Optalis Health And Rehabilitation At St. Francis
Inspection history, citations, penalties and survey trends for this long-term care facility in Saginaw, Michigan.
- Location
- 915 North River Road, Saginaw, Michigan 48609
- CMS Provider Number
- 235249
- Inspections on file
- 30
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation At St. Francis during CMS and state inspections, most recent first.
The facility failed to provide adequate nursing staff to meet residents’ care needs, particularly on afternoon and evening shifts, resulting in prolonged call light response times, staff turning off call lights without assisting, and repeated reports of missed or delayed care. Residents with PICC lines, dialysis access, infections, and IV antibiotics described inconsistent help, with some days having enough staff and other days very few. Multiple residents reported waiting hours for incontinence care, meal corrections, and other assistance, and resident council notes over several months documented ongoing concerns about missed showers, infrequent checks and changes, double‑briefing, CNAs using phones during care, and insufficient CNA presence in the dining room during meals. The facility’s staffing assessment listed nurse numbers by shift but did not define resident acuity or complexity despite the high‑acuity population.
A resident with a PEG tube and multiple complex medical conditions was not placed on Enhanced Barrier Precautions (EBP) despite facility policy and CDC guidance requiring EBP for residents with indwelling medical devices. Surveyors observed no EBP signage, no PPE supply or receptacle at the room, and the resident reported that staff did not wear gowns when providing care or handling tube feedings. Chart review showed multiple orders and care plan interventions related to tube feeding and site care, but no EBP order or EBP-related care plan interventions. During interviews, the DON/ICP confirmed that feeding tubes require EBP, that residents on EBP should have door signage and PPE available, and that this resident had not been identified or managed under EBP since admission, leading to the cited infection prevention and control deficiency.
A resident with severe cognitive impairment, a history of falls, and multiple comorbidities experienced two falls within eight days. After the first fall, no new supervision interventions were added to the care plan. The second fall occurred when the resident, left unsupervised in a wheelchair, stood up, tripped, and sustained a head injury requiring hospitalization. Increased supervision was only implemented after the second incident.
The facility failed to administer scheduled 5:00 PM medications to multiple residents, including critical medications for conditions like DVT/PE and diabetes. An LPN left at 4:00 PM, and the oncoming RN did not administer the medications. The facility did not conduct audits to monitor medication administration compliance.
A resident experienced significant weight fluctuations, ranging from 10 to 82 pounds over short periods, which were not adequately investigated by the facility. Despite being weighed almost daily due to conditions like lymphedema and heart failure, the facility failed to address these discrepancies. The Registered Dietitian noted the fluctuations but did not take further action, and the facility's weight management policy was not consistently followed.
Surveyors found that the facility could not provide adequate documentation to verify that all fire-rated doors had been inspected annually as required. The only available record was an invoice lacking itemized inspection details or criteria, and it could not be confirmed that all necessary doors were inspected.
The facility did not provide adequate documentation to verify that all electrical receptacles in patient care areas were inspected and tested annually as required, and the records submitted lacked itemized details and inspection criteria, making it impossible to confirm compliance.
A facility failed to prevent a Stage III pressure ulcer in a resident, leading to infection and hospitalization. Another resident with existing DTIs was not repositioned as per care plan, resulting in new wounds. Inadequate documentation and communication contributed to these deficiencies.
The facility failed to conduct annual performance reviews for five CNAs, with the last evaluations completed in October 2023. The Human Resources Director noted that annual competency classes are held instead of evaluations based on hire dates. The Unit Manager/Educator, who started in October 2024, was initially focused on other tasks and became aware of the issue a month before the survey. This deficiency could lead to unmet resident care needs.
The facility failed to follow its medication management policies, resulting in unlocked medication carts, undated and expired medications, and improper storage practices. An LPN left a cart unattended, and inspections revealed open, undated, and expired medications, as well as improper storage of non-medication items. A soiled syringe was found in a cart, indicating hygiene issues. These actions violated the facility's policy for secure and accurate medication handling.
Two residents in the facility did not receive adequate bathing and hygiene care. One resident was observed with greasy, unkempt hair and reported not having a shower in a long time, preferring bed baths that did not include hair washing. Another resident had long, dirty fingernails and reported infrequent brief changes and discomfort with the shower chair, with no alternatives offered. The call light was found out of reach, and staff were slow to respond. The facility's policy on call light accessibility was not followed.
