Niles Care Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Niles, Michigan.
- Location
- 911 S 3rd St, Niles, Michigan 49120
- CMS Provider Number
- 235361
- Inspections on file
- 33
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 33 (2 serious)
Citation history
Health deficiencies cited at Niles Care Center, Llc during CMS and state inspections, most recent first.
A resident with cognitive impairment, abnormal gait, and mobility limitations had a care plan requiring a two-person assist for transfers, but was transferred by a single CNA for ADL care. During the transfer, the resident’s legs gave way while turning, he slid, let go of the CNA, and fell to the floor, striking his leg and back and later reporting bruising and scratches. The CNA involved stated she had been informed the resident was a one-person extensive assist and this was her first time caring for him, while another CNA identified the resident as a two-person stand assist and the DON confirmed the resident was a two-person assist at the time of the incident.
The facility failed to maintain accurate MARs for two residents, leading to discrepancies between documented and actual medication administration. One resident with morbid obesity had an active order for weekly Wegovy injections, and the MAR showed a dose as given, but the pharmacist confirmed the drug was never supplied and the RN who charted it later stated it was likely a documentation error and did not recall administering the injection. Another resident with chronic pain had orders for scheduled and PRN Percocet; the MAR reflected five doses given on one day, while the controlled drug receipt and narcotic count supported only four tablets being dispensed. The LPN involved reported that the controlled drug record reflected what was actually administered and that the MAR entries were likely incorrect.
A cognitively intact resident reported that the food was so poor she ordered the same limited meal every night and had to buy her own preferred items, despite having discussed her preferences with the Dietary Supervisor. Two other cognitively intact residents stated that the kitchen frequently ran out of commonly used items such as brown sugar, butter, bananas, peach cups, pudding, and even hot dogs and hamburgers that were listed on the always available menu, especially from the middle to the end of the month. Dietary staff and the RD confirmed that corporate adjusted weekly food orders to stay within budget and that some items had been removed or had run out, while the NHA reported being unaware of residents’ concerns about food shortages.
A resident with severe chronic pain and osteoarthritis did not receive physician-ordered Norco for 11 days due to delays in obtaining the prescription and medication from the pharmacy. Despite staff awareness of the issue and the resident's ongoing severe pain, the medication was not administered until after intervention by the ombudsman. Documentation and staff interviews confirmed lapses in communication and medication management, resulting in unmet pain management needs.
A resident with chronic pain and osteoarthritis did not receive physician-ordered Norco for 11 days due to delays in obtaining the prescription and lack of timely follow-up by nursing staff and facility leadership. The resident experienced severe, uncontrolled pain during this period, and staff interviews revealed gaps in communication and awareness regarding the medication issue.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental hazards and insufficient staff monitoring.
The facility failed to adhere to food safety and sanitation standards, as observed during a survey. Cooked roast beef was improperly cooled, and various food items lacked proper date markings. Cleanliness issues were noted with kitchen equipment, and the dish machine did not reach required temperatures. A staff member was observed handling food with bare hands, violating contamination prevention guidelines.
The facility failed to implement proper infection control practices, as observed in multiple instances where staff did not adhere to PPE protocols for residents on contact precautions. The facility also lacked an ongoing infection control surveillance program, with no tracking of employee illnesses and no recent audits of hand hygiene or PPE use. Additionally, there was no active plan to manage the risk of legionella and other pathogens in the facility's water systems.
The facility failed to document and offer COVID-19 vaccination to its staff, specifically a CNA who was last vaccinated in 2021. The DON confirmed that the facility had not offered the vaccine in 2024 and had not tracked staff immunization status or provided education, increasing the risk of COVID-19 infections among residents.
The facility exhibited multiple environmental deficiencies, including structural damage, improper storage, and unsanitary conditions. Observations revealed holes in walls, moisture damage, stained and improperly stored items, non-operational equipment, and significant wear and tear in common areas. These issues increased the potential for contamination and decreased resident satisfaction.
