Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Rapids, Michigan.
- Location
- 1095 Medical Park Dr, Grand Rapids, Michigan 49506
- CMS Provider Number
- 235366
- Inspections on file
- 22
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
The facility did not maintain proper documentation for individual fire alarm device testing and failed to provide current records for bi-annual smoke detector sensitivity testing, as required by NFPA standards. These deficiencies were confirmed during a review of facility records and an interview with maintenance staff.
A deficiency was found when the A Hall Resident Care Supply room door did not self-close to a positive latch as required by LSC 8.7.1.3, leaving a hazardous area inadequately protected according to fire safety standards.
A corridor room door did not close to a positive latch as required, failing to resist the passage of smoke according to LSC standards. This deficiency was confirmed by observation and interview with maintenance staff and could potentially affect multiple occupants in the event of a fire.
A nurse in an LTC facility misappropriated controlled medications prescribed to two residents, diverting them for personal use. The facility's records showed discrepancies in medication destruction, with staff signing off without proper witnessing. Interviews revealed a pattern of non-compliance with medication destruction policies, leading to the nurse's ability to divert medications over time.
The facility failed to maintain professional standards when two residents' controlled medications were misappropriated by a nurse, who falsely documented their destruction. Other staff members signed off on the destruction without witnessing it, trusting the nurse's word. The issue was discovered when police found the medications at the nurse's home, leading to a review of the facility's controlled substance management practices.
A cognitively impaired resident eloped from the facility after being mistakenly allowed to exit by staff who thought he was a visitor. The resident traveled along a busy road before being found by community members and returned to the facility. The facility failed to properly assess and monitor the resident's elopement risk, and staff miscommunication contributed to the incident.
A resident was mistakenly given another resident's medications, including Dilaudid and Gabapentin, due to a mix-up by two LPNs who were unfamiliar with the facility's procedures. The error resulted in the resident becoming unresponsive and requiring ICU hospitalization. The incident was exacerbated by inadequate staff orientation and training, as well as a failure to follow medication administration guidelines.
A medication error occurred when an LPN administered another resident's medications, including opioids, to a resident, resulting in respiratory failure and hospitalization. The error happened due to a failure to verify the resident's identity, as the LPN relied on a first name match without checking further identification. The facility's medication administration policy was not followed, leading to the adverse event.
Two residents in a LTC facility did not receive appropriate care according to their needs. One resident, with a history of dementia and stroke, suffered a fall and later was found to have an undiagnosed hip fracture, with staff failing to manage his pain effectively. Another resident, post-spinal surgery, did not attend necessary follow-up appointments due to the facility's failure to schedule them, leaving spinal precautions unreviewed. These deficiencies highlight lapses in assessment, pain management, and coordination of care.
The facility was cited for not having a qualified Activity Director, leading to a deficiency in the activities program. A CNA on light duty, without prior experience in activities, was temporarily filling in as an activities aide. The facility had been without an Activities Director since mid-May 2024, and the administrator confirmed the use of a light duty CNA for resident activities.
The facility failed to ensure that five CNAs completed the required 12 hours of in-service education, with significant gaps in training across critical categories. Systemic issues in the training process were identified, including incomplete orientation and lack of oversight, despite notifications being sent to employees.
The facility failed to maintain sanitary conditions in the kitchen, with unlabeled and undated food items found in refrigerators and pantries, and expired yogurts. Physical facility issues included chipping paint, leaking condensate, floor cracks, and a broken dish machine gauge. The Dietary Manager and Regional Dietitian acknowledged lapses in staff adherence to labeling and maintenance protocols.
The facility failed to follow infection prevention standards, including improper labeling of wound dressings, inadequate cleaning of shared equipment, and non-compliance with enhanced barrier precautions for residents with wounds. Additionally, there was no active plan for managing Legionella in the water supply.
The facility failed to maintain an effective training program for nursing department employees, resulting in incomplete trainings in critical areas such as resident rights, abuse, and infection control. Interviews revealed a lack of oversight and accountability, with no staff member tracking training completion and new hire orientation not being conducted as expected.
The facility failed to create person-centered care plans for three residents, resulting in inadequate monitoring of anticoagulant side effects and a chronic skin condition. A resident with atrial fibrillation was prescribed Xarelto without a care plan for side effects, while another on Apixaban also lacked such a plan. Additionally, a resident with a chronic nasal lesion due to untreated skin cancer had no care plan, despite the lesion sometimes bleeding and requiring ointment. Staff interviews revealed a lack of awareness and documentation regarding these issues.
The facility failed to provide consistent and meaningful activities for residents, resulting in potential negative impacts on their well-being. The absence of an Activities Director and reliance on a CNA on light duty led to a lack of scheduled activities after hours and on weekends. Residents reported dissatisfaction with the lack of engagement and missed activities, and the facility's policy on activities was not being followed.
The facility failed to provide adequate staffing, resulting in prolonged wait times for assistance and unmet care needs for several residents. A resident with significant physical disabilities reported waiting over an hour for call light responses and missing scheduled showers. Another resident experienced extended wait times for incontinence care, leading to discomfort. Resident council members also reported excessive wait times, particularly during night shifts. Interviews with staff confirmed inadequate staffing levels, with CNAs overburdened by high resident-to-staff ratios.
A facility was found to have significant lapses in monitoring and maintaining proper temperatures of personal refrigerators in residents' rooms. The staff failed to consistently check and record temperatures, with multiple instances of refrigerators being kept at unsafe temperatures. The facility's policy was not followed, as evidenced by missing logs and unrecorded temperatures, posing a risk of food safety issues.
A resident with cognitive intactness and mobility issues experienced compromised dignity due to delayed responses to her call light for incontinence care. She reported waiting over an hour on multiple occasions, leading to frustration and anger. Interviews with CNAs indicated insufficient staffing levels, contributing to the delays. Observations confirmed the resident's call light was not promptly answered, despite her care plan indicating her preference for staff assistance with changing briefs.
Two residents experienced psychosocial abuse due to the facility's failure to provide an environment free from restrictions on their autonomy. A resident with a history of substance abuse was restricted from leaving the facility independently, despite being cognitively intact and having a physician's order allowing it. The facility's decision was influenced by family concerns and led to the resident feeling punished and on 'house arrest.' Another resident with dementia was restricted from smoking independently, despite a safe smoking assessment, due to a change in facility policy requiring supervision. These actions resulted in frustration and mental anguish for both residents.
A resident with type 2 diabetes did not receive their prescribed Ozempic medication due to misappropriation. The medication was delivered but not properly secured, leading to missed doses. Staff interviews revealed lapses in medication handling and security, including a propped open medication room door and missing keys.
