Munson Healthcare Crawford Continuing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grayling, Michigan.
- Location
- 1100 Michigan Avenue, Grayling, Michigan 49738
- CMS Provider Number
- 235201
- Inspections on file
- 19
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Munson Healthcare Crawford Continuing Care Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and known elopement risk was monitored with wanderguards and 15‑minute safety checks but had been restless and attempting to exit shortly before eloping. Earlier that day, a malfunctioning wanderguard door alarm was reset by a facilities staff member, who relied on a green indicator light and did not manually test the system with a probe as required by protocol. The resident then exited through the front door without triggering an alarm, was observed outside by the DON, and was ultimately redirected back inside by an RN and CNA after having walked a significant distance away from the entrance; the NHA later identified the failure to manually test the system after service as the root cause of the elopement.
The facility failed to document IDT collaboration and did not include residents or their representatives in quarterly care plan reviews for multiple residents. One resident’s MDPOA said she had not been invited to care conferences, while staff stated formal care conferences were not being held for LTC residents and that care plans were simply adjusted as needed. Records for residents with diagnoses including dementia, Alzheimer’s disease, CKD, agitation, incontinence, and a fracture showed no documentation of care plan discussion with the resident or DPOA, and one resident’s care plan goals were marked overdue.
Failure to obtain informed consent for psychoactive medications. A resident with severe vascular dementia and severely impaired cognition was prescribed quetiapine, an antipsychotic, and sertraline, an antidepressant, but the record showed no written or verbal consent from the responsible party and no documentation that side effects or adverse reactions were explained. The DON stated there was no consent for those meds.
Failure to provide written transfer notices and bed hold info for 3 residents. Three residents were transferred to the ED, but the transfer forms lacked signed receipt acknowledgement and did not include the facility bed hold policy. A social services designee confirmed the notices were not provided in writing and stated she was unaware the transfer notification needed to be given in writing.
Failure to monitor significant weight change: A resident with Alzheimer’s disease and severe cognitive impairment was on a modified diet and initially documented as stable, but monthly weights showed an 8.6-lb gain, no reweigh was done within 24 hours, and the RD was unaware of the change. The care plan was not updated after the significant weight increase, despite the facility’s weight procedure requiring reweighing for a 5-lb change.
Failure to provide ordered dining adaptive equipment: three residents were observed without the utensils or drinking aids listed on their meal tray cards. One resident with a shaking hand used a standard teaspoon instead of a larger spoon, another did not receive the ordered small-diameter straw, and a third was eating with regular utensils despite an order for built-up foam handles and stated he had not received them at breakfast either.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
The facility failed to implement proper infection control measures, affecting multiple residents. A resident's urinary catheter bag was found on the floor, and another resident's drinking cup was placed on the floor and not sanitized before use. A resident with Influenza A lacked an infection care plan, and soiled linens were improperly handled. Additionally, a CNA did not sanitize hands between glove changes while feeding two residents. The DON confirmed these actions violated facility policies.
A resident was placed on end-of-life care without a physician's order or care plan, and the durable power of attorney was activated without proper assessments. The resident was admitted for therapy services and was alert and oriented, but the family decided on comfort care without documented physician assessments indicating the resident's incapacity to make medical decisions.
A facility failed to assess and document the use of a reclining wheelchair as a physical restraint for a resident with Alzheimer's and Parkinson's. The resident, unable to disengage the leg rest independently, was placed in the chair for safety without proper assessments or documentation. Interviews with staff revealed uncertainty about the restraint's classification, and the facility's policy on restraint-free environments was not followed, leading to potential negative outcomes.
The facility failed to ensure MRRs were reviewed and addressed by physicians for two residents, leading to potential medication management risks. One resident with severe cognitive impairment had no MRR documentation for several months, and recommendations for a digoxin level test were not addressed. Another resident's MRRs and physician responses were missing for two months, with incomplete blood test recommendations followed. The facility's policy on MRR documentation was not followed.
The facility failed to document non-pharmacological interventions before administering PRN anti-anxiety medication to two residents with severe cognitive impairments. Despite care plans outlining strategies like redirection and therapeutic listening, these were not documented as attempted prior to medication use. Facility policies require non-pharmacological interventions to be tried and documented before using medications, but this was not adhered to, as revealed by record reviews and interviews with the DON.
