Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Hancock, Michigan.
- Location
- 1400 Poplar Street, Hancock, Michigan 49930
- CMS Provider Number
- 235552
- Inspections on file
- 27
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
The facility did not employ a certified dietary manager or certified food service manager to oversee the food service department, as required by the facility's job description and the FDA Food Code. The individual promoted to Dietary Manager had not obtained the necessary certification, and this was acknowledged by facility leadership.
Surveyors identified deficiencies in food storage and dietary staff competency, including undated and expired food in the resident refrigerator, improper storage of deli meat above fresh produce, and staff uncertainty regarding food safety protocols. The NHA acknowledged issues with food dating and staff skills.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not have a licensed NHA overseeing daily operations for a period of time, with the DON managing all responsibilities in the absence of an administrator. The previous NHA's license remained posted despite her departure, and a new NHA was only hired on the day of the survey.
The facility did not implement or maintain an effective QAPI program, as evidenced by the absence of data collection, performance improvement projects, action plans, and regular team participation. The DON reported no ongoing QAPI activities and expressed uncertainty about the program's purpose, while the NHA and IP were not present at a recent QAPI meeting.
The facility did not establish priorities, develop action plans, or analyze data for its QAPI program. The DON reported no ongoing PIPs, no data collection, and no QAPI activities, and expressed not understanding the QAPI program's purpose, despite facility policy requiring a comprehensive, data-driven approach.
The QAPI committee did not meet quarterly as required and lacked attendance from the NHA and an Infection Preventionist, as the facility did not have one. Sign-in sheets confirmed missed meetings and absent required members, contrary to facility policy.
The facility did not follow its antibiotic stewardship policy, as multiple residents received antibiotics without consistent use of McGeer's Criteria or other accredited standards. The DON, acting as Infection Control Preventionist, acknowledged that antibiotics were sometimes prescribed based on clinical judgment rather than established protocols, and lacked the required training certificate. Documentation showed that antibiotic use was not accurately tracked or reviewed as required by facility policy.
The facility did not assign a qualified infection preventionist to oversee the infection prevention and control program, resulting in a lack of designated responsibility for infection control practices.
A resident with severe cognitive impairment, dysphagia, and a feeding tube did not have a person-centered care plan addressing the feeding tube or related interventions. Staff interviews confirmed the resident had a history of aspiration pneumonia and multiple hospitalizations, but the required care planning was not completed or updated as per facility policy.
A resident who required assistance with bathing and shaving did not receive a shower or grooming services for an extended period, despite being cognitively intact and expressing a desire for care. Staff interviews and documentation confirmed that scheduled ADL care was not provided as required, resulting in unmet care needs.
A resident with chronic respiratory conditions received oxygen therapy without proper humidification and with tubing that had not been changed according to facility policy. Observations showed an empty humidification bottle and outdated tubing, and the resident reported nasal discomfort. Staff interviews confirmed that the equipment was not maintained as required by policy.
Two residents experienced medication administration errors when an RN failed to properly prime an insulin pen according to manufacturer instructions and left a prepared dose of Miralax unattended without confirming ingestion or the resident's ability to self-administer. These actions resulted in a medication error rate above 5%, contrary to facility policy and best practices.
The facility did not ensure that two residents' responsible parties were informed about the purpose of binding arbitration agreements or their right to refuse, as required by facility policy. In both cases, the agreements were signed before responsible parties were designated, and the agreements were not reviewed with those parties afterward.
A resident with a history of falls and multiple medical conditions experienced several recent falls while attempting to self-transfer, but the care plan interventions were not updated to reflect these incidents or to include additional preventative measures. The DON confirmed that care plan revisions were not completed as required, citing recent staff changes as a contributing factor.
The facility's call light system was found to be non-operational for several residents, leading to delays in emergency care. A resident experienced a significant delay in assistance due to a malfunctioning call light, and staff confirmed ongoing issues with the system, including frayed cords and malfunctioning bulbs. Despite audits and replacements, the system continued to fail without a clear pattern.
A resident's dentures were reported missing shortly after admission, and the facility failed to provide the resident with information on facility rules and denture policies upon admission. The admission paperwork was completed only after the dentures were lost, and the facility's policies on lost or damaged property were not provided to the resident or their representative in a timely manner.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant delay in receiving necessary medical attention due to the facility's failure to respond promptly to a change in condition. Despite clear signs of distress and a request for hospital transfer, the attending RN delayed action to complete routine tasks, resulting in a delayed transfer and treatment. The facility's lack of effective monitoring and communication contributed to the deficiency.
The facility failed to monitor and document resident weights, resulting in significant weight loss for a resident with severe cognitive impairment and health issues. Admission weights were not obtained for two residents, and weekly weights were missing for another. The facility's weight monitoring policy was not followed, as confirmed by the DON.
The facility failed to implement a comprehensive infection control program during a COVID-19 outbreak, resulting in 40 out of 45 residents contracting the virus, with one death and multiple hospitalizations. The facility did not conduct adequate infection surveillance or implement effective transmission-based precautions. Staff inconsistently wore PPE, and there was a lack of proper signage and isolation measures. Additionally, the facility failed to implement a water management program and did not properly transport and sort linens, contributing to the sustained transmission of COVID-19.
The facility was found to have numerous maintenance and cleanliness issues, including stained carpets, broken furniture, and unsafe gaps in bed frames. A resident's room had a strong urine odor and split flooring seams, while another had a leaky ceiling. Maintenance staff acknowledged these issues, and the Nursing Home Administrator recognized the facility's failure to provide a safe and homelike environment.
The facility failed to ensure that two CNAs completed their annual competency training, as required. Interviews with the DON and the Human Resources/Business Office Manager revealed that the competency records were missing, and the NHA confirmed the absence of a policy on competency training. The Facility Assessment indicated that nursing staff should complete a competency checklist annually.
The facility did not conduct performance reviews for five CNAs within the required 12-month period. Personnel records showed that CNAs hired between 2016 and 2023 had not been evaluated. The HR/Business Office Manager could not provide the evaluations, and the NHA confirmed the absence of a policy for staff performance reviews.
The facility did not include resident census information on the Nursing Department Daily Staffing sheets, which are essential for calculating appropriate staffing levels. This issue was identified during a review of staffing hours, revealing missing census data on several dates. The Nursing Home Administrator acknowledged the oversight, admitting the sheets were not completed correctly, contrary to the facility's policy requiring the inclusion of current resident census.
