Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Holly, Michigan.
- Location
- 313 Sherwood Street, Holly, Michigan 48442
- CMS Provider Number
- 235722
- Inspections on file
- 33
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
The facility failed to maintain a clean, comfortable, and homelike environment on the A, B, and D units. Surveyors observed overflowing bagged soiled linens stored on the floor, a strong urine odor in the front lobby and hallways, and heavily soiled ceiling vent grids and washable filters at the lobby and nursing stations. The Housekeeping/Maintenance Director acknowledged the soiled vents, said housekeeping should have cleaned them, and stated some were missed; the director also reported no monitoring of the ceiling ventilation systems.
Failure to Protect Residents from Abuse and Neglect: Staff exchanged profanity with a resident after a request for coffee, residents used derogatory and disparaging language toward each other during bingo, a nurse allegedly failed to timely provide ordered pain medication after repeated call light requests, and two residents were involved in a physical altercation in which one struck the other in the face. The facility later acknowledged verbal abuse, neglect, and physical abuse in its interviews and records.
Failure to Report Resident Abuse and an Injury of Unknown Origin: The facility did not report witnessed resident-to-resident verbal abuse during bingo, where one resident used derogatory language toward another and a third resident was also involved. The Administrator later acknowledged the incident should have been reported as verbal abuse. The facility also did not report a resident’s unexplained fatal entrapment, where the resident was found with the head stuck between the bed and dresser, had no pulse or respirations, and was pronounced deceased; the Administrator said she was notified but did not report it to the State Agency.
Plumbing, drain, and ice machine cleanliness deficiencies were observed in the kitchen area. Surveyors noted sewer gas odor near the grease trap and multiple drains, dark soil buildup on kitchen sink drain lines, pink substance forming on the ice machine drip panel, and plumbing cross-connection concerns including a janitor sink water line without a wasting/vented T device and a garbage disposal sink with a submerged jet inlet and no cross-connection prevention in place.
Failure to Investigate Injury of Unknown Origin: A resident with impaired cognition, dependence for most care, and no fall history was found deceased with his head wedged between the bed and wardrobe after being last seen alive repositioned and changed. The nurse pronounced the resident dead and an incident report was completed, but no investigation was documented. The Administrator said there was no specific investigation and did not interview the CNA who provided care or found the resident, while the DON stated the event was not investigated and should have been.
Failure to care plan for an ileostomy. A resident with intact cognition and an ostomy stated she needed help emptying and changing the bag, but the comprehensive care plan had no ileostomy-related interventions. The DON stated any type of ostomy should be included in the care plan, and the facility policy required a baseline care plan with instructions for special needs.
Failure to Keep Walker at Bedside for Resident With Falls History: A resident with dementia, Parkinson’s Disease, impaired cognition, and a history of falls had a care plan intervention requiring the walker to be kept next to the bed during rounding and med pass, but staff observed the walker and wheelchair placed across the room instead of at bedside. The resident later had a fall after attempting unassisted ambulation to the bathroom, and the record identified the root cause as unassisted ambulation.
Nephrostomy drainage bags were found positioned above kidney level for a resident with nephrostomy tubes, despite an order to keep the bags below the kidneys for dependent drainage. The resident, who had acute kidney failure, bladder cancer, hydronephrosis, and moderately impaired cognition, was observed in bed on multiple occasions with both bags placed on an overbed tray table or pillow above the bed level; the DON confirmed the bags should be below the kidneys, and the resident said staff put them on the tray table after emptying them.
A resident with lung cancer had a change in condition with twitching, altered responsiveness, and later a hospital transfer by EMS, but the record lacked a documented reason for the transfer, a transfer form, a complete change of condition assessment, and a readmission note. Earlier, the resident also had a severe oxygen desaturation episode that was documented incompletely, with no recorded physician response or documented instructions from the physician.
Failure to Follow Pressure Ulcer Treatment Orders: A resident with an unstageable coccyx pressure injury, diabetes, heart failure, and impaired cognition had wound care orders for NS cleansing, Medihoney, and dressings, later with calcium alginate added. The wound consultant said Medihoney had been ordered from the start, but the TAR did not show it until about a month later, and the resident’s wound remained largely slough-covered on observation. A prior coccyx dressing order was also discontinued and never documented as being done.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with complex psychiatric and neurological diagnoses was subjected to mistreatment when a CNA placed a hand over the resident's mouth to muffle yelling during care. Another CNA witnessed the incident and reported it to facility management. The staff member involved expressed frustration with the resident's behavior and made an inappropriate comment about the resident's mental health.
