Munson Healthcare Otsego Memorial Hospital Ltcu
Inspection history, citations, penalties and survey trends for this long-term care facility in Gaylord, Michigan.
- Location
- 825 North Center Street, Gaylord, Michigan 49735
- CMS Provider Number
- 235006
- Inspections on file
- 18
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Munson Healthcare Otsego Memorial Hospital Ltcu during CMS and state inspections, most recent first.
A resident with dementia and severely impaired cognition, identified as a fall risk, was found on the floor after ordered fall precautions were not in place. The care plan required a mat on the left side of the bed and a bed alarm while in bed, but the mat was placed on the wrong side and the alarm was not turned on. The resident had a hematoma to the forehead and was later found to have an indeterminate fracture of the left 5th digit.
Food Service Plumbing and Storage Sanitation Deficiencies: The facility failed to prepare food in accordance with professional standards when the three-compartment sink was observed without a proper air gap and soap was bubbling up from the floor drain, the vegetable wash sink had an air-break instead of an air gap, and the ice machine drain extended into the floor drain without an air gap. Surveyors also observed the floor and drain lines under the sink and utensil rack soiled with grease, grime, and debris, and damaged pipe insulation near shelving where clean utensils were stored.
Failure to Track and Monitor Infections: The facility did not maintain an IPCP with infection identification and surveillance for all residents. A resident transferred in with CDI was not included in the infection control mapping, line listings, logs, or data analysis, and several residents with symptomatic infections were listed but not reflected in the facility’s tracking documents. Staff could not explain how CDI or other GI symptoms were being monitored, and no infection documentation was available for one month.
The facility failed to complete a discharge medication reconciliation for one resident discharged with home health services, with the discharge summary lacking a physician’s order listing and resident signatures. The facility also failed to provide written transfer notification for another resident sent to the hospital ED; staff stated they only sent bed-hold information instead of the required transfer notice.
Missing MRR documentation and physician rationale for pharmacist recommendations were found for three residents. One resident with dementia and behavioral symptoms had pharmacist GDR requests for divalproex, but the related reports were missing and the physician declined without documenting clinical reasoning. Another resident with osteoporosis had a pharmacist recommendation to add calcium/vitamin D to alendronate therapy, but the report was missing and the physician’s declination had no rationale. A third resident with dementia and anxiety had a pharmacist GDR request for risperidone, but the report was missing and no physician explanation for declining was found.
The facility failed to maintain hospice documentation for two residents who were receiving hospice services. One resident with CHF and intact cognition had hospice participation documented in the MDS and care plan, but no hospice visit notes, care records, or service documentation were found in the EMR. Another resident with CAD, vascular dementia, hemiplegia, COPD, and PVD also had hospice participation documented, but the EMR lacked hospice visit notes showing the care and services provided by the hospice agency. Staff stated the notes should be in the EMR, but they were not uploaded or available in the record.
The facility failed to ensure the QAPI committee met quarterly with required members, potentially affecting care for all 27 residents. The Medical Director or designee did not attend the February meeting, and no attendance record was found for October. The interim NHA could not locate the missing records by the survey exit.
The facility failed to document monthly pharmacy medication regimen reviews and did not follow pharmacy recommendations for four residents with various diagnoses, including dementia and heart failure. The physician order reports lacked evidence of ordered labs as recommended by the consultant pharmacist, and the Medical Director admitted not seeing all recommendations. This deficiency could lead to adverse medication side effects.
The facility failed to follow regulations for psychotropic medications, including not specifying an end date for a PRN lorazepam prescription and lacking documented rationale for its continued use. Additionally, two residents on antipsychotic medications did not receive required AIMS assessments to monitor for side effects, contrary to facility policy.
A resident with moderate cognitive impairment and limited mobility experienced a non-functional call light system, leading to dissatisfaction with care timeliness and fear of unmet needs in emergencies. Despite multiple work orders and staff awareness, the issue persisted due to a lack of a contract with a third-party contractor for repairs and no facility policy on call light maintenance.
Failure to Implement Ordered Fall Precautions
Penalty
Summary
The facility failed to implement fall prevention measures for one resident with dementia and severely impaired cognition who was identified as a fall risk due to gait and balance problems and being unaware of safety needs. The resident’s care plan called for an anti-fatigue mat to be placed on the left side of the bed and for a bed alarm mat to be used at all times while in bed, with the devices in place and functioning properly. After the resident was put to bed by an RN, the resident was later found on the floor on the left side of the bed with a hematoma to the left forehead and was sent to the ED for evaluation. During the investigation, it was noted that the fall mat had been placed on the wrong side of the bed and the bed alarm had not been turned on. In the ED, the resident was noted to have pain in the left hand, and x-ray showed an indeterminate fracture of the left 5th digit.