The facility failed to adhere to food safety standards, with expired and unlabeled food items found in storage, unsanitary conditions in freezers and an ice machine, and a dishwasher that did not properly sanitize items. These deficiencies posed a risk of foodborne illness to residents.
The facility did not complete a comprehensive assessment to identify necessary resources for resident care, lacking training in key areas like ethics, communication, and infection control. Interviews with the DON and NHA revealed unawareness of required training components, and the Facility Assessment failed to evaluate the training program to meet staff and volunteer needs.
The facility failed to accurately report Payroll Based Journal (PBJ) information to CMS, leading to incorrect staffing level data. A review of the CMS PBJ Staffing Data Report for fiscal year Quarter 2 of 2024 showed excessively low weekend staffing on several dates. The Nursing Home Administrator (NHA) was unaware of the issue, suggesting possible data entry errors. Facility policy requires quarterly submission of accurate staffing data, with the NHA responsible for validation and corrections.
The facility failed to implement and monitor an antibiotic stewardship program, as the DON/IP did not maintain current listings or track antibiotic use. There was no documentation of residents receiving antibiotics, and the monthly infection summary lacked reports on infection data or antibiotic stewardship. These deficiencies were not reported to the QAPI meeting, violating facility policies.
The facility failed to educate and offer COVID-19 vaccinations to its staff, increasing the risk of infection spread. The DON admitted no education or vaccine offerings had been made, and the NHA confirmed the inconsistency. An RN reported not receiving education or vaccine offers in nearly two years. Facility policies required education and vaccine offerings per CDC guidelines, but these were not followed.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety risks for residents. A significant gap was found between a mattress and footboard, exceeding safety standards. Interviews revealed a lack of documentation for bed measurements, indicating inspections were not conducted. The facility's policy mandates regular inspections, but no records were found, posing a risk of injury to residents.
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential zones of entrapment for residents. A large gap was found between a resident's bed mattress and footboard, which was outside the acceptable measurement for safety. Interviews revealed a lack of documentation for bed measurements and inspections, with staff confirming that such tasks had not been performed since the previous Maintenance Director's departure. The facility's policy requires regular inspections to prevent entrapment, but this was not adhered to, posing a risk to residents.
A facility failed to provide a resident with the prescribed minced and moist diet, serving diced turkey instead, which was inappropriate for the resident's dysphagia condition. Additionally, 46 residents received less protein than required due to incorrect portioning of a turkey casserole. The facility's diet manual was outdated, lacking current IDDSI standards.
A facility failed to provide written transfer notification to a resident and their representative when the resident was transferred to the hospital for nausea, vomiting, and uncontrolled pain. The Regional Clinical Consultant RN was unaware of the requirement, and the Nursing Home Administrator confirmed that the transfer form was not given or mailed to the resident or their representative.
A facility failed to provide proper wound care and infection control for a resident with a history of stroke and hemiplegia. The RN did not follow physician orders or infection control practices, using contaminated gloves and failing to apply the correct dressing. Additionally, a CNA was improperly instructed to apply a wound dressing, which is outside their scope of practice. The facility's policy requires licensed nurses to perform wound care, but this was not adhered to, resulting in a deficiency.
A resident with severe cognitive impairment and legal blindness suffered a hip fracture after an unwitnessed fall in a facility. The resident's care plan lacked interventions for her visual impairment, and frequent checks were not implemented despite her increased fall risk and unfamiliarity with the environment. Limited staff availability and a closed door due to COVID-19 isolation further contributed to the delay in assistance.
The facility did not ensure that all staff received training on resident rights, as required by its policy. A review revealed that two CNAs hired in late 2022 had not completed this training. The Facility Assessment also lacked a requirement for such training, potentially affecting the rights of all 45 residents.
The facility failed to provide QAPI training to all staff, as evidenced by a CNA hired in 2022 not receiving the training. The facility's assessment lacked a requirement for QAPI training, and no QAPI policy was provided to the surveyor. This deficiency could lead to unmet care needs due to an ineffective performance improvement program.
The facility failed to provide mandatory infection control training for a CNA hired in March 2023, as required by its infection prevention and control program. This deficiency was identified during a review of training logs and the facility's assessment, which lacked a requirement for such training. The oversight had the potential to spread diseases among all 45 residents.
The facility failed to ensure two CNAs received the required 12 hours of annual in-service training, with one completing only 10 hours and the other 11.75 hours. The Human Resource/Business Office Manager noted the training requirement is based on hire date, and the NHA admitted to a lack of communication about training requirements, relying on a vendor-provided online system. This oversight potentially affected care for all 45 residents.
A resident was discharged to his home without notifying family members, without provision of home health services, and without necessary medical equipment and supplies. This led to emotional distress and a return to the hospital due to unaddressed care needs. The discharge was forced due to behavioral issues, but there was no consistent documentation of these behaviors, and the family was not given a choice in the discharge decision.
A resident with multiple medical conditions was discharged due to behavioral issues without a 30-day written notice to the resident, their representative, the Ombudsman, and the State Agency. The facility staff admitted to not following proper procedures, and the resident's family was left without necessary support.
A resident with complex medical conditions was inappropriately discharged without proper planning and support, leading to emotional distress and potential harm. The facility failed to provide necessary home health services, medical equipment, and proper communication with the resident's family and DPOA.
The facility failed to report timely an allegation of misappropriation of narcotics for a resident with neurocognitive disorder. Despite receiving a complaint about the resident's medication being tampered with, the facility did not report it to the State Agency as required by their policy. The internal investigation was incomplete and lacked proper documentation.
The facility failed to conduct a thorough investigation into an allegation of medication tampering for a resident with neurocognitive disorder. The investigation lacked proper documentation and witness statements, and the medication was destroyed without adequate evidence.
Lack of Certified Dietary Manager in Food Service Department
Penalty
Summary
The facility failed to employ a certified dietary manager or certified food service manager to oversee the food service department. Interviews with the Business Office Manager/Human Resources Manager revealed that the individual promoted to Dietary Manager had not obtained the required certification since their promotion. Review of the facility's job description for the Dietary Manager confirmed that certification was a stated requirement for the position. The Nursing Home Administrator acknowledged that the Dietary Manager did not meet the qualifications outlined in the job description. The report references the FDA Food Code, which requires the person in charge of food service operations to demonstrate knowledge of foodborne disease prevention and to be a certified food protection manager through an accredited program.