The facility failed to maintain food safety standards during meal preparation and service. Fresh-cut cantaloupe melon was served at temperatures above the safe range, and the kitchen had discontinued using a cleaner for the melons' exterior. Additionally, mechanical chicken was served at temperatures below the required holding temperature. These deficiencies violate the 2017 FDA Food Code and pose a risk of foodborne illness to residents.
The facility failed to report PBJ information to CMS, leading to inaccurate staffing level reports potentially affecting all 26 residents. The CMS PBJ Staffing Data Report for FY Quarter 2 2024 showed a lack of 24-hour licensed nursing coverage and no RN hours, with daily infractions. The Business Office Manager, responsible for PBJ submissions, could not provide confirmation of successful submission for the required period.
The facility failed to implement an effective QAPI program, as the DON was unaware of Performance Improvement Projects and could not provide evidence of regular review or data analysis. The facility's policy outlines necessary QAPI elements, but documentation and evidence of an ongoing program were lacking, potentially affecting all 26 residents.
The facility failed to ensure the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) meetings quarterly, as required by policy. The Director of Nursing (DON) confirmed the IP's absence from the last three meetings, which could lead to ineffective interdisciplinary communication affecting all 26 residents.
The facility failed to track communicable diseases during a Covid-19 outbreak, potentially exposing 23 residents. The DON did not maintain detailed records or conduct a required RCA. Additionally, the facility's laundry procedures for contaminated items were not followed, risking pathogen transmission. Laundry staff were unaware of proper disinfectant use, and chemicals were incorrectly connected.
The facility did not have a qualified Infection Preventionist working at least part-time, leading to inadequate management of the Infection Prevention and Control Program. The DON and an RN were in the process of completing necessary training but had not finished. The hospital affiliate Infection Preventionist was only a resource and did not provide oversight. The facility failed to conduct outbreak investigations or track symptoms for a Covid-19 outbreak, and no official records of illness were kept unless antibiotics were prescribed.
The facility failed to provide written notifications to residents or their representatives for transfers to acute care hospitals. Three residents were transferred due to medical conditions such as acute anemia, respiratory failure, and hypokalemia without receiving written notices. The Business Officer Manager confirmed the lack of written notifications and admitted to not being trained to complete transfer agreements.
The facility failed to provide safe wheelchair mobility assistance for three residents, as foot pedals were not used, posing injury risks. Additionally, the facility did not investigate a self-injurious incident involving a resident with dementia, as the DON was unaware of the event and no investigation was initiated. The lack of a policy on resident supervision and safety was also noted.
A facility failed to investigate allegations of abuse involving a resident with severe cognitive impairment, who was involved in two incidents with another resident. Despite the resident reporting a threat of harm, no investigations were conducted as there was no physical contact. This inaction violated the facility's policy, which requires thorough investigations of all abuse reports, including verbal threats.
A resident with dementia and impaired cognitive skills was found with a call light cord around her neck, yet her care plan lacked interventions for her impulsive behavior and safety needs. Staff confirmed the need for frequent safety checks, but these were not documented, leading to potential unmet safety needs.
A resident with chronic respiratory failure and hypoxia was not administered supplemental oxygen as per physician orders. The resident was observed multiple times without her prescribed oxygen, and staff interviews revealed a misunderstanding of her oxygen requirements. Despite an order for continuous oxygen, there was no documented physician directive to trial weaning off the oxygen, and the facility's policy lacked guidance on oxygen weaning.
A resident with acute pain due to trauma and contusions experienced untreated leg cramps and muscle spasms, despite repeated complaints documented in her EMR. The facility failed to follow its pain management policy, as no physician addressed her pain, and communication errors were identified by the Clinical Care Coordinator/RN.
A facility failed to conduct a gradual dose reduction (GDR) for a resident on olanzapine, despite recommendations from the Consultant Pharmacist. The resident, with dementia and delusional disorders, continued receiving the same dosage without documented evaluation or rationale for not performing the GDR. The Nursing Home Administrator cited issues with medical providers' understanding of GDR regulations.
A facility failed to maintain a medication administration error rate below five percent, resulting in a 6.45 percent error rate. Errors included a missed dose of gabapentin due to unavailability and incorrect documentation, and improper insulin administration using a Humalog KwikPen without priming. These errors affected a resident and were due to staff not following procedures and being unaware of medication administration requirements.