A long-term care facility reported a 20% medication error rate involving four residents. Errors included improper injection sites, late medication administration, missed doses, and crushing of delayed-release medication. LPNs administered injections incorrectly, misunderstood timing protocols, failed to use backup medication supplies, and crushed medication against prescription instructions.
The facility's ineffective pest control program resulted in an ant infestation in resident rooms, hallways, and visitor restrooms. Despite having a monthly pest control service, the Maintenance Assistant did not treat the building for ants between visits. The Nursing Home Administrator was unaware of the issue, which persisted for several days, contributing to potential food infestation and resident discomfort.
A resident with a gastrostomy tube was not receiving the prescribed enteral feeding due to improper management by nursing staff. The feeding pump was often off during scheduled times, and the total volume of formula was not documented, leading to insufficient nutritional intake. The facility's staff failed to adhere to the prescribed feeding schedule and volume, as confirmed by the RD and DON.
Three residents in an LTC facility did not receive adequate assistance with ADLs, leading to dissatisfaction and hygiene concerns. A resident expressed dissatisfaction with the frequency of showers, while another appeared disheveled with long, dirty fingernails due to missed shower opportunities. A third resident was observed with soiled fingernails and expressed frustration over inadequate assistance with personal hygiene.
A resident with a G-tube was not administered enteral feeding as ordered, leading to potential health risks. Observations showed the feeding pump was often off, and the tubing was not connected. LPNs reported inconsistencies in feeding times, and the MAR lacked documentation of the total formula volume. The DON confirmed the resident did not receive the full prescribed amount of formula.
A facility failed to conduct gradual dose reductions (GDRs) for a resident on Duloxetine for major depressive disorder. The resident's dosage remained unchanged for over a year, and no attempts at GDR were made in 2024. The facility lacked documentation of GDR or physician rationale against it.
The facility failed to prevent scalding hazards by allowing hot water temperatures to exceed safe limits and did not consistently monitor these temperatures. Additionally, a resident at high risk for elopement exited the facility unnoticed due to unsecured and unalarmed doors, despite having a history of wandering behavior. The resident's wander guard was not properly checked or ordered after readmission, contributing to the incident.
A resident with Alzheimer's was physically abused by another resident with a history of aggressive behavior in the dining room. Despite interventions in place, the aggressive resident flipped the other resident's wheelchair, leading to threats and police involvement. The facility's abuse prevention measures were insufficient to prevent this incident.
A facility failed to report a suspected abuse incident involving a resident with schizophrenia, anxiety, depression, dementia, and aphasia to Law Enforcement. The incident, where a CNA allegedly held the resident's breast, was reported internally but not to authorities, violating the facility's policy and federal requirements.
A facility failed to address a resident's skin integrity in the baseline care plan, despite the resident's history of skin issues and a rash noted upon admission. The care plan did not include skin integrity, and this omission was confirmed by the DON. The facility's policy requires addressing such concerns within 48 hours of admission.
A resident admitted for a respite stay under Hospice care developed a yeast infection under her breast due to the facility's failure to address a pre-existing rash noted upon admission. The rash was documented but not followed up on, leading to a lapse in care continuity. Facility staff were unaware of the condition, resulting in the infection being discovered by a Hospice LPN four days later.
A resident with cognitive impairment reported being left in a soiled brief for over six hours and experiencing long wait times for assistance. The facility's investigation into the grievance was inadequate, with only verbal staff education conducted without documentation, failing to meet the grievance policy requirements.
A resident with moderate cognitive impairment alleged rough handling by a CNA and an LPN, which was not reported immediately to the NHA or law enforcement, violating facility policy. The NHA admitted to only reporting significant incidents, leading to an incomplete investigation. Additionally, a neglect concern was raised by the resident, which was not reported to the state agency, indicating systemic issues in handling such allegations.
