Notting Hill Of West Bloomfield
Inspection history, citations, penalties and survey trends for this long-term care facility in West Bloomfield, Michigan.
- Location
- 6535 Drake Rd, West Bloomfield, Michigan 48322
- CMS Provider Number
- 235663
- Inspections on file
- 37
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Notting Hill Of West Bloomfield during CMS and state inspections, most recent first.
A resident with advanced dementia, osteoarthritis, and full dependence for ADLs sustained an acute, displaced spiral fracture of the distal humerus during morning care when a CNA was dressing the resident in a pull-over shirt. Night-shift staff reported no falls or incidents, and the resident, who previously had functional upper-extremity ROM and no contractures, was found with a swollen, painful, and deformed right arm during dressing. The CNA acknowledged the resident was wincing, resisting, and signaling for care to stop but continued dressing instead of stopping. ER and orthopedic evaluations described the fracture pattern as atypical and usually caused by significant trauma, a fall, or hard twisting, while the facility’s investigation concluded the cause was unknown and did not substantiate abuse. The DON did not obtain a witness statement from the prior day-shift LPN, and the record at the time of transfer lacked a full nursing assessment, pain assessment, change-of-condition assessment, and transfer form, while the facility’s incident policy addressed documentation of injuries of unknown origin but not their prevention.
Surveyors found that the facility failed to maintain an effective water management and infection control program, including control of Legionella and other waterborne pathogens. A hopper in the soiled laundry room produced discolored water, boiler temperatures were below the facility’s stated settings, and the Legionella plan lacked a flow diagram and current water management team activity. The AMS reported no active water management team, no involvement in the plan, no flushing logs, and exclusion of the laundry hopper from flushing routines, while the NHA acknowledged that water management meetings had not occurred as required. The infection control surveillance program was not continuous, line listings lacked key infection data and McGeer’s criteria, and requested lab and antibiotic rationale documentation for residents were unavailable, with the ICP reporting they were frequently used as a floor nurse and had not received needed support or additional training.
Food service practices were not maintained in accordance with FDA Food Code standards. The DM identified a corporate 14-day discard policy for cheeses and pepperoni, but a shredded mozzarella container was labeled with a 14-day use-by date despite the product typically being used within 7 days, and an opened nutritional shake in a nourishment room had no open or discard date. Surveyors also observed soiled ice bin drain lines, buildup on juice nozzles, chipped and damaged spatulas, preset tableware exposed on napkins, a cooler holding TCS foods above safe temps, and a nourishment room hand sink water line turned off while an ice machine was disconnected after leaking.
Improper waste disposal and dumpster area maintenance were observed when overfilled trash bins and a foul odor were found in the soiled linen/trash room, and outdoor waste receptacles were left open with debris scattered around and behind the units. The AMS stated housekeeping and maintenance shared responsibility for the area, while the NHA said staff were responsible for keeping the garbage storage area cleaned. Facility policy required trash removal on a schedule to prevent spillage and odors and for the dumpster area to remain free of debris.
Surveyors found that the facility failed to honor resident mealtime and dining location preferences when multiple residents reported that the main dining room was frequently closed and never open on weekends, despite their desire to eat there to socialize and receive warm, complete meals. Residents stated that when they were served in their rooms, items they had selected on weekly menus were often missing, and soup and salad routinely offered in the dining room were not provided. The DON indicated that the Dining Manager (DM) decided when the dining room was open, and the DM acknowledged the dining room had been closed for several days due to equipment issues and remained closed on weekends as part of a post-COVID "plan" without an official written reopening plan. These practices conflicted with facility policies requiring support of resident choice regarding dining location and affirming residents’ freedom of choice in how they live and receive care.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with food debris and trash along hallway handrails, heavily soiled doors, damaged drywall, and exposed sharp metal in resident rooms. Several residents reported infrequent room cleaning, persistent urine on floors, foul-smelling heater filters, unrepaired leaking toilets, and broken toilet seats that had been reported weeks earlier. One resident had no toilet paper in their bathroom despite notifying CNAs and had to use paper towels, while other rooms had non-functional or inaccessible call systems. Observations also showed peeling drywall, leaking toilets with basins catching water, limited clean linens and disposable briefs in supply rooms, heaping soiled linen bins, and CNAs reporting frequent linen shortages that disrupted shower schedules. Work order logs lacked documentation of current environmental issues and did not reflect residents’ reported concerns, despite staff stating that supplies were adequate and that housekeeping was responsible for restocking resident rooms and bathrooms.
The facility failed to ensure nurse coverage for a hallway of resident rooms, leading to widespread missed medications and treatments for multiple residents. A resident with CHF and atrial fibrillation did not receive day-shift medications until late evening, and record review showed numerous missed medication doses and treatments for that resident and many others on the same unit. CNAs reported there was no nurse assigned to the hallway, that residents did not receive medications, and that many were in pain when they were changed without pain meds. Staffing records showed no nurse scheduled for the first floor despite a substantial census, and the DON later acknowledged possible miscommunication about nurse assignments and identified extensive missed medications on a facility report, in contrast to the facility’s own abuse/neglect policy defining neglect as failure to provide necessary care and services.
Surveyors found that medications and treatments were not administered according to physician orders or facility policy. Multiple residents reported delayed or missing morning medications, and MAR reviews showed 9:00 AM doses for several residents with complex cardiac and diabetic conditions were not documented as given, with no physician notification or progress notes. A nurse acknowledged not completing a heavy morning med pass and not informing administration or the physician. Additionally, two residents with intact cognition were observed with soiled, undated, or long‑unchanged dressings on the hand, arm, and knee, despite care plans and orders for scheduled wound care. TAR entries indicated treatments were completed on certain days, but the observed condition of the dressings and resident reports conflicted with this documentation, and required skin assessments and dressing dating were not consistently performed.
The facility failed to maintain sufficient nursing staff on all shifts, leading to prolonged call light response times and delayed medication administration and treatments. Multiple residents reported waiting from 20 minutes to over two hours for assistance, missing or receiving very late morning and evening medications, and observing staff talking at the nurses’ station while they waited. A resident described frequent 1–1.5 hour call light delays and late or next-morning administration of night medications when no nurse was available to relieve the day nurse. Another resident reported no nurse present until late morning on a recent Sunday, resulting in missed morning medications, while a family member stated their loved one stopped using the call light and fell when attempting to toilet independently. LPNs and the staffing coordinator confirmed ongoing nurse shortages, reduction in nurse numbers, elimination of a dedicated treatment nurse, and reliance on corporate PPD-based staffing without direct adjustment for resident acuity, contrary to the facility’s own policy requiring 24-hour nursing coverage and staffing based on resident needs.
The facility failed to maintain an effective antibiotic stewardship program when the ICP, who was hired for infection control, reported spending most of their time working as a floor nurse due to staffing shortages and could not consistently perform stewardship duties. The ICP described intended practices such as using McGeer's criteria, audits, and an infection screening tool, but review of infection control records showed missing documentation of resident lab results, clinicians' rationale for antibiotic use, and criteria supporting prescribed antibiotics. The ICP stated the program was only compliant for one month when staffing was adequate, and that requests for additional help and training from corporate were denied. When surveyors requested the antibiotic stewardship policy, no additional information was provided.
Two residents with existing pressure ulcers did not consistently receive or have documented the ordered wound care. One resident admitted with a Stage 3 heel ulcer reported missed every-other-day treatments and painful, overly tight wraps; TAR review showed multiple missed or undocumented Monday/Wednesday/Friday treatments, and the wound care nurse confirmed that a Kerlix wrap was used instead of the ordered border foam dressing and that required weekly wound photos were not obtained due to an uncharged camera. Another resident admitted with multiple pressure injuries, including a Stage 4 and an unstageable ulcer, had detailed twice-daily wound care orders on hospital discharge paperwork, but no corresponding physician wound orders or TAR documentation for several days after admission, and an early skin check documented "No skin issues" despite later same-day documentation of significant heel and coccyx ulcers. The ADON acknowledged that the admitting nurse failed to enter the wound care orders and that there was no documentation of wound care before the TAR entries began, contrary to the facility’s skin management policy.
Surveyors found that the facility’s medication error rate exceeded 5% after observing an RN administer a morning medication pass in which Duloxetine 60 mg, ordered to be given at bedtime for depression, was instead given in the morning, and Famotidine 20 mg, ordered once daily in the morning for GERD, was not observed being administered but was signed out as given on the MAR. These administration and documentation errors contributed to a calculated medication error rate of 6.45%.
A resident was found with gabapentin kept in a bedside drawer and said nursing staff had left it there after a double dose, which he took and saved for later pain relief. The NM stated only residents assessed to self-administer may keep meds at bedside, but the record had no assessment, MD order, or care plan showing this resident was authorized for self-administration; the resident had diagnoses including spinal stenosis and altered mental status, and the MDS showed intact cognition with assistance needed for some ADLs.
A resident with bipolar disorder, schizophrenia, and anxiety disorder, and a BIMS score of 13/15, was documented spitting out and hoarding medications under the bed. Nursing notes described pills found under the bed on more than one occasion, while the care plan addressed psychotropic medication use but did not include interventions for medication refusal. The resident reported believing staff were trying to poison them, and RN HH and the DON confirmed concerns about medication refusal and improper administration.
The facility failed to ensure monthly pharmacist MRRs were completed and that irregularities were documented with physician responses for two residents. One resident with Parkinson's disease, dementia, hallucinations, and severely impaired cognition had an MRR irregularity noted, but no chart documentation of the issue or physician response was found. Another resident with traumatic ischemia, schizoaffective disorder, Alzheimer's disease, and severely impaired cognition had repeated MRR recommendations related to Ferrous Sulfate, including a physician agreement to change the dose, yet the MAR continued to show daily administration and later MRRs had no responses in the record.