The facility failed to complete nursing assessments for two residents, leading to delays in treatment for bowel management and a skin rash. A resident developed a rash from incontinence briefs, which was not documented promptly, causing discomfort. Another resident experienced a lack of communication regarding bowel movements, resulting in delayed care for constipation. The facility lacked a bowel management policy, contributing to these deficiencies.
A facility failed to ensure safe administration and maintenance of a PowerMidline IV catheter for a resident, leading to improper medication reconstitution and inappropriate flushing technique. An LPN did not properly reconstitute Cefepime in a Duplex IV bag, used outdated IV tubing, and failed to disinfect the catheter hub correctly. The LPN also did not check for blood return, indicating a lack of knowledge of facility policies and professional standards. The resident, with a history of acute cystitis and other conditions, required ongoing antibiotic treatment, but the facility staff did not adhere to the care plan and physician orders.
A resident with severe cognitive impairment and multiple diagnoses was not provided with necessary behavioral health services, resulting in emotional distress and a lack of timely assessment and consent for mental health services. Despite frequent crying and expressions of wanting to go home, the facility did not engage a mental health provider or implement effective non-pharmacological interventions.
The facility failed to maintain sanitary conditions in the kitchen and nourishment rooms, resulting in improper sanitization of kitchenware and soiled floors and equipment. Used gloves were found on the ground, and the floor near the stove and sink was visibly soiled. The dishwasher was not tested for appropriate sanitization temperatures, and ice machines had residue buildup. Facility policies on warewashing and equipment maintenance were not consistently followed, leading to unsanitary conditions.
The facility was found to have significant cleanliness issues, including dust-filled heater covers, cobwebs, spiders, and dirty floors in the main dining room, activity room, and several residents' rooms. Observations were made with facility staff, who acknowledged the unclean conditions. The facility's cleaning policy was not effectively implemented, leading to the deficiency.
A resident with COPD and lung cancer was left without a clean urinal, leading to the use of a dirty, discolored one. The facility's supply rooms were found to be lacking urinals, and staff initially provided an inappropriate substitute. The resident expressed that this was a recurring issue, and the Unit Manager confirmed the absence of urinals, later stating that some were purchased externally.
A resident who had undergone hip surgery experienced significant pain due to the facility's failure to provide timely pain management. Despite being in pain and crying throughout the night, the resident did not receive pain medication until the following morning. Medical records showed a delay in administering the prescribed Hydrocodone-Acetaminophen, with the first documented administration occurring nearly 15 hours after admission. Although a tablet was signed out of the Omnicell system, there was no documentation confirming its administration to the resident.
A resident with Crohn's Disease and other conditions was found with medication cups and loose pills on the floor, indicating a failure in medication administration. The resident, who did not wish to self-administer medications, was unsure about the spilled pills. The facility's policy to remain with residents until medication administration is complete was not followed.
A facility failed to prevent and document pressure ulcers for two residents. One resident was found with an abrasion and a deep tissue injury due to not wearing a prescribed Profa boot and lack of repositioning. Another resident developed a Stage III pressure ulcer and a Stage II ulcer due to inadequate monitoring and documentation. The facility's guidelines for skin and wound care were not followed, compromising residents' health.
Two residents experienced inadequate incontinence care, leading to complaints and potential health risks. One resident, with severe cognitive impairment, was found with a wet brief and an abrasion, while another resident reported long wait times for care. Both residents received insufficient incontinence changes, highlighting systemic issues in the facility's care practices.
Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly on the afternoon and evening shifts, despite a policy stating that staffing would be based on resident population and acuity and would ensure competent care 24/7. Multiple residents reported prolonged call light response times, sometimes up to two hours or more, and staff turning off call lights without providing the requested assistance or asking what was needed. Resident council minutes over a six‑month period documented repeated concerns about inadequate staffing, including missed showers, residents not being checked and changed every two hours, residents being double‑briefed, and CNAs disappearing from the dining room during meals. Several residents with significant medical needs described unmet care needs related to staffing shortages. One resident with a right upper arm PICC line, a dialysis port in the right chest, and scheduled hemodialysis three times weekly, as well as IV Micafungin therapy, reported that some days there were enough helpers and other days there were none, describing staffing as “feast or famine,” and noted not going to the therapy gym despite being in the facility for rehab. Another resident with a left upper arm PICC line for treatment of a right foot infection complained of call light wait times of about two hours and agreed with her roommate that the facility was short staffed. Other residents reported specific care delays and omissions tied to low staffing, especially on the afternoon shift. One resident stated she was supposed to have her brief checked or changed every two hours but sometimes waited four to six hours, had soiled herself while waiting, and once activated her call light at 8:30 p.m. and did not receive help until bedtime. Another resident reported waiting two hours after receiving the wrong lunch tray, with staff shutting off the call light and not returning. Additional residents stated that afternoon shift staff took longer to answer call lights, that aides would enter the room and shut off the call light without asking what was needed, and that aides had to be told not to use their phones in resident care areas. The facility assessment listed general nurse staffing numbers but did not define resident acuity or complexity, despite the presence of residents with high‑acuity needs.
