Medilodge Of Sterling Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling Heights, Michigan.
- Location
- 14151 East 15 Mile Road, Sterling Heights, Michigan 48312
- CMS Provider Number
- 235263
- Inspections on file
- 45
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Medilodge Of Sterling Heights during CMS and state inspections, most recent first.
A resident with limited mobility and multiple chronic conditions did not consistently receive restorative therapy services as ordered, with only partial documentation of therapy sessions and missed opportunities for care. Staff interviews confirmed both missed treatments and incomplete documentation, contrary to facility policy.
A resident experienced ongoing discomfort due to an inadequate mattress and reported the issue to multiple staff members over several months. Despite these reports, no documentation or maintenance work order was submitted, and the mattress was not replaced, even though other mattress replacements were processed for different residents during the same period.
A resident with significant mobility limitations and a care plan requiring two-person assistance for bed mobility fell from bed when a hospice aide provided care alone, contrary to the documented intervention. Facility records and staff interviews confirmed the care plan was not followed, resulting in the resident's fall.
The facility failed to serve food in a palatable manner and at preferred temperatures for several residents, leading to dissatisfaction. Residents reported the food as cold, unappetizing, and sometimes difficult to chew. A lunch tray was found to have food items served at lukewarm temperatures, and group interviews highlighted food quality as a significant concern. The facility's policy on food preparation and serving temperatures was not consistently met.
The facility's kitchen dish machine area was not maintained in a clean manner, leading to a gnat infestation. Numerous gnats were observed due to wet, murky standing water and black slimy substances on pipes. Pest control reports from August 2024 to January 2025 highlighted heavy gnat activity due to poor cleanliness, particularly around the dish tank, sinks, corners, and drains.
The facility failed to ensure call lights were within reach for five residents, leading to a deficiency in call light accessibility. Observations showed call lights on the floor and out of reach, despite staff knowing the proper placement requirements. Residents had various medical conditions and required different levels of assistance, yet the issue persisted across multiple observations and interviews.
A facility failed to promptly investigate an abuse allegation involving a resident with severe cognitive impairment. The incident, where a staff member allegedly mocked the resident, was reported by a witness but not investigated until 13 days later. The delay and inconsistency in witness statements indicate a deficiency in following the facility's abuse policy.
The facility failed to complete an annual PASARR for two residents. One resident with severe cognitive impairment had no level II PASARR request, while another resident with intact cognition had no updated PASARR available. The facility's policy requires coordination with the PASARR program, which was not followed.
A resident with PTSD and Major Depressive Disorder was admitted to the facility, but the care plan failed to address the PTSD diagnosis and known triggers. Despite the resident's intact cognition and acknowledgment of PTSD, the mood/behavior care plan lacked necessary details. Interviews with staff revealed communication lapses, as the PTSD diagnosis was not included in the care plan during the behavior meeting, contrary to facility policy.
The facility failed to provide timely ADL assistance to two residents. One resident experienced delays in receiving care, including being left on a bedpan for two hours. Another resident, who requires 1:1 feeding assistance, was observed eating without help despite having impaired cognition and shaking hands. The facility's policy mandates necessary services for residents unable to perform ADLs.
A resident with Down's syndrome, Schizophrenia, and Chronic kidney disease expressed concerns about long toenails causing discomfort. Despite having intact cognition, the resident's medical records lacked a current podiatry consultation. Facility staff acknowledged the need for nail care, but the social services team was still establishing connections with ancillary services, resulting in a deficiency in timely podiatry care.
A resident with quadriplegia and gastrostomy was observed with an unlabeled and undated tube feeding bottle. An LPN confirmed that the tube feeding is set up during the evening shift and should be labeled. The DON also stated that the tube feeding should be labeled and dated when set up. However, the facility's policy on Feeding Tubes did not address labeling and dating requirements.
The facility failed to discard expired medications from a medication cart, as observed by an LPN. Two expired medications, Glucosamine Chondroitin and Oyster Shell Calcium, were found in the cart. The DON confirmed that expired medications should be removed, but the facility did not provide a Medication Storage policy.