A facility failed to update a resident's care plan, leading to potential inaccuracies in care interventions. The resident, with significant medical conditions, was unable to leave the property despite physician orders allowing it. The care plan contained conflicting information about smoking and elopement risk, and staff interviews revealed confusion about the resident's status. The unit manager admitted the care plan needed updating.
Two residents in the facility were not consistently provided with showers or bathing assistance, leading to unmet personal hygiene needs. One resident, with multiple health issues, was observed disheveled and unkempt, while another, with mobility impairments, reported not having a proper bath since admission. Staffing challenges and documentation inconsistencies contributed to the deficiency.
A resident with anxiety, depression, and dementia was left in urine for about an hour, raising concerns about skin breakdown. The resident had moisture-associated skin damage upon admission, and subsequent skin sweeps revealed further issues. Despite this, the care plan lacked a urinary toileting program or bladder training. Staff interviews highlighted a lack of awareness and communication regarding the resident's condition and necessary treatments. The facility's incontinence policy, which requires appropriate treatment based on assessments, was not followed.
A facility failed to maintain proper infection control for a resident's BiPAP equipment, leading to potential cross-contamination risks. The resident, with multiple health conditions, reported that staff did not clean or replace her CPAP/BiPAP mask as required, and observations confirmed the mask was improperly stored. Interviews revealed that nursing staff were responsible for these tasks, but they were not consistently performed, violating the facility's infection control policy.
A resident with PTSD and significant medical issues was sent to a psychiatric hospital without a trauma assessment, leading to fear and resistance to care. The facility failed to address her PTSD triggers, resulting in a deficiency in trauma-informed care.
The facility failed to ensure nursing staff competencies were evaluated appropriately, with only 12 out of 50 employees completing their annual evaluations. The DON reported poor attendance at a non-mandatory competency fair, and the NHA confirmed that many evaluations were overdue or incomplete. Additionally, new hire competency evaluations were not conducted as expected.
A facility failed to provide appropriate mental health services to a resident with spinal issues, leading to her being sent to a psychiatric hospital. The resident experienced pain and fear of falling, affecting her therapy participation. Despite no mental health diagnosis, the facility's IDT decided on psychiatric hospitalization due to perceived self-neglect, without conducting a trauma assessment or referring to mental health services. The resident reported distress during her hospital stay, indicating a lack of person-centered care.
A facility failed to follow up on pharmacy recommendations to discontinue certain medications for a resident, despite the physician's agreement. The resident, who was cognitively intact and had a history of multiple conditions, continued to have active orders for Meclizine and Dicyclomine, which were flagged for discontinuation due to their high anticholinergic load. This oversight was acknowledged by the facility's administration and nursing staff.
The facility failed to properly label, date, and store medications, with issues found in a medication room and carts. Temperature logs for a medication refrigerator were incomplete, and several medications lacked proper labeling. Additionally, a medication room door was left open due to a missing key, coinciding with a report of missing medication for a resident.
The facility failed to provide timely vaccinations to two residents, resulting in a deficiency. One resident consented to vaccines but was not offered additional pneumococcal vaccines, while another resident's records showed inconsistencies and delays in vaccine administration despite consent. The DON was unable to explain these discrepancies, indicating a lapse in the facility's vaccination procedures.
The facility failed to educate, offer, and document COVID-19 vaccinations for a resident and staff. A resident's records showed a refusal without a date, conflicting with their consent to receive the vaccine. The DON could not explain the discrepancy. Staff were not educated or offered the vaccine, and their vaccination status was not tracked, contrary to facility policy.
A resident under hospice care with severe cognitive impairment was found with a non-functioning call light, leading to potential delays in emergency response. Observations showed the call light was not consistently within reach, and staff were unaware of the issue until it was pointed out. Monthly inspections were conducted, but immediate reporting and resolution of call light problems were lacking.
A resident at risk for pressure ulcers developed ulcers on both heels due to inadequate care and failure to update the care plan. Despite being identified as at risk, the resident's care plan included only general interventions and was not updated to reflect individual needs. The resident experienced heel pain and pressure-induced deep tissue damage, with missed documentation and inappropriate treatment orders, such as the use of unna boots. Interviews revealed frequent complaints of being wet and soiled, and the resident's care plan did not adequately address the pressure wounds.
Deficient Fire Alarm System Testing and Maintenance Documentation
Penalty
Summary
The facility failed to ensure that the fire alarm system was installed, tested, and maintained in accordance with Life Safety Code (LSC) Section 19.3.4.1, 9.6, and NFPA 72. During a review of facility records, it was found that documentation for the testing of fire alarm devices did not include individual device testing by location with a minimum pass or fail result, as required by NFPA 14.6.2.4(7). Additionally, there was no current documentation for the required bi-annual smoke detector sensitivity testing, with the last record dated 12/30/2022, which does not meet the requirements of NFPA 72 14.4.5.3. These findings were confirmed during an interview with a maintenance staff member at the time of the records review.
Plan Of Correction
Element #1: Fire alarm devices have been recorded and tested by location to at a minimum of pass or fail by 07/09/2025 by Boynton Fire Safety Service. Bi-annual smoke detector sensitivity testing has been completed on 07/09/2025 by Boynton Fire Safety Service. Element #2: This deficient practice could potentially affect all occupants in the event of failure to the fire alarm system. Ensure fire alarm system is tested and maintenance in accordance with LSC Section 19.3.4.1, 9.6 and NFPA 72. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Services Director on Fire Alarm System policy by the completion date. Element #4: Environmental Services Director/designee will complete audits to ensure that Fire alarm devices have been recorded and tested by location to at a minimum of pass or fail and the smoke detector sensitivity testing gets completed as required. Audits will be completed weekly for four weeks and then monthly thereafter until substantial compliance has been sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved.
Hazardous Area Door Failed to Self-Close and Latch
Penalty
Summary
A deficiency was identified when the A Hall Resident Care Supply room door was observed not to self-close to a positive latch as required by Life Safety Code (LSC) 8.7.1.3. This observation was made during a facility inspection and confirmed in an interview with a maintenance staff member. The lack of a self-closing, positively latching door in this hazardous area means the area was not properly protected as required for spaces containing combustible or hazardous materials, as outlined in LSC 19.3.2.1. The deficiency was specifically noted in relation to the protection of hazardous areas, which is necessary to prevent the spread of fire and smoke within the facility.