Failure to Implement Enhanced Barrier Precautions for Resident With PEG Tube
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling percutaneous endoscopic gastrostomy (PEG) tube. The resident was admitted for skilled nursing care with multiple diagnoses including cerebral edema, oropharyngeal dysphagia, severe protein-calorie malnutrition, metastatic lung cancer with bone metastases, and had a PEG tube placed prior to or at the time of admission. The resident’s MDS showed a BIMS score of 11/15, indicating moderately impaired cognition. Facility policy and the DON/Infection Control Preventionist’s (ICP) own EBP quick reference guide both identified feeding tubes as indwelling medical devices that require EBP. On observation of the resident’s room, surveyors noted there was no EBP signage posted on the door, no PPE immediately present at the door, and no PPE receptacle in the room. The resident reported that staff assisted with daily care such as showers and that he could perform his own oral care and grooming, and ambulate to the restroom with a walker, but he stated that staff did not wear gowns when providing care or handling his tube feeding or dressing, questioning why they would need a gown. This contrasted with the facility’s EBP policy, which required gown and glove use during high-contact resident care activities and care and use of indwelling medical devices, including feeding tubes. Record review showed multiple orders related to the PEG tube, including checking the tube site every shift for signs of infection and complications, monitoring for signs of misplaced tube, changing the irrigation kit every 24 hours, and providing enteral tube site care. However, there were no orders for EBP in the resident’s chart. The resident’s care plan addressed nutritional risk and the need for a feeding tube, including interventions for tube feeding administration, tube placement checks, positioning, lab monitoring, and reporting signs and symptoms of infection, but it did not include any interventions related to EBP. The DON/ICP confirmed during interview that residents with indwelling devices such as feeding tubes are required to be on EBP, that residents on EBP should have signage on the door and PPE available, and that the facility only had EBP in place at that time. During a hall walk-through, the DON/ICP identified five residents on EBP based on posted signage, but did not identify this resident. After reviewing the resident’s chart, care plan, Kardex, and orders, the DON/ICP acknowledged there was no EBP sign, no EBP order, and no EBP care plan for this resident and stated that staff had probably not followed EBP for the resident since admission because of this lack of identification and documentation. The facility’s written EBP policy specified that residents with indwelling medical devices, including feeding tubes, are required to be placed in EBP, that a physician order is to be obtained, that EBP signage is to be posted outside the resident’s room, and that gowns and gloves are to be available outside the room and used during high-contact resident care activities and care of indwelling devices. The policy also stated that EBP should be maintained for the duration of the resident’s stay or until the indwelling device is discontinued. CDC guidance reviewed by surveyors similarly indicated that EBP are recommended for residents with indwelling medical devices, even without known MDRO colonization or infection. Despite these clear policy and guidance requirements, the resident with a PEG tube was not placed on EBP, had no related orders or care plan interventions, and staff did not use gowns and gloves for high-contact care or PEG-related care, resulting in the cited deficiency.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
A resident with a history of falls, severe cognitive impairment (BIMS score of 0), and multiple diagnoses including Alzheimer's disease, dementia, muscle weakness, and reduced mobility, was admitted to the facility and experienced two falls within eight days. The first fall occurred by the resident's bed, with no injury documented and no new interventions for increased supervision added to the care plan. The resident's care plan included a low bed and orientation to the call light, but did not address the need for increased supervision despite the resident's repeated self-transfer attempts, poor safety awareness, and failure to use the call light. The second fall occurred when the resident, left unsupervised in a wheelchair near fire doors, stood up, tripped over the foot pedals, and fell, striking her head on a metal door frame. The incident was captured on facility video, and staff at the nursing station did not have the resident in view at the time. The resident sustained a laceration above the left eye, a skin tear on the nose, pain, and required hospitalization and admission to the ICU. Increased supervision was only added to the care plan after this second fall with injury.
Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to ensure that medications were administered to multiple residents, including four sampled residents and ten unsampled residents, on the evening of February 25, 2025. Observations and record reviews revealed that medications scheduled for 5:00 PM were not administered to residents, including critical medications such as Xarelto for deep vein thrombosis/pulmonary embolism and insulin for diabetes management. The Medication Administration Records (MAR) for these residents were not signed, indicating that the medications were not given, and there was no documentation of medication refusal. Interviews with facility staff revealed a breakdown in the medication administration process. Licensed Practical Nurse (LPN) H, who was responsible for administering medications, left the facility at 4:00 PM, and the oncoming nurse, Registered Nurse P, did not administer the 5:00 PM medications. The facility's policy requires medications to be administered according to physician orders and documented in the MAR, but this was not followed. Additionally, the facility did not conduct audits or reviews of medication administration records to monitor compliance, contributing to the oversight.
Plan Of Correction
F760 Residents are Free of Significant Med Errors Element 1: Residents #702 and #705 continue to reside within the facility. An audit was conducted to ensure both residents have been receiving their medications per physician orders. Resident #703 and #704 no longer resides in the facility. Element 2: Like residents were identified as residents who reside in the facility. Like residents have been audited to ensure their medications have been being administered per the physician orders. Element 3: The procedure to implement the plan of correction included: 1. IDT reviewed F760. 2. IDT reviewed the Medication Administration policy and deemed appropriate. 3. RN/LPN were re-educated on the Medication Administration policy on ensuring medications are always administered. Element 4: The process to ensure that the specific citation remains corrected includes: 1. The Director of Nursing / Designee will audit 10 residents weekly to ensure medication are signed out and administered. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. 2. The Administrator will be responsible for sustained compliance.
Failure to Address Significant Weight Fluctuations in Resident
Penalty
Summary
The facility failed to address significant weight fluctuations in a resident, identified as Resident #701, who was being monitored for weight loss. The resident had a history of lymphedema, cellulitis, congestive heart failure, anxiety, and an ulcer on the left lower leg. Despite being weighed almost daily, the resident's weight varied dramatically, with differences ranging from 10 to 82 pounds over short periods. These fluctuations were not meaningfully investigated or addressed by the facility, and there was no substantial intervention to determine the accuracy of the weights recorded. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA), revealed that the weight discrepancies were noted but not adequately addressed. The ADON and CNA reweighed the resident after noticing an 82-pound drop in three days, confirming the weight but failing to investigate further. The Registered Dietitian (RD) acknowledged the weight fluctuations but attributed them to the resident's disease process and did not take further action to address the inconsistencies. The RD's progress notes were contradictory, as they mentioned both intended weight loss and a lack of discussion with the resident about such plans. The facility's policy on weights required reweighs when a resident's weight changed by more than five pounds, but this was not consistently followed. The RD's documentation did not provide a clear explanation for the extreme weight variations, and there was no documentation around the time of the most significant weight drop. The facility did not provide additional documentation to explain the weight variations, indicating a lack of compliance with their weight management program.
Plan Of Correction
F692 Nutrition/Hydration Status Maintenance Element 1 Resident #701 currently does not reside within the facility. Element 2 Like residents were identified as residents that reside within the facility. Like residents was audited to ensure they have accurate weight. A facility weight schedule was audited to ensure residents have been weighed and documented accurately. Element 3 The procedure to implement the plan of correction included: 1. IDT reviewed F692. 2. The weight schedule was reviewed and deemed appropriate. 3. The policy Weight was reviewed and deemed appropriate. 4. CNAs and Nurses were re-educated on the documentation of weight with emphasis on ensuring weights are documented accurately. 5. Dietician was re-educated on addressing fluctuations on residents weights. Element 4 The process to ensure that the specific citation remains corrected includes: 1. The Director of Nursing / Designee will audit 10 residents weekly scheduled for weights to ensure they have been provided and documented accurately. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. 2. The Administrator will be responsible for sustained compliance.
Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation verifying that all fire-rated doors were inspected annually as required by NFPA 101 and NFPA 80 standards. During a record review, surveyors were unable to obtain evidence that annual inspections of all facility fire doors had been completed, as the documentation was not immediately available and was later provided via email. Upon review, the provided document was an invoice from a door service company that did not include an itemized inspection of all fire doors or any criteria used for the inspection, making it impossible to confirm that all required doors were inspected. These findings were confirmed through an interview with the maintenance director.