Incomplete medical records were found for two residents with severely impaired cognition. Monthly pharmacist medication reviews identified medication irregularities, but the chart lacked documentation of the physician response, and the DON reported the records had been shredded after a pharmacy service change and were not scanned into the chart.
Daily nurse staffing information was not accurately posted or updated for each shift. Surveyors observed that the staffing board at the entrance showed an outdated posting that did not reflect the current census or active shift staffing. An SC stated they were responsible for updating the posting, but weekend postings were not updated daily and the front receptionist was responsible for changing them on weekends.
Surveyors found that multiple opened and prepared food items in the kitchen, including sour cream, fruit, desserts, and salad dressings, were not labeled or dated as required by facility policy and food safety standards. Dietary staff confirmed these items should have been labeled and dated, and the deficiency had the potential to affect all residents receiving food from the kitchen.
A resident with a temporary Foley catheter developed a full-thickness penile wound due to excessive tension and trauma from the indwelling catheter. The injury, confirmed by wound care staff and a physician, was identified as ventral urethral erosion and required surgical evaluation. Facility leadership acknowledged the catheter as the cause of the injury.
Three residents with severe cognitive impairment and high risk for accidents were not adequately supervised, resulting in one resident sustaining fractures during a transfer, another ingesting a bleach sheet despite 1:1 supervision, and a third exiting through an alarmed door and descending a staircase. Staff were assigned to supervise multiple high-risk residents simultaneously, and lapses in supervision and lack of incident investigations contributed to these deficiencies.
A resident with multiple psychiatric diagnoses was not consistently offered or provided scheduled bathing, with documentation showing bathing was only offered four times in a month and provided twice, despite facility policy and the resident's stated needs and preferences. The DON confirmed the expectation for twice-weekly bathing and proper documentation, but could not provide evidence of compliance.
A resident with multiple chronic conditions did not receive scheduled and as-needed pain medications due to pharmacy delays, despite both morphine and oxycodone being available in the facility's back-up supply. Nursing staff did not access the back-up medications as required, leading to uncontrolled pain and a transfer to the emergency room for pain management. The facility's medication administration policy did not address procedures for pulling medications from the back-up supply.
A resident with multiple mental health diagnoses did not receive meals according to their documented food preferences, including double portions and cheese on eggs, and was repeatedly served food at temperatures below facility standards. Observations confirmed that meal tickets were not followed and food was not kept warm, as acknowledged by the kitchen manager.
Two residents were subjected to abuse and neglect by staff members. One resident was slapped by a CNA during an altercation, while another resident was neglected when their wheelchair was pushed into objects, causing potential harm. The facility's policies on abuse and neglect were not followed, leading to these deficiencies.
The facility's kitchen was found to have several sanitation deficiencies, including undated food items in the walk-in cooler, improper storage of utensils in dry storage, and a shelving unit with accumulated grease and debris. These issues were confirmed by the Dietary Manager and are not in compliance with the 2017 FDA Food Code.
The facility failed to provide privacy for Resident Council meetings, which were held in an open room frequently accessed by staff, leading to interruptions. Residents' grievances were not documented or addressed, and many were unaware of the grievance process. The Resident Council President often missed meetings due to lack of assistance, further hindering the council's effectiveness.
The facility failed to maintain a sanitary and homelike environment in several areas, including resident rooms, the central shower room, and dining areas. Observations revealed unkempt floors, dried food substances, and improper storage of personal items and cleaning supplies. The Housekeeping Director confirmed that housekeeping was responsible for these areas, but they had not been adequately cleaned, contrary to the facility's housekeeping policy.
A resident with severe cognitive impairment and a history of falls experienced multiple incidents without proper investigation or intervention by the facility. The facility's documentation was incomplete, lacking staff interviews, root cause analyses, and notifications to the physician or responsible party. The Director of Nursing acknowledged the issues but could not provide further explanations or documentation.
The facility failed to provide sufficient nursing staff, leading to delayed care and lack of supervision for residents, including one with wandering behaviors and cognitive challenges. Despite a staffing plan requiring 16 licensed nurses and 24 nurse aides, actual staffing levels often fell short, resulting in inadequate supervision. A resident with Down syndrome and intellectual disabilities was observed wandering unsupervised, entering other residents' rooms, and displaying distress without staff intervention. The DON did not believe increased supervision was necessary, and the facility lacked documentation for certain dates, posing a risk to all residents.
The facility failed to ensure proper medication storage and labeling, with pills found on the floor and unsecured medication carts. A resident with severe cognitive impairment had unauthorized eye drops at bedside. COVID-19 Rapid Tests were stored unsecured, and staff were unaware of unlocked medication carts, violating facility policy.
The facility failed to implement effective infection control practices, including hand hygiene during medication administration and Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. Observations showed a lack of appropriate signage and PPE for EBP, and multiple nurses did not perform hand hygiene before and after administering medications, despite the DON's confirmation of this requirement.
A resident with severe protein-calorie malnutrition and morbid obesity did not have a comprehensive nutritional care plan developed. The care plan was incomplete, lacking specific interventions, and there was conflicting documentation regarding nutritional monitoring. The RD did not perform the evaluation due to absence, and the facility's policy on nutritional documentation was not followed.
A resident with a history of hepatitis, hypertension, diabetes, and psychiatric conditions was found to have a deficiency in medication administration and documentation. The resident expressed concerns about a medicated lotion left uncovered at their bedside, which was not applied by the LPN as per the MAR. The LPN left the medication without confirming its application, and the resident was unaware of its purpose. The Nursing Home Administrator was informed but provided no further explanation.
The facility failed to provide timely incontinence care for three residents, leaving them wet for extended periods. One resident was left waiting for assistance despite requesting help, while another was found in wet sheets overnight. The residents expressed discomfort and upset due to the lack of care, and a CNA confirmed that such incidents were frequent. The residents required assistance with activities of daily living, as indicated by their care plans.
A resident with a history of nontraumatic subdural hemorrhage and other conditions reported skin itching and burning, suspecting an abscess. Despite informing the nursing staff, no action was taken, and the issue was not documented in weekly skin assessments. The Director of Nursing was unaware until informed by a surveyor, leading to a delayed response in addressing the resident's condition.
A resident with limited range of motion in their legs did not receive restorative therapy services after returning from a hospital stay, despite expressing a desire to continue therapy. The facility lacked a fully functioning restorative program and a restorative nurse to oversee it. The Director of Nursing acknowledged the oversight and the need for screening, but the resident's care plan did not reflect the need for restorative therapy, leading to a deficiency in care.
A facility failed to conduct a comprehensive nutritional assessment for a resident with significant nutritional needs following gastric sleeve surgery. Despite serious diagnoses, the care plan was incomplete, and there was no evidence of a comprehensive assessment by the RD. The RD was unaware of a STAT order for evaluation and did not complete the necessary documentation, leading to the deficiency.
A facility failed to document non-pharmacological interventions before administering PRN Alprazolam to a resident with severe cognitive impairment and multiple diagnoses. The medication was given multiple times without proper documentation, and the behaviors recorded did not match the times of administration. The DON acknowledged the lack of documentation and questioned the appropriateness of the medication order.
A facility failed to provide timely radiology services for a resident who fell and was ordered an X-ray for their left shoulder. Despite the physician's order, the X-ray was not completed until after the survey identified the issue. The resident, with a history of neurological conditions, reported significant shoulder pain. The DON stated X-rays should be completed within 24 hours, but there was no policy in place to ensure this.
A resident with a history of influenza and pneumonia consented to receive pneumococcal and influenza vaccines through their daughter, who served as a translator. However, the facility did not administer the vaccines, and the orders were discontinued by the physician without documented rationale. The Infection Control Preventionist confirmed the oversight, and there was no follow-up with the resident or their daughter, who believed the vaccines had been given.
A resident with a history of diabetes and peripheral vascular disease experienced a worsening diabetic ulcer due to the facility's failure to timely assess and treat the condition. Despite documentation inconsistencies and delays in treatment orders, the ulcer progressed, resulting in a hospital transfer and amputation of the resident's left great toe. Interviews with facility staff revealed issues with wound management and documentation, highlighting a lack of adherence to the facility's skin management policy.
A strong, putrid odor was detected in the hallway near the main dining room, attributed to a dish machine issue. Despite acknowledgment from several staff members, including the RD and Maintenance Assistant, the source of the odor remained unidentified for weeks. The Administrator was unable to detect the odor, while the dish room itself did not contain the odor, only the hallway did.
A registered nurse (RN) failed to administer medications to three residents, as confirmed by surveillance footage and resident reports. Despite documentation indicating medications were given, the RN did not enter the residents' rooms during the administration period. Interviews and time card discrepancies further highlighted the neglect in care.
A nurse at the facility, referred to as Nurse A, was found to be working with a suspended LPN license. Despite the suspension in February 2024, Nurse A continued to work shifts, including a recent night shift. The facility's HR staff had not reviewed all nursing licenses, and the DON and Administrator were unaware of the suspension until the investigation. The facility's policy required current licenses for all staff, but this was not followed for Nurse A.
