Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Belding, Michigan.
- Location
- 414 E State Street, Belding, Michigan 48809
- CMS Provider Number
- 235357
- Inspections on file
- 25
- Latest survey
- September 26, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with dementia and wandering behaviors repeatedly entered the rooms of other residents, despite care plans and staff attempts at redirection. On one occasion, this led to a physical altercation in which another resident sustained facial injuries and significant distress. Staff interviews revealed ongoing challenges with supervision, lack of effective interventions, and insufficient activities, contributing to the failure to protect residents from abuse.
The facility did not provide a meaningful activity program for cognitively impaired residents on the locked unit, leaving many unengaged and without posted activity schedules. Two residents with significant behavioral and cognitive needs were not provided with appropriate activities, leading to increased agitation and a physical altercation. Staff interviews confirmed that activities were often not conducted due to staffing shortages, and documentation of interventions was incomplete.
The facility did not conduct a thorough investigation into an alleged resident-to-resident abuse incident, as required by its policy. Although two residents were involved in a physical altercation resulting in injury, staff members who were present at the time were not interviewed or asked to provide statements, and there was no documentation of potential witnesses.
A resident with dementia and a history of falls was able to leave the facility unsupervised and was found in the parking lot attempting to open car doors. The resident was not under 1:1 supervision and did not have a WanderGuard device at the time, and staff were unable to determine exactly how the resident exited the building. The resident was outside for several minutes before being redirected back inside, with no reported injuries.
The facility failed to ensure call lights were within reach for five residents, despite care plans and assessments indicating their necessity. Observations revealed that call lights were consistently out of reach for residents with Alzheimer's, dementia, and other conditions, contrary to facility policy requiring staff to ensure accessibility during each interaction.
The facility failed to follow professional standards in administering treatments and medications for four residents. One resident missed multiple skin treatments, while another did not receive a scheduled pain medication dose without documentation or provider notification. A third resident missed an anxiety medication dose, and a fourth received insulin despite low blood sugar levels. An internet outage contributed to these issues, affecting the use of the Electronic Medical Record system.
A resident with severe cognitive impairment was allowed to self-administer hydrocortisone cream without an assessment by the interdisciplinary team, contrary to facility policy. The resident, who did not know the name of the cream, was left with the medication in his room, and staff had not documented any evaluation of his ability to safely self-administer the medication.
The facility failed to follow physician orders for daily weight monitoring and medication administration for two residents with CHF. One resident did not have weights recorded on several dates, and significant weight increases were not reported to the provider. Another resident did not receive as-needed Lasix despite weight gain. The DON confirmed the lapses in care, attributing them to assumptions made by nursing staff and a lack of specific CHF management policies.
Two residents experienced falls due to the facility's failure to follow care plans. One resident with Huntington's Disease was transferred by a single CNA instead of two, resulting in a fall and injuries. Another resident, who required assistance with a walker and gait belt, was observed walking independently without a gait belt. These incidents demonstrate non-compliance with care plans and facility policies.
The facility failed to thoroughly explain the arbitration agreement to two residents during the admission process. A visually impaired resident was not offered an audio explanation, and another resident with quadriplegia could not recall the details of the agreement. Both residents indicated that the agreement was not adequately explained, leading to a deficiency in the facility's admission process.
The facility failed to report alleged abuse within the required two-hour timeframe for four residents. An incident involving two residents was reported to the NHA four days late, and another incident was delayed due to the NHA's lack of internet access. The facility's policy requires immediate reporting, which was not followed.
The facility failed to properly monitor and treat the conditions of two residents, leading to severe outcomes including ICU admission and delayed treatment. Additionally, the facility did not ensure proper coordination of hospice services, complete wound treatments as ordered, or maintain a functioning air mattress for other residents.
The facility failed to ensure a dignified dining experience and proper hand hygiene for several residents. Staff were observed standing over residents while assisting them with meals, moving between them without practicing proper hand hygiene. One resident waited 20 minutes to be served his meal, and another was intermittently assisted while the CNA was focused on her phone.
The facility failed to provide meaningful activities to a resident with severe cognitive impairment and all residents in the S-1 and S-2 memory care units. Observations showed residents unengaged, and interviews revealed that staffing cuts significantly impacted the ability to provide activities. The activities calendar showed limited scheduled activities, with some only performed outside the memory care units.
A resident with severe cognitive impairment and a history of falls experienced multiple falls over a 60-day period due to the facility's failure to provide consistent assistance with mobility, transferring, and toileting. Despite physical therapy recommendations and various interventions, the resident continued to fall, resulting in minor injuries.
The facility failed to safeguard a resident's medical records, accurately document a guardian's name, obtain a proper signature on a Medical Treatment Decision Form, and ensure timely documentation by a PA, leading to potential impacts on resident care and confidentiality breaches.
The facility failed to maintain an effective QAPI committee, resulting in repeated deficiencies and undesired outcomes for residents. Surveyors observed residents in the memory care unit with no meaningful engagement and found quality of care issues such as unmonitored weight loss and lack of coordination with hospice. The DON acknowledged the issues but stated that the QAPI committee felt it was meeting regulatory expectations and had no performance improvement plans in place.