Failure to Prevent Elopement After Improper Testing of Wanderguard System
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident who was known to be at risk for wandering and elopement. The resident had dementia with behavioral disturbances, a BIMS score of 2 indicating severe cognitive impairment, and a quarterly elopement evaluation score of 6.0 indicating risk of elopement. Prior to the incident, the resident’s elopement prevention interventions included wanderguards on both wrists and 15‑minute safety tracking. On the day of the event, the resident had been restless and had attempted to exit through a facility door approximately 15 minutes before the successful elopement. On the afternoon of the incident, a facilities staff member (Staff A) was called to address a malfunctioning wanderguard alarm at the front door that would not stop sounding. Staff A unplugged the power to reset the system, and after the reset, the alarm was silenced and the system’s green light was illuminated. Relying on the green light as an indication of proper functioning, Staff A left the facility without manually testing the system with a probe or sensor. The Maintenance Director later stated that protocol was to manually test the system after any maintenance rather than relying solely on the green light. Subsequently, the resident exited through the front door without the wanderguard system alarming. The DON, who was leaving the building, observed the resident in the parking lot approximately 75 feet from the entrance and called an RN inside the facility for assistance. The RN reported that the resident had progressed to the hospital driveway and was beginning to walk toward the road, and described redirecting the resident back to the facility with the help of a CNA after negotiating nearly a block and a half. The CNA confirmed that the door alarm did not sound when the resident successfully eloped. The NHA confirmed that the resident was unattended in the parking lot for approximately 19 seconds and identified the root cause of the elopement as the failure to manually test the wanderguard system after it was serviced, resulting in a faulty alarm.
Failure to Document IDT Care Plan Reviews and Resident/Representative Involvement
Penalty
Summary
The facility failed to document collaboration among the interdisciplinary team (IDT) and failed to offer and provide inclusion of residents or their representatives in quarterly reviews of the comprehensive care plan for three residents. For Resident #5, the medical durable power of attorney reported she had not been alerted or invited to review the plan of care with the IDT and wanted the opportunity to hear what everyone had to say about the resident’s health. The resident’s EMR showed diagnoses including diabetes, chronic kidney disease, and dementia, with a comprehensive care plan addressing nutrition, falls, activity participation, skin integrity, pain, and ADL completion. Review of the record from 10/01/2025 through 3/24/2026 showed no documentation of IDT collaboration or review of the comprehensive plan of care with the resident or her DPOA, and all care plan entries were completed by RN A without notation that the IDT reviewed their respective care areas. For Resident #7, the EMR showed diagnoses including Alzheimer’s disease with behavioral disturbances, altered safety awareness, and incontinence, with multiple care plan areas and interventions listed. RN A stated the resident had never had a care conference and that there was no documentation of discussion of the plan of care in the EMR. For Resident #13, the EMR showed Alzheimer’s disease, dementia with agitation, anxiety, and a significant decline in status due to a fall resulting in fracture; the care plan goals were printed in red and marked overdue. RN A stated she updated the MDS assessments and care plan but must have missed the care plan update, and also stated the resident probably had not had a care conference since admission, although the son was the activated DPOA and staff talked to him often.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to obtain informed consent for psychoactive medications for one resident with severe vascular dementia with behavioral disturbance. The resident was admitted on 2/21/2024, and the most recent MDS assessment showed severely impaired cognition, with Section C indicating the resident was rarely/never understood. The medical record also documented that the resident had an appointed responsible party for health care and financial decision making. The resident’s physician orders showed quetiapine fumarate 25 mg, an antipsychotic, was prescribed and initiated on 7/10/2025, and sertraline HCl 25 mg, an antidepressant, was prescribed and initiated on 1/9/2026. The record contained no evidence that the responsible party had given written or verbal consent for either medication or had been informed of potential side effects or adverse reactions. On 3/25/2026, consents for both medications were requested, and during an interview that same day, the DON stated, “We do not have a consent for those meds.”
Failure to Provide Written Transfer Notices and Bed Hold Information
Penalty
Summary
The facility failed to provide written notification of transfer or discharge and failed to include the facility bed hold policy for three residents who were transferred to the Emergency Department. For Resident #3, the record showed a transfer to the ED on 2/7/26 for chest pain, and the Transfer Notice was completed with the reason for transfer, transfer location, and RN signature, but the acknowledgement of receipt was unsigned and undated. The record also did not contain documentation that an explanation of the bed hold policy had been given to the resident or the resident's responsible party. For Resident #6, the EMR showed transfer to the ED on 1/05/26 for an acute episode of shortness of breath, and the Transfer Notice listed the reason as medically unstable and needing treatment at another facility. The notice was signed by a facility nurse, but the receipt line was blank, and a handwritten note stated that voicemail was left for the resident representative at 7:35 p.m. The form did not include the facility bed hold policy or any indication that the written notice was provided to the resident or representative. For Resident #32, the EMR showed transfer to the ED on 1/18/2026 for evaluation, with the reason listed as resident requesting; the receipt line was also blank, and the form did not include the bed hold policy or any indication that the written notice was provided to the resident or representative. Staff C confirmed the forms did not include acknowledgement of receipt and stated she was unaware the notification of transfer needed to be provided in writing, adding, 'We're not doing that.'