Failure to Prevent Injury of Unknown Origin During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to prevent an injury of unknown origin and to ensure adequate supervision and accident hazard prevention for a cognitively impaired resident who sustained a right humerus fracture during care. The resident had Alzheimer’s disease, dementia, kidney disease, anxiety, and depression, was severely cognitively impaired, and was dependent for dressing, bed mobility, toileting, transfers, and largely for eating. Prior assessments and therapy records showed no documented contractures and upper extremity range of motion within normal limits, with the resident able to assist with feeding when items were placed in the hand. The resident was not on pain medication prior to the incident and had no documented pain on the most recent MDS. On the night and early morning in question, staff working the night shift reported no falls or incidents and stated the resident slept through the night without signs of distress. At approximately 5:00–5:15 a.m., a CNA entered the room to provide morning care and dress the resident, who was scheduled to be gotten up and dressed on the midnight shift. The CNA reported the resident was wearing a pull-over pajama top and was changed into another pull-over shirt. During dressing, the CNA noted the resident’s right arm appeared swollen and limp, and that when the resident attempted to help push the right arm through the sleeve, the resident expressed pain and the arm became limp. The CNA acknowledged that the resident was wincing, waving for care to stop, and more verbal than usual, but the CNA continued dressing instead of stopping care, later stating they should have stopped when resistance and increased pain were observed. Subsequent nursing assessment documented that the resident’s upper arm was swollen, abnormal in appearance, and misaligned at the elbow joint, suspicious for a fracture, with pain on minimal movement. The resident was sent to the ER, where imaging showed a displaced, angulated, spiral fracture of the distal humerus, described as atypical and typically resulting from significant trauma, a fall, or a hard twisting motion. Hospital and orthopedic records characterized the injury as an acute, unstable fracture, presumed to be from an unwitnessed fall or twisting trauma, while the facility’s internal investigation concluded the exact cause was unknown and did not substantiate abuse or neglect. The DON, who led the investigation, did not obtain a witness statement from the day-shift LPN who had cared for the resident before the transfer, and the medical record lacked a complete nursing assessment, pain assessment, change-of-condition assessment, and transfer form at the time of the resident’s transfer. The facility’s Incidents and Accidents policy addressed documentation and reporting of injuries of unknown origin but did not address prevention of such injuries.
Failure to Maintain Effective Water Management and Infection Control Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective water management and infection prevention and control program, including control of Legionella and other opportunistic premise plumbing pathogens. Surveyors observed a functional hopper in the soiled laundry sorting room that produced discolored water for several seconds before running clear. In the boiler room, one boiler was observed at 128°F and the second at 122°F, despite facility documentation indicating usual boiler settings of 150°F and CDC guidance in the facility’s materials stating that hot water should be stored above 140°F and recirculated hot water should not fall below 120°F. The facility’s Legionella Environmental Plan binder lacked a flow diagram and written description of how water travels through the building, despite the written policy requiring description of building water systems using flow diagrams and written descriptions. The Assistant Maintenance Supervisor (AMS) reported that the Maintenance Director had left suddenly two weeks earlier and that there was no water management team to their knowledge. The AMS stated they were not involved in the water management plan, were unsure of the Maintenance Director’s responsibilities regarding the plan, and that flushing of tubs, hoppers, and eyewash stations was done weekly based on TELS notifications, without keeping logs. The AMS also indicated that the hopper in the laundry room was not part of their flushing routine. The Nursing Home Administrator (NHA) stated that the water management team previously consisted of the NHA, DON, Infection Preventionist, and Maintenance Director, and that the AMS was now assuming those responsibilities. When asked about formal water management meetings, the NHA acknowledged that the team needed to meet and did not dispute that the last documented minutes were from 2024, with no documentation of a 2025 meeting and no additional water management documentation beyond what was in the binder. The facility’s infection control surveillance program was also found to be deficient. The Infection Control Preventionist (ICP) reported no recent outbreaks or trending infections but acknowledged that the surveillance program was not ongoing or continuous and was a month behind. The line listing lacked key information such as type of infection, duration of treatment, and location, and McGeer’s criteria were not provided or implemented. When surveyors requested laboratory results, clinicians’ rationale for antibiotic use, and documentation of McGeer’s criteria for several residents, the requested materials were not available. The ICP stated they had been working as a floor nurse due to staffing shortages, leaving the infection control program noncompliant except for one month when staffing allowed them to focus on their hired role, and reported they had not been offered assistance or support and had been denied additional help and training from corporate staff after orientation. No additional information was provided at survey exit.
Food Service Sanitation, Date Marking, and Equipment Deficiencies
Penalty
Summary
The facility failed to maintain food service practices in accordance with professional standards in multiple areas of the kitchen and nourishment rooms. During observation, a posted food discard schedule on the walk-in cooler door listed a 14-day discard period for cheeses and pepperoni, and the Dietary Manager identified this as a corporate policy. A container of shredded mozzarella cheese was observed with a facility date-marking sticker showing an open/prep date of 3/21/26 and a use-by date of 4/4/26, and the Dietary Manager stated the product was typically used within 7 days and would be relabeled with a 7-day discard date. An opened fortified nutritional shake was also observed in the 2nd floor nourishment room with no facility open or discard date, and the Dietary Manager discarded it after stating the product should be discarded 3 days after opening. Additional observations identified sanitation and equipment concerns in the food service area. The kitchen ice bin drain line terminated below the flood rim of the floor drain, and the 2nd floor nourishment room ice bin drain line also terminated below the rim of the drain opening; the drain cup and end of the drain line were soiled with a green and black substance. Two juice nozzles had colored buildup on the inside edges. In the clean utensil storage area, 4 of 5 plastic spatulas were chipped, stained, and damaged on the food-contact portion. Dining room tables were pre-set with utensils stored on top of napkins and exposed to potential contamination, despite the facility policy stating the eating surfaces of the flatware should be covered. The report also documented temperature control and plumbing issues. A Delfield upright 2-door cooler displayed 45 F, but a probe thermometer measured 50 F and yogurt in the unit measured 52 F; the Dietary Manager stated the unit was used for day storage of yogurts, nutritional shakes, and juices and would be returned to the walk-in cooler and serviced. In the 1st floor nourishment room, the hand sink water service line was turned off with a sign posted not to turn on the water, and the ice machine was not connected to water or power because it had been leaking after installation. The report cited FDA Food Code requirements related to date marking, backflow prevention, clean food-contact surfaces, preset tableware protection, proper equipment repair, and cold holding.
Improper Waste Disposal and Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests. On 3/23/2026 at 12:31 PM, two overfilled wheeled trash bins and a foul odor were observed in the 1st floor soiled linen/trash collection room. Later that day at 2:00 PM, two outdoor waste receptacles in separate adjacent enclosures were observed with lids and access doors left open, with scattered debris around the enclosures. One receptacle had its top lid and sliding access door open, and the other had its top lid open with cardboard, plastic bags, gloves, wrappers, and other debris scattered along the side and in a matted pile behind the unit. During interview, the Assistant Maintenance Supervisor stated housekeeping staff are responsible for maintaining the outdoor waste receptacle area and small objects around it, while maintenance handles larger discard items. He stated trash is picked up daily and that staff try to keep the receptacle lids closed between use, but at 2:20 PM both outdoor receptacle lids were still observed open and he acknowledged this. The Nursing Home Administrator stated responsibility for the outdoor garbage storage area was shared among staff to keep it cleaned. Facility policy for Housekeeping Services, last revised 7/8/2025, states trash will be removed from all areas on a specific schedule to prevent spillage and odors, and that the area surrounding the dumpster will be kept free of debris.
Failure to Honor Resident Mealtime and Dining Location Preferences
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ mealtime preferences and support resident choice regarding dining location and meal service. During an observation of the main dining room, surveyors noted residents interacting and staff taking meal orders in a restaurant-style format. However, in a confidential meeting with eight residents who usually attended resident council, six reported that the main dining room was frequently closed and not open at all on weekends. These residents stated they preferred eating in the dining room because it allowed them to get out of their rooms, socialize, receive warm meals, and obtain all menu items they had selected. They reported that when they received meal trays in their rooms during dining room closures, items were often missing despite their pre-completed weekly menu selections, and that soup and salad routinely offered in the dining room were not offered when they ate in their rooms. Residents reported that these dining restrictions had been in place for a long time and expressed frustration over their loss of choice to eat in the main dining room, with several stating they believed the dining room was only opened that week because the State Agency was present. The DON stated that decisions about opening or closing the main dining room were made by the Dining Manager (DM). The DM reported that the dining room would only close for emergencies such as an outbreak, but also acknowledged it had been closed for four or five days earlier in the month due to a fuse box issue with the dish machine. The DM further stated the main dining room was not open on weekends, explaining this was their plan since COVID-related dining room shutdowns, and that there was no official written plan for reopening. These practices conflicted with facility policies stating that residents would be interviewed about their preference to eat in the dining room or their room and that residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care.