The facility failed to maintain adequate ventilation, resulting in stagnant, humid air and unpleasant odors in the North Hall. Observations revealed non-functioning exhaust vents in the shower room and bathrooms of two resident rooms. The Maintenance Director stated that the ventilation system is inspected twice a year and that the North halls have a separate rooftop unit from the South Halls.
The facility failed to ensure CNAs completed a minimum of twelve hours of in-service training annually. CNA D had 5.25 hours of training, CNA E had no record of in-service hours, CNA Q had 1 hour of training, and CNA X had 2 hours of training. Abuse and dementia training were either incomplete or initiated only after the survey began. The DON confirmed that Human Resources tracks employee in-service training.
The facility failed to obtain informed consent from the responsible parties of two residents before administering psychotropic medications. One resident was given Zyprexa without the legal guardian's knowledge, and another was given Lorazepam without the DPOA's awareness. Documentation errors and lack of timely communication were identified.
The facility failed to provide a clean, comfortable, and homelike environment for a resident with multiple medical conditions, resulting in potential safety hazards and compromised care. The resident's room was cluttered, obstructing access to the bed and oxygen concentrator, and there was no consistent documentation of interventions to address the clutter.
The facility failed to revise care plans for two residents and implement necessary revisions for one resident. One resident with severe cognitive impairment and a history of falls did not receive the required assistance, leading to multiple falls. Another resident experienced significant weight loss and edema, but the care plan was not updated to address these issues. A third resident, dependent on staff for eating, was not provided the necessary adaptive equipment and one-to-one assistance, compromising their care.
The facility failed to ensure proper medication administration for three residents. A nurse allowed a resident's husband to administer medications without staying in the room, another nurse left a resident unattended during a breathing treatment, and an IV antibiotic was administered outside of the physician-prescribed orders.
The facility failed to provide restorative nursing services for a resident with severe cognitive loss and multiple medical conditions, resulting in the potential for a decline in the resident's condition. Despite the need for range of motion (ROM) exercises, the resident's care plan and physician orders did not include any mention of such services, and the facility did not have a restorative nursing program in place.
A resident experienced significant weight loss due to the facility's failure to assess and monitor weight changes. Despite the resident's care plan to maintain nutritional status, the weight loss was not addressed, and no follow-up weight monitoring was conducted after diuretic treatment. The Registered Dietitian dismissed the weight loss warning based on an unverified hospital weight record.
A facility failed to follow accepted standards of practice for a PICC line dressing change for a resident with multiple health issues, resulting in improper hand hygiene, lack of use of a sterile barrier, and failure to measure the external catheter length. The nurse did not adhere to the facility's policy on central venous catheter dressing changes, as confirmed by nurse managers.
The facility failed to ensure unobstructed access to an oxygen concentrator and provide proper humidification for a resident with COPD and chronic respiratory failure. The resident's oxygen equipment was inaccessible due to clutter, and the humidification bottle was found empty, causing discomfort and potential respiratory distress.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant decline in health, which was not timely documented or acted upon by the facility's medical provider. Despite observable changes in the resident's condition, the provider did not order additional monitoring or lab work. The resident was later hospitalized with severe sepsis and other critical conditions, raising concerns about potential neglect.
The facility failed to provide medically-related social services for a resident, resulting in the resident not having current up-to-date guardianship documentation. The resident had multiple diagnoses and moderate cognitive impairment, but the temporary guardianship order for the primary contact had expired, and no updated documentation was available.
A resident with severe cognitive impairment was not properly monitored for psychotropic medication side effects, leading to hospitalization in critical condition. The facility failed to document Risk versus Benefit analyses for prescribed medications and did not act on documented signs of adverse effects.
The facility failed to publicly post nurse staffing data as required. The daily staff posting was found inside a binder at the main Nurses Station, but it was not publicly posted, and the binder did not indicate that it contained public information.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Inadequate Supervision and Ineffective Interventions
Penalty
Summary
A resident with a history of dementia, behavioral disturbances, and wandering behaviors repeatedly entered other residents' rooms, including that of another resident who was cognitively intact but had a history of behavioral and physical aggression. The care plan for the resident with dementia identified risks for wandering, impaired safety awareness, and lack of personal boundaries, with interventions such as redirection and offering diversions. Despite these interventions, documentation shows that the resident continued to wander, enter other residents' rooms, and exhibit exit-seeking behaviors. Staff notes indicated that the resident was not effectively redirected and that interventions to address aggressive behavior were not always documented or effective. On the day of the incident, there were no planned activities on the unit, and staff struggled to keep the resident with dementia occupied. Multiple staff interviews confirmed that the resident was in and out of rooms, taking items, and that other residents were becoming agitated by these intrusions. Staff attempted to redirect the resident with various activities, but these efforts were short-lived and did not prevent further wandering. The resident ultimately entered the room of another resident, resulting in a physical altercation where the cognitively intact resident sustained a bruise and skin tear to the face, as well as significant pain and distress. Interviews with staff and the affected resident revealed that the resident with dementia had been entering the same room multiple times over several days, and the affected resident had repeatedly reported this to staff without effective resolution. Staff acknowledged that 15-minute checks were routine and not a significant new intervention, and that the lack of activities and high resident acuity made supervision difficult. The facility's policy required identification, assessment, and intervention for residents at risk of conflict, but documentation and staff actions did not demonstrate effective implementation of these measures, resulting in physical and psychosocial harm to the resident who was assaulted.