The facility failed to maintain resident equipment in a clean and safe condition, affecting three residents with severe cognitive impairments. Observations revealed issues with a bedside dresser and overbed table, and the Maintenance Director found no submitted orders for repair or cleaning. The facility's Preventative Maintenance Program policy was not effectively implemented, as no maintenance requests were documented for the observed issues.
A facility failed to conduct weekly skin checks for a resident, leading to gangrene in the right great toe and hospitalization. The resident, with multiple health conditions, was at risk for impaired skin integrity, but an eight-week gap in assessments allowed the condition to worsen. The issue was discovered by a family member, and the facility's DON acknowledged the lapse in care.
The facility failed to provide adequate incontinence care, repositioning, and hydration for three dependent residents. Two residents were left without water and timely incontinence care, while another was found in a soiled state for hours without intervention. Despite staff presence, necessary care was not provided, leading to deficiencies in adherence to care plans and facility policies.
The facility failed to ensure a homelike environment in resident rooms and common areas, with issues such as non-functional lights, exposed wires, and cluttered shower rooms. Observations revealed safety hazards like sharp metal objects in hallways and inadequate maintenance of resident rooms, including missing light covers and rusting sink repairs. Maintenance logs showed unresolved issues, and interviews indicated delays in providing necessary items to residents.
A resident with a history of falls and moderate cognitive impairment experienced nine falls without adequate interventions being implemented in their care plan. Despite multiple incidents, the facility failed to consistently update the care plan to prevent further falls, contrary to their fall prevention policy.
The facility failed to serve food in a palatable manner and at the preferred temperature for three residents, leading to dissatisfaction during meals. A complaint was submitted, and a surveyor's taste test revealed issues with food temperature and flavor. Interviews with the Dietary Manager and residents confirmed these issues, despite the facility's policy stating that food should be palatable and served at an appetizing temperature.
The facility failed to maintain adequate lighting in the East Dining Room, as observed by surveyors and reported by a resident. Five lights were not functioning, and attempts to operate them were unsuccessful. The NHA was unaware of the issue until informed by the Activities Director, despite the facility's policy requiring maintenance requests to be documented in an electronic system.
The facility failed to maintain sanitary conditions of a steam table in the East Dining Room, where loose crusted material and mold were observed. The Nursing Home Administrator acknowledged the expectation for cleanliness, and the facility's cleaning policy highlights the importance of removing debris and bacteria.
The facility failed to maintain a clean and comfortable environment for two residents, leading to feelings of anger and frustration. A complaint revealed bugs and a black substance leaking from the air conditioner in their rooms. Despite reporting the issue, it persisted for months without resolution. Housekeeping confirmed the presence of bugs and the unsuccessful removal of the black substance, which was reported to maintenance. The Maintenance Director was unaware of the issues, and pest control had not been conducted. Facility policies on maintaining a safe environment were not followed.
The facility failed to notify the guardian of a resident's transfer to the hospital. The resident, with severe cognitive impairment and multiple diagnoses, required immediate medical intervention and was transferred via EMS. Despite the facility's policy and expectations, the responsible party was not informed of the change in the resident's condition.
Failure to Provide and Document Ordered Restorative Therapy Services
Penalty
Summary
A deficiency occurred when the facility failed to provide restorative therapy services as ordered for a resident with diagnoses including spinal stenosis, multiple sclerosis, and fibromyalgia. The resident, who was alert and oriented and required extensive assistance with bed mobility and transfers, was observed lying in bed and confirmed not receiving consistent restorative therapy during the week. Physician orders specified skilled restorative nursing three times a week for 12 weeks, focusing on active range of motion (ROM) exercises for both upper and lower extremities. However, a review of the clinical record over a 14-day period showed that restorative therapy was only documented as provided on three out of six possible occasions. Further investigation revealed discrepancies in documentation, as a CNA reported providing restorative therapy on additional dates that were not recorded in the medical record. The Assistant Director of Nursing acknowledged the lack of accurate documentation and stated that the restorative program was under review. Facility policy requires that implementation of restorative nursing programs be documented in the delivery record or electronic medical record, but this was not consistently done for the resident in question.