Environmental Cleanliness, Maintenance, and Supply Failures Affect Resident Rooms and Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in multiple resident rooms and common areas, as well as failures in basic housekeeping, maintenance response, and supply availability. Surveyor observations over several days showed food debris, used tissues, and other trash accumulated along the inner bottom portions of handrails throughout a second-floor hallway, and multiple resident room and private dining room doors were heavily soiled with dirt, debris, and dried liquid splatter. One resident’s room had a corner wall with missing drywall crumbled onto the floor and an exposed metal brace with sharp edges, and the resident’s dresser had a thick layer of dust across the top. In another room, drywall was peeling away from the walls in multiple areas, exposing the underlying cardboard, and this condition persisted on re-observation two days later. During a confidential resident council interview, several residents reported housekeeping and maintenance concerns. One resident stated their carpet was so dirty that their wheelchair wheels turned their hands black when propelling, and another reported their room was only cleaned twice a week. A resident described a roommate who used a urinal and frequently missed, leaving urine on the floor and between the room divider that remained for a long time and smelled strongly of urine. Other residents reported a thick, foul-smelling heater filter, a leaking toilet that required the resident to dump collected water every night, and a broken toilet seat that had been reported about a month earlier without repair. One resident reported having no toilet paper in their bathroom since the previous night despite informing two CNAs, resulting in the resident using paper towels to clean themselves, which caused discomfort; the bathroom was observed to have no toilet paper. Additional observations showed environmental and safety issues related to call systems and room conditions. In one bathroom, the call light pull cord was wrapped around a grab bar, making it non-functional for the resident. In another room, the resident’s call button was on the floor and out of reach. A room with a leaking toilet had a small plastic basin under the pipes that was nearly full of water; when the toilet was flushed, the leak worsened. Another room had a loose toilet seat that slid easily from side to side. The facility’s maintenance worker later confirmed that the peeling drywall in one resident’s room would need repair and painting and stated they had not been made aware of the issue, despite the facility having a notification system that should have been used. The facility’s housekeeping and laundry operations also contributed to the deficiency. The Director of Housekeeping and Laundry acknowledged staffing issues and that housekeeping staff did not work weekends, resulting in accumulated housekeeping concerns by Monday. The director confirmed the observed debris along the hallway handrails and the damaged wall and debris in the resident’s room. Laundry observations showed both washers and dryers running and large amounts of clean linens awaiting folding, with housekeeping staff pulled from their usual duties to help catch up on laundry. CNAs reported frequent shortages of clean linens, particularly towels, which disrupted shower schedules. Clean linen rooms on both floors were observed with limited supplies of washcloths, bath towels, and disposable briefs in certain sizes, while soiled linen rooms contained heaping, unemptied bins of bagged soiled linens and personal laundry. Record review of the facility’s work order log from a several-month period showed only completed items, with no documentation of existing environmental concerns, no dates of when issues were reported, and no dates of correction. The log did not include any of the specific resident-reported concerns such as leaks, broken toilet seats, or wall damage. Staff interviews indicated that housekeeping was responsible for restocking toilet paper in resident rooms and public restrooms, including on weekends, and that central supply maintained adequate stock of linens, briefs, and toilet paper. However, the observed lack of toilet paper in at least one resident’s bathroom, the low levels of linens and briefs in clean supply rooms, and the reported disruptions to shower schedules due to linen shortages demonstrated that supplies were not consistently delivered to resident care areas as needed, contrary to the facility’s housekeeping policy requiring daily cleaning of surfaces and regular carpet care, as well as prompt response to visible soiling and spills.
Failure to Assign Nurse Coverage Resulting in Widespread Missed Medications and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not ensuring that a nurse was assigned to a block of rooms (125–147, Orchard Lake hallway) during a day shift, resulting in missed medications and treatments for multiple residents. A family member reported that one resident did not receive any day-shift medications until approximately 9:00 p.m., and stated that a nurse told them no nurse was assigned to that hallway and that other nurses could not assume responsibility without risking their licenses due to high resident loads. Review of the medical record for this resident, who had been admitted with diagnoses including congestive heart failure and atrial fibrillation and required assistance with most activities of daily living per the MDS, showed approximately 16 missed doses of medications/supplements and three missed urostomy treatment opportunities on that day. Further review of the MARs and TARs for 17 additional residents on the same unit revealed numerous missed medications and treatments during the same day shift. The missed items included, for example, six medications for one resident; 10 medications for another; six medications and eight treatments for another; and up to 18 medications and one treatment for another resident. Additional residents had between three and 17 missed medications each, with several also missing one to four treatments. Certified nursing assistants assigned to the Orchard Lake rooms confirmed that there was no nurse assigned to those rooms during the day shift and reported that, while a nurse from another hallway occasionally came over, they believed residents did not receive medications and that many residents were in pain because they were changed without pain medications. Review of the facility’s nurse staffing assignment for the day in question showed no nurse scheduled to work the first floor, which had a census of 38 residents, while CNAs were assigned to the Orchard Lake rooms. The DON stated they were unaware that the hallway had no assigned nurse and explained that with a census of 86, three nurses should have divided the building, with one nurse covering a split assignment between floors. The DON indicated there may have been a miscommunication regarding nursing assignments and reported that a missed medication report for that day generated 15 pages of residents with missed medications. A nurse interviewed by phone described poor staffing, noted that usually four nurses were scheduled (two per floor), and acknowledged that on a few occasions only three nurses were scheduled, stating they had informed the facility they could not safely split the building in that manner. The facility’s Abuse Prohibition Policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress and included alleged violations where the facility demonstrates indifference or disregard for resident care, comfort, or safety resulting in such outcomes.
Untimely Medication Administration and Poor Wound/Dressing Management
Penalty
Summary
Surveyors identified that medications were not administered according to physician orders, resident preferences, and facility policy for multiple residents. During a confidential resident council interview with eight residents, five reported concerns about delayed medication administration, including the absence of a nurse on their wing until midnight and not receiving scheduled morning medications such as a pain patch due between 9:00 AM and 10:00 AM. At the time of the interview, three additional residents also reported they had not yet received their 9:00 AM medications. Review of Medication Administration Records (MARs) on 3/24/26 at 12:40 PM showed that several residents had no documentation of their scheduled 9:00 AM medications or treatments being administered, and there were no progress notes or physician notifications regarding missed or late doses. Record review for one resident with diagnoses including atrial fibrillation, congestive heart failure, diabetes, and chronic kidney disease showed multiple daily medications such as Eliquis, furosemide, lisinopril, and potassium chloride ordered, but the 9:00 AM MAR entries for that day were blank. Another resident with acute and chronic respiratory failure, COPD, heart failure, atrial fibrillation, and multiple cardiac and anticoagulant medications had orders for time-specific doses at 9:00 AM and 9:00 PM, including apixaban, hydralazine, sacubitril-valsartan, and isosorbide dinitrate, yet the 9:00 AM medications were not documented as given by 12:40 PM. A third resident with heart failure, COPD, diabetes, hepatitis C, and neuropathy had multiple scheduled medications and sliding scale insulin ordered before meals and at bedtime; documentation showed the last blood sugar check and insulin administration at 7:00 AM, with no documentation of a blood sugar check before the noon meal despite the resident already being in the dining room and a history of frequent sliding scale insulin coverage before meals. A fourth resident with dementia, hypertension, diabetes, hyperlipidemia, and anemia had several daily medications and nutritional supplements ordered at 9:00 AM and 5:00 PM, but the 9:00 AM medications were not documented as administered. When interviewed, the nurse assigned to the unit stated the morning medication pass was not completed due to a heavy med pass and acknowledged not notifying administration or the physician about the delays. The facility’s Medication Administration policy required medications to be given within 60 minutes of the scheduled time, but the policy did not address late or missed medications, and the DON could not explain the lack of documentation or notifications. Surveyors also found failures in wound and dressing management for two residents. One resident with intact cognition and diagnoses including heart failure, peripheral vascular disease, and diabetes had a right knee abrasion care plan and a physician order to cleanse the abrasion and apply triple antibiotic ointment with a border gauze dressing on Monday, Wednesday, Friday, and as needed. On observation, the resident’s right leg dressing was visibly soiled, saturated, and dated 3/17, and the resident reported no one had offered to change it since that date. The Treatment Administration Record (TAR) showed the treatment documented as completed on 3/18 and 3/20 by the nurse manager, but the observed condition of the dressing and the resident’s report conflicted with that documentation. In another case, a cognitively intact resident admitted with pleural effusion, sepsis, and malnutrition was observed with an undated, worn bandage on the right hand that the resident stated had been applied at an outside appointment on 3/17/26 and had not been assessed or changed by facility staff. The same resident also had an undated foam border dressing on the left outer arm, which the resident reported had not been changed for a couple of days, despite a care plan requiring weekly head-to-toe skin assessments and a physician order for right arm abrasion care every Monday, Wednesday, Friday, and as needed. The TAR showed the right arm treatment marked as completed on 3/20 and left blank on 3/23, and a skin check dated 3/21 documented no skin issues. When the DON later removed the hand dressing, an old, soiled dressing was revealed over a scabbed area, and the DON confirmed that dressings should be dated and that nurses were expected to assess any dressing without an order and obtain appropriate treatment orders. The facility’s Skin Management policy required licensed nurses to monitor, evaluate, and document changes in skin condition, including dressings and surrounding skin, and to notify the resident, responsible party, practitioner, DON/designee, and treatment team when a new area of skin impairment was identified. Despite these requirements, the observations and record reviews showed that dressings were left in place for extended periods without being changed, were not dated, and were not consistently assessed or documented. In addition, there were discrepancies between TAR documentation and the actual condition of residents’ dressings, with one nurse manager having documented treatments as completed on dates when the dressing remained unchanged and soiled. These actions and inactions led to deficiencies in ensuring medications and treatments were provided according to physician orders, resident needs, and facility policies.
Failure to Maintain Sufficient Nursing Staff Leading to Delayed Care and Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet resident needs, resulting in prolonged call light response times and delays in medication administration and treatments. During a confidential resident council interview with eight residents, all participants reported concerns about staffing and response times. Residents stated that at times there was no nurse on their wing until midnight, that the day nurse had to stay late, and that morning medications and pain patches due between 9:00 AM and 10:00 AM were not administered on time. Multiple residents reported waiting from 20 minutes up to two hours for call lights to be answered, and described going to the nurses’ station to find staff talking and laughing while they were still waiting for assistance. Individual resident and family interviews further detailed the impact of inadequate staffing. One resident reported that call light responses averaged 1 to 1.5 hours and that there were also insufficient housekeeping and laundry staff, resulting in rooms being cleaned only every other or third day and laundry not being returned as expected. The same resident reported that on some occasions there was no nurse to relieve the day nurse, causing evening medications to be given very late or not until the next morning. Another resident reported that on a recent Sunday there was no nurse available until 11:00 AM, causing them to miss their morning medications, and stated that staffing had worsened since the beginning of the year, with only one nursing aide assigned to an entire hall. A third resident reported long call light response times, especially on the afternoon shift, and a family member reported that their loved one had stopped using the call light because there were not enough staff to answer it and had fallen over a weekend while attempting to go to the bathroom. Staff interviews and facility documentation confirmed ongoing staffing shortages and practices that did not ensure adequate nurse coverage. An LPN reported that staffing had declined from three nurses on the first floor to two nurses and four to five CNAs, which they felt was not enough to meet resident needs, leading to treatments being done late or not at all after the treatment nurse position was eliminated and floor nurses assumed all treatments. Another LPN stated that staffing had been poor, that usually four nurses were scheduled for the building, and that on some occasions only three nurses were scheduled, which they felt could not safely cover both floors. The staffing coordinator acknowledged that the building was short staffed, that about five nurses had recently resigned, and that the facility did not permit the use of agency or PRN nurses to fill gaps. The coordinator stated that staffing was based on PPD levels set by corporate, without directly incorporating resident acuity, and that nursing managers were expected to adjust for acuity. The facility’s own nursing staffing policy required 24-hour nursing services, a licensed nurse on each shift, and staffing based on resident number, acuity, and diagnoses, but the reported practices and outcomes showed these standards were not consistently met.