Deficient Food Storage and Dietary Staff Competency
Penalty
Summary
The facility failed to ensure that dietary staff possessed the necessary competencies and skills to safely and effectively manage food and nutrition services. During observations, surveyors found two small containers of food in the resident refrigerator labeled with a resident's name but lacking dates indicating when the food was brought in or a use-by date. Additionally, four containers of applesauce with a use-by date that had already passed were found in the same refrigerator. Dietary staff interviewed claimed that all items were checked and labeled, but this was contradicted by the surveyor's findings. One dietary staff member was also unsure of the required temperature for serving resident food. Further observations revealed two opened packages of deli meat placed on a wet tray in the resident refrigerator, with an opened box of apples stored directly underneath, creating a risk of cross-contamination. When questioned, a dietary staff member acknowledged the improper storage but stated they would not discard the apples, indicating a lack of authority or initiative. Another staff member admitted that dates on food items in storage areas were not routinely checked. The Nursing Home Administrator confirmed concerns regarding food dating and staff competency in dietary services.
Failure to Follow Professional Standards for Food Procurement and Service
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Employ Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to employ a licensed Nursing Home Administrator (NHA) to oversee its day-to-day operations, as required by federal and state regulations. According to interviews, the Director of Nursing (DON) confirmed that there was no NHA present and that she was managing all facility operations. The Business Office Manager/Human Resource Manager stated that the NHA had been absent since May, and a new NHA was scheduled to start the following day. During the survey, it was observed that the previous NHA's license was still posted in the hallway, despite the former administrator confirming she had not been present since May and was unaware her license remained displayed. Review of the employee list indicated that the new NHA was only hired on the day of the survey, confirming a period without a licensed administrator in the facility.
Failure to Implement and Maintain QAPI Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective and comprehensive Quality Assurance Performance Improvement (QAPI) program that addresses the full range of services provided. During interviews, the DON stated that during a recent QAPI meeting, no topics were discussed as the full team was not present, with both the NHA and IP absent. The NHA reported that the DON supervised the QAPI program, while the DON admitted that the facility was not working on any Performance Improvement Projects (PIPs), was not collecting data to assess problems, and had no action plans or ongoing QAPI activities. There was also no feedback, analysis, or tracking for the QAPI program, and the DON expressed a lack of understanding regarding the purpose of QAPI. Review of the facility's policy confirmed the requirement for a data-driven QAPI program focused on care outcomes and quality of life, which was not being followed.
Failure to Implement and Operate QAPI Program
Penalty
Summary
The facility failed to establish priorities for improvement activities, develop and implement action plans, and review or analyze data collected under its Quality Assurance Performance Improvement (QAPI) program. During an interview, the DON stated that the facility was not working on any Performance Improvement Projects (PIPs), was not collecting data to assess for problems, and had no action plans or ongoing QAPI activities. The DON also expressed a lack of understanding regarding the purpose of the QAPI program. Review of the facility's policy confirmed that it requires the development and maintenance of a comprehensive, data-driven QAPI program focused on care outcomes and quality of life, which was not being followed.
QAPI Committee Lacked Required Members and Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with all required committee members. Review of QAPI sign-in sheets showed that a meeting was held on 5/15/25, but the Nursing Home Administrator (NHA) and the Infection Preventionist did not attend. Additionally, there were no QAPI meetings held in April or June of 2025. During an interview, the Director of Nursing (DON) confirmed that the NHA did not attend the meeting and that the facility did not have an Infection Preventionist. The facility's policy requires the QAPI committee to include the DON, Medical Director or designee, three other staff members (including the administrator), and the infection control and prevention officer, and to meet at least quarterly. These requirements were not met, affecting all 38 residents in the facility.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize its antibiotic stewardship program as outlined in its own policy, resulting in inaccurate monitoring of antibiotic use for all 38 residents. Review of the Infection Prevention and Control binder showed that multiple residents who had taken antibiotics during the look-back period were marked as not meeting the criteria for antibiotic use on tracking sheets, despite the facility's protocol requiring the use of McGeer's Criteria. The policy mandates that the Infection Preventionist, with oversight from the DON, coordinates stewardship activities, maintains documentation, and ensures protocols are followed, including the use of McGeer's Criteria to define infections and the review of antibiotic orders for appropriateness. During an interview, the DON, who also served as the Infection Control Preventionist, admitted that neither she nor the physicians consistently used McGeer's Criteria or any other accredited antibiotic criteria when prescribing antibiotics. Instead, decisions were sometimes based on clinical experience and observed symptoms, even when residents did not meet established criteria. The DON also lacked the required Infection Control Preventionist training certificate. The facility's policy further requires regular monitoring, documentation, and review of antibiotic use, as well as annual education for nursing staff, but these processes were not consistently followed, as evidenced by the documentation and interview findings.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a qualified infection preventionist responsible for the infection prevention and control program. This omission indicates that the required oversight and management of infection control practices were not assigned to a qualified individual as mandated.
Failure to Develop and Implement Person-Centered Care Plan for Resident with Feeding Tube
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a male resident who was admitted with diagnoses including unsteadiness on his feet and dysphagia. The resident was severely cognitively impaired, as indicated by a BIMS score of 0 out of 15, and had a feeding tube due to difficulty swallowing and refusal to eat or drink. Despite these significant care needs, a review of the resident's care plan revealed that there was no focus area or interventions documented for the feeding tube. Interviews with staff confirmed that the resident had a history of aspiration pneumonia and multiple hospitalizations, yet the necessary care planning was not completed. Further interviews with the DON revealed an awareness that care plans were not being developed, implemented, or revised as required. The facility's policy mandates the creation of a baseline care plan within 48 hours of admission, including all necessary interventions and measurable goals, and requires ongoing updates based on changes in the resident's condition. However, these procedures were not followed for this resident, as evidenced by the lack of a person-centered care plan addressing the feeding tube and related risks.
