Optalis Health And Rehabilitation Of Allen Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Allen Park, Michigan.
- Location
- 9150 Allen Rd, Allen Park, Michigan 48101
- CMS Provider Number
- 235439
- Inspections on file
- 35
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Allen Park during CMS and state inspections, most recent first.
A resident with a history of stroke and communication/swallowing difficulties experienced a change in respiratory condition, prompting a physician to order blood work and a urinalysis. The UA later showed elevated WBCs and significant gram-negative bacterial growth consistent with a UTI, but there was no documentation that the physician or NP was notified and no orders for UTI treatment were found. The resident was later sent to the hospital for mental status changes and returned with diagnoses including pneumonia and UTI. The DON and physician confirmed the lack of notification, and leadership acknowledged there was no formal policy for notifying practitioners of abnormal UA results, though it was considered standard practice.
A resident with recent orthopedic injuries reported that an LPN delayed her admission and later confronted her in an aggressive manner, accusing her of making a report. After being suspended, the LPN reentered the facility and spoke to the resident, contrary to facility policy requiring immediate removal of staff under investigation for abuse. This resulted in a failure to protect the resident from intimidation and staff-to-resident abuse.
A resident with dementia and a history of falls was found to have a right hip fracture of unknown origin after being sent to the hospital for mental status changes. Despite facility policy requiring immediate reporting of such injuries, the incident was not reported to the State Agency, and staff interviews confirmed a lack of documentation and follow-through on required reporting procedures.
The facility did not maintain an Emergency Preparedness plan that was reviewed and updated annually, and failed to provide documentation of a written, geographically specific risk assessment for hazards identified in the emergency plan. Required documentation supporting compliance with an all-hazards approach, including missing residents, was not available for review, as confirmed by the Maintenance Director and Corporate Operations Director.
Surveyors identified multiple deficiencies in the maintenance and testing of the facility's automatic sprinkler system, including dirty sprinkler heads, missing escutcheon rings, recessed sprinkler heads, missing ceiling tiles, and improper storage of combustible materials within 18 inches of sprinkler heads. These issues were confirmed by the facility's Maintenance Director and Corporate Operations Director.
Surveyors observed multiple deficiencies including broken light bulb bases left in ceiling sockets, combustible materials stored too close to electrical panels, and exposed wiring behind a boiler. These issues were confirmed by facility leadership during the inspection.
A smoke detector in the north elevator room was found disconnected from its ceiling mount and hanging by wires, as observed during a facility inspection and confirmed by the Maintenance Director and Corporate Operations Director. This failure to maintain the fire alarm system in accordance with NFPA 70 and NFPA 72 requirements could affect 48 of 124 residents.
Surveyors observed that the facility did not display the required cautionary signage prohibiting oxygen use in the hair salon, as mandated by NFPA 99. This deficiency was confirmed by the Maintenance Director and Corporate Operations Director during the survey.
Surveyors identified that the facility did not maintain a comprehensive infection prevention and control program, with missing surveillance data, incomplete infection tracking, and lack of staff education. Additionally, several residents with indwelling devices or wounds were not properly identified for enhanced barrier precautions, with missing or unclear signage and inconsistent physician orders, contrary to facility policy.
The facility did not offer or administer seasonal influenza vaccines in a timely manner, as required by policy, to five residents. All affected individuals received the 2024-2025 influenza vaccine at the end of the vaccination period, rather than at the beginning of the season. Documentation and staff interviews confirmed that the delay was due to the vaccine not being offered at the appropriate time.
A resident with Parkinson's Disease and poor dental health, requiring substantial assistance with ADLs, did not have a dental care plan implemented despite documented dental needs and multiple oral surgery appointments. The DON confirmed the absence of a care plan addressing the resident's dental issues.
A resident dependent on staff for personal hygiene was found with long, jagged, and dirty fingernails over multiple days, despite a care plan requiring nail care twice weekly and as needed. The resident, who had moderate cognitive impairment and chronic medical conditions, had not refused care, and staff confirmed the lack of nail care.