Failure to Monitor Significant Weight Change
Penalty
Summary
The facility failed to assess, monitor, and maintain the nutritional status of one resident with Alzheimer’s disease and severe cognitive impairment. The resident was admitted with a primary diagnosis of Alzheimer’s disease, had a BIMS score of 2 of 15, and was observed feeding herself successfully at lunch. The durable power of attorney stated the resident had been very active earlier in life but was not active now and was gaining weight and might outgrow her clothes. The registered dietitian’s quarterly note documented that the resident was on a level 7 diet with thin liquids and that her weight was considered overall stable, with a plan to continue monitoring weight trends and food acceptance records. However, the resident’s recorded weights showed 126.7 pounds in January 2026 and 135.3 pounds in March 2026, with no weight recorded for February 2026. The 8.6-pound gain represented a significant 6.7% change from the previous monthly weight, but no reweigh was completed within 24 hours, no further RD notes were recorded, and the care plan was not updated after the significant weight change. The RD stated she had not been aware of the weight change and agreed the facility had not followed the weight procedure.
Failure to Provide Ordered Dining Adaptive Equipment
Penalty
Summary
The facility failed to provide dining adaptive equipment for three residents reviewed for dining assistive devices. During lunch observation, one resident was feeding himself but had a shaking hand and was spilling food down the front of his clothing protector; his meal tray card instructed a larger spoon, but he was using a standard teaspoon instead. Another resident’s meal tray card instructed a small diameter straw, but he did not have a straw at all, and a CNA stated the smaller straw had been missed. A dietary manager agreed staff should have been following the instructions on the meal tray cards. A third resident was observed eating lunch in his room with regular utensils even though his meal tray card instructed built-up foam for utensils, which was typed in capital letters, in red ink, and highlighted in yellow. He was struggling to feed himself and stated he needed the foam and had not received it at breakfast either. The dietary manager stated the therapy department had been working with this resident and had supplied the built-up foam handled utensils, and the facility policy referenced rehabilitation services providing equipment training, recommendations, and adaptive aids for activities of daily living.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures, affecting five residents. Resident #5 was observed with a urinary catheter drainage bag and tubing dragging on the floor beneath her wheelchair on multiple occasions, without a barrier to prevent contamination. Resident #10 had a plastic drinking cup placed on the floor, which was later picked up by a registered nurse and placed on a table without sanitization or replacement. Resident #23, diagnosed with Influenza A, did not have an infection care plan to guide staff in preventing the spread of the virus. Additionally, a certified nurse aide was seen placing soiled linen bags on the floor instead of in the designated soiled utility room. Further observations revealed that a certified nurse aide was feeding two residents simultaneously while wearing examination gloves, changing gloves without sanitizing hands in between. A bag containing clean clothing protectors was also found on the floor in the dining room. The Director of Nursing confirmed that these practices were against the facility's policies, which require hand sanitization between glove changes, proper handling of soiled linens, and ensuring that urinary catheter bags and drinking cups are not placed on the floor. The facility's policies on infection control and urinary catheter care were not adhered to, contributing to the deficiencies observed.