Failure to Provide Timely ADL Care: Bathing and Grooming
Penalty
Summary
A deficiency was identified when a resident who required partial to moderate assistance with bathing and set up or clean-up assistance for shaving did not receive these services as needed. The resident, who was cognitively intact, reported not having had a shower in two weeks and not being offered a shower on the morning of observation. The resident also expressed discomfort due to long facial whiskers and disheveled hair, stating a desire to be shaved and to have a haircut. Observations confirmed the resident remained unshaved and unkempt over multiple days. Interviews with facility staff, including the DON and a CNA, revealed that showers and shaving were scheduled weekly, typically on the same day. However, review of the CNA shower log showed the resident had not received a shower since a specific date and had not refused care. The resident's care plan indicated a need for one-person assistance with showers. Facility policy required provision of ADL care, including bathing and grooming, but this was not followed for the resident in question, resulting in unmet care needs.
Failure to Provide Proper Oxygen Humidification and Tubing Changes
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy. Observations revealed that the resident, who had diagnoses including COPD and chronic respiratory failure with hypoxia, was receiving oxygen via nasal cannula with an empty humidification bottle attached to the concentrator. The oxygen tubing in use was labeled with a date indicating it had not been changed in over three weeks. The resident reported experiencing a sore and dry nose, which coincided with the lack of humidification. Multiple observations confirmed the absence of humidification solution in the bottle over consecutive days. Interviews with staff, including an LPN and the DON, indicated that facility policy required weekly changes of oxygen tubing and regular monitoring and refilling of the humidification solution. The facility's own policies specified that humidification is required for oxygen flow rates of 4 liters and that the humidifier bottle should be changed when empty. Despite these policies, the resident's oxygen equipment was not maintained as required, resulting in discomfort and unmet care needs.
Medication Administration Error Rate Exceeds 5% Due to Improper Insulin Priming and Unobserved Medication Ingestion
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, resulting in a 7.69% error rate based on 2 errors in 26 observed opportunities. In one instance, a registered nurse (RN) was observed preparing an insulin pen for a resident but did not properly prime the pen according to manufacturer instructions. The RN primed the pen while holding it horizontally with the needle cover on and did not confirm that insulin was visible at the tip of the needle, nor did he repeat the priming process as required if insulin was not observed. Manufacturer instructions specify that the pen should be held with the needle pointing up, and insulin should be visible at the tip after priming, with steps to repeat if necessary. In another instance, the same RN left a prepared dose of Miralax on a resident's over-bed table and exited the room without confirming whether the resident was able to self-administer medications. The RN was unable to confirm the resident's ability to self-administer and stated he would return to observe the medication being taken. Facility policy requires that medications are administered at the time they are prepared and that staff observe residents to ensure the medication is completely ingested. These actions resulted in medication administration errors for two residents.
Failure to Inform Resident Representatives of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that resident representatives were properly informed about binding arbitration agreements and their right to refuse such agreements. For two residents, one with Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder, and another with non-Alzheimer's dementia, cerebrovascular accident, and seizure disorder, the responsible parties were not provided with an explanation of the arbitration agreement. In both cases, the residents signed the arbitration agreements before responsible parties were designated, and the agreements were not subsequently reviewed with those responsible parties. Interviews with the facility's social worker confirmed that the arbitration agreements were not discussed with the responsible parties after their designation. Review of the facility's policy indicated that the facility is required to explicitly inform residents or their representatives of their right not to sign the agreement, explain the agreement in an understandable manner, ensure acknowledgment of understanding, and grant the right to rescind within 30 days. These steps were not followed for the two residents in question.
Failure to Update Care Plan Interventions After Resident Falls
Penalty
Summary
The facility failed to update and revise care plan interventions for a resident with a history of repeated falls. The resident, who had diagnoses including repeated falls and a history of cerebrovascular accident, muscle weakness, seizures, encephalopathy, impaired safety awareness, fatigue, use of antipsychotic medications, and prior falls, reported having fallen out of bed multiple times while attempting to reach for items or self-transfer. Despite these recent falls, the care plan interventions were not updated to reflect the resident's current status or to address additional preventative measures. The care plan had last been revised the day before the interview, but did not include new interventions based on the resident's recent fall history. During an interview, the DON acknowledged that the care plan interventions for falls should have been updated and revised to reflect the resident's current needs. The DON attributed the lack of timely care plan updates to recent staff changes, which made it difficult to ensure care plans were individualized and current. Review of facility policy and regulatory guidance confirmed that care plans must be reviewed and revised after each assessment and in response to changes in the resident's condition, goals, or needs.
Call Light System Malfunction in LTC Facility
Penalty
Summary
The facility failed to ensure that the call light communication system was fully operational for six residents, leading to an inability to utilize the system for emergency care needs. This deficiency was observed through various interviews and record reviews, revealing that the call lights were not functioning for several residents, including Resident #2, who experienced a significant delay in receiving assistance for a bowel movement due to a non-operational call light. The Director of Nursing confirmed the malfunction and attempted a temporary fix by replacing the call light cord, but the issue persisted. Further observations and interviews with staff and residents indicated ongoing problems with the call light system, affecting multiple residents. Residents reported that call lights in bathrooms sometimes rendered the main room call lights inoperative, and staff acknowledged frequent issues with frayed cords and malfunctioning bulbs. The Nursing Home Administrator noted that despite audits and replacements, the call lights continued to fail without a discernible pattern, suggesting a systemic issue with the facility's call light system.
Failure to Provide Admission Information and Denture Loss
Penalty
Summary
The facility failed to provide a resident, identified as R2, with information regarding facility rules and regulations, including policies on denture loss, prior to or upon admission. R2 was admitted to the facility with upper and lower dentures, which were reported missing shortly after admission. The resident's family member, Complainant F, cleaned the dentures and placed them in a case on the bedside table. The following day, the dentures were missing, and the facility did not reimburse or replace them promptly. The Nursing Home Administrator (NHA) confirmed that the admission paperwork, including the acknowledgment of facility rules, was completed only after the dentures were lost. Interviews with facility staff, including CNA E, revealed that the dentures were last seen in a clear bowl on the bedside table. The facility's policy on lost or damaged personal property requires a prompt investigation, but there was no evidence that R2 or their representative received this policy before the dentures were lost. The facility's Dental Policy, which outlines the procedure for handling lost dentures, was also not provided to R2 upon admission. The NHA acknowledged the lack of documentation and could not provide additional information from the Admission Director regarding the delay in completing the admission paperwork. The facility's procedures for admission contracts and agreements require that all necessary documents be completed within 24 hours of admission. However, R2's admission documents were not completed until five days after admission, and two days after the dentures were lost. The facility's Resident Rights policy mandates that residents be informed of their rights and responsibilities both orally and in writing upon admission, but this was not done for R2. The NHA attempted to contact the Admission Director for further clarification but was unsuccessful before the survey concluded.