Failure to Provide Meaningful Activities for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide a meaningful activity program for cognitively impaired residents on the locked unit, as well as for two sampled residents. Observations revealed that, at multiple times, residents were left unengaged in common areas, with only one activity assistant present and no other staff facilitating activities. Activity calendars were not posted in the hallways, common areas, or resident rooms, and where a calendar was present, it was left blank. Scheduled activities were not carried out as planned, and there was no system in place to indicate which activities had been completed or canceled. Staff interviews confirmed that activities were often not happening, particularly on the locked unit, and that staffing shortages contributed to the lack of engagement for residents. Two residents were specifically identified as being affected by the lack of meaningful activities. One resident, with a history of bipolar disorder, frontotemporal neurocognitive disorder, and other mental health diagnoses, was noted to have behaviors such as talking to themselves, agitation, and a history of physical aggression. The care plan for this resident included interventions to analyze triggers and de-escalate behaviors, but there was no evidence that meaningful activities were provided to address these needs. Another resident, with unspecified dementia and behavioral disturbances, was described as physically active, social, and in need of frequent one-on-one attention. This resident exhibited wandering, exit-seeking, and intrusive behaviors, and staff struggled to find activities to keep him occupied. Attempts to redirect him with simple tasks were only briefly effective, and documentation of interventions and outcomes was incomplete. Staff interviews further highlighted the deficiency, with multiple CNAs and LPNs reporting that there were no planned activities on the unit and that they struggled to keep residents engaged. Staff described increased resident agitation and behavioral incidents, including a physical altercation between two residents, which occurred in the absence of meaningful activities. The facility's own policy required ongoing activity programs tailored to residents' needs and preferences, including special considerations for those with dementia, but these requirements were not met as evidenced by the observations, interviews, and record reviews.
Failure to Conduct Thorough Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of resident-to-resident abuse involving two residents. One resident, who was moderately cognitively impaired with a history of dementia and behavioral disturbances, entered another resident's room and a physical altercation occurred, resulting in physical contact and injury. Both residents claimed to have been struck by the other, and immediate interventions such as separation, 15-minute checks, and notifications to appropriate parties were implemented. However, the investigation report did not include statements from staff members who were present and working with the residents at the time of the incident. Multiple staff members, including CNAs and nurses who were on duty during the event, reported during interviews that they were not asked to provide statements for the investigation. The facility's policy requires identifying and interviewing all involved persons, including witnesses and others who might have knowledge of the allegations, but there was no evidence that this was done. The investigation also lacked documentation regarding the presence of visitors or other employees who may have witnessed the incident, resulting in an incomplete investigation as required by facility policy.
Resident Elopement Due to Lapse in Supervision
Penalty
Summary
A resident with vascular dementia, aphasia, and a history of falls was admitted to the facility and was not her own responsible party. On the date of the incident, the resident was found outside the facility in the parking lot, unsupervised. The resident was observed by a recreation department staff member and an activity aide, who noted that the resident was attempting to open car doors and expressed a desire to go home and see her family. The staff member spent several minutes convincing the resident to return inside the facility. The facility was unable to determine with certainty how the resident exited the building, but it was believed that she left through a door near the parking lot. At the time of the incident, the resident was not under 1:1 supervision and did not have a WanderGuard device in place. The resident was unsupervised for approximately 3 to 4 minutes before being found and redirected back into the facility. There were no reported injuries or lasting harm as a result of the incident. Interviews and record reviews confirmed that the resident was able to leave the facility without staff supervision, and the facility acknowledged that the resident eloped. The incident highlighted a lapse in supervision and monitoring for a resident with known cognitive impairment and elopement risk, resulting in the resident's unsupervised exit from the facility.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents who were assessed or care planned for their use. Resident #294, a female with Alzheimer's and other health issues, was observed multiple times with her call light out of reach, despite her care plan specifying the need for an accessible call light to reduce fall risk. Similarly, Resident #32, a male with Alzheimer's and other conditions, was repeatedly observed with his call light out of reach, contrary to his care plan that required personal items and the call light to be within reach. Resident #70, a female with a history of falls and severe cognitive impairment, had no safety interventions involving the call light in her care plan, and her call light was consistently out of reach. Resident #14, a female with dementia and other health issues, was unable to reach her call light, which was wrapped around the bed rail. Resident #9, a female with dementia and anxiety, was observed with her call light out of reach and was unable to locate it. The facility's policy required staff to ensure call lights were within reach during each interaction, but this was not adhered to, as evidenced by the observations and interviews conducted.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice in the administration of treatments and medications for four residents. For one resident, there were multiple instances where skin treatments were not documented as completed, indicating they may not have been administered. Another resident did not receive a scheduled dose of a controlled pain medication, with no documentation explaining the omission or notification to the provider. Similarly, a third resident did not receive a scheduled dose of a controlled medication for anxiety, with no documentation or provider notification regarding the missed dose. Additionally, a fourth resident received insulin injections despite blood sugar levels being below the specified threshold for withholding the medication. The Director of Nursing reported that the facility's Unit Managers were expected to identify missed medications or treatments daily, but an internet outage on a specific date hindered the use of the Electronic Medical Record system, contributing to the medication administration issues. The facility's policy requires medications to be administered according to prescriber orders and within a specific time frame, which was not adhered to in these cases.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to perform a resident assessment for self-administration of prescription medication for a resident diagnosed with dementia and chronic obstructive pulmonary disease. The resident, who was admitted to the facility with a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, was observed with two medication cups containing a white cream in his room. The resident reported that staff left the cream for him to apply to a rash on his chest, although he did not know the name of the cream. A Registered Nurse (RN) confirmed that the resident had an order for staff to apply hydrocortisone cream to the rash, but the resident insisted on applying it himself. The RN admitted to leaving the cream in the resident's room without the interdisciplinary team discussing or determining the resident's safety in self-administering the medication. The Director of Nursing (DON) confirmed that there was no documentation in the electronic medical record (EMR) of an assessment to determine the resident's capability to self-administer the cream, which was against the facility's policy that requires an interdisciplinary team assessment before allowing self-administration of medication.