Failure to Properly Activate DPOA and Establish EOLC Plan
Penalty
Summary
The facility failed to ensure that a resident, who was placed on end-of-life care (EOLC), had a care plan and physician's order for terminal care, and that the activation of the patient's advocate/durable power of attorney was appropriately conducted. The resident was admitted for skilled therapy services and was alert and oriented, as documented in the nurses' progress notes. However, a progress note indicated that the family decided to make the resident comfort care without a physician's order for EOLC or a care plan in place. Additionally, there were no documented assessments by physicians indicating that the resident was incapable of making medical treatment decisions, which was necessary to activate the patient advocate designation. The facility's social services director and the director of nursing confirmed that the durable power of attorney should not have been activated without assessments by two physicians declaring the resident incapable of making medical decisions. The facility's policy required that if a patient loses decision-making capacity, the DPOA must be activated by the attending physician and one other physician. In this case, the resident's daughter was allowed to make decisions regarding EOLC without the proper assessments and documentation, leading to a deficiency in the facility's handling of the resident's end-of-life care.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to provide appropriate assessments and documentation for the use of a physical restraint on a resident diagnosed with Alzheimer's dementia and Parkinson's Disease. The resident, who was unable to participate in the Brief Interview for Mental Status and was assessed to have severely impaired cognition, was observed multiple times seated in a reclining wheelchair with the leg rest engaged in the up position. The resident was unable to disengage the leg rest independently, and staff repositioned the resident without documented assessments or justification for the use of the reclining wheelchair as a restraint. Interviews with facility staff, including a CNA and the Director of Nursing (DON), revealed that the resident was placed in the reclining wheelchair for safety reasons, as the resident exhibited fidgety behavior and was at risk of falling forward when tired. However, the DON was unsure if the reclining wheelchair should be considered a restraint and confirmed that no assessments were completed to ensure the resident's safety or ability to remove themselves from the chair independently. The resident's care plan indicated the use of a geri chair for comfort and positioning but lacked documentation of behaviors or restlessness targeted by the use of the reclining wheelchair. The facility's policy on a restraint-free environment requires documentation of medical symptoms warranting the use of restraints, attempts of less restrictive alternatives, and ongoing re-evaluation of the restraint's necessity and effectiveness. The resident's electronic medical record lacked documentation of these requirements, and no regular assessments were conducted to ensure the resident's safety and psychosocial well-being while using the reclining wheelchair. This oversight resulted in the potential for negative outcomes such as decreased physical functioning and loss of autonomy and dignity.
Failure to Address Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRR) were properly reviewed and addressed by the physician for two residents, resulting in potential risks related to medication management. For Resident #3, who has severe cognitive impairment and diagnoses including heart failure and dementia, there was no documentation of MRRs in the electronic medical record from August 2024 to December 2024. Although a paper record indicated a review was conducted in December 2024, no pharmacy recommendations were documented. Further, recommendations made in January 2025 regarding the need for a digoxin level test were not addressed by the nursing staff or the physician, and the last recorded digoxin level test was from March 2024. For Resident #23, who is cognitively intact and has multiple diagnoses including atrial fibrillation and renal insufficiency, the medical record lacked MRR recommendations and physician responses for November and December 2024. The Director of Nursing (DON) was unable to provide documentation of the MRR for November 2024 and reported that only one of the recommended blood tests from December 2024 was obtained, with no documentation from the physician regarding the declination of additional tests. The facility's policy requires that MRRs and prescriber responses be documented and maintained, which was not adhered to in these cases.
Failure to Document Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to ensure proper documentation and implementation of non-pharmacological interventions before administering as-needed (PRN) anti-anxiety medication to two residents. Resident #3, who was admitted with dementia and depression, had severe cognitive impairment as indicated by a low score on the Brief Interview for Mental Status (BIMS). The resident's Medication Administration Record (MAR) showed multiple instances where lorazepam was administered without documentation of specific behaviors or symptoms, and without evidence of attempted non-pharmacological interventions. The care plan for Resident #3 included interventions such as redirection with snacks or conversation, but these were not documented as attempted prior to medication administration. Resident #10, diagnosed with Alzheimer's dementia and Parkinson's Disease, also exhibited severely impaired cognition. The MAR for this resident indicated that lorazepam was administered for anxiety and agitation, but there was a lack of documentation regarding specific behaviors and non-pharmacological interventions prior to medication use. The care plan for Resident #10 included strategies like stopping and reapproaching if the resident was uncooperative, and providing therapeutic listening, but these were not documented as being attempted before administering lorazepam. The facility's policies on Behavioral Health Services and Behavior and Symptom Management require that non-pharmacological interventions be tried and documented before resorting to pharmacological measures. However, the review of the electronic medical records and interviews with the Director of Nursing revealed that these protocols were not followed, leading to the administration of PRN medications without proper documentation and attempts at non-pharmacological interventions.