A resident admitted with alcohol dependence and withdrawal did not have the hospital's CIWA-Ar protocol for lorazepam administration reconciled or implemented upon admission. The DON and physician were unaware of the protocol on the discharge medication list, resulting in the protocol not being reviewed or acted upon.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Facility staff did not follow a psych NP's recommendation to rule out a UTI in a resident with dementia who exhibited behavioral changes. Despite a documented history of agitation linked to UTIs and ongoing symptoms, staff did not obtain a repeat urinalysis. The resident was later hospitalized, where sepsis and a UTI were diagnosed, and the DON acknowledged the recommendation had been missed.
A resident with dementia who required full staff assistance experienced a significant weight loss over a short period, but staff failed to confirm the loss, notify the DON, or update the nutrition care plan as required by facility policy. The DON was not informed of the weight change, and no follow-up actions were documented.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in the lack of a systematic process for identifying and addressing quality issues.
A resident with severe cognitive impairment and multiple diagnoses received opioid pain medications, but there were repeated discrepancies between the MAR and controlled substance records. Doses were documented as administered on the MAR but not reflected on the CS forms, with no refusals or explanations noted. The DON acknowledged gaps in the auditing process, and facility policy requiring reconciliation of controlled substance records was not consistently followed.
The facility's kitchen was found to have several sanitation deficiencies, including improper storage of raw and cooked foods, a dirty ice scoop holder, and a hose sprayer touching a soiled drain board. These issues were confirmed by the Dietary Manager and violated FDA Food Code regulations.
The facility failed to maintain a safe and clean environment, with deficiencies including overbed tray tables with exposed particle board, sharp sink vanity edges, soiled privacy curtains, and dusty ceiling vents. The Maintenance Manager acknowledged the issues but cited limitations in replacing tables, while the Maintenance & Housekeeping Manager did not provide clear responses regarding routine cleaning of vents.
A facility failed to ensure consistent documentation and communication for a resident receiving dialysis. The resident, with acute kidney failure and end-stage kidney disease, was scheduled for dialysis twice a week, but the MDS assessment did not reflect this. Documentation and assessments were missing for six treatments, and there was no follow-up with the dialysis center when paperwork was not returned. The DON confirmed the missing documentation and acknowledged the issue.
The facility failed to secure medication storage areas, with an LPN leaving a medication room door propped open and loose pills found in a medication cart. Insulin pens were improperly stored with food items, and a treatment cart was left unlocked near residents. The DON acknowledged these practices violated facility policy.
The facility failed to ensure accurate MDS assessments for two residents. One resident with end-stage renal disease was incorrectly marked as not receiving dialysis, despite having orders for it. Another resident was inaccurately documented as being discharged to a hospital instead of an assisted living facility. The errors were acknowledged by the MDS Coordinator.
A resident with impaired cognition and multiple diagnoses was found with undated and dated dressings on their arm, with no orders for wound care documented. The facility failed to ensure proper assessments and documentation, as the Wound Care Nurse and Consultant Wound Provider were unaware of the dressings, and the LPN who applied the initial dressing did not recall placing an order for changes. The DON confirmed that nurses should ensure physician orders are in place, as per facility policy.
The facility failed to ensure proper infection control practices during medication administration for two residents. An LPN was observed not performing hand hygiene before and after administering oral medications and eye drops to a resident. Additionally, the LPN did not perform hand hygiene after retrieving and administering Gabapentin to another resident. The DON acknowledged the oversight, which was against the facility's hand hygiene policy.
The facility failed to ensure proper sanitizing and washing practices for dishes and utensils, and lacked proper hand washing facilities in the kitchen. The kitchen had been without hot water for weeks to months, leading staff to use boiling water for washing. However, the sanitizing process was not conducted according to standards, with expired test strips and incorrect solution temperatures. The facility's policy and FDA guidelines were not followed, posing a risk of improper sanitation.
A resident admitted for hospice respite care, with severe cognitive impairment and total dependence on staff for ADLs, did not have their clothing changed for two days. The facility's failure to update the care plan in a timely manner resulted in CNAs not being informed of the need to change the resident's clothing daily, as confirmed by the DON.
A facility failed to readmit a resident after a hospital transfer, despite the resident being medically cleared. The resident had severe cognitive impairment and a history of aggressive behavior, which was known prior to admission. The decision not to readmit was made by Corporate, but the facility did not provide the required documentation or notice to the family. The facility's policy requires a 30-day written notice before involuntary transfer or discharge, which was not followed.