Failure to Follow Two-Person Transfer Requirement Resulting in Fall
Penalty
Summary
The facility failed to ensure a safe transfer and adequate supervision to prevent an accident for one resident. Resident #103, a male with diagnoses including other abnormal involuntary movements, restless legs syndrome, abnormalities of gait and mobility, and limitation of activities due to disability, was moderately cognitively impaired with a BIMS score of 8/15. His baseline care plan effective 2/11/26 documented that he required support for mobility and a two or more person physical assist for transfers. On 2/26/26, an attended fall report documented that while staff were transferring the resident from bed for ADL care, the resident stated his legs were giving way and he was lowered to the floor by CNAs, then assisted to stand and transferred to his wheelchair, with ADLs completed without further incident and the resident denying pain at that time. A grievance form later submitted by Resident #103 stated that on that date he was lifted out of bed by only one person, despite being a two-person assist, and that during the lift he fell to the floor, hitting his leg and back on the bed and floor, causing severe bruising and scratches on his legs and back. In interviews, the resident reported that when the one CNA attempted to transfer him, they both started to turn, he began to slide, let go of the CNA, and hit the floor hard, resulting in two black and blue marks on his leg. Another CNA reported that the resident was a two-person stand assist. CNA X stated she had been told the resident was an extensive assist of one person for transfers and that this was her first time caring for him; she later learned he was actually an extensive assist of two and acknowledged she had essentially attempted to transfer him alone. The DON confirmed that the resident was a two-person assist for transfers on the date of the incident and that CNA X had transferred him by herself.
Inaccurate MAR Documentation for Wegovy and Percocet
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records for two residents, resulting in medication administration records (MARs) that did not accurately reflect what was actually given. For one male resident with morbid obesity, an active order dated mid-October for Wegovy (semaglutide) 2.4 mg subcutaneously once weekly for obesity was present, and the October MAR showed the dose as administered by an RN on the scheduled date. However, the pharmacist reported the pharmacy had never sent Wegovy for this resident because the insurance did not cover it and confirmed the facility had never received the medication. The RN who documented the administration stated it was probably a mistaken computer click, did not recall giving the injection, and later told the resident he did not remember administering the shot and believed it was incorrect documentation. For another male resident with diagnoses including unspecified low back pain and unspecified pain, there were active orders for Percocet 7.5-325 mg: one tablet by mouth three times daily for pain, and one tablet by mouth as needed once daily for severe breakthrough pain. The March MAR showed three doses of the scheduled Percocet and two doses of the PRN Percocet documented as administered on the same day, totaling five tablets. In contrast, the controlled drug receipt for that date showed only four Percocet tablets signed out at four documented times. The LPN involved recalled giving the resident his routine Percocet and an additional PRN dose for increased pain, stated that whatever was on the controlled drug receipt reflected what was actually given, and acknowledged that the MAR must contain documentation errors since the narcotic count at shift end was correct. The DON confirmed that the MAR documentation indicating five tablets had to be an error because the narcotic count supported administration of only four tablets.
Failure to Honor Food Preferences and Maintain Adequate Food Supply
Penalty
Summary
The deficiency involves the facility’s failure to honor resident food preferences and maintain adequate food supplies as required by policy. One cognitively intact resident, Resident #37, reported that the food was so poor that she ordered the same dinner every night—two hamburger patties without a bun and dessert—and that she had to purchase her own English muffins because the kitchen would not obtain them for her. She also stated she preferred tomatoes on salads and more vegetables and had previously discussed her preferences with the Dietary Supervisor but remained dissatisfied. Review of the facility’s Food Preference Policy indicated that if a resident is unhappy with their diet, staff will create a care plan that the resident is satisfied with and that the Food Services Department will offer a variety of foods at each scheduled meal. Two other cognitively intact residents, Resident #16 and Resident #29, reported that the kitchen frequently ran out of various food items, particularly from the middle to the end of the month. Resident #16 stated the kitchen ran out of brown sugar, butter, bananas, peach cups, and that hot dogs and hamburgers—listed on the always available menu—had been unavailable for a week, and that food served was often disliked and condiments were not available. Resident #29 similarly reported that hot dogs, hamburgers, pudding, and bananas ran out often, especially mid- to late month. The Dietary Supervisor and Registered Dietitian confirmed that food orders were placed weekly, then adjusted by corporate to stay within budget, and acknowledged that brown sugar had been removed from orders and that bananas had run out in the past, though alternative fruits were available. The Nursing Home Administrator stated she was not aware that residents reported food running out mid- to late month.
Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
A resident with chronic pain, obesity, depression, and severe osteoarthritis of the left hip was admitted to the facility and required physician-ordered pain management, including Norco (hydrocodone-acetaminophen). Despite having clear physician orders for Norco, the resident did not receive the medication for 11 consecutive days. During this period, the resident reported severe, uncontrolled pain, rating it as 10 out of 10, and stated that alternative pain medications such as Tylenol and Ibuprofen were not effective. The resident indicated that staff were aware of the missing Norco and repeatedly informed him that the pharmacy had not shipped the medication yet. Review of the resident's medical records and medication administration records confirmed that Norco was not administered from the start date of the order through the period in question. Progress notes documented ongoing issues with obtaining the medication, including references to awaiting supply, missing scripts, and delays attributed to the Thanksgiving holiday. Staff interviews revealed that delays in receiving medications from the pharmacy were not uncommon, and several nurses believed that facility management was aware of the issue. However, both the DON and NHA stated they were not aware of the resident missing Norco until the ombudsman intervened. Further interviews with facility leadership and the prescribing physician highlighted communication breakdowns and procedural lapses. The DON reported that the pharmacy did not receive the necessary script and that there was difficulty getting the physician to provide it due to the holiday. The physician acknowledged he could have sent the script electronically but did not recall the specifics of the situation. The facility's policy required providing care and services according to established guidelines, but the resident's pain management needs were not met due to these failures in medication procurement and communication.
Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
The facility failed to follow professional standards of practice by not ensuring timely follow-up on a physician-ordered pain medication for a resident with chronic pain, osteoarthritis, obesity, and depression. The resident was admitted with significant pain issues and had a physician order for Norco (hydrocodone-acetaminophen) to manage pain. Despite the order, the resident did not receive the prescribed Norco for at least 11 days, missing 11 doses, due to delays in obtaining the medication from the pharmacy and issues with obtaining the necessary prescription script. During this period, the resident reported severe, uncontrolled pain, rating it as 10 out of 10, and stated that alternative pain medications such as ibuprofen and acetaminophen were not effective. Nursing staff were aware that the Norco had not arrived and communicated this to the resident, but there was no documented escalation or effective resolution of the issue. Progress notes repeatedly indicated that the medication was "awaiting supply" or that the pharmacy had not received the script, yet there was no evidence of timely follow-up with the physician or pharmacy to resolve the delay. Interviews with nursing staff and facility leadership revealed a lack of awareness and communication regarding the ongoing medication issue. The DON and NHA were not aware of the missed doses until informed by an ombudsman. The physician and nurse practitioner involved were also not fully aware of the extent of the delay, and the physician did not review the medication administration record during a subsequent visit. Facility policy required providing care and services according to established practice guidelines, but this was not followed in ensuring the resident received the ordered pain medication.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards for food service safety, as observed during a survey. In the kitchen's walk-in cooler, containers of cooked roast beef were found with condensation and moisture, and their temperatures were not adequately cooled to the required standards. The Director of Housekeeping, filling in for the Dietary Manager, was unsure about the cooling logs for these items. Additionally, various food items in the cooler and nourishment room were improperly dated or lacked date markings, violating the FDA Food Code requirements for date marking and disposition of ready-to-eat foods. The survey also revealed several cleanliness and maintenance issues in the kitchen. Mechanical scoops and the coffee spout were found with dried food debris and coffee accumulation, respectively. The microwave had crusted debris, and the ventilation filters on the cook line had excess grease accumulation. The preparation sink was not properly set up, allowing water to dispense onto the floor, and the chemical closet's setup put undue pressure on the mop sink faucet's vacuum breaker. Furthermore, the dish machine was not reaching the required temperatures for washing and rinsing, and an open gallon of soy sauce was improperly stored in the dry storage room. During meal service, a staff member was observed handling baked potatoes with bare hands, deviating from the initial use of utensils and gloves. This practice violated the FDA Food Code's guidelines for preventing contamination from hands. These deficiencies collectively indicate a failure to adhere to food safety and