Failure to Maintain an Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program that promotes appropriate antibiotic use and includes a system of monitoring. During an interview, the ICP stated that their role included ensuring residents met McGeer's criteria for antibiotic use, confirming staff followed protocols and procedures, educating staff on infection control policies, and using audits and an infection screening tool to determine if residents met criteria for antibiotics. The ICP reported they began the position in November 2025 and were hired specifically for infection control. However, the ICP explained that due to staffing shortages they were frequently assigned to work as a floor nurse and could only perform infection control duties when time allowed. Review of the infection control books showed that requested information, including specific resident lab results, clinicians' rationale for antibiotic use, and documentation of McGeer's criteria supporting prescribed antibiotics, was not available. The ICP acknowledged that the program was not compliant except for one month when staffing was adequate. The ICP also reported that they had requested additional help and training from corporate staff but were denied, and that they had functioned more as a floor nurse than an ICP. When the antibiotic stewardship policy was requested, no additional information was provided.
Failure to Provide and Document Ordered Pressure Ulcer Treatments for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered pressure ulcer treatments were obtained, carried out as ordered, provided in a timely manner, and accurately documented for two residents with pressure injuries. One resident was admitted with a Stage 3 pressure ulcer and a surgical wound, and another was admitted with multiple pressure injuries including a Stage 4 and an unstageable ulcer. For the first resident, the MDS showed admission with a Stage 3 pressure ulcer on the right heel. The resident reported that wound care was supposed to be done every other day without exception, but stated that treatments were sometimes missed and that the leg wrap was often applied too tightly, causing pain. The resident specifically reported missing a scheduled treatment on a Friday and showed the surveyor a wrap that hurt. Record review for this resident’s March Treatment Administration Records (TARs) showed multiple missed or undocumented wound treatments despite active physician orders. An order dated early in the month directed cleansing the right heel with normal saline, applying collagen, and covering with ABD pad and Kerlix wrap on Monday, Wednesday, and Friday. The TAR showed a blank, unexplained box for a Wednesday treatment and another blank for a Friday treatment when the order was discharged that same day. A subsequent order to cleanse with normal saline, apply collagen, and cover with border gauze on Monday, Wednesday, and Friday also showed missing treatments on a Wednesday and Friday, with only Saturday initialed as completed. Review of all March TAR entries confirmed that wound treatments were not documented as completed on the identified dates. The facility’s wound care nurse later acknowledged understanding the concern about missed treatments and stated that at least one treatment had been done but not documented. The nurse also confirmed that the correct treatment per current orders was a border foam dressing, not a Kerlix wrap, and that Kerlix had been used instead of the ordered border dressing. The same resident also reported that on a later date the wound had worsened because the wrong dressing was used, stating that gauze was used instead of a bandage and that the wound bled more and appeared larger when the dressing was removed by the nurse and physician. The wound care nurse confirmed that the order called for a border foam dressing and not a Kerlix wrap, and that Kerlix was a rolled gauze wrap used for cushioning or compression rather than as the primary ordered dressing. The nurse further reported that the facility’s standard was to obtain wound photos every seven days, but no photo was taken because the camera battery had not been charged while the nurse was off work. The surveyor was unable to observe the resident’s scheduled wound care because it was completed earlier in the day than arranged, and the Nursing Home Administrator later accepted responsibility for the missed observation. For the second resident, who was admitted with sepsis, atrial fibrillation, chronic kidney disease, and multiple pressure injuries, the MDS documented one Stage 4 and one unstageable pressure ulcer on admission. The admission nursing evaluation noted skin impairment to both heels and the sacrum, and an admission nurse’s note described wounds to both heels and an open wound to the coccyx, with measurements to be obtained per wound care protocol and dressings in place per hospital discharge orders. The hospital discharge paperwork contained detailed wound care orders for the left buttock, coccyx to right buttock, left heel, and right heel, all to be treated twice daily. However, the facility’s physician orders contained no wound treatment orders until several days after admission, and the TAR showed no documentation of wound care until the date after those orders were entered. A skin check entry for this second resident dated several days after admission documented “No skin issues,” while a separate skin/wound entry later that same morning identified a left heel unstageable pressure ulcer and a coccyx Stage 4 pressure ulcer with specific measurements. During interview, the ADON, who had been the wound care coordinator, stated that the resident was admitted on a Saturday and that the admitting nurse did not enter the wound treatment orders from the hospital discharge paperwork. The ADON confirmed that wound care orders from the hospital should be entered the same way as medication orders and acknowledged that there was no documentation of wound care provided before the TAR entries began. The facility’s Skin Management policy required that residents admitted with skin impairment have appropriate interventions implemented, a physician’s order for treatment, and documentation of wound location, measurements, and characteristics, as well as photos unless refused, which contrasted with the gaps in orders, documentation, and initial assessments identified in the record review for this resident.
Medication Administration and Documentation Errors Result in Elevated Medication Error Rate
Penalty
Summary
Surveyors determined that the facility failed to maintain a medication error rate below 5%, with an observed rate of 6.45%. During a medication pass observed at 9:18 AM, a registered nurse administered multiple medications, including Lasix 20 mg, a multivitamin, MiraLAX 17 g, Duloxetine 60 mg, allopurinol 100 mg, carvedilol 3.125 mg, vitamin B12, and lisinopril 5 mg. A subsequent review of the medication administration record at 12:38 PM revealed that Duloxetine 60 mg, ordered as a delayed-release capsule to be given by mouth at bedtime for depression, was instead administered during the morning medication pass. The review also showed an active order for Famotidine 20 mg by mouth once daily in the morning for GERD, which was not observed being administered during the medication pass but was documented on the medication administration record as having been given. These observed discrepancies between physician orders, actual medication administration times, and documentation on the medication administration record constituted medication errors that contributed to the facility’s medication error rate exceeding the 5% threshold.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure a resident was assessed for safe self-administration of medication and failed to have medication kept at bedside for one resident reviewed for self-administration. During an interview, the resident was observed with a large oblong cream-colored pill in the top bedside dresser drawer and stated it was gabapentin, explaining that nursing staff had left it there after giving a double dose and that he took one dose and saved the other for later use when he had pain. The resident described the medication as being for nerve pain in his leg, which he said felt like bee stings and hurt badly. The Nurse Manager stated that medication should only be kept at bedside if a resident is assessed to self-administer and said only one resident had that status, adding that this resident was not one of them. The clinical record showed the resident was admitted with diagnoses including spinal stenosis of the lumbar region with neurogenic claudication and altered mental status unspecified, and the MDS indicated intact cognition with varying levels of assistance needed for activities of daily living. However, there was no documentation of any assessment, physician order, or care plan showing the resident had been evaluated or authorized to keep medication at bedside for self-administration. The facility policy stated that self-administration requires physician authorization, a self-administration evaluation, and reflection in the care plan.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure acceptable standards of nursing care and services were provided for one resident reviewed for medication administration. The resident was admitted with diagnoses including bipolar disorder, schizophrenia, and anxiety disorder, and had a BIMS score of 13/15 indicating intact cognition. The clinical record documented that on 2/2/26 the resident appeared to be spitting out medication in the room and under the bed, and on 3/22/26 staff documented that the resident appeared to be hoarding medications and throwing them away under the bed, with several days of medication found. The care plan identified the resident as at risk for adverse reactions related to receiving multiple psychotropic medications and included administering medications per orders, but it did not contain interventions related to refusal of medications. During interview, the resident stated they often did not want to take medication because staff tried to poison them, and reported that sometimes they refused medication, sometimes staff left it in the room, and sometimes they spit it out and put it under the bed. RN HH confirmed finding pills under the bed and stated the resident had refused medication at times, and the DON stated staff should remain in the room to ensure residents take their medication and correctly mark refusals.
Missing and Incomplete Pharmacist Medication Review Documentation
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly drug regimen reviews with the medical chart and that irregularities identified in those reviews were documented and addressed in the record for two residents. One resident had Parkinson's disease, dementia, hallucinations, and severely impaired cognition. A monthly pharmacist review dated 8/15/25 identified irregularities, but no documentation of the irregularities or the physician's response was found in the clinical record. The DON stated she could not find the documentation in the chart and that the pharmacy resent the reviews, but the resent documents still did not include a physician response, and no MRR was provided before the end of the survey. For another resident with traumatic ischemia, schizoaffective disorder, Alzheimer's disease, and severely impaired cognition, the monthly medication reviews showed repeated irregularities related to Ferrous Sulfate 325 mg. On 6/16/25, the pharmacist recommended changing the dose to Monday-Wednesday-Friday to optimize iron absorption, and the physician signed "Agree" on 7/2/25, yet the MAR for July, August, and September documented daily administration. Later MRRs on 9/16/25, 11/14/25, 12/9/25, 1/16/26, and 2/11/26 also contained recommendations, but there were no responses in the electronic record.