Delayed Response to Resident's Change in Condition
Penalty
Summary
The facility failed to respond timely to a change in condition for a resident, identified as R2, which resulted in a delayed transfer and treatment. On two consecutive days, a complainant noticed R2 in distress, with symptoms including flailing limbs and apparent pain. Despite these observations, the nursing staff initially dismissed the concerns as part of R2's decline. The following day, the complainant insisted on hospital transfer, but the attending RN delayed the process to complete a medication pass, resulting in a significant delay before R2 was sent to the hospital. R2's medical history included severe cognitive impairment and multiple active diagnoses such as cancer, heart failure, and urinary tract infection. The resident was unable to swallow and was lethargic, with symptoms worsening over several days. Despite these signs, there was a lack of timely intervention and communication with the physician, which contributed to the delay in addressing R2's deteriorating condition. The facility's documentation revealed inconsistencies in the assessment of R2's condition, further complicating the situation. The facility's policy for monitoring residents at risk was not effectively implemented, as R2 was not tracked by the interdisciplinary team prior to the transfer. The Director of Nursing acknowledged the delay in transferring R2 to the hospital and the failure to prioritize the resident's urgent needs over routine tasks. The Regional Clinical Director also confirmed that the facility lacked a specific policy for emergency transfers, which contributed to the inadequate response to R2's change in condition.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to appropriately assess and document the weights of residents, leading to significant weight loss in one resident and inadequate weight tracking for others. Resident R2, who was admitted with severe cognitive impairment and multiple health issues, experienced a significant weight loss of 30 pounds, as noted in a hospital progress note. The facility did not obtain an admission weight for R2, and only a few weight measurements were documented in the electronic medical record. The Nursing Home Administrator acknowledged the failure to obtain an admission weight for R2. Additionally, Resident R4 did not have an admission weight documented until three days after admission, and Resident R8 had missing weekly weight measurements for two weeks following admission. The Director of Nursing confirmed these lapses in weight monitoring and documentation. The facility's weight monitoring policy requires weights to be obtained upon admission, readmission, and weekly for the first four weeks, but this protocol was not followed for the residents in question.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement a comprehensive infection control program during a COVID-19 outbreak, resulting in significant adverse outcomes. The outbreak led to 40 out of 45 residents contracting COVID-19, with one death and multiple hospitalizations. The facility did not conduct adequate infection surveillance, tracking, or trending, and failed to implement effective transmission-based precautions. Observations revealed that staff did not consistently wear personal protective equipment (PPE) correctly, and there was a lack of proper signage and isolation measures for COVID-positive residents. The facility's Director of Nursing/Infection Preventionist admitted to not performing any monitoring or surveillance for infection control during the outbreak. The outbreak was exacerbated by a lack of testing and isolation of symptomatic individuals, including a certified nursing assistant who worked throughout the facility without being tested promptly. Residents continued to participate in group activities and dining, further contributing to the spread of the virus. The facility's policies on COVID-19 prevention and response were not effectively implemented, as evidenced by the lack of tracking and tracing of the outbreak. Additionally, the facility failed to implement a water management program and did not properly transport and sort linens to prevent cross-contamination. The Maintenance Director did not maintain records for water management, and laundry staff did not follow proper procedures for handling soiled linens. These deficiencies in infection control practices contributed to the sustained transmission of COVID-19 within the facility.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as observed during a survey. The hallways were noted to have stained and bleached carpets with separated seams, and multiple rooms had significant maintenance issues. For instance, a resident's room had a large gap between the bed mattress and footboard, posing an entrapment risk, and the radiator covers were missing, exposing metal fins that could cause injury. Another room had a strong urine odor, with a split seam in the vinyl flooring that allowed liquids to seep through, and the resident was noted to wear the same clothing for multiple days. Additional observations included a dining room with a patio door that had condensation and spider webs, broken cabinets, and stained carpets. Maintenance staff acknowledged these issues, noting that the gap between the mattress and footboard exceeded safe limits, and radiator covers were missing. Other rooms had broken furniture, chipped paint, and dirty mechanical lifts. The facility's closet doors were rusted and chipped, and air filters were covered in dust and debris. A leaking faucet and a rusty commode were also noted, along with a previous incident of a leaky ceiling in a resident's room. Interviews with staff revealed awareness of the facility's disrepair, with maintenance staff having previously obtained quotes for carpet replacement that were not acted upon. The Nursing Home Administrator acknowledged the concerns about the facility's environment, noting that the Maintenance Director was no longer employed due to not fulfilling job responsibilities. The report highlights the facility's failure to maintain a safe and homelike environment, as evidenced by the numerous maintenance and cleanliness issues observed during the survey.
Failure to Ensure Annual Competency Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nurse Aides (CNAs) had completed their yearly competency training, which includes demonstrating skills and techniques necessary for resident care. During interviews, the Director of Nursing (DON) admitted that competency training is supposed to be completed upon hire and annually but could not recall when the last competencies were completed. The DON referred the surveyor to the Human Resources/Business Office Manager, who also confirmed the absence of staff competencies. Further interviews revealed that the competencies were typically completed in May or June, but the records could not be located. Additionally, the Nursing Home Administrator (NHA) stated that there was no policy on competency training. The Facility Assessment, last updated in May, indicated that all nursing staff should complete a competency checklist annually.
Lack of Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct performance reviews for five Certified Nurse Aides (CNAs) within the required 12-month period. Personnel records revealed that CNAs hired as far back as 2016 and as recently as 2023 had not received any performance evaluations. During interviews, the Human Resource/Business Office Manager admitted to not having the staff evaluations and was unable to provide them upon request. Furthermore, the Nursing Home Administrator confirmed that the facility did not have a policy in place for conducting performance reviews for staff.