Food Safety Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. During the morning meal service, a large pan of fresh-cut cantaloupe melon was found to have temperatures ranging between 45°F and 48°F, which is above the recommended safe temperature for cold foods. Dietary Aide E mentioned using a special wash for the melon, but Prep Cook F revealed that the kitchen had stopped using any cleaner for the exterior of the melons a year prior. The Certified Dietary Manager confirmed the absence of a process to ensure thorough cleaning of the melons, which is a violation of the 2017 FDA Food Code that requires raw fruits and vegetables to be thoroughly washed before being cut or served. Additionally, during the noon meal observation, a pan of mechanical chicken was found to have temperatures between 119°F and 131°F, which is below the required holding temperature of 135°F as per the FDA Food Code 2017. Dietary Aide E stated that the temperatures had been taken and the food was ready for service, indicating a failure to maintain the appropriate temperature for hot foods. This deficiency in maintaining proper food temperatures and cleaning procedures poses a risk of foodborne illness to the 26 residents in the facility.
Failure to Report PBJ Information to CMS
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 had the potential to affect all 26 residents in the facility. During the review of the CMS PBJ Staffing Data Report for the fiscal year Quarter 2 of 2024, it was found that the facility did not maintain licensed nursing coverage 24 hours a day and had no Registered Nurse (RN) hours, with daily infractions occurring from January 1 to March 31, 2024. An interview with the Business Office Manager (BOM) revealed that she was responsible for submitting the PBJ information but was unable to provide confirmation emails from CMS indicating successful submission of the required information for Quarter 2 of 2024. The PBJ XML Submission Process requires that after submission, a Final Validation Report is generated within 24 hours, detailing any errors found during the validation of the records in the PBJ submission file.
Facility's QAPI Program Lacks Implementation and Documentation
Penalty
Summary
The facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program, which is crucial for maintaining quality care standards. During an interview, the Director of Nursing (DON) admitted to being unaware of the concept of a Performance Improvement Project (PIP) and was unable to provide any formal records of such projects. The DON also could not present evidence of regular review or data analysis under the QAPI program, including tracking and measuring performance, establishing goals and thresholds for performance improvements, or monitoring and evaluating the effectiveness of corrective actions. The DON expressed difficulty in understanding the requirements of the QAPI program due to insufficient orientation for the role. The facility's policy on Quality Assurance and Performance Improvement, revised in July 2023, outlines the necessary elements of the QAPI plan, including tracking performance, setting goals, identifying deficiencies, analyzing causes, and implementing corrective actions. However, the facility failed to maintain documentation or demonstrate evidence of an ongoing QAPI program. This deficiency had the potential to affect all 26 residents in the facility, as the lack of a structured QAPI program could lead to unaddressed quality issues and systemic deficiencies.
Infection Preventionist Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis, as required. This deficiency was identified through an interview with the Director of Nursing (DON) and a review of attendance documents from the previous three quarterly meetings, which confirmed the absence of the IP. The DON acknowledged that the IP does not attend these meetings and instead serves as a resource in the acute-care portion of the facility. The facility's policy on Quality Assurance and Performance Improvement, revised on July 12, 2023, mandates that the Quality Assessment and Assurance (QAA) Committee be interdisciplinary and include the IP as a member. The absence of the IP from these meetings resulted in the potential for ineffective interdisciplinary communication regarding facility processes, potentially affecting all 26 residents residing in the facility.
Deficiencies in Infection Control and Laundry Procedures
Penalty
Summary
The facility failed to implement a system for recording and tracking communicable diseases during a Covid-19 outbreak, which potentially exposed 23 uninfected residents to the virus. The Director of Nursing (DON), who was also the acting Infection Preventionist, did not maintain a written summary of the outbreak or systematically track infections that did not require antibiotic use. Although the facility conducted testing on residents and staff, the DON could not provide detailed information on the symptoms, onset, or resolution of the illness for the Covid-19 positive residents. The facility's policy required a Root Cause Analysis (RCA) after an outbreak, but no RCA was conducted to evaluate the effectiveness of the actions taken or to identify areas for improvement. The facility also failed to develop and implement appropriate laundry policies and procedures for residents' personal laundry, which could prevent the transmission of resistant pathogens. The existing policy outlined procedures for handling potentially contaminated laundry, including the use of red bags and specific washing instructions. However, the DON acknowledged that the policy was not followed, as potentially contaminated laundry was sent to the hospital laundry staff, who used yellow bags instead of red and did not use bleach or high-temperature wash cycles as required. Interviews with the hospital laundry manager, laundry staff, and maintenance supervisor revealed that the chemicals used in the washing machine were not connected correctly, and there was no awareness of the need to use or monitor chlorine disinfectant levels. The facility's policy did not address the need to ensure proper disinfectant levels during the washing process, leading to a failure in preventing the transmission of infections through laundry handling.