Failure to Implement Physician Orders for CHF Residents
Penalty
Summary
The facility failed to implement physician's orders for daily weight monitoring and medication administration for two residents with congestive heart failure (CHF). Resident #17, a female with acute on chronic combined systolic and diastolic CHF, had orders for daily weights and to report significant weight changes to her physician. However, weights were not recorded on several specified dates, and there was no documentation that the provider was notified of weight increases exceeding 2-3 pounds in one day, which could indicate worsening heart failure. Similarly, Resident #89, a male with chronic combined systolic and diastolic CHF, had orders for daily weights and as-needed Lasix for weight gain. Weights were not obtained on several dates, and the as-needed Lasix was not administered despite significant weight increases. The Director of Nursing (DON) confirmed that the weights were not obtained daily for both residents and acknowledged that licensed nurses were responsible for ensuring daily weights and monitoring weight trends. The DON identified that the inconsistency in obtaining weights was due to nursing staff assuming that certified nursing assistants had completed the task without verification. The facility lacked a specific policy or procedure for managing residents with CHF, contributing to the oversight in care. The report highlights the importance of accurate weight monitoring as an indicator of fluid status and the need for adherence to physician orders to manage CHF effectively.
Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to ensure that residents were transferred according to their care plans, leading to accidents involving two residents. Resident #66, a male with Huntington's Disease and a history of falls, was supposed to be transferred with the assistance of two staff members using a gait belt. However, a CNA attempted to transfer him alone, resulting in the resident falling and sustaining multiple injuries, including lacerations and abrasions. The incident occurred when the resident attempted to reposition himself after being transferred, and the CNA was unable to prevent the fall due to the lack of a second staff member. Resident #78, who was severely cognitively impaired and required assistance with ambulation using a wheeled walker and gait belt, was observed walking independently in the hallway. A CNA assisted the resident to a chair without using a gait belt, contrary to the care plan requirements. The CNA acknowledged the oversight, and the facility's policy mandates the use of gait belts for residents who cannot ambulate independently. These incidents highlight the facility's failure to adhere to care plans and policies designed to prevent accidents.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to two residents, leading to a deficiency in the admission process. Resident #58, a visually impaired female with glaucoma, was not given the opportunity to listen to an audio recording explaining the arbitration process for visually impaired residents. During her admission, she allowed administrative personnel to electronically sign the forms on her behalf, but she did not recall being informed about the arbitration agreement. The staff member responsible for the admission process admitted to not reading every paragraph of the agreement to the resident and was advised by corporate to provide only a brief explanation of the forms. Resident #88, a cognitively intact male with quadriplegia, also experienced a lack of thorough explanation regarding the arbitration agreement. He could not recall the details of the agreement when he signed it and stated that if it had been explained to him more thoroughly, he might have reconsidered signing it. The failure to provide a comprehensive explanation of the arbitration agreement to these residents highlights a deficiency in the facility's admission process.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report alleged resident abuse within the required two-hour timeframe for four residents. An incident involving two residents was reported to the Nursing Home Administrator (NHA) four days after it occurred, and subsequently reported to the state survey agency later that same day. The NHA acknowledged that staff are expected to report allegations of abuse immediately, but this did not occur in this instance. Another incident of alleged resident-to-resident abuse was reported to the NHA shortly after it occurred, but the state survey agency was not notified within the two-hour timeframe due to the NHA's lack of internet access at the time. The facility's policy requires immediate investigation and reporting of abuse allegations, but these procedures were not followed, resulting in a delay in reporting to the appropriate authorities.
Failure to Monitor and Treat Residents' Conditions
Penalty
Summary
The facility failed to identify, assess, properly monitor, and treat mental and/or physical changes in condition for two residents, resulting in severe outcomes. Resident #85, who had severe cognitive impairment and multiple diagnoses including dementia and anxiety, experienced a significant decline in mental and physical health. Despite documented concerns about her condition, including lethargy, refusal to eat, and altered mental status, the facility did not take timely and appropriate actions. Vital signs were not regularly monitored, and necessary risk versus benefit assessments for medications were not completed. This led to Resident #85 being admitted to the ICU in critical condition with severe sepsis, acute metabolic encephalopathy, and other life-threatening conditions. The Director of Nursing acknowledged the failures in monitoring and documentation, and the Physician Assistant responsible for the late entries was no longer employed at the facility due to these issues. Resident #76, who was cognitively intact and had a history of cellulitis, experienced a fever that was not adequately monitored or treated. Despite a physician's order to alternate Tylenol and Ibuprofen and to dip urine for testing, these orders were not promptly followed. The resident's temperature was not consistently recorded, and there was no documentation of the physician being notified about the resident's refusal to provide a urine sample. This lack of monitoring and timely treatment led to a delay in addressing the resident's condition, which was later diagnosed as cellulitis requiring antibiotic treatment. Additionally, the facility failed to ensure coordination of hospice services for one resident, complete wound treatments as ordered for another, and maintain a functioning air mattress for a third resident. The hospice notes were missing from the medical record, which hindered proper care planning. Wound treatments for one resident were frequently missed, and the monitoring of IV antibiotic treatment was not consistently documented. Another resident's air mattress was not functioning properly, and there were no clear instructions for its settings in the care plan. These deficiencies indicate a pattern of inadequate care and documentation, leading to potential harm and unmet care needs for the residents involved.