sanitation standards, potentially leading to foodborne illnesses among residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices during resident care, as evidenced by multiple observations and interviews. For instance, a housekeeping aide was observed not wearing personal protective equipment (PPE) while handling trash and cleaning surfaces in a resident's room who was on contact precautions due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. This aide believed that the contact precautions did not apply to housekeeping staff, a misunderstanding that was echoed by the Director of Housekeeping, despite the Director of Nursing's (DON) assertion that all staff should adhere to these precautions. Additionally, the facility did not maintain an ongoing infection control surveillance program. The Director of Nursing/Infection Preventionist (DON/IP) admitted that there was no tracking of employee illnesses, which could potentially lead to the spread of illness among residents. Furthermore, the facility had not conducted hand hygiene or PPE audits since May 2024, increasing the risk of cross-contamination between residents and staff. The facility also lacked an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). Observations revealed multiple stagnant water lines, and interviews with maintenance and housekeeping staff indicated a lack of awareness and documentation regarding a water management plan. The facility's policy on water systems and legionella risk prevention was not actively implemented, as there was no evidence of a completed risk assessment or a building-specific list of areas at risk for legionella growth.
Failure to Document and Offer COVID-19 Vaccination to Staff
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination status, education, and offering for its staff, specifically for a Certified Nursing Assistant (CNA) identified as DD. The CNA was last vaccinated on November 24, 2021, and there was no documentation of any subsequent offering or education regarding the COVID-19 vaccine. During an interview, the Director of Nursing (DON), who also serves as the Infection Preventionist, confirmed that the facility had not offered the COVID-19 vaccination to staff in 2024 and had not tracked their immunization status or provided education on the matter. This lack of documentation and action increased the risk of COVID-19 infections among residents.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by multiple observations during a survey. In the nourishment room, a large hole under the sink exposed the back wall, presenting a potential entry point for pests, along with moisture damage and a black staining-like substance. An empty resident room was found with a large brown splash stain and bubbling walls, indicating possible water damage. The 200 hall bath had towels and washcloths improperly stored, and a shower chair with dried brown stains. The 200 Hall Soiled Utility room had brown-tinted water from the faucet, a slow leak, and a musty odor from moisture-damaged cabinetry. The 300 Hall Soiled Utility room had a leaking valve, incomplete flushing of the hopper, and a non-operational sink with a disconnected wastewater line and a large hole in the cabinetry. Further deficiencies were noted in the 200 hall janitor's closet, where a chemical pre-dispense system was improperly set up, risking damage to the faucet's vacuum breaker. The boiler room had one non-operational water heater, though the maintenance staff believed they could meet hot water demand. The 500 hall bath had missing floor tiles, debris under shower beds, and an unused tub with dirt and debris. The lobby area had significant drywall damage, and the dining room had bubbled wallpaper, rusted floor vents, and built-up debris around door frames. These conditions collectively increased the potential for contamination and decreased resident satisfaction with their living environment.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a total error rate of 20% among four residents. For Resident #15, the error involved improper administration of subcutaneous injections. The LPN administered insulin aspart and Mounjaro injections into the deltoid muscle, which is not an acceptable location for subcutaneous injections according to the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON). This error was confirmed through interviews with the LPNs and the DON, who clarified that subcutaneous injections should be given in fatty areas such as the back of the arms, abdomen, and outer thighs. Resident #25 experienced a late administration of baclofen, which was ordered to be given at 3:00 PM but was administered at 4:28 PM. The LPN believed that medications could be given within an hour before or after the scheduled time, but the DON confirmed that the administration was late. This discrepancy in understanding the timing of medication administration contributed to the error. For Resident #30, the error involved a missed dose of gabapentin due to its unavailability in the medication cart. The LPN did not retrieve the medication from the facility's backup medication box, despite its availability, citing a lack of time. Resident #43's error involved the crushing of acamprosate, a delayed-release medication, which should not be crushed as it alters absorption. The LPN crushed the medication despite the prescription label indicating 'Do Not Crush,' and this was confirmed by the pharmacist and the DON.