Soiled vents, urine odors, and overflowing linens
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for residents on the A, B, and D units. On 3/30/2026, surveyors observed bagged soiled linens overflowing from vendor-provided storage containers and being stored on the floor, with a strong urine odor present in the area near the building entrance. Staff W, the Housekeeping/Maintenance Director, stated that laundry pickup occurred on Monday, Wednesday, and Friday around 11:00 AM and that Monday was the heaviest collection day, and indicated they could check whether another collection bin was available. Staff W also stated that housekeeping staff cleaned the carpeting in the urine-odor areas each morning after arriving. During the survey, a complaint allegation stated that the entire unit smelled like rotting bodies and urine. Surveyors noted a strong urine odor immediately upon entering the front lobby, and the odor remained prevalent throughout the front lobby and hallways on the A, B, and D units. Two ceiling air units in the front lobby had vent grids heavily soiled with stringy dust debris. Additional observations at the A/B nursing station and D nursing station revealed heavily soiled ceiling vent air units and heavily soiled internal washable filters with dust debris. Staff W acknowledged the soiled condition of the vents and filters, stated housekeeping should have cleaned them, and reported that some were missed. Staff W also stated they did not monitor the ceiling ventilation systems and that the contracted heating and cooling company must have missed a couple.
Failure to Protect Residents from Verbal Abuse, Physical Abuse, and Neglect
Penalty
Summary
The facility failed to protect residents from verbal abuse, physical abuse, and neglect involving multiple residents. The cited issues involved a staff member exchanging profanity with a resident after the resident requested coffee, a resident-to-resident verbal altercation during bingo that included derogatory and disparaging remarks, an allegation that a nurse did not timely respond to a resident’s repeated requests for pain medication, and a resident-to-resident physical altercation in which one resident struck another after being hit on the buttocks. For one incident, a dietary/kitchen aide refused a resident’s request for coffee, and the resident responded with profanity. The staff member then replied with profanity and walked away. The incident was witnessed by a nurse, and the facility later acknowledged that verbal abuse had occurred, although it had initially been documented as inconclusive. The resident involved had diagnoses including bipolar disorder with psychotic features, mild neurocognitive disorder, Parkinson’s disease, schizoaffective disorder, chronic pain syndrome, and PTSD, and the resident reported being upset that staff should not have spoken that way. A separate resident-to-resident incident involved a resident with intact cognition who reported being called a derogatory name related to sexual orientation during bingo. Facility documentation showed that the resident had also used insulting language toward another resident and that another resident had responded with a derogatory remark and comments about the resident acting like a little girl. The administrator later stated the incident had not been reported because it was verbal and the resident had started it, even though the documentation included disparaging remarks. Another incident involved a resident with intact cognition and advanced cancer diagnoses who reported that a nurse turned off the call light and left the room after the resident requested pain medication, then returned later without giving the medication and left again, resulting in a prolonged wait before the medication was provided. The administrator stated the event was considered neglect because the resident needed narcotic pain medication regularly due to hospice status and aggressive cancer diagnoses. The report also described a physical altercation between two residents, one with severe cognitive impairment and vascular dementia and the other with intact cognition and schizoaffective disorder/dementia. Facility records showed one resident went up to the other, yelled, and hit the other on the buttocks; the other resident turned and struck back in the chin/face with a closed fist. The facility’s investigation included resident statements and staff observations, but the summary did not include a conclusion, and the incident was reported to the State Agency as unsubstantiated. During interview, the administrator acknowledged that the resident who punched the other in the face had committed physical abuse.