Failure to Document and Verify Annual Electrical Receptacle Inspections
Penalty
Summary
The facility failed to ensure that all patient-care related electrical equipment, specifically electrical receptacles in patient care vicinities, were inspected and tested annually as required by the 2012 NFPA 99 standards. During a record review, the facility was unable to produce documentation verifying that these inspections and tests had been completed for all relevant receptacles. The maintenance director indicated that the administrator had the documentation, but the administrator was unavailable at the time of the review. Later, the inspection documentation was provided via email by the administrator. However, upon review, the document titled "Receptacle Tests (patient care vicinity)" did not contain an itemized inspection of all facility electrical receptacles in the patient care vicinity, nor did it list any criteria for the inspection of individual receptacles. As a result, it could not be verified that all receptacles were inspected as required. These findings were confirmed through an interview with the maintenance director.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a Stage III coccyx pressure ulcer for a resident, resulting in an infected ulcer requiring IV antibiotics and hospitalization. The resident, who had been admitted to the facility after a hospital stay for COVID-19 and pneumonia, was found to have a large Stage III pressure ulcer on the coccyx area upon discharge to an assisted living facility. The ulcer was not documented upon admission, and there was a lack of consistent documentation and communication regarding the resident's skin condition. The resident's family member reported that the resident was often found soiled and wet, and the resident did not have any pressure ulcers upon admission to the facility. Another resident, who was admitted with deep tissue injuries (DTIs) on their left ankle and both heels, was observed with their heels positioned directly against the bed and the footrest of a Broda chair, contrary to care plan interventions. The resident was severely cognitively impaired and required maximum assistance with daily activities. Observations revealed that the resident was not repositioned for several hours, and new wounds were discovered on the resident's coccyx and left thigh, the latter potentially caused by the Hoyer sling used for transfers. The facility's documentation was incomplete, with several treatments not recorded as completed in the resident's treatment administration record. The facility's policies required weekly skin checks and documentation of any skin abnormalities, but these were not consistently followed. The lack of adherence to care plans and failure to document and communicate skin conditions contributed to the development and worsening of pressure ulcers for both residents. The facility's failure to implement meaningful and planned interventions resulted in significant harm and the potential for delayed healing of pressure ulcers.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete a performance review every 12 months for five Certified Nurse Aides (CNAs) reviewed for annual performance evaluations. This deficiency was identified during a review of human resource files, which revealed that the last completed annual skills checks for CNAs S, T, U, V, and X were in October 2023, with no evaluations conducted in 2024. The Human Resources Director explained that the facility holds annual competency classes for staff instead of basing them on individual hire dates, and noted that the 2023 competencies were filed with completion dates spread over several months. An interview with the Unit Manager/Educator, who assumed the role in October 2024, revealed that his initial focus was on Unit Manager tasks, and he became aware of the incomplete skills checks about a month prior to the survey. The facility's policy, dated February 2024, requires skills evaluations to be completed during job-specific orientation, re-validated annually, and completed as needed, with the employee's immediate supervisor responsible for the annual review. The lack of timely performance reviews resulted in the potential for inadequate and unmet resident care needs.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to its policies and procedures for medication and medical supply labeling, storage, and disposal, as observed in one medication room and two medication carts. On one occasion, an LPN left a medication cart unlocked and unattended in a hallway, which was later confirmed by the LPN to be against facility policy. During a tour of the medication cart, several issues were identified, including open and undated medications, expired medications, and medications not stored according to manufacturer recommendations. For instance, an open and undated foil pouch of Ipratropium/Albuterol inhalation solution was found, which should have been used within a week of opening according to manufacturer guidelines. Further inspection revealed additional deficiencies, such as an earwax removal kit and several inhalers that were either expired or not dated upon opening. A Proheal Liquid Wound Recovery container was found open and undated, and insulin for a discharged resident was still present. The LPN was unable to complete a narcotic medication count due to time constraints, highlighting a lack of proper medication management. In the medication room, non-medication items like batteries were improperly stored in the medication refrigerator, and several expired medications and supplies were found, including fecal occult blood test kits and various liquid medications. In another medication cart, an expired urinary pain relief supplement and an open, undated inhalation solution were found. A visibly soiled oral syringe was stored with other medications, and the LPN confirmed that there were no extra syringes available, indicating improper storage and hygiene practices. The facility's policy requires accurate labeling, dating, and secure storage of medications, which was not followed, leading to the potential for residents to receive medications with altered efficacy.