Failure to Ensure Dignified Dining Experience and Proper Hand Hygiene
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during lunch meal service. Certified Nurse's Aide (CNA) D was seen standing over three residents while assisting them with their meals, moving between them without practicing proper hand hygiene. One resident, R70, who was dependent on staff for eating, struggled to drink from a straw and was left unattended for several minutes. This resident also expressed a need to use the bathroom during the meal. Another CNA, E, was observed assisting multiple residents in a similar manner, without practicing hand hygiene between residents. South CCC F also failed to practice hand hygiene while assisting residents during the meal service. Resident R29, who had multiple diagnoses including Cerebral Palsy and Dysphagia, was observed being assisted by CNA E and South CCC F while they stood over him. R29 was repeatedly instructed to put his chin down while being assisted. Additionally, CNA Q was observed sitting next to R29 and another resident, focused on her phone, and only intermittently assisting R29 with his meal despite the resident's coughing and difficulty clearing his throat. Resident R82, who had severe cognitive impairment and a history of falls, was observed sitting at a dining room table for an extended period without being served his meal. He watched other residents eat for approximately 20 minutes before his meal was brought to him after a Regional Nurse Consultant intervened. The Director of Nursing (DON) acknowledged awareness of the hand hygiene concerns during lunch and mentioned that staff were being re-educated on proper practices.
Failure to Provide Meaningful Activities to Memory Care Residents
Penalty
Summary
The facility failed to ensure meaningful activities were provided to a resident with severe cognitive impairment and all residents in the S-1 and S-2 memory care units. The resident, who has diagnoses including dementia, anxiety, and major depressive disorder, was observed sitting unengaged in the dining room on multiple occasions. The resident's care plan included activities that exceeded their capabilities, and there was no documentation of the resident being offered or participating in group or one-on-one activities in the previous thirty days. The facility's memory care units, housing 52 residents, were observed to have residents unengaged in any activities or diversions. The activities staff was observed playing a card game with a few residents, while others were left unengaged. The activities calendar showed limited scheduled activities, with no activities on weekends or evenings, and some activities were only performed outside the memory care units, making it difficult for memory care residents to participate. Interviews with the Activities Director and a Registered Nurse revealed that staffing cuts had significantly impacted the ability to provide meaningful activities to residents. The Activities Director reported being left with only one assistant for the entire facility, making it challenging to keep residents engaged. The Registered Nurse confirmed that the activities staff was instrumental in keeping residents engaged before the staffing cuts, but the current staffing levels made it difficult to provide the same level of attention and engagement.
Failure to Prevent Repeated Falls for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to prevent repeated falls for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with Parkinson's disease and dementia, experienced multiple falls over a 60-day period. Despite the resident's need for assistance with mobility, transferring, and toileting, as indicated by physical therapy evaluations, the facility did not consistently provide the required support. This resulted in the resident sustaining minor injuries from falls on several occasions. The resident's care plan was not promptly updated to reflect the necessary interventions recommended by physical therapy. For instance, the care plan was only revised two months after the initial evaluation. The facility's fall investigation reports revealed that the resident fell multiple times due to attempting to self-ambulate, unassisted transfers, and poor safety awareness. Interventions such as placing non-slip strips, conducting medication reviews, and using sensor mats were implemented, but the resident continued to fall. The Director of Nursing acknowledged that the resident required assistance at all times with mobility and transfers, yet the facility failed to ensure this level of care was consistently provided. The resident's severe cognitive impairment further complicated the situation, as they were unable to learn or retain new tasks or skills. The facility's failure to implement appropriate safety precautions and provide adequate supervision led to repeated falls and injuries for the resident.
Confidentiality and Documentation Failures
Penalty
Summary
The facility failed to safeguard the confidentiality of medical records for one resident and maintain complete, accurate, and timely medical records for three residents. During an observation, a computer screen on a medication cart was left open, displaying a resident's electronic Medication Administration Record (e-MAR) with personal and health information visible. The responsible RN acknowledged the mistake but did not fully understand the severity of the breach in confidentiality. Another RN confirmed the proper protocol of logging off and closing the computer screen to protect resident information, which was not followed in this instance. For another resident, the facility failed to accurately document the guardian's name on a Risk vs. Benefit/GDR Form. The form listed an incorrect name, and neither the Nursing Home Administrator (NHA) nor the Director of Nursing (DON) could identify the person listed. The DON later admitted it was a typo, but the error remained uncorrected, leading to inaccurate medical records. Additionally, the facility did not obtain a proper signature from a guardian on a Medical Treatment Decision Form for another resident. The form noted a verbal confirmation via phone but lacked the guardian's name and signature, which are required for legal documentation. Furthermore, a resident's medical records contained late entries by a Physician Assistant (PA), which were not documented until three days after the resident was admitted to the hospital. This delay in documentation meant critical health information was not available to other medical providers and staff, potentially impacting the resident's care and leading to hospitalization.