Failure to Report Resident Abuse and an Injury of Unknown Origin
Penalty
Summary
The facility failed to report witnessed resident-to-resident verbal abuse and an injury of unknown origin to the State Agency. During review of a separate verbal abuse concern involving a staff member and one resident, additional resident-to-resident abuse concerns were identified involving three residents during bingo. One resident, who had a BIMS score of 15 and diagnoses including bipolar disorder, neurocognitive disorder, schizoaffective disorder, and generalized anxiety disorder, reported that another resident called him a derogatory name related to sexual orientation. The same resident also reported that he was upset during bingo because another resident was called names and because of how the bingo screen was positioned. Another resident with a BIMS score of 15 stated he did not use the derogatory term but did call the first resident a fat punk and said he acted like a little girl. A third resident with a BIMS score of 3 and severe cognitive impairment was also involved in the incident. The Administrator later acknowledged the incident should have been reported and stated it was not reported because it was verbal and the resident had started it. Facility documentation and staff interviews showed the bingo incident involved derogatory and disparaging remarks between residents, but it was not treated as reportable abuse at the time. The activity staff member who witnessed the event reported that the first resident was upset, another resident intervened, and the first resident became increasingly upset. The staff member said the incident was reported to CNAs, nurses, and later to their supervisor, but not immediately to the abuse coordinator. The Activity Director later stated the staff member had only reported that the resident was upset and left, and that no derogatory statements were reported to them. The Administrator later acknowledged that the derogatory remarks should have been identified as verbal abuse and that staff should have notified the abuse coordinator immediately. The facility also failed to report an injury of unknown origin involving a resident who was admitted, readmitted, and later expired in the facility. That resident had moderately impaired cognition, one-sided upper and lower extremity impairment, and was dependent on staff for toileting hygiene, rolling, transferring, and moving from sitting to lying. Progress notes documented that the resident was last seen alive after being repositioned and changed, then was found out of bed with the head stuck between the bed and wardrobe, face down, with no pulse, respirations, or heart sounds and was pronounced deceased. The Administrator, who was also the Abuse Coordinator, stated she was notified that the resident was found with the head stuck between the bed and dresser and deceased, but she did not report the incident to the State Agency and did not provide a reason. The nurse assigned to the resident reported the resident was found wedged between the bed and armoire in an unusual position, could not be freed without moving furniture, and was not a fall risk and unable to move himself in bed.
Plumbing, Drain, and Ice Machine Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of plumbing and the ice machine. During a kitchen tour with the dietary manager, sewer gas odor was observed near the sub floor grease trap by the 3-compartment sink, at 3 in-floor drains, and near 3 kitchen sink drains. The dietary manager stated he had a diminished sense of smell and was not aware of the odor or what the issue might be. He also stated the grease trap was serviced about every 6 months and that the building was serviced by the village sanitary sewer. At a later interview, the dietary manager said service records should be with the maintenance supervisor or administrator and that it would probably be a good idea to have the grease trap serviced more frequently. The maintenance director stated no plumbing service records were available, that the last service was in August 2025, and that the grease trap had been cleaned/serviced annually. Observations also found two kitchen sink drain lines with dark soil buildup at the end of the drain line, the kitchen ice machine drip panel with spots of a pink substance forming, the D Hall janitor sink connected to the chemical supply tower with an atmospheric vacuum breaker but no wasting/vented T device, and the garbage disposal sink with a submerged jet inlet below the sink flood rim and no cross-connection prevention in place when the inlet valve was turned on and water came out.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for one resident who was admitted, later readmitted, and died in the facility. The resident had moderately impaired cognition, one-sided impairment of the upper and lower extremities, and was dependent on staff for toileting hygiene, rolling, transferring, and going from sitting to lying. The resident did not stand or walk and had no history of falls. According to the record, the resident was last seen alive after being repositioned and changed, and was later found out of bed with his head stuck between the bed and wardrobe, face down, with no pulse, no respirations, and no heart sounds. The nurse pronounced the resident deceased and notified the Administrator, DON, and unit managers. An incident report documented the same event, but no investigation was included with the report. When questioned, the Administrator stated there was no specific investigation and that the progress notes were the documentation for the event. The Administrator also reported she did not interview the CNA who provided care or found the resident, and did not interview the roommate. The DON stated the event was not investigated and should have been. The facility policy identified physical injury of unknown source as a possible indicator of abuse and stated that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation occurs.
Failure to Care Plan for Ileostomy
Penalty
Summary
The facility failed to develop a comprehensive care plan to address a resident's ileostomy for one resident reviewed for ostomies. The resident was observed sitting on the side of the bed and stated she had an ileostomy and needed assistance emptying and changing the bag. The clinical record showed the resident was admitted with diagnoses including kidney disease, osteoarthritis, and ileostomy status, and the MDS assessment indicated intact cognition and the presence of an ostomy. Review of the resident's comprehensive care plan revealed no care plan for the ileostomy. The DON stated that if a resident had any type of ostomy, it should be included in the care plan. The facility policy on care planning stated that the facility will develop and implement a baseline care plan for each resident that includes instructions needed to provide effective and person-centered care, including any special needs.