Ineffective Pest Control Program Leads to Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live ants in various areas, including resident rooms, hallways, and visitor restrooms. Observations on multiple occasions revealed live ants on the bathroom floor of a resident's room, in the hallway outside the room, and in the visitor restroom. Open food containers with resident food were also found stored on the floor, which could contribute to the ant infestation. Interviews with housekeeping aides confirmed the presence of ants throughout the building, particularly around food crumbs in resident areas. Despite having a pest control service that visits monthly, the Maintenance Assistant admitted to not chemically treating the building for ants between visits. The Nursing Home Administrator was unaware of the ant issue in the visitor bathroom, despite staff using the facility and the problem persisting for several days. The lack of timely intervention and awareness of the pest issue by the facility's staff contributed to the ongoing presence of ants, posing a potential risk for food infestation and resident discomfort.
Failure to Maintain Professional Standards in Enteral Feeding Administration
Penalty
Summary
The facility failed to maintain professional nursing standards during the administration of enteral feeding for a resident with dysphagia and a gastrostomy tube. The resident was prescribed an NPO diet with enteral feeding of Vital 1.5 formula at 75cc/hr for 20 hours, starting at 3:00 PM and ending at 11:00 AM. However, observations revealed that the feeding pump was often powered off during the prescribed feeding times. Interviews with nursing staff indicated discrepancies in the start times of the feeding, with one LPN stating the feeding began at 6:00 PM instead of the ordered 3:00 PM. Additionally, the total volume of formula administered was not documented in the Medication Administration Record (MAR), and the resident did not receive the full prescribed amount of 1500 ml daily. The Registered Dietitian and Director of Nursing both confirmed the expectation that the feeding should start at 3:00 PM and end at 11:00 AM, with a total of 1500 ml administered. However, observations showed that the feeding pump was alarming due to an empty formula bottle and air bubbles in the tubing, indicating that the feeding was not properly managed. The LPNs involved did not hang a second bottle of formula, resulting in the resident not receiving the full nutritional intake as ordered. The MAR lacked documentation of actual start and stop times, further contributing to the deficiency in care.
Inadequate Assistance with ADLs and Hygiene Concerns
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to dissatisfaction with care and hygiene concerns. Resident #46, who was cognitively intact, expressed dissatisfaction with the frequency of showers received, stating he had only a couple of showers since admission, despite a preference for two showers a week. The facility's records confirmed that Resident #46 did not receive the scheduled showers consistently, with only three showers documented over a period of several weeks. Resident #27, who was moderately cognitively impaired, required supervision or touching assistance for bathing. Observations and family reports indicated that Resident #27 appeared disheveled with long, dirty fingernails, suggesting inadequate assistance with personal hygiene. The facility's records showed that Resident #27 was offered showers on only 16 out of 27 scheduled opportunities, indicating a failure to adhere to the shower schedule. Resident #38, who was cognitively intact but required maximal assistance for personal hygiene, was observed with soiled fingernails on multiple occasions. The resident expressed frustration and embarrassment over the dirty appearance of her nails and reported needing more assistance from staff. Family members also noted the resident's dirty fingernails during visits, highlighting a lack of adequate care in maintaining personal hygiene.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that enteral feeding was administered as ordered for a resident with a gastrostomy tube, resulting in the potential for weight loss, dehydration, and overall deterioration of wellbeing. The resident, who had a history of dysphagia following a stroke, was observed multiple times with her feeding pump powered off and the feeding tubing not connected to her G-tube, despite orders for continuous feeding from 3:00 PM to 11:00 AM at a rate of 75cc/hr. Interviews with nursing staff revealed inconsistencies in the administration of the resident's tube feeding. One LPN reported turning off the feeding an hour earlier than ordered, while another LPN admitted to starting the feeding later than the prescribed time. The Medication Administration Record lacked documentation of the total volume of formula administered, and observations confirmed that the resident did not receive the full prescribed amount of formula. The Director of Nursing confirmed that the resident should receive a total of 1500 ml of formula daily, which was not achieved due to the failure to hang a second bottle of formula. The Registered Dietitian also emphasized the importance of adhering to the feeding schedule to ensure the resident received the necessary nutrition. The lack of adherence to the prescribed feeding schedule and documentation requirements led to the deficiency identified by the surveyors.