Plan Of Correction
Element #1: A Hall Resident Care Supply room door self-closer has been adjusted. The A Hall Resident Care Supply room door was checked to ensure the door self-closed to a positive latch. Element #2: This deficient practice has the potential to affect 15 occupants of the facility in the event of a fire not being contained to the hazardous area. Hazardous area doors in the facility have been checked and verified that they self-close to a positive latch. Doors that did not self-close to a positive latch were fixed at the time of the audit. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Service Director on the Fire and Smoke Doors policy by the completion date. Element #4: Environmental Services Director/designee will complete audits on hazardous area doors to ensure they self-close to a positive latch. Audits will be completed weekly for four weeks and then monthly thereafter until substantial compliance is sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Nursing Home Administrator is responsible for attaining and maintaining compliance.
Corridor Door Failed to Latch and Resist Smoke Passage
Penalty
Summary
During an inspection, it was observed that the corridor room door at resident room #20 did not close to a positive latch as required by Life Safety Code (LSC) 19.3.6.3.5. The door failed to meet the standard for resisting the passage of smoke, which is necessary for corridor doors in areas other than required enclosures of vertical openings, exits, or hazardous areas. The deficiency was identified through direct observation and confirmed in an interview with a maintenance staff member at the time of the inspection. The report specifies that the door in question did not provide the required positive latching hardware, which is essential for ensuring the door remains closed and can resist smoke passage. This failure was noted as a violation of the applicable regulations and could potentially affect 15 occupants in the event of a fire not being contained to the smoke compartment. No additional details about the medical history or condition of the residents in the affected room were provided in the report.
Plan Of Correction
The Nursing Home Administrator is responsible for attaining and maintaining compliance. Element #1: The corridor room door at resident room #20 has been repaired. Resident room #20 door has been checked to ensure the door closed to a positive latch. Element #2: This deficient practice could potentially affect 15 occupants of the facility in the event of a fire not being contained to the smoke compartment. Resident room doors in the facility have been checked and verified that they close to a positive latch. Any doors that did not close to a positive latch were fixed at the time of the audit. Element #3: Nursing Home Administrator/designee has completed re-education with the Environmental Services Director on the Fire and Smoke Doors policy to a positive latch by the completion date. Element #4: Environmental Services Director/designee will audit to ensure resident room doors close to a positive latch. Audits will be completed for 10 random resident rooms weekly for four weeks and then monthly thereafter until substantial compliance has been sustained. Results of the audits will be reported to facility QAPI committee for review and recommendations. This plan of correction will be monitored at the routine Quality Assurance (QAPI) meeting until such a time it is identified by the committee that sustained substantial compliance has been achieved. The Nursing Home Administrator is responsible for attaining and maintaining compliance.
Misappropriation of Resident Medications by Nurse
Penalty
Summary
The facility failed to prevent the misappropriation of resident medications by a licensed nurse, RN M, who diverted controlled medications for personal use. This incident involved two residents, Resident #109 and Resident #110, whose medications were found in RN M's home. The local police discovered narcotic medications, including Lorazepam, Oxycodone, and Tramadol, prescribed to these residents, during an investigation at RN M's residence. The facility's records indicated discrepancies in the destruction of these medications, with RN M and other staff members signing off on the destruction without proper witnessing or verification. Interviews with staff members revealed a pattern of non-compliance with the facility's policy on medication destruction. LPN K and RN H admitted to signing off on the destruction of narcotic medications without witnessing the process, trusting RN M's word that the medications had been destroyed. This breach of protocol was not reported to management, despite the staff's awareness that it was against professional standards and facility policy. The Controlled Substance Proof-Of-Use Records showed inconsistencies, with medications marked as destroyed but later found in RN M's possession. The facility's failure to adhere to its medication destruction policy and the lack of oversight allowed RN M to misappropriate medications over an extended period. The incident highlights the vulnerability of the facility's medication management system, as the lack of proper witnessing and verification procedures enabled the diversion of controlled substances. The facility's response included suspending involved staff members and initiating re-education, but the deficiency itself stemmed from inadequate adherence to established protocols and insufficient monitoring of medication handling processes.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to maintain professional standards of nursing care, as evidenced by the misappropriation of controlled medications involving two residents. Licensed nurses falsely documented the destruction of narcotic medications, which were later found in the possession of a registered nurse (RN M) at their home. The incident was discovered when the local police informed the Director of Nursing (DON B) about the medications found at RN M's residence, leading to a full narcotic count and pain assessments for all residents in the facility. The investigation revealed discrepancies in the Controlled Substance Proof-Of-Use Records for the affected residents. For Resident #109, records showed that Lorazepam and Tramadol tablets were falsely documented as destroyed by RN M, with LPN K witnessing the destruction without actually seeing the medications. Similarly, for Resident #110, Oxycodone tablets were falsely documented as destroyed by RN M, with RN H witnessing the destruction without verifying the medications. Both LPN K and RN H admitted to signing off on medication destruction without witnessing it, trusting RN M's word instead of following facility policy. Further observations during the survey indicated ongoing issues with the controlled substance count process. The Controlled Substance Shift Inventory record was not properly signed by both outgoing and oncoming nurses, as required. LPN L admitted to not signing the record at the start of her shift, and UM C and DON B confirmed that the process was not being followed correctly, indicating a lack of adherence to the facility's policies for controlled substance management.
Failure to Prevent Resident Elopement Due to Staff Miscommunication
Penalty
Summary
The facility failed to prevent the elopement of a cognitively impaired resident, identified as Resident #305, who was mistakenly allowed to exit the facility by staff. On the evening of 6/13/2024, Resident #305, who had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was let out of the facility by an LPN who mistook him for a visitor. The resident then traveled on foot along a busy road, posing a significant risk to his safety. This incident resulted in an Immediate Jeopardy situation, as the resident was found by community members and returned to the facility by staff who were searching for him. The facility's failure to properly assess and monitor Resident #305's risk for elopement contributed to the incident. The resident's admission assessment did not identify him as at risk for elopement, despite his cognitive impairment and history of wandering behaviors. Additionally, the facility's elopement and wandering residents policy, which requires systematic monitoring and management of residents at risk for elopement, was not effectively implemented. Staff interviews revealed a lack of awareness and communication regarding the resident's status, leading to the mistaken assumption that he was a visitor. Further investigation revealed that the facility did not have adequate procedures in place to ensure the safety of residents at risk for elopement. The facility's admission process failed to capture critical information about the resident's elopement behaviors from the hospital, and there was a lack of coordination among staff to address potential risks. The facility's oversight in conducting daily door alarm checks also contributed to the deficiency, as several days were missed, compromising the security measures intended to prevent such incidents.
Removal Plan
- R305 was placed on a 1:1 supervision upon return to the facility.
- Employee placed on administrative leave. Upon return from administrative leave, this staff member was provided 1:1 education on the elopements and wandering residents policy.