Failure to Keep Walker at Bedside for Resident With Falls History
Penalty
Summary
The facility failed to consistently implement fall prevention interventions according to one resident’s plan of care. The resident had a care plan for potential injury related to a history of falls, weakness, poor safety awareness, routine psychotropic medication use, and Parkinsonism with impaired gait. An intervention initiated on 3/10/25 directed staff to ensure the walker was next to the bed during all rounding and during medication pass each shift, but on 3/30/26 and 3/31/26 the resident was observed sleeping in bed with the walker and wheelchair placed across the room near the window rather than at bedside. The resident had a fall on 3/24/26 and was found on the floor of his room lying on his left side after reporting he was getting up to go to the bathroom. A Nursing: Antigravity Team Note dated 3/25/26 documented the root cause as unassisted ambulation to the bathroom and noted the prior intervention to ensure the walker was next to the bed during all rounding and during medication pass. The resident was admitted to the facility on 3/26/21 and readmitted on [DATE] with diagnoses including dementia and Parkinson’s Disease, and an MDS assessment dated [DATE] showed moderately impaired cognition and a history of falls.
Nephrostomy drainage bags positioned above kidney level
Penalty
Summary
The facility failed to ensure nephrostomy tube drainage bags were positioned for dependent drainage for one resident with nephrostomy tubes. The resident was admitted with diagnoses including acute kidney failure, bladder cancer, and hydronephrosis, and had a BIMS score of 12/15 indicating moderately impaired cognition. The physician order dated 3/3/26 directed staff to keep the nephrostomy tubing taped to the skin and connected to a drainage bag placed below the level of the kidneys. During multiple observations, the resident was lying in bed while both nephrostomy drainage bags were positioned above the height of the bed and above the level of the resident’s kidneys. On 3/30/25 at 9:34 AM, one bag was on an overbed tray table and the other was on a pillow against the wall; neither bag nor tubing appeared to have drainage fluid. The same condition was observed again on 3/30/26 at 12:35 PM and on 3/31/26 at 12:27 PM, when both bags were still lying on the tray table above the resident. The DON stated that nephrostomy drainage bags should be below the level of the kidneys for dependent drainage, and the resident said staff would place the bags on the tray table after emptying them.
Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to thoroughly assess and document a change in condition for one resident who was sent to the hospital and later returned the same day. On 3/30/26, the resident was observed in bed with twitching movements, disheveled appearance, and mumbled responses that were difficult to understand, and was later seen leaving the facility on a stretcher with EMS. The clinical record contained a Medication Administration Note stating the resident was sent to the hospital, but there was no documentation explaining why the transfer occurred, no progress note documenting the reason for the hospital transfer, no transfer form, and no change of condition assessment showing what was happening with the resident at the time of the event. There was also no progress note documenting the resident’s readmission back to the facility. The resident had been admitted to the facility with a diagnosis that included lung cancer. The record also showed an earlier change in condition when the resident reported trouble breathing and an oxygen saturation of 68% on 4L, requiring a non-rebreather on 6L before returning to 96%, but the change of condition assessment was incomplete and left blank, and there was no documentation of the physician’s response or whether the physician was reached. Staff interviews confirmed that the resident was sent to the hospital because he was not verbally responding, but the expected discharge emergent note, physician order, and transfer form were not completed, and instructions from the physician regarding oxygen monitoring were also not documented.
Failure to Follow Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to follow physician/extender pressure ulcer treatment orders for a resident with an unstageable coccyx pressure injury. The resident was admitted and readmitted with diagnoses including acute and chronic respiratory failure, diabetes, and heart failure, and had moderately impaired cognition on the MDS. A weekly skin sweep identified an open area on the coccyx, and a wound consult on 2/18/26 documented an unstageable pressure injury measuring 1.8 cm by 2 cm by 0.1 cm with 70% slough and 30% granulation. The wound consultant ordered cleansing with normal saline, application of Medihoney gel daily and as needed, and a secondary dressing, with the plan discussed with the treatment nurse. Subsequent wound consults on 2/25/26, 3/4/26, and 3/11/26 continued the Medihoney treatment plan, and later consults on 3/18/26 and 3/25/26 added calcium alginate while continuing normal saline, Medihoney, and a dressing daily and as needed. However, the February TAR only showed barrier cream to the buttocks, and the March TAR did not begin Medihoney wound care until 3/12/26. During observation on 4/1/26, the wound still appeared almost completely obscured with yellow slough and was measured at 2 cm by 1.6 cm by 0.1 cm with 90% slough and 10% granulation. The wound consultant stated she had ordered Medihoney from the beginning and was not aware it had not been started for about a month, and the DON stated all treatment orders should be entered into the TAR and initiated. The record also showed a discontinued order for cleansing the coccyx with normal saline and applying a border gauze or coccyx dressing until wound care was seen, which was never documented as having been done.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Protect Resident from Staff Mistreatment
Penalty
Summary
A staff member failed to protect a resident's right to be free from mistreatment. During an incident, a Certified Nurse's Aide (CNA) was observed placing her hand over a resident's mouth while the resident was yelling during care. Another CNA witnessed this action, which resulted in the resident's voice being muffled, and confronted the staff member. The CNA who committed the act reportedly expressed frustration with the resident's behavior and made an inappropriate comment about the resident's mental health status. The incident was reported to the nurse manager and subsequently to the facility administrator. The resident involved had a medical history including parkinsonism, bipolar disorder with severe psychotic features, and schizoaffective disorder. The facility's policy prohibits abuse, neglect, and exploitation, and requires immediate investigation of any allegations. The staff member accused of the mistreatment was suspended and later terminated following the incident. The deficiency centers on the failure to protect the resident from physical and psychosocial harm by a staff member during the provision of care.