Failure to Post Resident Census on Staffing Sheets
Penalty
Summary
The facility failed to include the resident census information on the Nursing Department Daily Staffing sheets, which are used to calculate appropriate staffing levels. This omission was identified during a review of the direct care staffing hours on August 7, 2024, which revealed missing census information on multiple dates from January to March 2024. During an interview on the same day, the Nursing Home Administrator acknowledged the absence of the resident census on the staffing sheets and admitted that the sheets were not filled out correctly. The facility's policy on Nurse Staffing Posting Information, last revised in March 2024, mandates that the nurse staffing information should include the facility's current resident census.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies in food storage, preparation, and serving. During an initial tour of the kitchen, it was observed that expired food items, such as a gallon container of fruit salad and a container of soup, were not discarded. Additionally, several items in the walk-in refrigerator, including a jug of cranberry juice and apple juice, were found unlabeled and undated, contrary to the facility's expectations for marking perishable items with a use-by date. The facility also failed to maintain its freezers and ice machine in a sanitary condition. Three smaller freezers, used in place of a non-operational walk-in freezer, lacked thermometers to monitor temperatures, and one freezer had significant ice buildup, indicating improper maintenance. A package of frozen roast beef was found thawed and refrozen, suggesting temperature control issues. The ice machine was observed with a mold-like substance on its deflector shield, and there was no record of cleaning since it was procured from another facility. The Director of Maintenance was unaware of the issue and improperly attempted to clean the machine without removing the ice, risking contamination. Furthermore, the facility's dishwasher failed to properly sanitize items, as evidenced by test strips registering zero sanitizer levels during multiple tests. The dish machine logs for the first four days of August were incomplete, lacking records of chemical sanitization or temperature checks. These deficiencies collectively posed a risk of foodborne illness to the 46 residents receiving meals at the facility.
Inadequate Facility Assessment and Training Program
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both regular operations and emergencies. During interviews, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed a lack of awareness regarding the required training components that should be included in the facility assessment. Specifically, the competency and training list did not cover essential areas such as ethics, communication, resident rights, infection control, abuse and neglect, or Quality Assurance Performance Improvement (QAPI). The facility's policy on Facility Assessment, last revised in July 2023, mandates that the assessment should address facility resources, including personnel education and training related to resident care. However, a review of the Facility Assessment showed no evaluation of the training program to ensure that training needs were met for all staff and volunteers according to their roles. This oversight resulted in the potential for unidentified resources necessary to provide adequate care and services to the resident population.
Failure to Accurately Report Staffing Levels
Penalty
Summary
The facility failed to report Payroll Based Journal (PBJ) information to the Centers for Medicare and Medicaid Services (CMS), resulting in inaccurate reporting of staffing levels. This deficiency was identified through a review of the CMS PBJ Staffing Data Report for the fiscal year Quarter 2 of 2024, which revealed excessively low weekend staffing on multiple dates throughout January, February, and March. During an interview, the Nursing Home Administrator (NHA) admitted to not knowing what happened with the PBJ information, suggesting it might not have been entered correctly. The facility's policy, last revised in June 2024, mandates the electronic submission of complete and accurate direct care staffing information to CMS no less frequently than quarterly, with the NHA responsible for reviewing validation reports and ensuring corrections are made before the deadline.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement, monitor, and document an antibiotic stewardship program, which is a critical component of their infection prevention and control program. During interviews, the Director of Nursing/Infection Preventionist (DON/IP) admitted to not having a current listing for antibiotic stewardship for June or July and not tracing or monitoring the use of antibiotics. The DON/IP also stated that there was no written documentation for antibiotics on a line listing and that they relied solely on reports from the pharmacy without further tracking or monitoring. Further review revealed that the facility did not maintain any records of residents who received antibiotics, including details such as dosage, testing, or duration of antibiotic use. The monthly infection summary from July 2024 lacked any summary reports of infection data or antibiotic stewardship, including resistance patterns. There was no comparison of antibiotics to resident infections, nor documentation of whether the antibiotics were appropriate or effective. Additionally, there was no report of these findings to the Quality Assurance Performance Improvement (QAPI) meeting, as required by the facility's policies.
Failure to Educate and Offer COVID-19 Vaccinations to Staff
Penalty
Summary
The facility failed to educate and offer COVID-19 vaccinations to its staff, which increased the risk of COVID-19 infections and potential spread within the facility. During an interview, the Director of Nursing (DON) admitted that there had been no education about COVID-19 for staff, nor had the COVID-19 vaccine been offered to them. The Nursing Home Administrator (NHA) confirmed that while education and vaccination offerings were previously conducted, they had not been offered consistently or monthly. A Registered Nurse (RN) stated that in the nearly two years of working at the facility, they had not received education about COVID-19 or been offered the vaccine. The facility's policy on Employee Vaccinations, last revised in October 2023, stated that COVID-19 vaccinations would be provided to all healthcare providers per CDC guidelines. Additionally, the policy on COVID-19 Vaccination, last revised in March 2024, required the facility to educate and offer the vaccine to staff and maintain documentation of such actions. However, these policies were not followed, leading to the deficiency.
Failure to Conduct Regular Bed Safety Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential safety risks for all 47 residents. During an observation of a resident's room, a significant gap was found between the mattress and the footboard, which was outside the acceptable measurement to prevent entrapment. This gap was confirmed by staff, who acknowledged it exceeded the safety standard of four inches. Interviews with staff revealed a lack of documentation for bed measurements, indicating that regular inspections were not being conducted. Maintenance staff admitted to not having any records of bed rail and mattress measurements, and the facility's Director of Nursing and other staff confirmed they had never witnessed such measurements being performed. The absence of documentation suggested that the required safety checks had not been completed since the previous maintenance director left the facility. The facility's policy, implemented in 2021, mandates regular inspections and maintenance of bed equipment to prevent entrapment. However, the lack of adherence to this policy was evident, as no records of inspections or maintenance were found. The facility's failure to ensure compatibility and safety of bed equipment posed a risk of injury to residents, highlighting a significant oversight in their maintenance program.
Failure to Conduct Regular Bed Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential zones of entrapment for all 45 residents. During an observation of a resident's room, a large gap was found between the bed mattress and footboard, which was confirmed to be outside the acceptable measurement to prevent entrapment. This gap was measured by staff and acknowledged as a safety risk. Interviews with maintenance staff and nursing staff revealed a lack of documentation for bed measurements and inspections. Maintenance Staff Q admitted that he could not find any records of bed measurements, and it was confirmed that such documentation had not been maintained since the previous Maintenance Director left the facility. The Director of Nursing and other staff members also confirmed that they had not witnessed any bed safety measurements being conducted. The facility's policy, implemented in 2021, requires regular inspections and documentation of bed equipment to prevent entrapment. However, the lack of adherence to this policy was evident, as no records were found, and staff confirmed that inspections had not been performed. This oversight posed a risk to residents, as the compatibility and safety of bed equipment were not ensured.