- All newly admitted residents that have a guardian or activated DPOA were identified as being at risk for this deficient practice.
- All resident's elopement risk assessments reviewed and any identified elopement risks residents that were currently residing in the facility were reviewed to ensure appropriate interventions were in place.
- External door checks were completed by the Administrator.
- All-staff re-education was initiated.
- Education was completed to all-staff on elopement and wandering residents policy was initiated; any facility staff member and agency staff member who did not receive education will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. All facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their next shift.
- Administrator/designee audited daily door alarms checks to ensure proper functioning of the egress and wander guard system. The audits have been conducted weekly for four weeks and then monthly for two months.
- Elopement drill has been completed.
- Director of Nursing/designee audited new admission elopement risk assessments to ensure proper interventions have been placed if a resident triggers as an elopement risk and to verify a wander guard is in place for the first 7-days if the resident has a legal decision maker. The audit has been conducted weekly for four weeks and then monthly for two months.
Medication Error Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in an Immediate Jeopardy situation. On the morning of May 23, 2024, a resident, identified as R404, was mistakenly administered medications intended for another resident, R7. This error occurred when LPN WW prepped the medications and handed them to LPN XX, who then administered them to R404 instead of R7. The medications included potent drugs such as Dilaudid and Gabapentin, which led to R404 becoming unresponsive and requiring hospitalization in the ICU. The incident was compounded by a lack of proper orientation and training for the nursing staff involved. LPN WW, who had been working at the facility for just over a month, was still in her orientation phase and was paired with LPN XX, an agency nurse on his first day at the facility. Both nurses were unfamiliar with the residents and the facility's procedures, leading to the critical error. LPN WW admitted to pulling medications and having LPN XX administer them, a practice that deviated from standard medication administration protocols. The facility's failure to adhere to its own medication administration guidelines, which emphasize the Five Rights of medication administration, contributed to the error. Additionally, there was a lack of proper identification measures, such as wristbands or room identifiers, which could have prevented the mix-up. The incident highlighted significant lapses in the facility's training and orientation processes, as well as in the execution of medication administration protocols.
Removal Plan
- Newly hired nurses to only be assigned to follow facility nurses.
- Medication Administration Guidelines policy was reviewed by the administrator and Director of Nursing and deemed appropriate.
- Medication Administration - General Guideline to be followed at each medication pass.
- Daily schedules were reviewed by the DON and scheduler to ensure appropriate nurse orientation practice is occurring.
- Education was completed to nurses on medication administration-general guidelines; any facility staff member and agency staff member who did not receive education will receive education prior to the start of their next shift. All facility staff and agency staff who were present at the time of the incident were immediately educated. All facility staff and agency staff have completed the necessary required education. Education is completed for all new hires prior to their first shift.
- Medication administration audits began and were completed weekly x 2 weeks then monthly x 2 months to ensure the Medication Administration Guidelines were being completed.
- DON completed daily schedule audits when there was a nurse on orientation to ensure that they are scheduled with a facility nurse - ongoing.
- NHA/designee began to complete resident identifiers audits to ensure there was a picture uploaded to PCC (electronic medical records) and room is identified with the resident name once weekly x 2 weeks then monthly x 2 months.
- Results of audits have been reviewed with the QAA committee to ensure compliance and any further recommendations.
- Additional education provided on the Medication Administration - General Guidelines policy to 8 out of 21 licensed nurses, including licensed agency nurses. All licensed nurses including agency nurses will have education on the Medication Administration - General Guidelines policy completed prior to the beginning of their next shift.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration, resulting in a significant medication error involving two residents. One resident, identified as R404, was mistakenly given another resident's medications, including opioids, which led to respiratory failure and required hospitalization for life-sustaining treatment. The error occurred when LPN WW prepared medications for R7 but handed them to LPN XX, who administered them to R404 without verifying the resident's identity. The incident unfolded as LPN WW and LPN XX worked together, with LPN WW preparing medications and LPN XX administering them. LPN XX was given the medications intended for R7 and was told the resident's first name, which was the same as R404's. Without confirming the last name or checking identification, LPN XX administered the medications to R404, who had already received his own medications earlier. R404, who was cognitively intact, expressed confusion but ultimately took the medications after LPN XX insisted they were his. The facility's policy on medication administration was not followed, as the medications were not verified against the resident's identification, and the person who prepared the medications did not administer them. This breach of protocol led to R404 experiencing an overdose, requiring multiple doses of Narcan and hospitalization. The facility's failure to ensure the right resident received the right medication directly contributed to the adverse event experienced by R404.
Failure to Provide Appropriate Care and Follow-Up for Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents, resulting in significant deficiencies. Resident #27, a male with a history of dementia, stroke, and other medical conditions, experienced a fall from his wheelchair, leading to a laceration on his left eyebrow. Despite the fall, the resident did not receive a thorough assessment for potential injuries, particularly to his right hip, which was later found to have an intertrochanteric fracture of unknown origin. The resident had been complaining of increased pain in his right leg, but the facility's staff did not adequately address these complaints, leading to a delay in diagnosing the fracture. Interviews with staff revealed that the resident's pain was not properly managed, and his behaviors were misinterpreted, resulting in inadequate care. Resident #406, a female with spinal stenosis and a history of spinal surgery, did not attend follow-up appointments with her spinal surgeon as required. The Health Information Coordinator (HIC) failed to schedule these appointments, despite discharge instructions indicating the need for follow-up care. The resident had been back in the facility for approximately two weeks without seeing the spinal surgeon, and the Therapy Director confirmed that spinal precautions should remain in place until reviewed by the surgeon. The Director of Nursing confirmed that it was the HIC's responsibility to schedule these appointments, highlighting a lapse in the facility's coordination of care. These deficiencies demonstrate a failure in the facility's processes to ensure residents receive care in accordance with their needs and medical conditions. The lack of timely assessments and follow-up care for both residents resulted in prolonged pain and potential complications. The facility's staff did not adequately communicate or act upon the residents' needs, leading to significant oversights in their care.
Lack of Qualified Activity Director
Penalty
Summary
The facility failed to employ a qualified Activity Director, which resulted in a deficiency related to the activities program. The deficiency was identified through observations, interviews, and record reviews. A Certified Nursing Assistant (CNA) on light duty was temporarily filling in as an activities aide, despite lacking prior experience in activities. The CNA reported not having attendance sheets and documented activities in the electronic medical record. The facility had been without an Activities Director since mid-May 2024, and the administrator confirmed that a light duty CNA was being used to conduct activities for the residents.