Failure to Provide Adequate Bathing and Hygiene Care
Penalty
Summary
The facility failed to provide adequate bathing and hygiene care for two residents, resulting in a lack of showers, nail care, and personal hygiene. Resident #7 was observed in bed with greasy, unkempt hair and unshaven. The resident reported not having had a shower in a long time and preferred bed baths due to difficulty sitting up. However, the resident indicated that their hair was not washed during bed baths. The electronic medical record showed only two instances of bathing in the past 30 days, despite the resident's care plan indicating a need for assistance with bathing and grooming. Resident #59 was also observed in bed with long, dirty fingernails and reported dissatisfaction with the care received, specifically mentioning infrequent brief changes and bathing. The resident stated that the shower chair was uncomfortable and had informed staff, but no alternatives were offered. The resident's electronic medical record documented only two instances of bathing in the past 30 days, with no recorded refusals of care, despite the resident's complaints about the shower chair. Additionally, Resident #59's call light was found on the floor, out of reach, and the resident reported that staff were slow to respond and complained when the call light was used. The facility's policy requires call lights to be within reach and functioning, but this was not adhered to in this case. Interviews with staff confirmed that refusals of care should be documented, but this was not consistently done for Resident #59.
Failure to Complete Nursing Assessments Leads to Delayed Care
Penalty
Summary
The facility failed to complete nursing assessments for two residents, resulting in delays in treatment for bowel management and a skin rash. Resident #231 developed a rash on her coccyx and back, which she attributed to the briefs used for incontinence care. Despite the rash causing significant discomfort, it was not documented in her medical records until several days after it began. The facility's policy required body audits and documentation of skin conditions, but these were not followed, leading to a delay in addressing the rash. Resident #71 experienced a lack of communication among staff regarding bowel movements. Despite informing staff of not having a bowel movement for several days, no action was taken until the resident requested assistance again. The resident's medical records showed a history of gastrointestinal issues, but there was no care plan in place for bowel management. The facility's process for monitoring bowel movements was not effectively communicated to the nursing staff, resulting in a delay in addressing the resident's constipation. Interviews with staff revealed a lack of awareness and communication regarding the residents' conditions. The Director of Nursing was unaware of Resident #71's prolonged period without a bowel movement and acknowledged the need for a bowel assessment. The facility lacked a policy for bowel management, contributing to the oversight in care for Resident #71. These deficiencies highlight a failure in the facility's processes for monitoring and documenting resident conditions, leading to delays in necessary care.
Failure in Safe IV Administration and Midline Care
Penalty
Summary
The facility failed to ensure the safe administration and maintenance of a PowerMidline IV catheter for a resident, resulting in improper medication reconstitution, inappropriate flushing technique, and lack of adherence to infection control standards. During an observation, a Licensed Practical Nurse (LPN) was seen administering Cefepime, an antibiotic, without properly reconstituting the medication in a Duplex IV bag. The LPN did not mix the medication with the diluent as required, nor did they check for particulate matter before administration. Additionally, the LPN used outdated IV tubing and did not follow the correct procedure for disinfecting the IV catheter hub, failing to allow the alcohol to dry before connecting the flush. The LPN also did not check for blood return before administering the medication, which is a critical step to confirm the patency of the midline catheter. When questioned, the LPN admitted to not knowing the facility's policy on checking for blood return or the proper flushing technique, which should involve a pulsating motion. The LPN's lack of knowledge extended to the importance of blood return and the potential impact of extremity positioning on blood return, indicating a significant gap in training and adherence to professional standards. The resident involved had a history of acute cystitis, transient ischemic attack, diabetes mellitus, and orthostatic hypotension. They were cognitively intact and required supervision for certain activities of daily living. The resident had recently returned from the hospital with a midline catheter inserted for ongoing antibiotic treatment. Despite the care plan and physician orders outlining the necessary steps for midline care, the facility staff failed to implement these procedures, leading to potential risks for the resident's health.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, resulting in a lack of timely and ongoing assessment of distress related to adjustment, and timely evaluation for consent to receive behavioral health services. The resident, who was admitted with diagnoses including cerebral infarction, Multiple Sclerosis, and aphasia, was observed to be severely cognitively impaired and required maximum assistance with daily activities. Despite these needs, the resident's care plan lacked specific non-pharmacological interventions and did not address the resident's emotional and psychosocial distress. Observations revealed that the resident frequently cried and expressed a desire to go home, indicating emotional distress. Facility staff were present but did not provide emotional support or engage with the resident during these episodes. The resident's care plan included interventions such as offering reassurance and encouraging verbalization of needs, but these were not effectively implemented. Additionally, the resident had been moved from short-term to long-term care, which contributed to their distress, yet there was no documentation of a mental health provider evaluation or consent for such services. Interviews with facility staff, including the Director of Nursing and Social Work Designee, confirmed the lack of mental health provider involvement and the absence of a consent/declination form for mental health services. The facility's policy required assessment and interventions for behavioral health needs, but these were not adequately addressed for the resident. The initiation of an antidepressant medication was noted, but no further mental health evaluation was pursued, highlighting a significant gap in the resident's care plan and the facility's response to their emotional and psychosocial needs.