Failure to Timely Replace Uncomfortable Mattress After Resident Complaints
Penalty
Summary
A deficiency was identified when a resident reported having an uncomfortable mattress that felt as though it had a hole and caused them to feel the bed frame. The resident stated this issue had persisted since their admission approximately six months prior and that they had informed various staff members about the problem during this time. Despite these reports, the mattress was not replaced, and the resident continued to experience discomfort. Observations confirmed the mattress had a visible wrinkle and a compressed, softer center, supporting the resident's complaint. Interviews with staff, including a CNA and an LPN, confirmed that the resident had repeatedly voiced concerns about the mattress over several months. However, there was no documentation in the resident's progress notes regarding these complaints, and a review of the facility's maintenance reporting system (TELS) showed no work order had been submitted for a mattress replacement for this resident. Administrative staff confirmed that all staff are trained to enter work orders into TELS, and other mattress replacements had been processed for different residents during the same period. Maintenance staff also indicated that no work order had been received for this issue.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Primary Generalized Osteoarthritis, Spinal Stenosis, and Muscle Weakness, who was receiving hospice services, experienced a fall from their bed during care. The resident reported that the hospice aide was providing care alone and, while turning the resident in bed, the resident rolled off onto the floor. The resident's care plan specifically required two staff members to assist with bed mobility due to their fall risk, an intervention that was documented and in place prior to the incident. Facility records, including the incident/accident report and progress notes, confirmed that the hospice aide provided care without the required second staff member. The Director of Nursing acknowledged awareness of the incident and stated that the expectation was for care to be provided with two-person assistance, as outlined in the resident's care plan. The facility's policy also required care plans to be developed and implemented based on fall risk assessments.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food was served in a palatable manner and at the preferred temperature for several residents. Multiple residents, including those with intact cognition and various medical conditions such as COPD, osteomyelitis, and heart failure, reported dissatisfaction with the food quality. They described the food as cold, unappetizing, and sometimes difficult to chew. Specific instances included a resident noting that the food was better when surveyors were present, and another resident expressing that the food was cold and sometimes burnt. During the survey, a lunch tray was temperature checked, revealing that the food items were served at temperatures below what might be considered hot, with the chicken at 119.8°F, Brussels sprouts at 121.3°F, and rice pilaf at 122.1°F. The survey team also taste-tested the food and found it to be lukewarm and lacking flavor. The facility's dietary manager and corporate manager indicated that food temperatures were based on resident preferences, but no specific temperature guidelines were provided. A group interview with seven residents highlighted that food quality was a significant concern, with reports of the food being mostly warm rather than hot. The facility's food committee notes indicated mixed feedback, with 60% of residents finding the food tasty, but 35% reporting that it was not hot enough. The facility's policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served at a safe and appetizing temperature, but the observations and resident feedback suggest these standards were not consistently met.
Gnat Infestation Due to Poor Kitchen Cleanliness
Penalty
Summary
The facility failed to maintain the dish machine area in the kitchen in a clean manner, resulting in the presence of gnats. On March 10, 2025, numerous gnats were observed underneath the dish machine tank and drainboard, where the flooring was wet with murky standing water, and the pipes were coated with a black slimy substance. The Dietary Manager was unable to provide an explanation for the presence of gnats. Pest control service reports from August 2024 to January 2025 consistently noted heavy gnat activity due to poor cleanliness in the kitchen, particularly around and underneath the dish tank, sinks, corners, and drains. According to the 2017 FDA Food Code section 6-501.111, premises should be maintained free of insects, rodents, and other pests by eliminating harborage conditions.