Deficiency in CNA In-Service Training Completion
Penalty
Summary
The facility failed to ensure that five reviewed certified nurse assistants (CNAs) completed the required 12 hours of in-service education, which is essential for maintaining performance standards and ensuring resident safety. The Education Spreadsheet for 2024, provided by the Director of Nursing (DON), showed significant gaps in training completion across various critical categories, including abuse, compliance, infection control, quality assurance and performance improvement (QAPI), resident rights, and communication. None of the five CNAs reviewed (CNA H, CNA I, CNA O, CNA P, and CNA ZZ) completed all the assigned training, with some not completing any training at all. Interviews with facility staff, including the DON and the Nursing Home Administrator (NHA), revealed systemic issues in the training process. The facility relied on computer-based training assigned during new hire orientation and annually thereafter. However, the second day of orientation, which was supposed to include these trainings, was not being completed as expected. Additionally, there was no staff member dedicated to tracking the completion of the 12-hour in-service requirement, leading to a lack of oversight. Despite notifications being sent to employees about their training assignments, the CNAs did not complete the required courses, as confirmed by interviews with CNAs X and ZZ.
Sanitation and Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, several food items in the reach-in and walk-in refrigerators were found without proper labeling and dating, including salami sandwiches, lettuce and tomato slices, a pitcher of juice, macaroni noodles, BBQ pork, sour cream, and waffle fries. The Dietary Manager acknowledged that staff are supposed to label and date leftover foods but admitted to having to constantly remind them to do so. Additionally, expired yogurts and improperly stored food items were found in the A and B side pantries, with the Regional Dietitian stating that staff should check these units daily and follow expiration guidelines. Further observations revealed physical facility issues, including gray chipping paint inside a metal drawer for clean utensil scoops, leaking condensate from the overhead ventilation system, cracks and open pits on the floor near the three-compartment sink, and a broken temperature gauge on the dish machine. The Regional Dietitian confirmed the presence of debris accumulation and the use of a thermometer to check the dish machine's temperature. These findings indicate a lack of adherence to the 2017 FDA Food Code and the facility's own food storage policy, which requires proper labeling, dating, and maintenance of physical facilities.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention standards, as evidenced by multiple observations and interviews. One resident, identified as R7, had a wound dressing on his right elbow that was not labeled or dated, which is against the facility's protocol for infection control. The dressing was observed on multiple occasions without proper labeling, and staff acknowledged the oversight. Additionally, a soiled elbow pad with blood was found on the floor of R7's room, which was not addressed by the staff, posing a risk of infection. Another issue was the improper handling of resident-shared equipment. An LPN was observed using a vital sign machine on a resident without cleaning it afterward, despite the facility's policy requiring disinfection after each use. The LPN did not have disinfectant wipes readily available, and there was confusion about where to store them, indicating a lapse in infection control practices. The facility also failed to implement enhanced barrier precautions for residents with wounds or indwelling medical devices. For instance, Resident #23, who required such precautions, was assisted by staff who did not don the necessary personal protective equipment (PPE) during high-contact care activities. This non-compliance with enhanced barrier precautions was confirmed through interviews with staff and observations of care practices. Additionally, the facility lacked an active plan for managing Legionella and other pathogens in the water supply, as there was no regular sampling or team meetings to review the water management plan.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for its nursing department employees, which included essential trainings in areas such as resident rights, abuse, neglect, exploitation, quality assurance, infection control, compliance and ethics, and communication. The Education Spreadsheet 2024 revealed significant gaps in training completion, with numerous employees lacking recorded completion dates across various training categories. Specifically, 10 employees had not completed abuse training, 15 had not completed compliance training, 12 had not completed infection control training, 23 had not completed QAPI training, 18 had not completed resident rights training, and 13 had not completed communication training. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that there was no staff member assigned to track the completion of required trainings, and the expected in-person facility training during new hire orientation was not being completed as planned. Additionally, several Certified Nurse Assistants (CNAs) had not completed their assigned required trainings, with some not completing any trainings at all. Despite being notified by email about the trainings, the staff did not complete them, indicating a lack of oversight and accountability in the training process.
Failure to Develop Person-Centered Care Plans for Anticoagulant Monitoring and Skin Condition
Penalty
Summary
The facility failed to develop person-centered care plans for three residents, leading to inadequate monitoring of anticoagulant medication side effects and a known skin condition. Resident #34, diagnosed with dementia, atrial fibrillation, and cerebral infarction, was prescribed Xarelto for atrial fibrillation but lacked a care plan to monitor for bleeding or bruising, which are potential side effects of the medication. Similarly, Resident #49, with a history of atrial fibrillation and deep vein thrombosis, was prescribed Apixaban but also did not have a care plan addressing the monitoring of anticoagulant side effects, despite the physician's order to do so. Resident #6, who had a chronic lesion on her nose due to untreated skin cancer, did not have a care plan addressing the lesion, which sometimes bleeds. The lesion was noted during an observation, and interviews with staff revealed a lack of awareness and documentation regarding the condition. The resident's guardian had declined further treatment, and the lesion was managed with antibiotic ointment when it bled. The Director of Nursing acknowledged the need for a care plan and orders to monitor the wound, but these were not in place at the time of the survey.
Inadequate Activity Program for Residents
Penalty
Summary
The facility failed to provide consistent, meaningful, and person-centered activities for six residents, leading to potential negative impacts on their well-being. The report highlights that the facility did not have an Activities Director since mid-May 2024, and activities were being managed by a CNA on light duty, who lacked experience in activities. This resulted in a lack of scheduled activities after 4:00 PM, on weekends, and no outings for the months of May, June, and July 2024. Additionally, there were no individualized activities observed during the survey period, and scheduled activities were often canceled without replacements. Resident #11, a male with diagnoses including dementia and major depressive disorder, reported staying in his room most of the time due to a lack of activities that interested him, such as woodworking or building model cars. He also mentioned that the facility did not provide him with books or magazines, and he expressed a desire for outdoor activities like fishing. Resident #12, a female with cognitive communication deficit and other health issues, reported that a scheduled Bingo game was not conducted by staff, and another resident had to run it. She expressed interest in activities like coloring and playing games, but these were not consistently provided. Resident #17, a male with multiple health issues, reported that there were no activities staff after 4:00 PM or on weekends, and the facility had not replaced the activities aides who were let go due to budget cuts. Resident #40, a female with Alzheimer's disease, also reported that activities were not being conducted as scheduled. Resident #406 had no care plan for activities, and no Recreation Assessment was completed. Resident #34, with dementia and major depressive disorder, expressed dissatisfaction with the lack of engagement in activities and reported missing scheduled activities due to lack of reminders. The facility's policy on activities was not being followed, as it stated that activities should support residents' physical, mental, and psychosocial well-being, which was not observed during the survey.