Sanitation Deficiencies in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and nourishment rooms, leading to improper sanitization of kitchenware and soiled floors and equipment. During a tour of the kitchen, used gloves were found on the ground, and a container of oats had an unsecured lid. The floor near the stove and the three-compartment sink was visibly soiled with dirt, debris, and food particles. Additionally, vents were covered with thick dust, and a metal plate behind the juice machine had multiple residue streaks. The three-compartment sink could not be tested for sanitization as the quaternary sanitizer tape had expired, and no additional strips were available. In the dishwashing area, debris had accumulated across the floor, and the walls were speckled with dried substances. Dietary staff failed to test the dishwasher for appropriate sanitization temperatures before use, and the last recorded test was several days prior. The dishwasher had been serviced due to a malfunction, but the dietary aide was unaware of the requirement to test the temperature daily. The nourishment rooms also had issues, with ice machines showing residue buildup and water spigots having brown and yellow residues. Maintenance staff reported frequent clogs in the ice machine drainpipes due to improper disposal of items. The facility's policies on warewashing and kitchen equipment maintenance were not consistently followed. The policies required daily temperature checks of the dishwasher and regular cleaning of floors and equipment, but these tasks were not completed as required. The facility's cleaning logs were not consistently maintained, and the new cleaning log was only recently developed. Maintenance and housekeeping staff were unclear about their responsibilities for cleaning specific areas, leading to unsanitary conditions in the kitchen and nourishment rooms.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents, staff, and the public, as evidenced by observations of unclean conditions in various areas. During a survey, it was noted that the main dining room, main activity room, and several residents' rooms had significant cleanliness issues. These included dust-filled heater covers and ceiling vents, cobwebs and spiders, dirty floors and baseboards, and evidence of ceiling or roof leakage. The observations were made in the presence of facility staff, including the Housekeeping Supervisor, Unit Manager, and Infection Control Nurse, who acknowledged the unclean conditions. Specific rooms were found to have dirty baseboards, cobwebs, and spiders, with some rooms having brown residue on the floors and walls. The main dining room had cobwebs in the ceiling corners, dusty mini-split AC units, and heater fan covers with dusty debris. The main activity room also had cobwebs and a fan cover with a large amount of dust buildup. Additionally, the shower room near one of the rooms had a fan cover with dusty buildup. Maintenance staff confirmed that there had been a roof leak, which had been repaired, but the residue from the leak was still visible. The facility's policy on routine cleaning and disinfection was reviewed, which stated that the facility should ensure a safe, sanitary environment to prevent infections. However, the observations indicated that the policy was not being effectively implemented, as evidenced by the widespread unclean conditions throughout the facility. The staff's acknowledgment of the issues suggests a lack of adherence to the cleaning protocols, contributing to the deficiency.