Inadequate Infection Preventionist Presence and Program Management
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist was working at least part-time, which resulted in inadequate management of the Infection Prevention and Control Program. The Director of Nursing (DON) was responsible for infection prevention duties but had not completed the necessary Infection Preventionist training. Similarly, Registered Nurse (RN) L was also in the process of completing the training but had not finished. The hospital affiliate Infection Preventionist, RN Q, was only a resource and did not provide actual oversight or part-time presence at the facility. During a review of the facility's Infection Control Program, it was found that there was no outbreak investigation or symptom tracking for a Covid-19 outbreak in March 2024. The DON admitted to not systematically tracking infections that did not require antibiotic use, and no official records of illness onset or resolution were kept unless antibiotics were prescribed. The facility's policy did not include the regulatory requirement for a qualified Infection Preventionist to work on-site at least part-time.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the reasons for their transfers to acute care hospitals. This deficiency was identified for three residents who were transferred due to various medical conditions. Resident #82 was transferred twice, first for acute anemia and then for acute blood loss anemia, without receiving a written notice. Similarly, Resident #186 was sent to a hospital for acute respiratory failure with hypoxemia, and Resident #27 was transferred due to leukocytosis and severe hypokalemia, both without written notifications. During the survey, it was confirmed through an interview with the Business Officer Manager (BOM) that the facility did not issue written notifications for transfers or discharges. The BOM admitted to not having completed a transfer agreement and not being trained to do so. Additionally, the facility did not provide a transfer policy by the time of the survey exit, further indicating a lack of compliance with the requirement to notify residents or their representatives in writing about transfers or discharges.
Deficiencies in Wheelchair Mobility Assistance and Incident Investigation
Penalty
Summary
The facility failed to provide safe assistance with wheelchair mobility for three residents, leading to potential injury risks. During observations, it was noted that two residents were assisted to the dining room in wheelchairs without foot pedals, causing their feet to scrape the ground or requiring them to hold their feet up. A staff member admitted that foot pedals were rarely used for residents who could self-propel, citing time constraints as the reason for not retrieving them from residents' rooms. This practice posed a risk of injury or falls, as residents might not understand the need to keep their feet off the floor. Additionally, the facility did not investigate the root cause of self-injurious behavior for a resident with dementia. The resident was found with a call light cord wrapped around her neck, an incident that was not reported or investigated by the facility. The Director of Nursing (DON) was unaware of the incident until informed by the surveyor and confirmed that no investigation had been initiated. The resident had a history of impulsive behavior and required frequent checks to ensure her safety, but the incident was treated as isolated without further inquiry. The facility's lack of a policy related to resident supervision and safety was highlighted, as no such policy was provided upon request. The failure to investigate the self-injurious behavior and the unsafe wheelchair mobility assistance practices indicate deficiencies in the facility's supervision and safety protocols, potentially compromising resident safety.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to implement its abuse policy and investigate allegations of abuse involving a resident with severe cognitive impairment, who was admitted with diagnoses including stroke, dementia, and right-side hemiparesis. The resident was involved in two separate incidents where they were found in potentially threatening situations with another resident. In the first incident, staff intervened when the resident was yelling in the dining room due to another resident being in close proximity, although no physical contact occurred. In the second incident, the resident was observed with another resident with their fists up, and the resident reported that the other resident threatened to hit their genitals, but again, no physical contact was made. Despite these incidents, the Director of Nursing reported that no investigations were conducted because there was no physical contact between the residents. This inaction is contrary to the facility's policy, which mandates that all reports of abuse, including verbal threats, be promptly and thoroughly investigated. The policy defines verbal abuse as the use of language that includes threats of harm, regardless of the resident's ability to comprehend. The lack of investigation into these incidents resulted in a deficiency, as the facility did not adhere to its own policy to ensure the safety and well-being of its residents.