Inadequate Staffing Leads to Delayed Care and Unmet Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of several residents, resulting in prolonged wait times for assistance and unmet care needs. Resident #2, who has significant physical disabilities, reported waiting over an hour for staff to respond to call lights and missing scheduled showers due to staffing shortages. Similarly, Resident #15, who is dependent on a wheelchair and has severe obesity, experienced extended wait times for incontinence care, leading to discomfort and frustration. These issues were corroborated by observations and interviews with staff, who confirmed that staffing levels were inadequate to meet the residents' needs. Resident #17 and other members of the resident council also reported excessive wait times for call lights to be answered, particularly during night shifts. The resident council minutes from several months highlighted ongoing concerns about staffing levels and call light response times, with specific mentions of inadequate staffing on certain shifts. Interviews with CNAs and the Director of Nursing revealed that staffing levels were often below the required numbers, with CNAs being overburdened with high resident-to-staff ratios, leading to delays in care provision. Additional issues were noted with Resident #304 and Resident #406, who both reported being left in soiled conditions for extended periods due to insufficient staff availability. Resident #406, who requires significant assistance due to spinal issues, had not received a proper shower or bath for weeks. Interviews with staff indicated that the facility did not use agency staff for CNAs, further exacerbating the staffing shortages. The facility's assessment revealed a high number of residents requiring assistance with daily activities, yet the staffing did not reflect the acuity and needs of the residents, contributing to the deficiencies observed.
Failure to Maintain Proper Refrigerator Temperatures
Penalty
Summary
The facility was found to have significant lapses in monitoring and maintaining the proper temperatures of personal refrigerators in residents' rooms. During observations, it was noted that there were no visible temperature logs in the rooms, and the staff did not consistently monitor the refrigerators. In one instance, a refrigerator was found with a thermometer reading 46 degrees, indicating a failure to maintain the required temperature. The staff, including a Dietary Aide, admitted to not consistently checking the refrigerators, and there were significant gaps in the documentation of temperature checks. The facility's policy requires daily checks and recording of temperatures, but these were not consistently followed, as evidenced by missing logs and unrecorded temperatures. The facility's records showed repeated failures to maintain the required temperatures, with multiple instances of refrigerators being recorded at temperatures above the safe threshold of 41 degrees. The logs from May, June, and July 2024 showed significant lapses in monitoring, with many instances of missed checks and recorded temperatures that were too high. The staff's failure to maintain proper records and the lack of consistent checks on the refrigerators posed a risk of food safety issues, as the facility's policy was not adhered to. The facility's staff, including the Dietary Manager, acknowledged the lapses in maintaining the refrigerators and the lack of consistent checks, which could potentially lead to food safety issues.
Resident Dignity Compromised Due to Delayed Incontinence Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #15, who was cognitively intact and had diagnoses including muscle weakness, dependence on a wheelchair, and morbid obesity. The deficiency was identified through observations, interviews, and record reviews. Resident #15 reported multiple instances of having to wait for extended periods, sometimes over an hour, for her call light to be answered when she required incontinence care. This delay in response led to the resident sitting in a wet and soiled brief, causing feelings of frustration and anger. The resident documented specific dates when these delays occurred, highlighting the ongoing nature of the issue. Interviews with Certified Nurse Assistants (CNAs) revealed that staffing levels were insufficient to meet the needs of the residents, with one CNA reporting an assignment of about 14 residents per shift. Observations confirmed that Resident #15's call light was not promptly answered, with one instance where the call light was on for about 10 minutes before being addressed. The resident's care plan indicated her preference to use bariatric disposable briefs and notify staff when she needed to be changed, yet the facility's failure to respond promptly to her needs compromised her dignity and well-being.
Facility Fails to Provide Abuse-Free Environment for Residents
Penalty
Summary
The facility failed to provide an environment free from psychosocial abuse for two residents, resulting in feelings of frustration, mental anguish, and a loss of autonomy. Resident #2, who is cognitively intact and has a history of substance abuse, was restricted from leaving the facility independently due to safety concerns. Despite having a physician's order allowing therapeutic leave of absence and independent smoking, the facility placed a wander guard on his wheelchair and revoked his leave privileges. This decision was influenced by the resident's family and provider's concerns about his safety and substance abuse history. The resident expressed feelings of being on 'house arrest' and reported that he was being punished by not being allowed to leave the facility. Resident #2's situation was further complicated by the facility's communication with his family, who were pursuing guardianship. The facility's interdisciplinary team decided to revoke his leave privileges due to safety concerns and alleged illicit drug use. Despite being his own medical decision-maker, Resident #2 was informed that leaving the facility would be considered against medical advice (AMA), and he would not be allowed to return. The facility also began the process of involuntary discharge, which added to the resident's distress and feelings of being trapped. Resident #36, who has dementia and other medical conditions, was also restricted from smoking independently despite having a safe smoking assessment that allowed it. The facility changed the rules, requiring him to be accompanied by a responsible person, even though he had been smoking independently for 18 months. The resident's guardian had given permission for him to sign himself out to smoke, but the facility imposed additional restrictions, citing safety concerns. This change in policy led to the resident feeling blocked from going outside, contributing to his frustration and loss of autonomy.
Misappropriation of Resident's Diabetes Medication
Penalty
Summary
The facility failed to prevent the misappropriation of medications for Resident #36, who was diagnosed with type 2 diabetes and was cognitively intact. The resident's diabetes medication, Ozempic, was not administered as prescribed, resulting in missed doses on multiple occasions. The medication was supposed to be delivered and administered weekly, but records indicated missed doses on 4/23/24, 4/30/24, 5/2/24, and 5/9/24. This failure led to a delay in the treatment of the resident's diabetes. The issue began when the pharmacy delivered a tote of medications on 5/1/24, which included Resident #36's Ozempic. LPN R verified the delivery but mistakenly left the medication in the tote when transferring it to another hall. RN MM, who was informed of the delivery, did not have time to put away all the medications and later denied seeing the Ozempic. During an investigation, UM W found the empty box of Ozempic in the B hall medication room, indicating that the syringes were missing. Further interviews revealed that the B hall medication room door was propped open for several hours on the day of the delivery, and there were issues with missing keys. Despite the delivery being verified by LPN R, the medication was not properly secured, leading to its misappropriation. Resident #36 confirmed missing several doses of the medication and stated that no authorization was given for its use by others.