Incomplete Medical Records for Monthly Medication Reviews
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents reviewed for monthly regimen reviews. One resident was admitted with diagnoses including traumatic ischemia, schizoaffective disorder, and Alzheimer's disease, and had a BIMS score of 3/15, indicating severely impaired cognition. The resident's monthly medication reviews showed irregularities on 9/16/25, 11/14/25, 12/9/25, 1/16/26, and 2/11/26, but there was no documentation in the clinical record of any physician response to those irregularities. A second resident, admitted with diagnoses including Parkinson's disease, dementia, and hallucinations, also had severely impaired cognition on the MDS. The monthly pharmacist medication review for 8/15/25 identified an irregularity, but the clinical record contained no documentation of what the irregularity was or the physician's response. During interview, the DON stated she could not find the documentation in the chart and was told by the unit clerk in medical records that the MRRs had been shredded. The unit clerk reported that after the facility changed pharmacy services in July 2025, the documents were not scanned into the record and were shredded.
Daily Nurse Staffing Posting Not Updated
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was accurately posted and updated for each shift. On 03/23/2026 at approximately 8:33 a.m., surveyors observed that the staffing posting displayed at the entrance was dated 3/21/26 and was about two days old, and it did not reflect the current census of 106 or any staffing changes for the active shift. During an interview on 03/25/2026 at approximately 1:59 p.m., Staffing Coordinator B stated they were responsible for updating the staffing posting. SC B explained that when they leave for the weekend, they provide staffing postings for Saturday, Sunday, and Monday, but the postings are not updated on each weekend day. SC B also stated that the front receptionist was responsible for changing the staffing posting on weekends and must have forgotten. A facility document titled Required Regulatory Postings stated that the facility posts the total number and actual hours worked by nursing staff directly responsible for resident care for each shift, and that the information is to be posted daily at the beginning of each shift.
Failure to Label and Date Opened and Prepared Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items in the kitchen were properly labeled and dated when opened or prepared. During an inspection of the kitchen's refrigerators and freezer, multiple items were found without required labeling or dating, including two opened containers of sour cream, trays of prepared fruit cups and sliced pears, a tray of sweet potato pie slices, a tray of dessert with whipped topping, and opened containers of ranch and Italian salad dressings. The dietary aide present confirmed that these items should have been labeled and dated according to facility policy and standard food safety practices. Further interviews with the Dietary Manager revealed that the facility's process required all food items to be labeled and dated before being placed in the refrigerator, and that prepared fruits and desserts were to be labeled and discarded within three days. Review of facility policies and storage charts confirmed these requirements, specifying timeframes for labeling and discarding various food items. The failure to label and date these food items had the potential to affect all residents consuming food from the kitchen.
Failure to Prevent Catheter-Related Urethral Injury
Penalty
Summary
A resident with a history of urinary retention and sacral wound infections was admitted with a temporary indwelling Foley catheter. The resident was cognitively intact and required ongoing medical and wound care. During the course of care, the resident developed a full-thickness wound on the penis, identified as a medical device-related injury associated with the indwelling catheter. Clinical documentation and wound care notes described the wound as having significant measurements and fresh blood drainage, with the wound bed showing 100% granulation. The injury was confirmed by both wound care staff and a physician, who attributed the trauma to the catheter. Further review and consultation with a urologist revealed that the resident had developed ventral urethral erosion, a rare but serious complication often caused by prolonged catheter tension, resulting in a partial or full-thickness wound of the urethra. The injury was significant enough to require evaluation for surgical correction. Facility leadership, including the DON and IDON, acknowledged that the injury was related to the urinary catheter and confirmed the findings with photographic evidence. The incident was discussed with the Nursing Home Administrator during the exit interview.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent accidents and falls for three residents. One resident with severe cognitive impairment and multiple diagnoses was being prepared for transfer to a shower chair by a CNA who was waiting for a second staff member to assist. The CNA sat the resident on the side of the bed with a walker in place and turned away to respond to another resident's question. During this time, the resident slid off the bed and sustained fractures to both legs. Documentation confirmed the injuries and the sequence of events, and the Director of Nursing acknowledged the deficient practice. Another resident, also with severe dementia and a history of wandering and ingesting non-food items, was assigned 1:1 supervision due to being a fall risk and exhibiting unsafe behaviors. Despite this, the resident was found sucking on a bleach sheet, requiring intervention from poison control. Staff assignment records showed that one CNA was responsible for supervising both this resident and his roommate, who also required close supervision. Staff interviews revealed that it was very difficult to supervise both residents simultaneously, and that lapses in attention allowed the resident to access hazardous items. The roommate, who had dementia and a history of wandering and exit-seeking behaviors, was also at risk for falls and elopement. Despite care plans indicating these risks, the resident was able to exit through an alarmed door and go down a flight of stairs without staff intervention. There was no investigation documented for this incident, and staff confirmed that supervision was not consistently provided as required. The facility did not provide incident reports or investigations for some of these events, and staff interviews confirmed that supervision protocols were not adequately followed.
Failure to Provide Regularly Scheduled Bathing
Penalty
Summary
The facility failed to ensure that a resident was offered and provided regularly scheduled bathing as required. The resident reported that staff often missed their scheduled showers and, if they declined a shower at the offered time, staff did not return to offer it again later. The resident stated that they were only bathed about once a week, despite needing more frequent bathing due to sweating and personal preference. The resident also indicated a preference for showers in the afternoon or evening, which was not accommodated. A review of the resident's medical record showed that bathing was only documented as offered four times in the previous 30 days, with only two instances where bathing was actually provided. There was no documentation to support that bathing was offered at least twice weekly as required. The DON confirmed that showers should be offered at least twice weekly and that all offerings should be documented, but was unable to provide additional documentation to show compliance. Facility policy stated that residents should receive necessary assistance to maintain personal hygiene, but there was no evidence this was consistently done for the resident in question.
Failure to Provide Timely Pain Medication Administration
Penalty
Summary
The facility failed to ensure timely administration and refilling of pain medications for a resident with multiple diagnoses, including morbid obesity, diabetes, peripheral vascular disease, and depression. The resident experienced uncontrolled pain and elevated blood pressure after not receiving scheduled doses of morphine due to a pharmacy shipment delay. Documentation showed that the last dose of morphine was administered in the morning, and subsequent scheduled doses were not given because the medication was not available. Additionally, there was a significant delay in administering as-needed oxycodone, with nearly twelve hours between doses, despite the resident's ongoing pain. Progress notes and medication administration records confirmed that both morphine and oxycodone were available in the facility's back-up medication supply at the time, but were not pulled or administered as per physician orders. Interviews with the Director of Nursing revealed that nurses are expected to check and pull medications from the back-up supply when a resident runs out, especially for controlled substances, but this was not done. The facility's provided medication administration policy did not address procedures for accessing the back-up supply, contributing to the failure to provide appropriate pain management, which resulted in the resident being transferred to the emergency room for pain control.
Failure to Honor Food Preferences and Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to honor a resident's food preferences and ensure meals were served at safe and appetizing temperatures. During observation, a resident reported that their meal tickets were repeatedly incorrect, resulting in not receiving double portions or cheese on their eggs as requested. The resident also stated that the food was consistently cold and unpalatable. Direct observation confirmed that the breakfast tray did not match the resident's documented preferences, and the food was not warm. Review of the meal ticket corroborated that the resident was supposed to receive double portions with cheese, which was not provided. Further observations during lunch revealed that the resident's tray again did not include the required double portions, and food temperatures were below the standards reported by the kitchen manager. The kitchen manager acknowledged issues with staff reading meal tickets correctly and noted that food items were not at the appropriate temperatures when served. The resident's medical record indicated multiple mental health diagnoses, and facility policy required that food preferences be identified and honored on tray tickets, which was not followed in this case.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from abuse and neglect by staff members. One resident, identified as R901, was forcefully slapped in the face by a Certified Nursing Assistant (CNA A) after an altercation where the resident was resistive while being wheeled down the hallway. The incident was captured on video, which showed CNA A slapping the resident while another staff member, Nurse B, was having their hair pulled by the resident. The facility's investigation confirmed the abuse, and the CNA was terminated following the incident. Another resident, R902, experienced neglect when Nurse D pushed their wheelchair into a medication cart and a metal doorframe, causing the resident to flinch. Nurse D did not acknowledge the incident and left the resident unattended while they accessed the medication cart. The resident, who had severe cognitive impairments and a history of wandering, was not properly monitored, leading to potential harm. Nurse D was observed to be unaware of the resident's name and was dismissive when approached about the incident. The facility's policies on abuse and neglect were not adhered to, as evidenced by the incidents involving R901 and R902. The facility's failure to protect these residents from harm and ensure their safety resulted in physical abuse and neglect. The incidents highlight a lack of adequate staff training and awareness regarding resident care and safety protocols.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour with the Dietary Manager (DM) Q. In the walk-in cooler, there were several undated food items, including a container of salad, a bag of diced chicken, and a bag of polish sausage. DM Q confirmed that these items should have been dated according to the 2017 FDA Food Code, which requires ready-to-eat, potentially hazardous food to be clearly marked with a date if held for more than 24 hours. This oversight in food labeling could potentially affect all residents consuming food from the kitchen. Additionally, in the dry storage room, scoops and Styrofoam bowls were improperly stored inside bins with their handles resting in the sugar, thickener, and corn starch. DM Q acknowledged that this was not the correct storage method. Furthermore, a shelving unit next to the oven, used for storing clean pots, was found to have a heavy accumulation of grease and food debris. DM Q mentioned that thorough cleaning is usually done on weekends, indicating a lapse in maintaining cleanliness as per the FDA Food Code requirements for nonfood-contact surfaces.