Failure to Reconcile and Implement CIWA-Ar Protocol on Admission
Penalty
Summary
The facility failed to ensure that all admission orders were reported and reconciled with the physician for a resident admitted with a primary diagnosis of alcohol dependence with withdrawal. Upon review, it was found that the hospital discharge medication list included a CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) protocol for administering lorazepam based on withdrawal assessment scores. This protocol specified dosing and reassessment intervals, as well as instructions to notify the provider if certain thresholds were met. However, the as-needed CIWA protocol was not reconciled or implemented upon admission, unlike the other medications listed on the discharge summary. Interviews with the Director of Nursing (DON) and the assigned physician revealed that neither was aware of the CIWA protocol included in the hospital discharge documentation. The physician confirmed that they had not been informed of the protocol, and the DON acknowledged being unaware of its presence on the discharge medication list. There was no documentation or evidence that the protocol was reviewed or acted upon at the time of admission.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Failure to Follow Psych NP Recommendation and Identify UTI in Resident with Behavioral Changes
Penalty
Summary
Facility staff failed to follow the recommendation of a psychiatric nurse practitioner to rule out underlying medical causes, specifically a urinary tract infection (UTI), in a resident with dementia who exhibited increased anxiety, agitation, and aggression. The psych NP had documented that the resident had a history of significant agitation in the presence of acute medical issues, particularly UTIs, and advised that if behavioral changes persisted, a repeat urinalysis should be considered. Despite ongoing behavioral changes, the medical record showed that a repeat urinalysis was neither considered nor obtained as recommended. The resident continued to display behavioral disturbances, including verbal aggression toward another resident, and was later transported to the hospital by family due to concerns about a change in mental status. Hospital records confirmed the presence of sepsis due to Enterobacter species, with bacteremia secondary to a UTI, and the resident was started on intravenous antibiotics. The Director of Nursing later acknowledged being unaware of the psych NP's recommendation and confirmed that the repeat urinalysis had been missed.
Failure to Identify and Address Significant Weight Loss
Penalty
Summary
The facility failed to identify, follow up, and adhere to its policy regarding significant weight loss for one resident with dementia who required staff assistance for all activities of daily living. The resident experienced a weight loss of 16.4 pounds in less than a month, as documented in the medical record. There was no evidence that a re-weight was performed to confirm the loss, nor was there any documentation of clarification of the recorded weight, notification to the dietician or physician, monitoring, or interventions or modifications to the resident's nutrition plan of care. The facility's policy required comparison of newly recorded weights to previous weights to determine if a re-weight was necessary, but this process was not followed. The DON confirmed that they were not notified of the weight loss and that therapy staff, who obtained the weights, did not inform them of the significant change.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no formal mechanism in place to ensure that quality deficiencies were consistently identified or that appropriate corrective actions were developed and implemented.
Failure to Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substances for one resident, as evidenced by multiple discrepancies between the Medication Administration Records (MARs) and the corresponding Controlled Substance (CS) records. The resident in question had diagnoses including fibromyalgia, cerebral atherosclerosis, and unspecified dementia with agitation, and was receiving both scheduled and PRN opioid pain medications. The MARs indicated that medications such as Hydrocodone-Acetaminophen and Morphine Sulfate were administered at scheduled times, but these administrations were not consistently documented on the CS forms as required. Specific instances were identified where the MAR showed that doses were given, but there was no corresponding entry on the CS form, nor any documentation of refusal or explanation in the progress notes. For example, doses of Hydrocodone-Acetaminophen and Morphine Sulfate were marked as administered on the MAR but were missing from the CS records on several dates. In some cases, the CS forms reflected different administration times or omitted doses entirely, and in other cases, doses were documented as held on the MAR but still recorded as removed on the CS form. During an interview, the Director of Nursing acknowledged awareness of issues with controlled substance documentation and described a process of auditing CS forms for missing entries, but not for discrepancies between the MAR and CS forms. Facility policy required that controlled substance inventory be regularly reconciled with the MAR and documented accordingly, but this was not consistently followed, resulting in incomplete and inaccurate records for controlled substance administration.