Failure to Address Safety Concerns in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address safety concerns for a resident with dementia, identified as R3. R3 was admitted with a primary diagnosis of dementia and exhibited short- and long-term memory problems, as well as severely impaired cognitive skills for daily decision-making. An observation revealed R3 seated in a reclining wheelchair with a call light positioned near her knee, and no staff present. A clinical progress note from earlier in the year documented an incident where R3 wrapped a call light cord around her neck, requiring intervention from CNA staff. Despite this incident, R3's care plan did not include any focus area or interventions related to her behavior or the need for frequent safety checks. Interviews with facility staff, including a CNA and an RN, confirmed that R3 was impulsive and unaware of her own safety needs, necessitating frequent safety checks and keeping her near the nurses' station during waking hours. However, these safety measures were not documented in R3's care plan. The lack of a comprehensive care plan addressing R3's specific safety needs resulted in the potential for unmet safety needs, as the facility did not formally recognize or plan for the resident's impulsive behavior and safety risks.
Failure to Administer Supplemental Oxygen Per Physician Orders
Penalty
Summary
The facility failed to administer supplemental oxygen per physician orders for a resident with chronic respiratory failure and hypoxia. The resident, who had intact cognition, was observed multiple times without her prescribed supplemental oxygen, despite having an order for continuous oxygen at 2 liters and up to 6 liters with exertion. On one occasion, a registered nurse noticed the resident had removed her oxygen and did not take immediate action to reapply it, instead stating they would see how she did without it. The resident's electronic medical record confirmed the need for continuous oxygen, and there was no documented physician order to trial weaning off the oxygen. Interviews with staff revealed a misunderstanding or lack of adherence to the resident's oxygen requirements. A CNA mentioned that the resident's oxygen saturation was at 97% on room air, leading them to try without supplemental oxygen. An RN stated they were told to wean the resident off oxygen during the day but could not provide a physician's order for this action. The Director of Nursing and Clinical Care Coordinator confirmed that continuous supplemental oxygen should be worn at all times if ordered, and there was no communication in the resident's record to support the cessation of oxygen. The facility's policy on oxygen delivery did not include expectations regarding physician orders on oxygen weaning.
Failure to Manage Resident's Pain
Penalty
Summary
The facility failed to assess and manage pain for a resident who was admitted with diagnoses including hypomagnesemia, acute pain due to trauma, and contusion of the left hip and knee. The resident, who had intact cognition, repeatedly complained of painful leg cramps and muscle spasms that disrupted her sleep. Despite these complaints being documented in the resident's electronic medical record (EMR) and communicated to the facility's clinical team, there was no follow-up or intervention by a physician to address her pain. The resident's daughter also contacted the primary care provider, expressing concerns about the lack of pain management for her mother. However, the primary care provider indicated that the resident was under the care of the facility's attending provider. An interview with the Clinical Care Coordinator/Registered Nurse revealed that the usual process for addressing such complaints was not followed, as the physician communication form was either lost or not properly transcribed. This resulted in the resident's pain going untreated, contrary to the facility's policy on aggressive pain prevention and management.
Failure to Conduct Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to appropriately conduct a gradual dose reduction (GDR) for a psychotropic medication for a resident diagnosed with dementia with behavioral disturbances and delusional disorders. The resident was admitted with a moderately impaired cognition score. The Consultant Pharmacist's Medication Regimen Review recommended a GDR evaluation for the resident's olanzapine, an antipsychotic medication, but the facility did not document any evaluation or rationale for not performing the GDR. The resident continued to receive the same dosage of olanzapine without any documented attempt at dose reduction or clinical contraindication. The Nursing Home Administrator acknowledged awareness of the GDR recommendation but cited issues with medical providers' understanding of GDR attempts per regulations. The facility's policy requires GDR attempts within the first year of admission or after initiation of a psychotropic medication, unless clinically contraindicated, with documentation in the clinical record. However, there was no evidence in the resident's electronic medical record that the facility addressed the pharmacist's recommendation or documented any clinical reasoning for not attempting a GDR.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in a rate of 6.45 percent. This was due to two errors identified out of 31 opportunities, affecting one resident. The first error occurred when a registered nurse (RN) was unable to administer a scheduled dose of gabapentin 800 mg to a resident because the medication was not available in the automatic dispensing cabinet. The RN did not follow the facility's policy to notify the pharmacy for a refill, and the missed dose was inaccurately documented as administered in the Medication Administration Record (MAR). The second error involved the administration of insulin using a Humalog KwikPen. The RN failed to prime the pen before administering the insulin, which is necessary to ensure the correct dosage is delivered. The RN was unaware of the priming requirement until after the administration, which was confirmed upon reviewing the manufacturer's instructions. These actions and inactions led to the medication administration errors, contributing to the facility's failure to meet the required error rate standard.
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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