Inadequate Dietary Practices and Nutritional Deficiency
Penalty
Summary
The facility failed to ensure that a resident received food in the appropriate form as prescribed by a physician. During a lunch meal service, the dietary tray line served a turkey casserole with diced turkey meat, which was not suitable for a resident who required a minced and moist diet due to conditions such as Alzheimer's disease, dysphagia, and malnutrition. The dietary manager admitted to not grinding the turkey and attempted to avoid giving the resident any chunks, despite the resident's care plan and physician's orders specifying a minced and moist texture. The facility's diet manual was outdated and did not include the current IDDSI diet level 5, which was necessary for the resident's dietary needs. Additionally, the facility failed to provide the appropriate nutritive content to 46 residents receiving meals from the dietary department. The turkey casserole recipe was intended to serve 50 residents with a portion size of 6 ounces, but only a 4-ounce scoop was used, resulting in approximately 1.5 ounces of protein per resident. This was below the standard meal plan pattern, which called for 3 ounces of protein with lunch. The consulting registered dietitian confirmed that the meal served did not meet the physician's order and that the facility's diet manual needed updating to reflect the current dietary standards.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written transfer notification to a resident and their representative, which is a requirement for transfers out of the facility. This deficiency was identified during a review of the case of a resident who was transferred to the hospital due to nausea, vomiting, and uncontrolled pain. During interviews, the Regional Clinical Consultant Registered Nurse admitted that the facility did not send written notifications and was unaware of this requirement. Additionally, the Nursing Home Administrator confirmed that although a transfer form was completed, it was not given or mailed to the resident or their representative.
Failure to Adhere to Wound Care Protocols and Infection Control Practices
Penalty
Summary
The facility failed to provide wound care according to the comprehensive care plan and physician orders for a resident, identified as R47, who was admitted following a short-term hospital stay. R47 had a history of stroke, aphasia, and hemiplegia, requiring supervision or assistance for certain movements. The physician's orders included specific instructions for wound care on the right buttock, which were not followed. During an observation, a registered nurse (RN) did not adhere to proper infection control practices, such as wearing eye protection and maintaining glove hygiene, while performing wound care. The RN used the same gloves after they became contaminated and failed to apply the correct dressing as per the physician's orders. Additionally, the RN did not perform hand hygiene after removing gloves and before donning new ones, which is a critical step in preventing infection. The RN also failed to ensure that the dressing was applied correctly and did not update the physician about the wound's condition in a timely manner. The resident's wound was found without a dressing, and barrier cream was improperly applied, indicating a lack of adherence to the care plan. Furthermore, a certified nurse aide (CNA) was instructed by the RN to apply a wound dressing, which is outside the scope of a CNA's practice. The CNA complied with the RN's request, despite understanding it was not within her duties. The facility's policy clearly states that wound care should be performed by licensed nurses, and the Director of Nursing confirmed that CNAs should not be applying wound dressings. This practice was previously identified and addressed by the DON, but it persisted, leading to the deficiency noted in the report.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident, identified as R50, who suffered a right hip fracture after an unwitnessed fall. R50 had severe cognitive impairment, as indicated by a BIMS score of 3 out of 15, and was diagnosed with macular degeneration, falls, and acute respiratory failure with hypoxia. Despite these conditions, the facility did not implement a toileting program or frequent checks to address R50's needs, particularly after the room door was closed due to COVID-19 isolation of R50's roommate. R50's care plan included interventions for severe cognitive impairment, impaired visual function, and increased risk for falls. However, the care plan did not mention R50's legal blindness, which was a significant factor given her inability to see in the dark and reliance on peripheral vision. The facility's Fall Reduction Policy required a standardized risk assessment and interventions based on identified risks, but these were not effectively implemented for R50, who was unfamiliar with the facility's surroundings and had severe cognitive and visual impairments. Interviews revealed that two CNAs were on break, leaving limited staff available to assist R50, who was in a COVID-19 isolation room with a closed door. R50's roommate had to use a phone to call for help after R50 fell, as the call light might not have prompted immediate assistance. The Nursing Home Administrator acknowledged that frequent checks and a toileting program were not added to R50's care plan, despite her recent admission and significant impairments, which could have potentially prevented the fall.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to ensure that all staff members received training on resident rights, which is a critical component of their responsibilities in caring for residents. During a review of the computer training logs from a vendor, it was discovered that two Certified Nurse Aides (CNAs), hired in late 2022, had not completed the required resident rights training. This oversight was identified during an interview and record review conducted on August 7, 2024. Additionally, the Facility Assessment did not include a requirement for resident rights training, despite the facility's policy stating that all direct and indirect care staff must be educated on the rights of residents. This deficiency had the potential to impact the rights of all 45 residents in the facility.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received training on the Quality Assurance and Performance Improvement (QAPI) program. Specifically, a Certified Nurse Aide (CNA) who was hired on November 21, 2022, did not receive the required QAPI training. This was identified during a review of the computer training logs on August 7, 2024. Additionally, the facility's assessment did not include a requirement for QAPI training for staff, and the facility was unable to provide a QAPI policy before the surveyor's exit on August 12, 2024. This deficiency had the potential to result in unmet care needs due to an ineffective performance improvement program.
Infection Control Training Deficiency
Penalty
Summary
The facility failed to provide mandatory infection control training as part of its infection prevention and control program for one of the five staff members reviewed. Specifically, a Certified Nurse Aide (CNA) hired on March 14, 2023, did not receive the required infection control training. This oversight was identified during a review of the vendor's computer training logs. Additionally, the facility's assessment did not include a requirement for infection control training for staff, despite the facility's policy stating that all staff should receive training on the infection prevention and control program. This deficiency had the potential to contribute to the spread of diseases and infectious processes among all 45 residents in the facility.
Deficient CNA Training Hours
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs), identified as L and N, received the required minimum of 12 hours of annual in-service training. CNA L, hired on November 21, 2022, completed only 10 hours, while CNA N, hired on October 26, 2022, completed 11.75 hours. This deficiency was identified during a review of their training logs. The Human Resource/Business Office Manager indicated that the 12-hour training requirement is based on the CNA's hire date. The Nursing Home Administrator acknowledged the lack of communication to staff regarding training completion requirements, stating that the facility relies on a vendor-provided online training system, which was last revised in 2017, to manage CNA training. This oversight resulted in the potential for unmet care needs for all 45 residents in the facility.