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDRs) for the ongoing use of psychotropic medications were completed for a resident reviewed for unnecessary medications. The resident had a diagnosis of major depressive disorder and was prescribed Duloxetine 60 mg to be administered enterally once a day. The Director of Nursing (DON) reported that the resident's dosage of Duloxetine had remained unchanged for over a year, and there had been no attempt at a gradual dose reduction during 2024. Additionally, the facility was unable to provide any documentation of a gradual dose reduction or a physician's rationale against it for the resident's Duloxetine prescription.
Failure to Prevent Scalding Hazards and Resident Elopement
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing hot water temperatures to exceed 120 degrees Fahrenheit in resident rooms and shower areas. During an inspection, it was observed that the water temperatures in several rooms and shower areas were above the recommended limit, with some reaching as high as 125.4 degrees Fahrenheit. The facility's maintenance director acknowledged the issue, citing difficulties in maintaining appropriate temperatures due to only one functioning boiler. Additionally, the facility's water temperature logs for August and October were missing, indicating a lack of consistent monitoring. The facility also failed to prevent an elopement incident involving a resident identified as high risk for elopement due to cognitive impairment and wandering behavior. The resident managed to exit the facility without staff knowledge and was found outside by a CNA. The therapy exit door, through which the resident exited, was not alarmed or locked at the time, allowing the resident to leave unnoticed. Interviews with staff revealed that the door was not secured after the last therapy session, and the alarm system was not functioning properly at the nurse's station. The resident involved in the elopement had a history of exit-seeking behavior and was supposed to have a wander guard in place. However, there was a lapse in ensuring the wander guard was checked and functioning, as there were no orders for its use after the resident's readmission to the facility. The facility's policies on monitoring residents at risk of elopement and ensuring door alarms were not adequately followed, contributing to the resident's ability to leave the premises undetected.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, resulting in physical abuse. Resident #104, a male with Alzheimer's disease and cognitive deficits, was physically abused by Resident #103, who has a history of dementia, anxiety, and aggressive behavior. The incident occurred in the dining room where Resident #104 was approached by Resident #103 and flipped over in his chair, leading to threats exchanged between the two residents. Resident #103 has a documented history of maladaptive behavioral symptoms, including verbal altercations and aggressive behavior towards other residents and staff. Prior to the incident, Resident #103 had been involved in a similar altercation where he attempted to swing a walker at another resident. Despite these behaviors, the care plan for Resident #103 included interventions such as behavior management techniques and stress management, but these measures were insufficient to prevent the incident. The incident was witnessed by staff and a visitor, who reported that Resident #104 was rearranging tables when Resident #103 became agitated and flipped him over. The facility's policy on abuse prevention defines abuse as the willful infliction of injury or intimidation, which was not adequately prevented in this case. The failure to effectively manage Resident #103's behavior and protect Resident #104 from harm constitutes a deficiency in the facility's abuse prevention measures.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically in the case of a resident with multiple diagnoses including schizophrenia, anxiety, depression, dementia, and aphasia. The incident involved a Certified Nursing Assistant (CNA) allegedly holding the resident's breast while changing the resident's brief. This incident was reported internally to the charge nurse and Nursing Home Administrator (NHA) but was not reported to Law Enforcement as required by the facility's Abuse Prevention Program Policy and Section 1150B of the Social Security Act. Interviews with the current NHA, Director of Nursing (DON), and another NHA revealed uncertainty and acknowledgment that the incident should have been reported to Law Enforcement. The facility's policy clearly states that such incidents should be reported immediately to Law Enforcement, but this procedure was not followed. The lack of reporting to Law Enforcement constitutes a deficiency in the facility's adherence to its own policies and federal requirements for reporting suspected abuse.