Food Service Plumbing and Storage Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety. On 03/31/2026 at 2:45 PM, the three-compartment sink was observed to not be properly air gapped, and soap was bubbling up out of the floor drain. Kitchen staff had just emptied the first compartment (wash) of the sink when the observation was made, and cook H stated that this happens all of the time, with other staff in the room agreeing. On 03/31/2026 at 3:00 PM, the vegetable wash sink was observed to have an air-break rather than an air gap between the food compartment drain-line and the floor drain. On 04/01/2026 at 10:05 AM, the Symphony Plus ice machine drain in the Clean Storage Room was observed extending down into the floor drain without an air gap. On 03/31/2026 at 2:49 PM, the floor and drain lines under the three-compartment sink and metal utensil storage rack were observed to be soiled with grease, grime, and debris. On 03/31/2026 at 2:48 PM, the insulation wrapping water lines behind the storage shelving units to the left of the three-compartment sink was observed to be damaged, while clean utensils were stored on the shelving unit a couple inches away from the damaged insulation covering the pipes.
Failure to Track and Monitor Infections
Penalty
Summary
The facility failed to implement an infection prevention and control program that included infection identification and surveillance for all residents. Resident #25 was transferred from the hospital to the facility with Clostridium difficile infection, but the February 2026 infection control documentation did not include this CDI in the infection mapping, line listings, logs, or other tracking documentation. Several residents with symptomatic infections were listed on the infection line listing, but they were not reflected in the facility’s mapping or data analysis documentation. There was no infection documentation provided for March 2026. During interview, the Infection Preventionist was unavailable, and RN B and the NHA were unable to explain why the CDI was not tracked or how the facility was monitoring and correlating other residents with gastrointestinal symptoms. RN B confirmed the CDI was not documented in the infection control information and stated she did not know how the facility was tracking or monitoring for CDI. The NHA reviewed the records and confirmed the CDI was missing from the infection control program documentation and that the IPCP was not in place.
Missing discharge medication reconciliation and transfer notification
Penalty
Summary
The facility failed to ensure that a discharge summary for one resident included a reconciliation of pre-discharge medications with post-discharge medications. The resident was discharged with home health care services, and the discharge summary documented that medications were called into a pharmacy, but the section directing the reader to a physician’s order listing was left blank and no physician’s order listing was included. The discharge summary also had blank resident and/or resident representative signature sections despite a date entry, and a signed copy was not found in the resident’s electronic medical record. Social Worker A stated that medication information was contained in the discharge summary, but the record review did not show documentation that a medication reconciliation was completed or that a discharge medication list was provided. The facility also failed to provide written notification of transfer for another resident who was transferred from the facility to the hospital emergency department. The electronic medical record did not contain documentation showing that written transfer notification was given to the resident or the resident representative. When asked for the written notification, Social Worker A stated that the facility did not do that and that only bed-hold information had been sent. The facility policy stated that the resident and/or representative would be notified of the transfer or discharge and provided information including the reason for transfer, the effective date, the location of transfer, and contact information for the state LTC ombudsman and the state agency handling appeals.
Missing MRR Documentation and Physician Rationale for Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRRs) were addressed by the attending physician for three residents reviewed for MRRs and unnecessary medications. For Resident 16, the record showed a diagnosis of dementia with behavioral disturbance and an order for divalproex twice daily. The pharmacist’s MRRs referenced gradual dose reduction (GDR) requests, but the related pharmacist reports could not be located in the resident’s electronic medical record. An undated pharmacist report to the physician recommended evaluating the resident for a GDR of divalproex, and the physician checked the disagree box and signed the form on 1/22/26, but did not document any clinical rationale for declining the recommendation in the form or in progress notes. For Resident 3, the record showed a diagnosis of osteoporosis and a pharmacist’s monthly MRR that referenced a medication addition request. The pharmacist report itself was not located in the resident’s record. An undated pharmacist report to the physician recommended considering adding a calcium/vitamin D supplement to augment alendronate therapy. The physician wrote declined and signed the report on 10/23/25, but there was no rationale documented on the report or elsewhere in the resident’s EMR explaining the declination. For Resident 4, the record showed diagnoses including non-Alzheimer’s dementia and anxiety disorder, with routine antipsychotic use and no GDR completed. A pharmacist recommendation on 11/19/25 requested a GDR of risperidone for hallucinations, but the corresponding pharmacist report was not located in the record. The physician response area showed decline see form with a signature dated 12/5/25, yet no physician rationale for declining the GDR recommendation was found in the resident’s record. The facility policy required the consultant pharmacist to report irregularities and for the prescriber’s response, including an explanation when disagreeing, to be recorded in the resident’s clinical record or on the consultant’s written report.