Deficiency in Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents, leading to a deficiency in call light accessibility. Observations revealed that residents' call lights were often found on the floor and out of reach, despite staff being aware of the proper placement requirements. For instance, Resident 612's call light was observed on the floor, and staff confirmed it should be within hand reach. Similarly, Resident 613's call light was repeatedly found on the floor, even after staff entered and exited the room. Interviews with staff, including a unit manager and the administrator, confirmed that call lights should be accessible to residents. The residents involved had various medical conditions, such as end-stage renal disease, type 2 diabetes, osteomyelitis, cerebral infarction, sepsis, respiratory failure, hemiplegia, muscle weakness, and dysphagia. Some residents had intact cognition, while others had impaired cognition, requiring different levels of assistance with activities of daily living. Despite these needs, the facility's failure to ensure call light accessibility was consistent across multiple observations and interviews, indicating a systemic issue in maintaining proper call light placement.
Delayed Investigation of Abuse Allegation
Penalty
Summary
The facility failed to timely complete an investigation for an allegation of abuse involving a resident with severe cognitive impairment. The incident in question occurred when a staff member allegedly mocked the resident, leading to the resident becoming visibly upset and crying. The Maintenance Director witnessed the incident and reported it to the Nursing Home Administrator. However, the investigation was not initiated until 13 days after the incident, and witness statements were not obtained until the same day the investigation began. The facility's policy requires immediate investigation of any allegations of abuse, neglect, or exploitation, but this protocol was not followed. The delay in obtaining witness statements and the inconsistency in the Maintenance Director's account of the incident highlight deficiencies in the facility's response to the allegation. The Nursing Home Administrator considered the incident a customer service concern, which may have contributed to the delay in addressing the issue according to the facility's abuse policy.
Failure to Complete Annual PASARR for Two Residents
Penalty
Summary
The facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for two residents, R70 and R139, out of six residents reviewed for PASARR screening. R70 was admitted with diagnoses including dysphagia, intellectual disabilities, and functional quadriplegia, and had a severe cognitive impairment as indicated by a BIMS score of 00. The medical record for R70 showed a PASARR dated 11/27/24, but there was no request for a level II PASARR, which is required for residents with mental illness or intellectual disabilities. R139, who was observed in bed watching television and expressed a desire to meet with a social worker regarding a change in guardianship, was admitted with diagnoses including adjustment disorder with anxiety and depressed mood, bipolar disorder, and chronic respiratory failure with hypoxia. R139 had an intact cognition as indicated by a BIMS score of 15. The medical record for R139 showed a PASARR dated 7/08/24 with a hospital exemption for 30 days, but no updated PASARR was completed or available at the time of the survey. The facility's policy requires coordination with the PASARR program to avoid duplicative testing and mandates preadmission screening for all individuals with mental illness or intellectual disabilities, which was not adhered to in these cases.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing Post-Traumatic Stress Disorder (PTSD) for a resident, identified as R62, who was admitted with diagnoses of Major Depressive Disorder and PTSD. The resident's medical record and the most recent Minimum Data Assessment (MDS) indicated an intact cognition with a score of 15/15. Despite the resident's acknowledgment of having PTSD and experiencing triggers, the mood/behavior care plan did not include the PTSD diagnosis or known triggers. Interviews with facility staff revealed lapses in communication and documentation. The Social Worker (SW) stated that the PTSD diagnosis and known triggers should have been included in the mood care plan upon the resident's admission. The Director of Nursing (DON) acknowledged that the PTSD diagnosis was not communicated during the behavior meeting, which resulted in the care plan not being developed as required. The facility's policy on Comprehensive Care Plans mandates that the care planning process should assess the resident's strengths and needs, incorporating personal and cultural preferences, and should be trauma-informed, which was not adhered to in this case.