Lack of Privacy and Grievance Follow-Up in Resident Council Meetings
Penalty
Summary
The facility failed to provide adequate privacy for Resident Council meetings, as observed during a survey. The meetings were typically held in the Piano Room, which lacked doors and was frequently accessed by staff, leading to interruptions and a lack of privacy. Residents expressed dissatisfaction with the meeting space, noting that staff ignored signs indicating a meeting was in progress and continued to enter the room. This lack of privacy hindered residents' ability to discuss their concerns freely. Additionally, the facility did not adequately address grievances raised during these meetings. Residents reported that their concerns, such as long call light response times and staff attitudes, were not followed up on. Many residents were unaware of the grievance process, with only two out of thirteen knowing about the existence of grievance forms. The facility's Grievance Officer, the Nursing Home Administrator, confirmed that no grievance forms had been filed in the past five months, indicating a failure to document and address resident concerns. The Resident Council President, who was responsible for leading the meetings, was often unable to attend due to not being informed or assisted in getting to the meetings. This further contributed to the residents' feeling that their concerns were not being taken seriously. The facility's policy required that a private space be provided for meetings and that grievances be documented and addressed, but these procedures were not followed, leading to the deficiency.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment in several residential common areas, including the central shower room, dining areas, and specific resident rooms. Observations revealed unkempt carpeted floors with debris, sticky ring marks on tiled floors, and dried food substances on walls and doors. In one resident room, dried brown tube feed was found on a dispensing machine and surrounding areas, while another room had a moderate pile of a cakelike substance on the floor. The central shower room had visibly soiled floors, chipped tiles, and non-functional lighting, with various personal items and cleaning supplies improperly stored. The common areas, such as the second-floor sitting area and the Piano Room, were observed with dust, unkempt tables, and dead insects on windowsills. The first-floor dining area had dead insects, webs, and stained tablecloths. During a tour with the Housekeeping Director, it was confirmed that housekeeping was responsible for maintaining these areas, but they had not been adequately cleaned. The facility's housekeeping policy, dated February 2023, emphasized the importance of maintaining a clean healthcare environment, but the observations indicated a failure to adhere to these standards.
Inadequate Fall Prevention and Documentation for Resident
Penalty
Summary
The facility failed to ensure timely and complete assessments and investigations into multiple falls experienced by a resident, identified as R85, who was at risk for fall-related injuries due to conditions such as hemiplegia, hemiparesis, and vascular dementia. The resident had a history of severe cognitive impairment and had experienced multiple falls, some resulting in injury, since admission. Despite these risks, the facility did not adequately document or investigate the falls, nor did they implement appropriate interventions to prevent future incidents. Observations and record reviews revealed that R85 was often found in precarious positions, such as lying halfway down the bed or on the floor, indicating inadequate supervision and fall prevention measures. The facility's incident/accident reports for R85's falls were incomplete, lacking crucial information such as staff interviews, root cause analyses, and notifications to the physician or responsible party. In several instances, the reports failed to document any new interventions or updates to the resident's care plan following the falls. Interviews with the Director of Nursing (DON) highlighted a lack of awareness and oversight regarding the incomplete documentation and insufficient fall investigations. The DON acknowledged the issues but was unable to provide additional documentation or explanations for the deficiencies. The facility's policy on fall management, which requires thorough evaluation and documentation of falls, was not adhered to, resulting in repeated failures to address the resident's fall risks effectively.
Inadequate Staffing and Supervision in LTC Facility
Penalty
Summary
The facility failed to consistently provide sufficient nursing staff to meet the needs of its residents, leading to complaints of delayed care and lack of supervision. The staffing plan outlined in the facility's policy required 16 licensed nurses and 24 nurse aides across various shifts, but the actual staffing levels often fell short of these requirements. This discrepancy resulted in inadequate supervision and care for residents, particularly those with wandering behaviors, such as a resident identified as R86. R86, who has diagnoses including dysthymic disorder, Down syndrome, and unspecified intellectual disabilities, was observed wandering unsupervised in the facility. On multiple occasions, R86 entered other residents' rooms and was found in areas without staff presence, displaying signs of distress and engaging in potentially harmful behaviors. Despite these observations, the Director of Nursing (DON) did not believe increased supervision was necessary, citing that the resident's outbursts would not be mitigated by one-on-one supervision. The facility's failure to provide adequate staffing and supervision was further compounded by the lack of documentation for certain dates and the absence of the Administrator during the survey. The DON, acting as the point of contact, did not express concern over staffing levels, even though the facility's staffing did not align with the documented plan. This lack of supervision and staffing inadequacy posed a risk to all residents, particularly those like R86, who require more attentive care due to their behavioral and cognitive challenges.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as evidenced by multiple observations of pills and capsules found on the floor in common areas. On one occasion, a pink oblong pill identified as omeprazole was found in the central shower room, which a Licensed Practical Nurse (LPN) retrieved with bare hands, indicating it may have fallen from a medication cart. Additional pills and capsules were found in the hallway and dining area, with staff members picking them up without proper precautions, suggesting a lack of adherence to medication handling protocols. A resident, identified as R70, was observed with a bottle of eye drops on their overbed tray table, despite a previous assessment indicating they were not capable of self-administering medication due to severe cognitive impairment. The Director of Nursing (DON) confirmed that the resident should not have had the eye drops at bedside and removed them, acknowledging that the family had brought in the medication without proper authorization or assessment. Further deficiencies were noted at the 2nd floor nursing station, where 25 boxes of COVID-19 Rapid Tests were stored unsecured on an open shelf, and both the medication and treatment carts were found unlocked with no staff present. The Infection Control Nurse and the assigned nurse were unaware of the unlocked carts, and the DON confirmed that this was against facility policy, which mandates that all medications and biologicals be securely stored in locked compartments.
Infection Control Deficiencies in Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to implement effective infection control practices, specifically in the areas of hand hygiene during medication administration and the application of Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter. Observations revealed that a resident with a urinary catheter did not have appropriate signage or Personal Protective Equipment (PPE) available, indicating a lack of EBP implementation. A Certified Nurse Aide (CNA) assigned to the resident was unaware of any infection control precautions, and it was only after the surveyor's intervention that signage and a PPE cart were placed outside the resident's room. The resident's clinical record indicated the need for EBP due to the presence of an indwelling urinary catheter, yet this was not initially adhered to. Additionally, during a medication pass, multiple nurses failed to perform hand hygiene before and after administering medications to residents. This was observed with several nurses who completed medication administration without washing their hands, despite the Director of Nursing (DON) confirming that hand hygiene is expected to be performed before and after each resident interaction. These lapses in infection control practices present a potential risk for cross-contamination and the spread of infection within the facility.
Incomplete Nutritional Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the specific nutritional needs of a resident, identified as R297, who was admitted with multiple complex medical conditions including severe protein-calorie malnutrition and morbid obesity. The care plan initiated by the Director of Nursing was incomplete, lacking specific interventions tailored to the resident's nutritional needs and risks. Despite the presence of a mechanically altered diet, there was no documentation of a thorough nutritional assessment or specific interventions in the resident's care plan. Conflicting documentation was noted in the physician and nurse practitioner progress notes, which referenced a nutritional care plan and monitoring that were not available in the clinical record. The Registered Dietitian (RD) confirmed that they did not perform the evaluation due to being out sick and was unsure who was responsible for nutritional monitoring in their absence. The facility's policy on nutritional services documentation was not adhered to, as the nutritional evaluation was not used to develop an individualized care plan for the resident, leading to the deficiency.
Deficiency in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure nursing services met professional standards for medication administration and documentation for a resident who was reviewed for self-administration. The resident, who was cognitively intact with a BIMS score of 14/15, had a medical history of hepatitis, hypertension, diabetes, and psychiatric conditions including major depressive disorder, bipolar disorder, and anxiety. During observations and interviews, the resident expressed concerns about the application of a medicated lotion left at their bedside. The resident was unaware of the lotion's purpose and noted that it was left uncovered, raising concerns about sanitation. The resident reported that nurses did not confirm whether the lotion was applied and simply left it at the bedside. A review of the Medical Administration Record (MAR) indicated that the resident was prescribed Benzoyl Peroxide External Gel 5% to be applied once daily for a topical infection/acne. However, the Licensed Practical Nurse (LPN) responsible for administering the medication acknowledged leaving it at the bedside without applying it or confirming its application with the resident. The LPN did not respond to questions about whether the resident had orders to self-administer the medication and walked away from the surveyor. The Nursing Home Administrator was informed of the interaction but provided no further explanation.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for three residents, resulting in them being left wet for extended periods. One resident was observed asking for assistance to be changed, but the staff member left without helping. A nurse later turned off the call light without providing assistance, and the resident was only helped after a significant delay. Another resident's call light was on for over 30 minutes before they were assisted, and they expressed discomfort from waiting to be changed. The Director of Nursing acknowledged that call lights should be answered within 30 minutes but did not provide further information by the survey's exit. Another resident reported being left in wet sheets overnight, despite informing the midnight aide, who did not return to assist them. The resident expressed feeling upset and uncomfortable due to the lack of care. A CNA confirmed that this resident was often found in such a condition at the start of their shift. The resident's care plan indicated they required assistance with activities of daily living due to weakness and needed to be checked every two hours for incontinence. The resident was cognitively intact, as indicated by their MDS assessment, which showed they required moderate assistance with toileting and were frequently incontinent.
Failure to Notify Physician of Resident's Skin Condition
Penalty
Summary
The facility failed to notify a physician of a change in condition for a resident who was experiencing skin issues. The resident, who was admitted with a diagnosis of nontraumatic subdural hemorrhage, major depressive disorder, and muscle weakness, reported itching and burning on their skin, suspecting an abscess. Despite informing the nursing staff, no action was taken to address the issue, and the resident's family member was also aware of the resident's discomfort and desire to see a doctor. The resident's medical record showed no indication of the skin issue in the weekly skin assessments. The deficiency was identified during an interview with the resident and their family member, where the resident expressed dissatisfaction with the delay in receiving care for their skin condition. The Director of Nursing was unaware of the issue until informed by the surveyor, and only then was a wound care consult and hydrocortisone cream order placed. This indicates a lapse in communication and timely response to the resident's change in condition, as the facility's staff did not document or address the resident's complaints until after the surveyor's intervention.