Failure to Provide Safe and Orderly Involuntary Discharge
Penalty
Summary
The facility failed to provide and document a safe and orderly involuntary discharge for a resident, resulting in harm. The resident was discharged to his home without notifying family members living in the home, without provision of home health services, and without necessary medical equipment and supplies. This led to emotional distress and a return to the hospital due to unaddressed care needs. The resident had multiple medical conditions, including stroke, heart failure, end-stage renal disease, and dependence on a wheelchair, and required maximal assistance for daily activities. The discharge instructions indicated that the resident would require daily assistance for activities of daily living and that a home health agency would admit him the day after discharge. However, no services were in place at the time of discharge, and the home health agency assessment the following day resulted in a denial of services. The facility also failed to provide necessary medical equipment, such as oxygen supplies and catheter supplies, and did not complete a home assessment prior to discharge. The resident's Durable Power of Attorney (DPOA) was not present at the time of discharge, and the facility did not document a review of medications with the DPOA. Interviews with facility staff and the resident's DPOA revealed that the discharge was forced due to the resident's behavioral issues, but there was no consistent documentation of these behaviors. The facility did not provide a 30-day notice for the discharge, and the resident's family was not given a choice in the discharge decision. The resident's return home without adequate support and services led to significant distress for both the resident and his family, and the resident had to return to the emergency room for a urinary tract infection shortly after discharge.
Failure to Provide 30-Day Written Notice of Discharge
Penalty
Summary
The facility failed to provide a 30-day written notice of discharge to a resident, their representative, the Ombudsman, and the State Agency. The resident, who had multiple medical conditions including stroke, heart failure, and dementia, was discharged due to behavioral issues without proper notification and appeal rights. The discharge documentation indicated that the resident required daily assistance for activities of daily living and was dependent on a wheelchair for mobility. Despite these needs, the resident was sent home without a prior home safety assessment or adequate support in place. Interviews with facility staff revealed that the Social Services Director was aware of the resident's behavioral issues but did not follow the proper procedure for an involuntary discharge. The staff member admitted to not knowing the exact steps for such a discharge and confirmed that no 30-day notice was provided. The Ombudsman also confirmed that they had not received any notification of the resident's discharge, and the resident's representative stated that they were not given a choice in the discharge decision. The Nursing Home Administrator acknowledged that the discharge documentation clearly stated the resident was being discharged due to behavioral issues, yet the required 30-day notice was not provided. The resident and their family were left without the necessary support and were stressed by the sudden discharge. The facility's policy on transfers and discharges was not followed, resulting in a deficiency in providing proper notification and appeal rights to the resident and their representatives.
Inappropriate Involuntary Discharge and Lack of Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services pertaining to the discharge of a resident, resulting in an inappropriate involuntary discharge. The resident, who had multiple complex medical conditions including stroke, heart failure, end-stage renal disease, and dependence on a wheelchair, was discharged without proper planning and support. The discharge plan did not ensure that necessary home health services and medical equipment were in place, and the resident's wife was not informed about the discharge. Additionally, the resident's activated Durable Power of Attorney (DPOA) was not present at the time of discharge, and there was no documentation that the DPOA was informed about the medications or the discharge plan. The Social Services Director admitted that no 30-day notice of involuntary discharge was provided to the resident, the DPOA, the Ombudsman, or the State Agency. The resident was discharged home without a proper assessment of the level of care needed, and no home health care services were in place at the time of discharge. The Social Services Director also acknowledged that no supplies for the resident's suprapubic catheter were provided, and the resident had to borrow an oxygen concentrator from the facility without additional necessary supplies. The Social Services Director failed to document consistent behavior tracking for the resident, who was allegedly involved in an incident of inappropriate touching. Despite this, there was no evidence to show that the resident was a consistent and imminent threat to other residents. The discharge was carried out without proper communication and coordination with the resident's family and home health care agencies, leading to emotional distress and potential harm to the resident due to the lack of necessary care and support at home.
Failure to Timely Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report timely an allegation of misappropriation of resident property (narcotics) to the State Agency (SA) for one resident. The resident, identified as R4, was admitted with diagnoses including neurocognitive disorder with Lewy Bodies, reduced mobility, and muscle weakness. The review of R4's medical records revealed inconsistencies in her cognitive assessments, with a significant change from being unable to complete the Brief Interview for Mental Status (BIMS) to scoring a 15/15 on a later assessment. The facility received a complaint about R4's Roxanol (Morphine Sulfate) being tampered with, but the Director of Nursing (DON) stated that it was not reported to the SA because the facility's internal investigation did not substantiate the claim. The investigation file was incomplete, with undated and unsigned witness statements and insufficient documentation to support the findings. Additional witness statements were only provided after the surveyor's request, and there was no statement from the pharmacists involved. The facility's policy mandates immediate reporting of such allegations, but this was not adhered to in this case. The facility's policy on Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property requires that all allegations be reported immediately, but not later than 2 hours if the events involve abuse or result in serious bodily injury, or within 24 hours if they do not. Despite this, the facility did not report the allegation of tampering with R4's medication to the SA within the required timeframe. The facility's failure to follow its own policy and federal and state laws regarding timely reporting of such allegations constitutes a deficiency in ensuring the protection of residents' health, welfare, and rights.
Incomplete Investigation of Alleged Medication Tampering
Penalty
Summary
The facility failed to conduct a thorough investigation for a misappropriation of resident property, specifically narcotic medication, for one resident. The resident, who had diagnoses including neurocognitive disorder with Lewy Bodies, reduced mobility, and muscle weakness, was admitted to the facility and had a prescription for Morphine Sulfate for end-of-life care. Despite the medication being refilled and delivered, the resident had not used any of it during the review period. The facility received a complaint alleging that the medication was tampered with, but the investigation was incomplete and lacked proper documentation and witness statements at the time of the initial report. The Nursing Home Administrator and Director of Nursing confirmed that the facility did not report the incident to the State Agency because they believed the medication was not tampered with or missing based on their findings. However, the investigation file was insufficient, containing only one unsigned and undated witness statement, and pictures with no clear indication of what should be reviewed. Additional witness statements were only provided after the surveyor's request, and there was no statement from the pharmacist. The DON admitted that the investigation was not complete and that the medication was destroyed without proper documentation from the regional consultation and pharmacy.
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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