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance for two residents in need of help with Activities of Daily Living (ADLs). Resident R24 reported that over a weekend, they requested ADL care at 6:15 AM, but did not receive assistance until 9:45 AM. On another occasion, they activated the call light at 7:00 PM and did not receive care until 9:30 PM. R24's medical records indicate they require assistance due to muscle weakness and limited mobility. The facility's concern forms documented multiple instances of delayed care, including an incident where R24 was left on a bedpan for two hours during the midnight shift. The Director of Nursing acknowledged issues with the midnight shift and stated that residents should be checked on hourly. Resident R154 was observed struggling to eat due to shaking hands and reported not receiving assistance with meals, despite having a physician's order for 1:1 feeding assistance. R154's medical records show they have impaired cognition and require assistance with eating. A nutrition note indicated that R154 benefits from supervision or assistance with meals. The Assistant Director of Nursing stated that R154 should receive help with meal setup and cueing, but observations showed R154 eating without assistance. The facility's policy on ADLs states that residents unable to perform these activities should receive necessary services to maintain good nutrition and hygiene.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide timely podiatry care for a resident, identified as R201, who expressed concerns about their toenails being too long and causing discomfort. During an observation, R201's toenails were noted to extend past the tips of their toes. The resident, who has a diagnosis of Down's syndrome, Schizophrenia, and Chronic kidney disease, could not recall their last podiatry visit. A review of R201's medical records did not show a current podiatry consultation, despite the resident having intact cognition as indicated by a BIMS score of 14. Interviews with facility staff revealed that R201 was on a list to be seen by podiatry, but the social services team was new and still working to establish connections with ancillary services. The Director of Nursing confirmed the need for R201's toenails to be cut. The facility's policy on nail care, revised in August 2024, requires assessments of residents' nails upon admission and readmission, and mandates reporting unusual nail conditions to a physician. However, this policy was not effectively implemented for R201, leading to the deficiency.
Failure to Label and Date Tube Feeding Bottle
Penalty
Summary
The facility failed to label and date a tube feeding bottle for a resident, identified as R75, who was observed on 3/11/2025 with an unlabeled and undated tube feeding bottle while laying in bed. Licensed Practical Nurse (LPN) A confirmed that the tube feeding is set up during the evening shift and acknowledged that it should be labeled. R75 was admitted with diagnoses of Quadriplegia and Gastrostomy and required staff assistance with bed mobility and transfers. The resident's recent Minimum Data Set assessment indicated a Brief Interview for Mental Status score of 99, showing they were unable to complete the assessment. The Director of Nursing (DON) also confirmed that the tube feeding should be labeled and dated when set up. However, a review of the facility's policy on Feeding Tubes revealed it did not address the requirement for labeling and dating.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure that medications were discarded when expired, as observed during a survey of one of the medication carts. On March 12, 2025, at 2:07 PM, an LPN identified two expired stock medications in the top drawer of Unit 100's lower numbered medication cart. The medications included Glucosamine Chondroitin, which had an open date of October 1, 2024, and a stamped expiration date of January 2025, and Oyster Shell Calcium 500mg, with an open date of September 25, 2024, and a stamped expiration date of August 2024. Later that day, at 4:15 PM, the DON confirmed that expired medications should be removed from use. Despite a request, the facility did not provide a policy for Medication Storage by the end of the survey.
Deficiency in Maintenance of Resident Equipment
Penalty
Summary
The facility failed to maintain resident equipment in a clean and safe condition, affecting three residents with severe cognitive impairments. Observations revealed that a bedside dresser for one resident had a two-inch gap between drawers, while another resident's overbed table was stained with dark circular marks. Additionally, a third resident's bedside dresser was stained, rough, and had uneven edges. These conditions were noted during observations conducted on March 10, 2025. The Maintenance Director reviewed the maintenance system and found no submitted orders for the repair or cleaning of the affected equipment. The facility's Preventative Maintenance Program policy, last reviewed in February 2022, requires the Maintenance Director to maintain a schedule of maintenance services to ensure equipment is safe and operable. However, the policy's implementation was lacking, as no maintenance requests were documented for the issues observed, indicating a failure in the facility's maintenance reporting and response system.