Failure to Provide Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative therapy services for a resident, identified as R25, who was observed with limited range of motion in their legs. R25 was previously receiving restorative therapy before a hospital stay but did not resume these services upon returning to the facility. The resident expressed a desire to continue therapy due to increased tightness in their legs, but no restorative therapy was provided during the 30-day look-back period. The Restorative Aide confirmed that R25 was not on their caseload post-hospitalization, and the Rehabilitation Director was unaware of the gap in services. The Director of Nursing (DON) acknowledged that the facility did not have a fully functioning restorative program and lacked a restorative nurse to oversee the program. The DON admitted that R25 should have been screened for restorative services after their hospital stay, especially given the report of contractures beginning. Despite the resident's needs and expressed wishes, there was no documentation of a contracture diagnosis in R25's records, and the care plan did not reflect the need for restorative therapy. Observations revealed that R25's heels were pressing on the mattress, and their legs showed signs of stiffness and limited range of motion. The DON attempted to perform range of motion exercises with R25, noting potential contractures. The facility's policy on restorative nursing emphasizes the importance of maintaining residents' physical well-being, but the lack of a structured program and oversight led to a deficiency in providing necessary restorative care for R25.
Failure to Conduct Comprehensive Nutritional Assessment
Penalty
Summary
The facility failed to conduct a comprehensive nutritional assessment and ongoing evaluation for a resident, R297, who was admitted with significant nutritional needs following a gastric sleeve revision surgery with complications. The resident's clinical record indicated multiple serious diagnoses, including severe protein-calorie malnutrition and morbid obesity. Despite these conditions, the facility did not complete a comprehensive nutritional assessment or provide specific interventions tailored to the resident's needs. The care plan initiated by the Director of Nursing was incomplete, and there was no evidence of a comprehensive assessment by the Registered Dietician (RD). The resident's physician orders included a mechanically altered diet and nutritional supplements, but there was no documentation of a comprehensive nutritional assessment or progress notes by the RD in the clinical record. The RD confirmed that they did not perform the evaluation and were unaware of a STAT order for an RD evaluation. The RD was out sick on a critical date and was unsure who was responsible for nutritional monitoring in their absence. The RD also acknowledged that the assessment was initiated but not completed, and there was no documentation of specific nutritional needs, including protein or TPN. The facility's policy required a comprehensive nutritional evaluation upon admission, which was not adhered to in this case. The RD reported having discussions with physicians via text but did not complete an actual nutritional assessment. The lack of a comprehensive nutritional assessment and care planning for R297, despite the resident's significant nutritional needs and physician orders, led to the deficiency identified in the report.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure appropriate use of psychotropic medication for a resident, identified as R85, who was admitted with multiple diagnoses including hemiplegia, generalized anxiety disorder, dysthymic disorder, and vascular dementia. Despite having severe cognitive impairment and no documented behaviors or psychosis, R85 was prescribed Alprazolam as needed for agitation. The medication was administered multiple times in December and January without documentation of non-pharmacological interventions being attempted first, as required by the facility's policy. Additionally, there were no corresponding entries in the interdisciplinary progress notes at the time of the PRN administrations, and the documented behaviors did not align with the times the medication was given. During an interview, the Director of Nursing acknowledged the lack of documentation and confirmed that the nurses should have recorded the interventions on the Medication Administration Records or progress notes. The DON also questioned the appropriateness of the medication being ordered for agitation and indicated a need to follow up with the contracted psych provider who issued the orders. The facility's policy on psychoactive medication management emphasizes non-pharmacologic interventions as the first choice for managing behavioral symptoms and requires a clinically supported diagnosis for pharmacological interventions.
Failure to Provide Timely X-Ray Services
Penalty
Summary
The facility failed to obtain and coordinate timely radiology services for a resident who experienced a fall. Following the fall, a physician ordered an X-ray of the resident's left shoulder on 1/13/25. However, as of 1/15/25, the X-ray had not been completed, and there was no radiology report available in the electronic medical record. The radiology log at the nursing station showed that the request for the X-ray had not been fulfilled, despite the physician's order. The Director of Nursing (DON) indicated that X-rays should typically be completed within 24 hours unless ordered STAT, but there was no facility policy addressing the timeframe for obtaining X-rays. The resident involved had a history of idiopathic normal pressure hydrocephalus, hemiplegia and hemiparesis following cerebral infarction, neurologic neglect syndrome, and a nonruptured cerebral aneurysm. At the time of the deficiency, the resident reported significant pain in the left shoulder, rating it as a seven on a scale of zero to ten. The resident's Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and occasional pain affecting daily activities. Despite the physician's order and the resident's reported pain, the X-ray was not completed until after the survey identified the issue.
Failure to Administer Vaccines After Consent
Penalty
Summary
The facility failed to ensure the administration of pneumococcal and influenza vaccines for a resident, identified as R3, who was admitted with a medical history of influenza, pneumonia, heart failure, osteoarthritis, and gastrointestinal hemorrhage. R3, whose primary language is Arabic/Chaldean, consented to receive the vaccines through their daughter, who acted as a translator. Despite this consent, the facility's Electronic Medical Record (EMR) showed no documentation of the vaccines being administered. The Infection Control Preventionist (ICP) confirmed that the vaccines were not given and that the physician had discontinued the orders without documented rationale. Furthermore, there was no follow-up communication with R3 or their daughter regarding the discontinuation of the vaccines, leading to the daughter mistakenly believing that R3 had received them.
Failure to Timely Treat Diabetic Ulcer Leads to Amputation
Penalty
Summary
The facility failed to accurately assess, timely treat, and identify the worsening of a diabetic ulcer for a resident, resulting in a hospital transfer and subsequent amputation of the resident's left great toe. The resident, who had a history of diabetes, peripheral vascular disease, and previous amputations, was admitted to the facility with a diabetic ulcer. Despite the presence of a wound on the left great toe, there was a significant delay in treatment orders, with no treatment initiated until several weeks after the ulcer was first documented. The facility's records revealed inconsistencies in the documentation of the wound's condition and treatment. The wound was first noted by a dietary note, but there were no prior progress notes mentioning the wound. The wound care assessments and consultations by the facility's contracted wound PA showed discrepancies in measurements and descriptions of the wound, with no treatment orders in place for a significant period. The facility's Wound Care Coordinator and PA failed to provide consistent and timely documentation and treatment for the resident's wound, leading to its deterioration. Interviews with facility staff, including the Wound Care Coordinator and the DON, highlighted a lack of proper wound management and documentation. The DON acknowledged issues with the previous Wound Care Coordinator and discrepancies in the wound consults. The facility's policy on skin management was not adhered to, as ongoing monitoring and evaluation were not provided to ensure optimal outcomes for the resident. This lack of adherence to policy and failure to provide timely and appropriate care resulted in the resident's condition worsening, necessitating a hospital transfer and amputation.
Unresolved Odor Issue in Hallway Near Dining Room
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment in the hallway near the main dining room, as evidenced by a strong, putrid, sour odor that was present. This odor was first observed in the hallway extending from the main dining room to the lobby. The Registered Dietician (RD) 'E' suggested that the odor might be due to a problem with the dish machine, which was located in the hallway where the odor was detected. The Infection Control Nurse/Staff Development Nurse, Staff 'D', also acknowledged the presence of the pungent odor in the same area. Further investigation revealed that the Housekeeping Supervisor (HK) 'F' attributed the odor to an issue with the dish machine that required repairs. An observation of the dish room showed a wet floor, but the odor was not present inside the dish room itself, only in the hallway outside. The Administrator reported being unable to detect the odor, while the Maintenance Assistant 'H' confirmed awareness of the odor, noting that the source had not been identified despite its presence for a couple of weeks.
Neglect in Medication Administration by RN
Penalty
Summary
The facility failed to protect residents from neglect, as evidenced by the actions of a registered nurse (RN B) who did not administer medications to three residents as documented. A complaint was filed alleging that RN B did not administer medications to a resident (R701) on a specific date, despite documentation indicating otherwise. Surveillance footage confirmed that RN B did not enter the resident's room during the time the medications were supposedly given. The resident's family member, who was present during the alleged time of administration, corroborated that the medications were not administered. Further investigation revealed that RN B also failed to administer medications to two other residents (R704 and R705) on the same unit. Both residents reported inconsistencies in receiving their medications, with one resident noting that they sometimes did not receive their medications at all. The facility's surveillance footage showed that RN B did not enter the rooms of these residents during the medication administration period, and the medication administration records (MAR) were inaccurately documented as if the medications had been given. Interviews with the Director of Nursing (DON) and other staff members revealed discrepancies in RN B's work schedule and time card punches, suggesting that RN B left the facility earlier than scheduled without properly administering medications. The DON and the facility's administrator were unable to provide explanations for the discrepancies observed in the surveillance footage and the MAR documentation. This failure to administer medications as prescribed and the inaccurate documentation constituted neglect of the residents' care needs.
Failure to Verify Active Nursing License
Penalty
Summary
The facility failed to ensure that a nurse, referred to as Nurse A, had an active license to practice as an LPN. A complaint was filed with the State Agency alleging that Nurse A was working with a suspended license. Upon investigation, it was confirmed that Nurse A's license had been suspended in February 2024. Despite this suspension, Nurse A continued to be employed and worked shifts at the facility, including a night shift on June 4, 2024. The facility's records showed that Nurse A had been employed since September 2023. Interviews with facility staff revealed gaps in the process of verifying nursing licenses. The Human Resources staff member responsible for checking licenses had only been employed for three weeks and had not yet reviewed all nursing staff licenses, including Nurse A's. The Director of Nursing and the Administrator were unaware of the suspension until it was confirmed during the investigation. The facility's policy required that all staff in licensed positions have a current license, but this policy was not effectively implemented in Nurse A's case.
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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