Failure to Revise Resident Care Plan
Penalty
Summary
The facility failed to revise the care plan for a resident, resulting in the potential for inaccurate care interventions. The resident, who had diagnoses including acquired absence of both legs above the knee and paraplegia, was cognitively intact with a BIMS score of 13/15. Despite having physician orders allowing therapeutic leave of absence and independent smoking, the resident reported being unable to leave the property and having a tracker on their power wheelchair. The care plan included conflicting information, such as the resident's ability to smoke independently and the use of a nicotine patch for smoking cessation, as well as the presence of a wander guard related to behavioral symptoms. The facility's records showed inconsistencies in the resident's elopement risk assessment and inclusion in the elopement book, which was not updated to reflect the resident's current status. Interviews with staff revealed confusion about the resident's elopement risk and smoking status, with some staff indicating the resident should be in the elopement book while others stated the resident was not an elopement risk. The unit manager acknowledged that the care plan contained conflicting information and needed updating, highlighting the facility's failure to maintain accurate and current care plans for the resident.
Failure to Provide Consistent Bathing Assistance
Penalty
Summary
The facility failed to consistently provide showers and bathing assistance to two residents, resulting in unmet personal hygiene needs. Resident #27, a male with multiple diagnoses including dementia and stroke, was observed on two occasions appearing disheveled, with uncombed hair and an untrimmed beard. His care plan indicated a preference for morning showers twice a week, but observations suggested these were not being consistently provided. Resident #406, a female with spinal stenosis and other mobility impairments, reported not having received a shower or full bed bath since her admission. Despite being cognitively intact, she expressed that it was very important for her to choose her bathing method. Observations and interviews revealed her hair was unkempt and had not been washed for 4-6 weeks. She was dependent on staff for bathing assistance, yet reported only minimal washing had been done. Interviews with staff, including CNAs and hospice aides, highlighted issues with staffing levels and documentation practices. CNA N reported being responsible for 15 residents and often working alone, which impacted her ability to complete all tasks, including showers. The facility's policy required documentation of bathing and refusals in the medical record, but inconsistencies in practice were noted, contributing to the deficiency in care.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to provide adequate incontinence care for Resident #304, who was admitted with diagnoses of anxiety, depression, and dementia. The resident was cognitively intact and expressed concerns about being left in urine for about an hour, which she feared could lead to skin breakdown. Upon admission, the resident had moisture-associated skin damage (MASD) to her buttocks and groin area, and subsequent weekly skin sweeps revealed an open area and rash/excoriation. Despite these findings, the resident's care plan did not include a urinary toileting program or bladder training to address her frequent incontinence. Interviews with staff revealed a lack of awareness and communication regarding the resident's skin condition and necessary treatments. The Unit Manager was unaware of the open area noted in a skin sweep, and the LPN who conducted the sweep could not recall if a treatment was initiated. The resident's care plan failed to address incontinence care adequately, and no treatment was ordered for the MASD upon admission. Additionally, the Therapy Director confirmed that therapy did not assist with the resident's bladder incontinence or staff training. The facility's incontinence policy mandates appropriate treatment and services based on comprehensive assessments, which were not provided in this case.
Inadequate Infection Control for BiPAP Equipment
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident using a BiPAP machine, leading to a potential risk of cross-contamination and transmission of disease. The resident, who had diagnoses including heart failure, pulmonary hypertension, insomnia, obstructive sleep apnea, and asthma, reported that staff did not clean her CPAP/BiPAP mask after use and did not replace the mask as required. Observations confirmed that the mask was left on the nightstand without a barrier or bag, contrary to the facility's protocol. The resident also reported having to ask staff to fill the distilled water tank and that her sister assisted her in changing the tubing, indicating a lack of adherence to the care plan and orders. Interviews with the Unit Manager revealed that the responsibility for cleaning the CPAP/BiPAP mask and filling the water reservoir lay with the nursing staff, who were expected to perform these tasks daily. However, the resident's reports and observations indicated that these tasks were not consistently performed. The facility's policy required daily cleaning of the mask with an approved disinfecting solution and proper storage in a mesh bag or approved container, which was not followed. This lack of compliance with established procedures for respiratory equipment maintenance resulted in a deficiency in infection control practices.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address post-traumatic stress disorder (PTSD) triggers for a resident, leading to a deficiency in trauma-informed care. The resident, who had a history of trauma and pertinent medical diagnoses including spinal stenosis and lumbar vertebra fractures, was sent to a psychiatric hospital in another state. During her stay, she experienced significant fear due to the behavior of a male resident in the adjacent room, which exacerbated her anxiety and fear of harm. This situation was not adequately addressed by the facility, as they did not conduct a trauma assessment or develop a care plan to mitigate these triggers. Interviews with facility staff revealed a lack of appropriate actions to support the resident's mental health needs. The Social Service Director admitted to not completing a trauma assessment before or after the resident's psychiatric hospitalization. The Director of Nursing acknowledged that the facility did not explore alternative, less restrictive services before sending the resident to a psychiatric hospital for declining care. The resident's ex-husband and roommate provided insights into her history of trauma and behaviors, which were not sufficiently considered in her care plan. The resident's fear and resistance to care were further compounded by her physical condition, including numbness and weakness in her extremities, which made her reluctant to participate in therapy and care activities. Despite being cognitively intact, the resident's needs were not met, leading to a decline in her physical condition, including the reopening of a surgical wound and the development of an open area on her bottom. The facility's failure to provide trauma-informed care and address the resident's PTSD triggers resulted in a deficiency that could potentially lead to re-traumatization.
Deficiency in Nursing Staff Competency Evaluations
Penalty
Summary
The facility failed to ensure that nursing staff were evaluated for appropriate competencies and skill sets, which could potentially impact the residents' ability to maintain their highest practicable physical, mental, and psychosocial well-being. The Director of Nursing (DON) reported that a competency fair was held for nursing employees, but attendance was not mandatory, resulting in poor participation. Additionally, the facility lacked a dedicated staff development role, leaving the responsibility to the DON. A review of an untitled spreadsheet revealed that out of 50 nursing department employees, only 12 had completed their annual competency evaluations for 2024, while the remaining 38 were either overdue or incomplete. The Nursing Home Administrator (NHA) confirmed that annual competencies and performance reviews were expected to be completed, but many were found to be overdue, missing, or incomplete. Furthermore, new hire competency evaluations, which were supposed to be completed on the second day of orientation, were not being conducted as expected. This lack of adherence to competency evaluation protocols highlights a significant deficiency in ensuring that nursing staff possess the necessary skills to provide optimal care for residents.