Failure to Conduct Weekly Skin Checks Leads to Gangrene
Penalty
Summary
The facility failed to complete weekly skin checks for a resident, resulting in the development of gangrene in the right great toe, right foot pain, and subsequent hospitalization. The resident, who had diagnoses including osteoarthritis, gout, adult failure to thrive, and end-stage renal disease requiring dialysis, was at risk for impaired skin integrity. The care plan for the resident included weekly skin inspections, but there was an eight-week gap between assessments, during which the condition of the resident's right foot deteriorated. The deficiency was identified when a family member visited the resident and discovered the gangrenous condition of the toe. The facility's Director of Nursing acknowledged the lapse in assessments and recognized the deficient practice. The resident was hospitalized for gangrene and sepsis, likely due to the gangrene, and continued to experience right foot pain even after returning to the facility.
Deficiencies in Resident Care: Incontinence, Repositioning, and Hydration
Penalty
Summary
The facility failed to provide adequate incontinence care, repositioning, and hydration for three dependent residents, leading to deficiencies in their care. Resident R703 and R707 were observed without water cups and reported not receiving timely incontinence care. R703 expressed concerns about not being turned as required, and both residents were left without water between meals, despite the availability of a water cart nearby. Staff were present in the hallway but did not address these needs, leaving the residents without necessary care for extended periods. Resident R706 was found in a soiled state, with a visible brown ring on the bed and gown, indicating a lack of timely incontinence care. Despite the presence of staff, R706 remained in the same position for several hours, with no intervention to change or reposition them. The resident's care plan indicated a need for assistance with toileting due to neuromuscular dysfunction, yet staff failed to provide the necessary care, leaving R706 in an unhygienic condition. The Director of Nursing acknowledged the need for repositioning, incontinence care, and hydration for dependent residents, confirming that no residents in the facility were fully independent. The facility's policies on Activities of Daily Living and Hydration were not adhered to, resulting in the observed deficiencies. The lack of staff intervention and adherence to care plans contributed to the inadequate care provided to these residents.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in resident rooms, common areas, and shower rooms on two nursing units. Observations revealed numerous deficiencies, including non-functional bathroom lights, unattached sink piping, and a burnt outlet. Sharp metal objects were found protruding from the hallway floor, posing a safety hazard. Resident rooms were observed with multiple white spackle patches on the walls, missing towel dispensers, and broken or missing light fixtures. Additionally, some rooms had exposed wires, rusting sink repairs, and missing light covers. Common areas and shower rooms were also found to be in disrepair and cluttered. The main hallway had a loose metal disc with bent edges, and baseboards were peeling away from the walls. Shower rooms contained various stored items, such as laundry bin frames and used foam wedges, and were not maintained in a clean state. Toilets in these areas had brown water stains, dead flies, and missing cabinet parts. The maintenance logs indicated unresolved issues, such as non-working lights and heating problems, which were reported but not promptly addressed. Interviews with residents and staff highlighted further issues, such as the delayed provision of necessary items like toilet seats and televisions upon admission. The facility's policies on maintaining a safe and homelike environment were not effectively implemented, as evidenced by the numerous maintenance and cleanliness issues observed. The administrator acknowledged that room readiness checks should be conducted by admissions, maintenance, and housekeeping staff before resident placement, but these checks were evidently insufficient or not performed.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement effective actions to prevent repeated falls for a resident, resulting in nine falls without appropriate goals and interventions to prevent further incidents. The resident, who was admitted after sustaining a fractured left wrist and left femur, had a history of dementia, heart disease, difficulty walking, cognitive communication deficit, and muscle weakness, with a BIMS score indicating moderate cognitive impairment. Despite experiencing multiple falls on various dates, the care plan was not adequately updated to address the resident's needs. A fall pad was only added to the care plan after a fall on 6/12/2024, and the care plan was revised again on 7/16/2024, 15 days after another fall, without interventions being put in place after the other falls. The facility's policy on fall prevention required reviewing and updating the care plan after any fall, which was not consistently followed.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for three residents, resulting in dissatisfaction during meals. A complaint was submitted to the state agency, stating that the food was terrible, and residents had to spend their own money on food, which they could not afford. During a surveyor's taste test of a random lunch meal, it was found that the cheeseburger and fries were only warm, the slaw lacked flavor, and the pickle spear was soggy, negatively impacting the meal's palatability. Interviews with the Dietary Manager and residents confirmed the issues with food temperature and palatability. The Dietary Manager acknowledged that hot food should be hot and cold food should be cold but could not explain why the last tray served was not warmer. Residents expressed dissatisfaction with the food, describing it as terrible. The facility's policy on food palatability, revised in 2017, stated that food should be palatable and served at an appetizing temperature, which was not adhered to in this instance.