Missing Hospice Documentation for Two Residents
Penalty
Summary
The facility failed to provide hospice documentation for two residents who were documented as receiving hospice care. One resident was admitted with congestive heart failure, had a BIMS score of 15/15 indicating intact cognition, and the MDS and care plan documented hospice participation and a terminal prognosis related to heart disease. Although a physician order indicated the resident may sign on to a hospice agency of choice with a start date of 3/2/26, the EMR contained no hospice visit notes, cares, or services provided by hospice during the course of care, and the facility was unable to provide additional documentation before the end of the survey. The second resident was admitted with diagnoses including CAD, vascular dementia, left-sided hemiplegia, COPD, PVD, and palliative care, and the MDS documented hospice participation with a BIMS score of 9/15. The EMR contained a hospice election statement and a hospice care plan, but the miscellaneous tab had no hospice visit notes showing care and services provided by the hospice agency since October 2025. During interviews, staff stated the daily hospice visit notes should be in the EMR, that notes had not been uploaded yet, and that hospice papers were being placed in the scanning bin. The facility’s hospice policy stated the facility would maintain a medical record on each hospice resident and retain hospice progress notes as part of the resident’s permanent record.
QAPI Committee Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members, which could potentially affect the quality of care for all 27 residents. During a review on February 13, 2025, it was found that the Medical Director or their designee did not attend the QAPI meeting held on February 5, 2025. Additionally, there was no attendance record available for the meeting held on October 24, 2024. The interim Nursing Home Administrator (NHA) was unable to locate the October 2024 attendance record and confirmed the absence of the Medical Director or designee at the February 2025 meeting. The missing attendance records were not provided by the time of the survey exit on February 13, 2025.
Failure to Document and Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to provide evidence of documented monthly pharmacy medication regimen reviews (MRRs) and did not appropriately follow pharmacy recommendations for four residents. These residents had various diagnoses, including dementia, rheumatoid arthritis, and heart failure, and were on multiple medications that required regular laboratory monitoring as per the consultant pharmacist's recommendations. However, the physician order recapitulation reports did not show any labs ordered in response to these recommendations, indicating a lack of action on the part of the facility to ensure proper medication management. During an interview, the Medical Director acknowledged not having seen all the pharmacy recommendations, particularly those related to laboratory tests, and admitted that the physician should be aware of all recommendations. The facility's policy on Medication Regimen Review states that the consultant pharmacist's evaluation should include reviewing laboratory results and that the prescriber's response should be recorded. This deficiency in following the established policy and procedures resulted in the potential for adverse medication side effects for the residents involved.
Failure to Adhere to Psychotropic Medication Regulations
Penalty
Summary
The facility failed to adhere to regulations regarding the administration of psychotropic medications for residents. Specifically, a resident was prescribed lorazepam PRN for anxiety without a specific end date, and there was no documented rationale for the continued use of this medication beyond the 14-day standard reevaluation period. The facility's policy requires that PRN orders for antianxiety medications not exceed 14 days without physician documentation, which was not followed in this case. Additionally, the facility did not conduct required Abnormal Involuntary Movement Scale (AIMS) assessments for two residents who were prescribed antipsychotic medications. One resident had no AIMS assessment documented in their electronic medical record, while another resident was missing two quarterly AIMS assessments. The facility's policy mandates that nursing staff are responsible for initiating AIMS assessments to monitor for adverse consequences or side effects of psychoactive medications, which was not adhered to in these instances.
Non-Functional Call Light System in Resident's Room
Penalty
Summary
The facility failed to ensure a functional call light system for a resident, leading to dissatisfaction with the timeliness of care and fear that care needs may not be met in an emergency. The resident, who had moderate cognitive impairment and limited physical mobility due to a history of stroke, reported that their call light was non-functional and that staff were aware of the issue. Despite multiple work orders being submitted to the maintenance department, the call light remained unrepaired, causing the resident to rely on their roommate's call light for assistance. Observations confirmed that the resident's call light was not working, as pressing the button did not trigger the indicator light inside or outside the room. Interviews with staff, including a CNA and an RN, revealed that they were aware of the issue and had submitted work orders, but the maintenance department had not addressed the problem. The maintenance director indicated that the facility staff were supposed to contact a third-party contractor for repairs, but there was no contract in place, and the facility lacked a policy regarding call light repairs. The review of work orders showed that the call light issue had been ongoing, with several closed work orders indicating attempts to fix the problem, but the issue persisted. The facility's interim NHA and DON acknowledged the problem and the lack of a contract with a third-party contractor for call light repairs. The deficiency highlights a breakdown in communication and responsibility between the facility's staff and maintenance department, resulting in unresolved safety concerns for the resident.
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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