Failure to Maintain Effective QAPI Committee and Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified care concerns, responded to deficiencies, and maintained compliance for all residents. This resulted in repeated deficiencies from the previous annual survey and undesired outcomes for residents. Specifically, the facility was found to be out of compliance with F-679, which pertains to meeting the activity needs and interests of residents. Surveyors observed residents in the memory care unit with no meaningful engagement, and the activities calendar showed no programming on weekends. Records for two residents did not reflect routine documentation for group or one-on-one activities. The Director of Nursing (DON) acknowledged the issue but stated that the QAPI committee felt it was meeting regulatory expectations and had no performance improvement plans in place to address the concern identified by the surveyors. Additionally, the facility was found to be out of compliance with F-684, which concerns quality of care issues such as identifying significant weight loss, ensuring nutritional needs are met, and assessing, monitoring, and reporting changes to the physician. During the annual survey, surveyors found evidence of quality of care concerns for multiple residents, including a resident whose change in condition was not identified, resulting in hospitalization, and another resident who had a fever reported to the physician but was not continuously monitored for infection. Other issues included a resident with an air mattress for impaired skin that was not operating as ordered, lack of coordination of care with hospice for another resident, and a significant weight loss in another resident that was not assessed or monitored. The DON was made aware of these findings but stated that the QAPI committee was not aware of the repeated deficient practices.
Inadequate Ventilation in North Hall
Penalty
Summary
The facility failed to maintain adequate ventilation, resulting in stagnant, humid air and unpleasant odors in the North Hall. On 4/1/24, observations revealed that the exhaust vents in the shower room and bathrooms of two resident rooms were not functioning, as evidenced by the lack of suction when tested with a paper towel. During an interview, the Maintenance Director stated that the ventilation system is inspected twice a year and that the North halls have a separate rooftop unit from the South Halls.
Failure to Ensure Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure Certified Nurse Aides (CNAs) completed a minimum of twelve hours of in-service training annually. During the survey, it was found that CNA D had only 5.25 hours of training, including abuse training, but had not completed dementia training. CNA E, hired on 6/5/23, had no record of in-service hours or abuse training. CNA Q had only 1 hour of in-service training, with no abuse training listed and dementia training initiated only after the survey began. CNA X had 2 hours of training, with no abuse training listed and dementia training completed after the survey began. The Director of Nursing (DON) indicated that Human Resources tracks employee in-service training and confirmed that the provided information was all that was available.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from the responsible parties of two residents before administering psychotropic medications. Resident 70, who had multiple diagnoses including depression, anxiety, and alcohol-induced persisting dementia, was administered Zyprexa without the knowledge of his legal guardian. The facility's records showed that an incorrect name was listed as the person informed about the medication, and there was no evidence that the guardian was aware of the medication's administration, indications, or risks and benefits until much later. The Director of Nursing acknowledged the error and stated it was a typo, but the facility could not provide adequate documentation to confirm that the guardian had been properly informed in a timely manner. Similarly, Resident 87, who had diagnoses including depression, dementia with psychotic disturbance, and visual hallucinations, was administered Lorazepam without the knowledge of his Durable Power of Attorney (DPOA). The facility's records did not show any indication that the DPOA was informed about the medication's risks, benefits, or reasons for use before it was administered. It was only 26 days after the administration of Lorazepam that the DPOA was documented as being informed. Interviews with the Nursing Home Administrator and the Director of Nursing revealed that they were unaware of the errors in the documentation and the failure to inform the responsible parties. The facility's attempts to rectify the situation included sending emails to the guardians, but these communications lacked proper documentation and timestamps, making it unclear whether the responsible parties were adequately informed in a timely manner.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for Resident #44, resulting in potential safety hazards and compromised care. Resident #44, who has diagnoses including bipolar disorder, heart disease, chronic obstructive pulmonary disease (COPD), and dependence on oxygen, was observed in a cluttered room with personal possessions piled on the floor, obstructing access to the bed and oxygen concentrator. The resident indicated that she had not been offered extra storage or shelves to organize her belongings. The clutter in the room posed a significant risk for falls and made it difficult to access the oxygen concentrator, which was necessary for the resident's respiratory condition. During a follow-up observation, the Nurse Manager confirmed the safety concerns related to the clutter and the inaccessibility of the oxygen concentrator. The resident's care plans indicated a potential for hoarding and clutter, with interventions such as staff offering to clean the room weekly and reducing fall risks by cleaning up spills and clutter. However, there was no documentation that these interventions were consistently attempted, and the clutter remained, making it impossible to visualize a marked spot for the resident's walker. The facility's failure to maintain a clean and safe environment for Resident #44 directly contributed to the deficiency noted in the report.