Inadequate Lighting in Dining Room
Penalty
Summary
The facility failed to maintain adequate lighting in the East Dining Room, one of two dining rooms reviewed for a homelike environment. During an interview, a resident mentioned that the lights in the East Dining Room had been out for some time, and staff were aware but frustrated with the maintenance issues. An observation confirmed that five lights were not illuminated, and attempts to operate the switches with the Activities Director were unsuccessful. The Nursing Home Administrator was unaware of the issue until notified by the Activities Director and indicated that maintenance requests should be submitted through the electronic maintenance request system. The facility's Preventative Maintenance Program policy requires documentation of all tasks in the electronic maintenance request system to ensure a safe and comfortable environment.
Unsanitary Steam Table Conditions
Penalty
Summary
The facility failed to maintain a sanitary condition of the steam tables in the East Dining Room, specifically the third steam table with a small hood. During an observation, loose crusted material and mold were noted on this steam table. When the material was touched, it fell onto the area where food would be placed during use. This observation was made in the presence of the Nursing Home Administrator, who acknowledged that the steam table hoods should be clean and free of mold and materials that could contaminate food. The facility's cleaning policy, provided by a cleaning company, emphasizes the importance of cleaning and sanitizing to maintain a safe operation for residents, stating that cleaning removes visible debris and sanitizing removes most harmful bacteria.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for two residents, resulting in feelings of anger and frustration. A complaint was submitted to the state agency regarding bugs and a black substance leaking from the air conditioner in the residents' rooms. During an interview, one resident expressed their upset and anger over the situation, which had been ongoing for two to three months without resolution. The surveyor observed a dried blackish substance on the rug under the air conditioner and a small black bug on the resident's bedding. Housekeeping aides confirmed the presence of bugs and the unsuccessful attempt to remove the black substance from the carpet, which was reported to maintenance. The Maintenance Director was unaware of the environmental issues and indicated that bug spray had been used, but a pest control contractor had not inspected or treated the room. The account manager for environmental services, who was filling in for the facility manager, stated that if a stain could not be removed, they would consult with the Administrator and Maintenance Director about further actions. The Nursing Home Administrator indicated that rooms should be deep cleaned on a schedule and that pest control was expected soon. The facility's policies on maintaining a safe and homelike environment and pest control were reviewed, highlighting the failure to adhere to these guidelines.
Failure to Notify Guardian of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the guardian of a resident's transfer to the hospital. The resident, who was admitted with diagnoses of Vascular Dementia, Acute Kidney Failure, and Hypertension, had a severe cognitive impairment as indicated by a BIMS score of 0. On the date of the incident, the resident was found to be tachypneic and required immediate oxygen administration. Despite the medical intervention and the decision to transfer the resident to the hospital via EMS, the responsible party was not notified of the change in the resident's condition as required by the facility's policy. Interviews with the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA) confirmed that it was the facility's expectation to notify the responsible party or family members as soon as possible about any change in condition. A review of the facility's policy on Notification of Changes, revised on 1/01/22, also supported this requirement. However, the failure to inform the guardian of the resident's transfer to the hospital resulted in a deficiency in adhering to the policy and ensuring the guardian was aware of the resident's condition.
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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