Sanitation Deficiencies in Kitchen Storage and Equipment
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. In the Traulsen reach-in cooler, raw chicken was stored directly on top of a box of cooked diced chicken, and raw pork was placed on top of a box of corn chowder soup. This improper storage of food items was confirmed by the Dietary Manager (DM) J, and it violated the 2017 FDA Food Code section 3-302.11, which mandates the separation and segregation of raw animal foods to prevent cross-contamination. Additionally, the ice scoop holder was found with black debris on the inside bottom surface, which was acknowledged by DM J. This condition did not comply with the FDA 2017 Model Food Code, Section 3-304.12, which requires in-use utensils to be stored in a clean, protected location. Furthermore, the hose sprayer at the soiled side of the dish machine was observed hanging down and touching the soiled drain board, which was also noted by DM J. This situation contravened the 2017 FDA Food Code section 5-202.13, which requires an air gap to prevent backflow contamination.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Overbed tray tables in multiple rooms, including D150, D151, D156, and others, were found with missing plastic edging and exposed rough particle board, making them difficult to sanitize properly. Additionally, the sink vanities in rooms C138, C142, and C143 had sharp edges due to missing laminate, posing a potential safety hazard. The privacy curtain in room D151 was soiled with dark brown debris, and the ceiling vent covers in the main dining room and fishbowl lounge were coated with dust, with mold-like stains observed on the ceiling surrounding one of the vents. The Maintenance Manager acknowledged awareness of the issues with the overbed tray tables but stated that the facility could only replace two tables per month. Despite being fully staffed, the Maintenance & Housekeeping Manager did not provide a clear response regarding the routine cleaning and maintenance of vents, relying instead on a contracted company to clean them three times a year. The electronic reporting system used for maintenance issues was mentioned, but no concerns with privacy curtains were acknowledged. The inability to properly sanitize the porous surfaces of the tray tables was recognized, yet the replacement rate remained limited to two tables per month.
Inadequate Dialysis Documentation and Communication
Penalty
Summary
The facility failed to ensure consistent documentation and communication for a resident receiving dialysis services. The resident, who was admitted with acute kidney failure, end-stage kidney disease, and dependence on renal dialysis, was scheduled for dialysis every Tuesday and Saturday. However, the Minimum Data Set (MDS) assessment did not identify the resident as currently receiving dialysis services. Additionally, there were missing documentation and assessments for six dialysis treatments, indicating a lack of communication and assessment of the resident's condition pre and post dialysis. The facility's policy required nursing staff to provide a report to the dialysis provider regarding the resident's condition and treatment provisions each dialysis day. If no written report was received upon the resident's return, the nursing staff was to call the dialysis provider for a report. Despite this policy, there was no documentation of follow-up communication with the dialysis center when paperwork was not returned with the resident. The Director of Nursing confirmed the missing documentation and assessments, acknowledging the concern.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and security of medications and biologicals, as observed in two medication rooms, one treatment cart, and one medication cart. During a medication administration observation, an LPN propped open the medication room door with a crash cart, leaving it unattended and accessible. Loose pills without patient identifiers were found in a medication cart drawer, which were acknowledged by an LPN and disposed of improperly. Additionally, the medication storage room on D hall contained insulin pens stored improperly alongside food items, including a large opened container of applesauce and moldy grapes. The treatment cart on D hall was found unlocked and unsupervised, with three residents seated nearby. A nurse returned to the medication cart next to the treatment cart but did not secure the treatment cart until prompted by the surveyor. The facility's policy requires that medication rooms, carts, and supplies be locked when not attended by authorized personnel, and refrigerated medications be stored separately from food items. The Director of Nursing acknowledged the issues and confirmed that the observed practices were against facility policy.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents during the Minimum Data Set (MDS) evaluations. One resident, who was admitted with acute kidney failure and end-stage renal disease, was incorrectly marked as not receiving dialysis in their MDS assessment, despite having physician orders for dialysis twice a week since admission. The MDS Coordinator, Nurse 'E', acknowledged the error, stating they were unaware of the resident's dialysis treatment, which was documented in the resident's orders and progress notes. Another resident, admitted with dementia, atrial fibrillation, and hypertension, was inaccurately documented as being discharged to a short-term general hospital in their MDS assessment. However, records indicated the resident was actually discharged to an assisted living facility. Nurse 'E' admitted to mistakenly selecting the wrong discharge location during the assessment process.