Failure to Provide Clean Urinals for Resident
Penalty
Summary
The facility failed to ensure dignity and provide a clean urinal for a resident, resulting in the use of an old, discolored, and dirty urinal. On December 23, 2024, a resident requested a new urinal from a staff member, who returned with a graduate container instead, stating there were no urinals available. The resident mentioned that the facility often runs out of urinals and had to dispose of their previous one because it was turning black after about a month of use. An observation of the disposed urinal confirmed it appeared old with dark brown residue and a black bottom. Further investigation revealed that the facility's clean supply rooms, including the main central supply room, had no urinals available for male residents. The Unit Manager acknowledged the lack of urinals and mentioned that they believed some were purchased from an external source. The resident, who had a medical history of Chronic Obstructive Pulmonary Disease (COPD), lung cancer, and muscle weakness, required assistance with activities of daily living and was happy with the new urinal they eventually received.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who had undergone hip surgery, resulting in the resident experiencing significant pain. The resident, who was admitted to the facility with a femur fracture and had undergone Open Reduction Internal Fixation surgery, reported not receiving adequate pain medication on the first night of their stay. Despite being in pain and crying throughout the night, the resident did not receive pain medication until the following morning when a manager intervened. The resident's pain level was reported to be at an 11 during the night, and it took several days to bring the pain under control. A review of the resident's medical records revealed that they were admitted to the facility in the evening and were prescribed Hydrocodone-Acetaminophen for pain management. However, there was a significant delay in administering the medication, with the first documented administration occurring nearly 15 hours after admission. Although a Hydrocodone tablet was signed out of the Omnicell system the night of admission, there was no documentation confirming its administration to the resident. The resident's admission assessment indicated a pain level of 6, yet no additional pain medication was provided until the next morning, nearly 8 hours later.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, resulting in significant medication errors. During an observation, it was found that a resident had three medication cups and loose pills scattered on the floor. The resident was unable to recall when the pills were spilled or what they were for. Additionally, a medication cup with two pills was found on the over-bed table, which the resident speculated might be steroids or stomach-coating medication. The Unit Manager, upon entering the room, confirmed that the pills should not have been on the floor and proceeded to collect and dispose of them. A review of the resident's electronic medical record indicated an admission with conditions including Crohn's Disease, debility, and sepsis, with the resident having intact cognition and requiring assistance with activities of daily living. The Medication Administration Record showed no missed or refused medications, and the resident had previously indicated they did not wish to self-administer medications. The facility's medication administration policy requires staff to remain with residents until medication administration is complete, which was not adhered to in this instance.
Failure to Prevent and Document Pressure Ulcers
Penalty
Summary
The facility failed to prevent and document the occurrence of skin abrasions and deep tissue injuries for two residents. One resident was observed with an abrasion on the left lateral hip and a deep tissue injury on the right heel. The resident was found asleep with the head of the bed elevated, slumped to the bottom of the bed, and without the prescribed Profa boot, which was found in the closet. The resident's care plan required the Profa boot to be worn at all times, but this was not adhered to. Additionally, the resident was observed with a wet brief and a whole baby carrot in her mouth, indicating a lack of proper monitoring and repositioning. Another resident developed a pressure ulcer on the left heel, which progressed to a Stage III pressure ulcer, and a pressure ulcer on the left foot's fifth toe, which increased in size to a Stage II ulcer. The resident was identified as high risk for developing pressure ulcers due to requiring total assistance with bed mobility and transfers. Despite this, the resident's wounds were not adequately monitored or documented, as evidenced by the progression of the ulcers. The facility's new electronic records system, implemented in August, may have contributed to the lack of proper documentation and monitoring. The facility's 'Skin and Wound Guidelines' outlined the necessary steps for identifying residents at risk for pressure injuries and the interventions required for management. However, these guidelines were not followed, leading to the development and worsening of pressure ulcers in the residents. The failure to adhere to care plans and properly document and monitor skin conditions resulted in skin breakdown, pain, and the potential for infection, compromising the residents' overall health and wellbeing.
Inadequate Incontinence Care and Resident Neglect
Penalty
Summary
The facility failed to provide consistent incontinence care for two residents, leading to complaints and potential health risks. Resident #1, who has severe cognitive impairment and multiple medical conditions, was observed in a state of neglect. The resident was found asleep with a wet brief and an abrasion on the left hip/abdomen area. The resident's oxygen was not properly administered, and the Profa boot, which was supposed to be on, was found in the closet. The resident had not been repositioned for several hours, and the oxygen concentrator was running without being connected to the resident. Resident #4, who is cognitively intact but physically dependent, reported long wait times for incontinence care, particularly during the second shift. The resident expressed embarrassment and frustration due to staff reactions when incontinence incidents occurred. The resident's medical history includes a range of conditions such as anemia, hypertension, and diabetes, which necessitate attentive care. Documentation revealed that both residents received only 1 to 3 incontinence changes daily, which is insufficient given their needs. The observations and interviews indicate a systemic issue with incontinence care in the facility, affecting the dignity and health of the residents. The lack of timely and adequate care increases the risk of skin breakdown and other complications. The facility's failure to adhere to its own incontinence care policy and the residents' care plans contributed to the deficiencies noted by the surveyors.
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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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