition and diagnoses including quadriplegia, bipolar depression, and traumatic brain injury, was involved in a series of inappropriate social media exchanges with a member of the housekeeping staff. The resident initiated contact with the staff member, and the conversation quickly escalated to discussions of a sexual nature, including the exchange of explicit messages and images. The issue was brought to light by the resident's guardian, who discovered the inappropriate messaging and reported it to the facility. Despite attempts to contact the staff member involved, the facility was unable to reach them initially due to disconnected phone numbers and a full voicemail box. Interviews with facility staff, including the Nursing Home Administrator and Director of Nursing, confirmed that such relationships between staff and residents are not permitted. The identity of the staff member was verified through social media profiles, confirming their involvement in the inappropriate exchanges.
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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