Failure to Ensure Proper Wound Care and Documentation
Penalty
Summary
The facility failed to provide appropriate assessments, monitoring, and treatments for a resident with non-pressure wound care needs. The resident, who had moderately impaired cognition and required assistance for all activities of daily living, was observed with undated and dated dressings on their left arm, with visible drainage. The clinical records did not contain any orders for wound care or dressing changes, and the resident was unsure of the reason for the bandages. A skin tear was noted after the resident rolled out of bed, but no further assessments or documentation were completed. The Wound Care Nurse and a Consultant Wound Provider were unaware of the dressings on the resident's arm, and the Licensed Practical Nurse who initially dressed the wound did not recall placing an order for dressing changes. The Director of Nursing confirmed that nurses should ensure physician orders are in place for dressings and treatments. The facility's policy requires wound treatments to be provided according to physician orders and documented appropriately, which was not followed in this case.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure appropriate infection control practices during medication administration for two residents. On the morning of February 5th, a Licensed Practical Nurse (LPN) was observed administering oral medications to a resident without performing hand hygiene before or after the process. Additionally, the LPN retrieved and administered lubricating eye drops to the same resident without performing hand hygiene, even after donning gloves. The LPN later acknowledged the oversight in hand hygiene. Later that morning, the same LPN was observed administering Gabapentin to another resident without performing hand hygiene after retrieving the medication from a separate medication room. The Director of Nursing was informed of these incidents and acknowledged that hand hygiene should be performed before and after medication administration, as per the facility's hand hygiene policy dated January 2024.
Improper Sanitizing Practices and Lack of Hot Water in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitizing and washing practices were used to clean dishes and utensils, and did not provide proper hand washing facilities in the kitchen. This deficiency was identified during an investigation following a complaint about the lack of hot water in the kitchen. Observations revealed that the kitchen staff were using boiling water to wash dishes and utensils, and then rinsing and sanitizing them in a three-compartment sink. However, the sanitizing process was not conducted according to professional standards, as the sanitizing solution was not at the correct temperature and the test strips used to check the solution's concentration were expired. Interviews with staff members, including the Administrator and Dietary Manager, confirmed that the kitchen had been without hot water for weeks to months. The staff reported using disposable foam containers and plastic cutlery to serve food, while reusable items were washed with boiling water. Despite these efforts, the sanitizing process was not properly executed. For instance, a staff member was observed submerging a pot in the sanitizing solution for only one second instead of the required one minute, and another staff member did not test the sanitizing solution before use. The facility's policy on the use of the three-compartment sink was not followed, as the sanitizing solution was not tested for appropriate concentration before use, and the water temperature was not maintained at the required level. The FDA Food Code specifies that handwashing sinks must provide water at a minimum temperature, and the sanitizing solution must be at a specific temperature and concentration. These requirements were not met, leading to the potential risk of improper sanitation of dishware and utensils used by the residents.
Failure to Assist Resident with Dressing
Penalty
Summary
The facility failed to provide assistance with dressing for a resident who was admitted for hospice respite care. The resident, who had diagnoses including heart failure and dementia, was totally dependent on staff for activities of daily living, including dressing. A complaint was submitted alleging that the resident's clothing was not changed for two days. Upon investigation, it was confirmed that the resident's clothing was indeed not changed during this period. The Director of Nursing (DON) confirmed that the care plan for the resident was not updated in a timely manner to include tasks for changing the resident's clothing daily. The resident's family had provided clothing and a nightgown for each day of the stay, and it was the facility's expectation that clothing would be changed daily. However, due to the lack of an updated care plan, the Certified Nursing Assistants (CNAs) were not informed of this task, leading to the deficiency.
Failure to Readmit Resident After Hospital Transfer
Penalty
Summary
The facility failed to permit a resident, who was transferred to the hospital, to return to the facility after being medically cleared. The resident, who had severe cognitive impairment and a history of aggressive behavior, was initially admitted to the facility despite known behavioral issues. The facility's decision not to readmit the resident was made by Corporate, citing the resident's aggressive behavior and attempts to elope as reasons. However, the facility did not provide the required documentation or notice to the resident's family regarding the decision not to readmit. The facility's policy requires a 30-day written notice before involuntary transfer or discharge, which was not adhered to in this case. The Nursing Home Administrator and Director of Nursing acknowledged that the resident was not an appropriate admission, and the Admissions Director indicated that Corporate had instructed the facility to increase admissions, leading to the acceptance of the resident. The facility's failure to follow proper procedures and provide adequate notice resulted in a deficiency citation.
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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