Failure to Provide Appropriate Mental Health Services
Penalty
Summary
The facility failed to provide appropriate mental health treatment and services for a resident, resulting in the resident being sent to a psychiatric hospital, which caused psychosocial distress and fear. The resident, who had a history of spinal stenosis, lumbar vertebra fractures, and recent spinal surgery, was admitted for subacute rehabilitation. Despite having no documented mental health diagnoses, the resident was sent to a psychiatric hospital due to perceived self-neglect and risk to herself and others, as determined by the facility's interdisciplinary team (IDT). The resident experienced significant pain and fear of falling, which affected her participation in therapy and care. She was resistant to therapy due to numbness in her extremities and fear of falling, which was documented by therapy staff. The resident's surgical wound began to open, and she developed an infection due to declining incontinence care and basic hygiene. Despite these issues, the facility did not conduct a trauma assessment or refer the resident to mental health services before deciding on psychiatric hospitalization. Interviews with facility staff revealed that the resident was not approached for mental health support, and the social service director did not contact the contracted mental health provider for evaluation. The decision to send the resident to a psychiatric hospital was based on the IDT's assessment of self-harm through self-neglect, without exploring less restrictive alternatives. The resident reported feeling fearful and distressed during her stay at the psychiatric hospital, highlighting the facility's failure to provide necessary behavioral health care services in a person-centered manner.
Failure to Follow Pharmacy Recommendations for Medication Discontinuation
Penalty
Summary
The facility failed to ensure follow-up on pharmacy recommendations for a resident, leading to a deficiency in medication management. The resident, who was cognitively intact and had a history of type 2 diabetes, bipolar disorder, anxiety, and depression, was admitted with PRN orders for Meclizine and Dicyclomine. These medications were flagged by the pharmacist for discontinuation due to their high anticholinergic load and potential inappropriateness for older adults, as per the Beer's List. The physician agreed with the pharmacist's recommendation to discontinue these medications. Despite the agreement to discontinue, a review of the resident's current physician orders revealed that the medications were still active several months later. This oversight was confirmed by the Nursing Home Administrator and the Director of Nursing, who acknowledged that the discontinuation of the medications was missed and only addressed on the day of the interview. The facility's Medication Regimen Review Policy mandates that staff act upon all recommendations, highlighting a lapse in adherence to established procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label, date, and store medications in one of two medication rooms and both medication carts, which could potentially decrease the efficacy of medications and lead to their compromise or misappropriation. During an observation, it was found that the refrigerator in the B hall medication room, which contained multiple resident medications and vaccinations, had missing temperature records for daytime monitoring and almost no monitoring at night. The Unit Manager reported that the night shift nurse was responsible for monitoring the refrigerator temperatures, but the logs were not being checked regularly, prompting the relocation of the binder with the logs to the nurses' station. Additionally, during a medication storage observation, several issues were identified, including stock OTC medications with worn-off expiration dates, an Anoro Ellipta inhaler without an open date, and another inhaler without a resident name, drug name, label, or open date. A loose pill was also found in the A hall medication cart, with the LPN unable to identify it or its intended recipient. Furthermore, the B hall medication room door was found propped open for several hours due to a missing key, which coincided with a report of missing medication for a resident. The Environmental Service Manager confirmed that extra keys had to be made because the previous unit manager had not returned her keys.
Deficiency in Timely Vaccination Administration
Penalty
Summary
The facility failed to ensure timely vaccination for two residents, leading to a deficiency in their immunization program. Resident #6, who had consented to all vaccines on December 2, 2022, was not offered additional pneumococcal vaccines despite being eligible. The Director of Nursing (DON) B acknowledged this oversight and had only recently audited residents' records for pneumococcal vaccination status, indicating a lapse in the vaccination tracking process. Resident #27's records showed inconsistencies, as the resident had consented to receive influenza and pneumonia vaccines on December 7, 2023, but the records inaccurately indicated a refusal without documentation of declination. Furthermore, the pneumococcal vaccine was delayed until June 25, 2024, despite the earlier consent. The DON was unable to explain these discrepancies, highlighting a failure in the facility's vaccination administration and documentation procedures.
Failure to Educate, Offer, and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to consistently educate, offer, and administer COVID-19 vaccines to residents and staff, as well as maintain valid declination documentation in the medical records. Specifically, for one resident, there was a discrepancy between the immunization record, which indicated a refusal of the COVID-19 vaccine without a recorded date, and a vaccine consent form that showed the resident's desire to receive the vaccine. The Director of Nursing (DON) was unable to explain this inconsistency or provide documentation of declination. Additionally, the facility did not ensure that staff were educated about or offered the COVID-19 vaccination, nor did it track the vaccination status of its staff. Interviews with the DON and the Infection Preventionist (IP) revealed a lack of familiarity with the process for tracking staff vaccinations and a cessation of offering the COVID-19 vaccine to staff. The facility's policy stated that COVID-19 vaccinations should be offered to healthcare personnel per CDC guidelines, and any declined vaccinations should be documented in the human resources file, which was not being followed.
Failure to Ensure Operable Call Light for Resident
Penalty
Summary
The facility failed to ensure that a working call system was available and within reach for a resident, identified as Resident #5, who was under hospice care and severely cognitively impaired. During an observation, the resident was found lying in bed with emesis on her arm, bed, floor, and fall mat, and her call light was not functioning. The unit manager was unaware of the resident's condition and the malfunctioning call light until it was brought to her attention by the surveyor. The call light was subsequently replaced with a working one. Further observations revealed that the resident's call light was not consistently within reach, as it was found under the bed and at the foot of the bed on separate occasions. Interviews with the Environmental Services Manager and the Unit Manager indicated that monthly inspections of call lights were conducted, but there was a lack of immediate reporting and resolution of call light issues. The facility's policy required staff to ensure call lights were within reach during each interaction and to report any problems immediately, which was not adhered to in this case.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide adequate care to prevent the development of pressure ulcers in a resident, resulting in the development of pressure ulcers on both heels. The resident, who was admitted with diagnoses including weakness, difficulty walking, and prediabetes, was identified as being at risk for pressure ulcers. Despite this, the resident's care plan included only general pressure interventions and was not updated to reflect the resident's individual status. The resident's practitioner noted heel pain and the presence of a blood blister on the left heel, indicating pressure-induced deep tissue damage. The resident's physical therapy notes also indicated a decline in participation due to bilateral foot pain. The facility's documentation and treatment administration records revealed several missed opportunities to document and implement prescribed treatments, such as floating the resident's heels off surfaces. Additionally, the use of unna boots, which are not indicated for pressure wounds on the heels, was ordered, further indicating a lack of appropriate care. Interviews with facility staff revealed that the resident frequently complained of being wet and soiled, and the Director of Nursing confirmed that the resident did not have any wounds upon admission. However, the resident's care plan and treatment records did not adequately address the identified pressure wounds, contributing to the development of pressure ulcers.
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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