Failure to Address Skin Integrity in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan addressing skin integrity for a resident admitted under hospice care for a 5-day respite stay. The resident, who had a history of skin integrity issues, was noted to have a rash under her right breast upon admission. However, the Baseline Care Plan assessment did not include any information regarding her skin risk or current skin condition, as the section for skin risk was left blank. Despite the resident's known history and current skin issues, the care plan initiated the day after admission did not address skin integrity. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the baseline care plan assessment failed to address the resident's skin risk and the rash under her right breast. The facility's policy requires that the Baseline Care Plan be completed within 48 hours of admission and address areas of imminent concern, which was not adhered to in this case.
Failure to Address Skin Concern Leads to Worsening Condition
Penalty
Summary
The facility failed to conduct a thorough assessment and follow-up on a skin concern for a resident admitted under Hospice care for a 5-day respite stay. Upon admission, the resident had a rash under her right breast, which was noted in the Admission/Re-Admission Screener and the Shower Sheet. However, this condition was not addressed in the resident's progress notes, care plan, or treatment record. The Director of Nursing and the Licensed Practical Nurse involved were unaware of the rash under the breast, despite it being documented upon admission. The lack of communication and follow-up resulted in the rash worsening into a yeast infection, which was only discovered by a Hospice LPN four days later. The Hospice team was not informed of the skin issue, leading to a lapse in continuity of care. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's skin condition, despite the family member and CNA noting the issue upon admission.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances for a resident, resulting in unresolved concerns and unmet needs. The resident, who had a moderately impaired cognitive status, reported being left in a soiled incontinence brief for over six hours without proper cleaning or changing of the bed linens. The resident also mentioned a two-hour wait time after pressing the call light. The grievance was documented by the Social Service Director on behalf of the resident, and it was assigned to the Unit Manager for resolution. The investigation into the grievance was inadequate, as the Unit Manager only conducted verbal education with staff at the nurse's station without any documentation. The Social Service Director, who had recently started, was unsure of the investigation's details and relied on the Nursing Home Administrator for assistance. The facility's grievance policy required a thorough investigation to identify the root cause and take corrective action, but this was not adequately followed, leading to the deficiency.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The report identifies a deficiency in the timely reporting of an allegation of abuse involving a resident with moderate cognitive impairment. The resident alleged that a CNA and an LPN were rough while assisting her, nearly causing her to hit her head. This incident was not reported immediately to the Nursing Home Administrator (NHA) or law enforcement, as required by the facility's policies. The LPN involved delayed reporting the incident, believing the allegation to be untrue, which contributed to the failure in timely notification. Further investigation revealed that the NHA was aware of the requirement to report such allegations immediately but admitted to only reporting significant incidents to law enforcement. This practice was contrary to the facility's abuse prevention policy, which mandates immediate reporting of any suspected abuse or neglect to the appropriate authorities. The NHA's failure to report the incident to law enforcement and the state agency resulted in an incomplete investigation and left the resident unprotected from potential abuse. Additionally, another concern was raised by the resident regarding neglect, which was documented in a grievance form. The resident reported being left in soiled conditions for an extended period without proper care. This allegation of neglect was not reported to the state agency, and there was no documented investigation or corrective action taken. The facility's policy requires immediate reporting and investigation of such concerns, but these procedures were not followed, indicating systemic issues in handling allegations of abuse and neglect.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