Failure to Revise and Implement Care Plans
Penalty
Summary
The facility failed to revise the care plan to meet identified care concerns for two residents and failed to implement revisions to the plan of care for one resident. Resident #82, who has severe cognitive impairment and a history of falls, was not provided the necessary assistance as recommended by a physical therapy evaluation. Despite recommendations for one assist with mobility and transfers due to poor safety awareness, the care plan was not updated until two months later, during which time the resident experienced multiple falls and minor injuries. Resident #101, who is cognitively intact, experienced significant weight loss and edema. Despite a 9.4 lbs weight loss over ten days and the administration of a diuretic for edema, the care plan was not updated to reflect these changes. The registered dietitian did not reweigh the resident to check the effectiveness of the diuretic, and the care plan did not address the issue of edema or its management. Resident #70, who has severe cognitive decision-making skills and is dependent on staff for assistance with eating, was not provided the necessary adaptive equipment and one-to-one assistance as required. During meal observations, the resident struggled to eat and drink independently, and the care plan was not updated to reflect the need for adaptive equipment and one-to-one assistance. Additionally, the CNAs assisting the resident were not familiar with the resident's needs, further compromising the resident's care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered per standards of practice for three residents. For Resident #60, the nurse allowed the resident's husband to administer medications without staying in the room, and there was no assessment to confirm the husband's ability to assist with medication administration. The resident had severe cognitive loss and needed assistance with all care, making the nurse's presence crucial during medication administration. The nurse manager confirmed that the nurse should have stayed in the room and acknowledged the lack of a process for the resident's husband to give medications. For Resident #93, the nurse initiated a breathing treatment and left the room, leaving the resident unattended. The resident had full cognitive abilities but required assistance with all care. The nurse manager confirmed that the nurse should have remained in the room during the breathing treatment and stayed until it was completed. For Resident #405, the nurse administered an IV antibiotic outside of the physician-prescribed orders. The antibiotic was ordered to be given every 12 hours, but the nurse administered it at inconsistent times, interpreting the order as allowing a window between 0700-1000. The Director of Nursing confirmed that the antibiotic should be given every 12 hours as per the physician's order and not within a flexible time window. The facility's standard medication administration times were also reviewed and found to be inconsistent with the physician's order.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services for Resident #60, who had a history of stroke, brain and ovarian cancer, Alzheimer's Dementia, heart disease, falls with vertebral fracture, anxiety, depression, diabetes, and lymphedema. The resident was observed with severe cognitive loss and required assistance with all care. Despite the resident's need for range of motion (ROM) exercises, there was no evidence of such services being provided. The resident's care plan and physician orders did not include any mention of ROM exercises or maintenance services, and the Director of Nursing (DON) confirmed that the facility did not have a restorative nursing program in place. Instead, the facility relied on nurse aides to provide maintenance ROM, but this was not documented or observed for Resident #60. During interviews, it was revealed that the facility did not have a restorative nurse or restorative nurse aides, and the nurse aides were responsible for providing maintenance ROM. However, the care plan for Resident #60 did not mention any ROM exercises or maintenance services, and the resident was not receiving these services. The facility's policy on restorative nursing programs stated that all residents should receive maintenance restorative nursing services, but this was not being implemented for Resident #60. The lack of restorative nursing services resulted in the potential for a decline in the resident's condition.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to assess and monitor weight changes for a resident, resulting in significant weight loss. The resident, who was admitted with diagnoses including acute gastric ulcer, kidney disease, and a blood clot in the right leg, experienced a weight loss of 9.4 lbs (5.72%) over ten days. Despite the resident's care plan indicating a goal to maintain nutritional status, the weight loss was not addressed in a timely manner. The resident was given a diuretic for edema, but no follow-up weight monitoring was conducted to assess the effectiveness of the treatment or to ensure accurate weight tracking. The Registered Dietitian (RD) overseeing weight changes did not reweigh the resident after the diuretic treatment and dismissed the weight loss warning based on an unverified hospital weight record. The care conference notes and weight change notes did not reflect the significant weight loss or any changes in care planning regarding nutrition, hydration, edema, or weight monitoring. This lack of proper assessment and monitoring led to the resident sustaining a significant weight loss without appropriate intervention.
Failure to Follow PICC Line Dressing Change Protocols
Penalty
Summary
The facility failed to follow accepted standards of practice for a peripherally inserted central catheter (PICC line) dressing change for a resident, resulting in improper hand hygiene, lack of use of a sterile barrier, and failure to measure the external catheter length. The resident, who had multiple health issues including meningitis, brain abscess, brain and lung cancer, diabetes, chronic kidney disease, and a history of pulmonary embolism, was observed with an IV running via an electronic pump. The IV dressing on the resident's right upper arm was dated 3/27/2024, and the IV bag contained Ceftriaxone, an antibiotic. During the dressing change, the nurse did not use the sterile barrier provided in the PICC line dressing change kit, did not perform hand hygiene after removing the old dressing and before applying sterile gloves, and did not measure the central line length or arm circumference as required by the physician's orders. The facility's policy on central venous catheter dressing changes, revised in July 2016, specifies that hand hygiene should be performed, a sterile barrier should be used, and the catheter insertion site should be cleaned with an approved antiseptic solution. The policy also requires measuring the external catheter length on admission, with each dressing change, and as needed. During an interview, nurse managers confirmed that the nurse should have washed her hands between gloves and used a sterile barrier. The failure to adhere to these protocols could result in complications, including infection and migration of the catheter, although these potential consequences were not directly stated in the report.
Failure to Ensure Unobstructed Access and Proper Humidification for Oxygen Concentrator
Penalty
Summary
The facility failed to ensure unobstructed access to an oxygen concentrator and provide oxygen humidification for a resident, resulting in the potential for inadequate oxygen delivery and discomfort. Resident #44, who has diagnoses including COPD and chronic respiratory failure, was observed with a nasal cannula but without visible oxygen equipment due to clutter in the room. The oxygen concentrator was found behind personal belongings, making it inaccessible from the resident's bedside. The resident reported that the humidification bottle had been empty, causing dryness in her nose, and a nurse had to bring a new humidification container during the observation. Further observations revealed that the humidification bottle was not properly maintained, with a date discrepancy indicating it had not been changed as reported. The physician's orders and care plans did not include instructions for ensuring humidification or maintaining unobstructed access to the concentrator. This oversight led to the resident experiencing discomfort and potential respiratory distress due to inadequate oxygen humidification and access issues.
Failure to Document and Act on Resident's Declining Condition
Penalty
Summary
The facility failed to timely document assessments and findings in the medical record by a medical provider and did not ensure necessary monitoring, care, and medical treatment when changes in condition were noted for a resident. The resident, who had severe cognitive impairment and multiple diagnoses including Pseudobulbar Affect, Bipolar Disorder, Dementia, and Anxiety, was admitted to the facility and later experienced a significant decline in health. Despite observable changes in the resident's condition, such as increased weakness, decreased mental status, and refusal to eat, the medical provider did not act upon these changes in a timely manner. The resident's electronic medical record (EMR) showed that vital signs were only obtained twice between 2/7/24 and 2/23/24. The Physician's Assistant (PA) made several late entries into the medical record, documenting observations and changes in the resident's condition that were not available for other healthcare providers or the supervising physician to review in real-time. The PA also made medication changes without ordering additional monitoring or lab work, despite the resident's deteriorating condition. On 2/23/24, the resident was transported to the hospital with severe symptoms including high fever, high heart rate, and altered mental status. The hospital diagnosed the resident with severe sepsis, acute metabolic encephalopathy, hypernatremia, acute cystitis with hematuria, and acute kidney injury. The hospital's social work consult raised concerns about potential neglect, as the resident appeared to have been in a minimally responsive state for a week. The facility's Director of Nursing (DON) acknowledged that increased monitoring should have been ordered and that the PA's documentation and actions were inadequate.
Failure to Provide Updated Guardianship Documentation
Penalty
Summary
The facility failed to provide medically-related social services for a resident (R98), resulting in the resident not having current up-to-date guardianship documentation. R98, a [AGE] year-old resident with multiple diagnoses including brain cancer, cerebral edema, convulsions, delusional disorder, pulmonary embolism, and aphasia, was admitted to the facility with Guardian K as the primary contact for healthcare needs. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment. The temporary guardianship order for Guardian K had expired, and there was no updated guardianship documentation in the resident's medical record. The medical record did not contain documentation from two physicians or a physician and a psychologist determining that R98 could no longer make medical decisions. Additionally, there was no evidence that the resident's mental capacity had changed since the temporary guardianship order. Therefore, Guardian K could not legally make medical decisions for R98 without a valid guardianship order. The Nursing Home Administrator confirmed that the expired temporary guardianship order was the most current documentation available in the resident's medical record.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to properly monitor for psychotropic medication side effects and failed to identify and report signs resulting from medication changes for one resident. The resident, who had diagnoses including Pseudobulbar Affect, Manic Depression, Dementia, and Anxiety, was admitted to the facility and later experienced severe cognitive impairment. The resident was transported to the hospital with altered mental status and functional decline, where it was noted that the resident had a high fever, high heart rate, and was minimally responsive. The hospital suspected polypharmacy, Serotonin Syndrome, or Neuroleptic Malignant Syndrome as potential causes of the resident's condition. The facility's records revealed that the resident had been prescribed multiple medications, including Zyprexa, clonazepam, and lorazepam, without proper documentation of the Risk versus Benefit analysis for these medications. The Social Worker responsible for initiating the Risk and Benefit forms admitted to missing the orders for lorazepam and clonazepam. Additionally, the resident exhibited signs of excessive sedation, lethargy, and refusal to eat, which were documented in the facility's records but not acted upon by the nursing staff. The Director of Nursing acknowledged that increased monitoring should have been ordered and that the abnormal observations should have been addressed. The Medication Administration Record for the resident showed that staff documented no abnormal findings despite clear indications of adverse side effects. The lack of proper monitoring and failure to act on documented concerns led to the resident being admitted to the hospital in critical condition. The facility did not provide further documentation or information before the survey exit.
Failure to Publicly Post Nurse Staffing Data
Penalty
Summary
The facility failed to publicly post nurse staffing data as required. On 4/8/24 at 11:20 AM, a review of the facility's posting was conducted, and the staff posting could not be located. At 11:30 AM, the Unit Manager (UM) was asked about the location of the daily staff posting data. The UM took the surveyor to the main Nurses Station where a binder titled the facility's Schedule Book was found. Inside the book, along with the staff schedule, was the completed daily staff posting form for 4/8/24. When asked if this information was posted in the facility, the UM stated No and indicated that the daily staff posting is kept in the Schedule Book. The book cover did not reflect that the daily staff posting was inside the binder or that public information was contained within.
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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