A resident missed the majority of prescribed pregabalin doses for neuropathy due to staff not utilizing available backup medication and failing to follow up with the physician and pharmacy. Additionally, two residents with PICC lines did not receive proper line care, with discrepancies between documentation and observed dressing changes, and unclear or missing records for required line flushes and dressing change frequency.
A resident with a gastrostomy tube did not have their tube feed dressing changed daily as ordered by the physician, with the dressing remaining unchanged for ten days. An LPN confirmed the lapse, and the DON stated that the expectation was for nurses to follow the daily dressing change order. Facility policy also required adherence to physician orders for tube feeding management.
A resident with ESRD on hemodialysis was repeatedly observed with a large cup of water or ice at the bedside, despite physician orders and dialysis center instructions for strict fluid restriction. The care plan and Kardex did not reflect the fluid restriction, and staff interviews confirmed that the order was not communicated or implemented, resulting in a lack of coordination between the facility and the dialysis center.
A resident with moderate cognitive impairment and multiple medical conditions was found with prescription medication left unattended at the bedside during a med pass. An LPN discovered the pills, and the resident reported that this occurs frequently because staff say they cannot wake her. Facility policy and the DON confirmed that medications should not be left at the bedside and must be secured.
A resident with Parkinson's Disease requiring significant ADL assistance did not receive timely dental care after multiple canceled oral surgery appointments for full extractions. Staff failed to reschedule or ensure the resident received needed dental services, despite facility policy requiring assistance with routine and emergency dental care.
A resident with a gastrostomy tube did not receive daily dressing changes as ordered, and staff documented wound care as completed on days when it was not performed. An LPN confirmed the documentation was inaccurate and discussed the issue with the RN involved. The DON stated that records are expected to be accurate and treatments provided as ordered.
A resident with multiple health conditions experienced verbal abuse from a CNA, who used derogatory language after refusing to provide adequate care. The incident was witnessed by a nurse, leading to the CNA's termination. The facility's investigation confirmed the abuse, violating their policy against verbal abuse.
A resident with a history of spinal issues and leg amputation fell out of bed due to the absence of a proper bed frame extender. The resident, who required assistance with toileting, was in a 42-inch bed without extenders, causing the mattress to slip during care by a CNA. The facility's maintenance confirmed the lack of extenders, and the DON agreed this contributed to the fall.
A facility failed to use the correct sanitizing product to kill C. diff spores, risking infection spread. A housekeeper used a multi-purpose cleaner instead of bleach in a resident's room under transmission-based precautions. The Infection Preventionist and Housekeeping Supervisor confirmed the error, and the Nursing Home Administrator expected proper product use.
A facility failed to properly complete Advance Directive documentation for a resident with a DNR order. The DNR form was not signed by witnesses on the same date as the guardian, as required by policy. This oversight could lead to the resident's medical care preferences not being followed. The resident had mild cognitive impairment.
A facility failed to complete an annual OBRA Level II Evaluation for a resident, potentially leading to unmet mental health services. The resident, with diagnoses including adjustment disorder, dementia, bipolar disorder, and major depressive disorder, had a Level II PASARR due for renewal, which was not submitted. The NHA stated PASARRs should be completed upon admission, a change in condition, and annually, but no additional documentation was provided during the exit conference.
The facility failed to provide wound care as ordered for a resident with skin conditions, resulting in unmet treatment needs. Additionally, the facility did not follow up on pharmacist recommendations for a resident's medication regimen in a timely manner. Furthermore, antihypertensive medication was not consistently held per physician's order, and blood pressure was not checked prior to administration for two residents, leading to unmet care needs.
A resident at high risk for pressure ulcers was observed with their heel resting directly on the mattress, despite care plans requiring heel lift boots. Staff inconsistencies and lack of documentation on boot application and refusals were noted. The resident had a history of severe cognitive impairment and previous pressure sores, increasing their risk. The facility's policy on skin and wound care was not adequately followed, contributing to the deficiency.
The facility failed to obtain weekly weights and perform timely nutrition reviews for two residents at high nutritional risk. One resident, with fluctuating weight due to multiple health conditions, had only one weight recorded over a month despite recommendations for weekly monitoring. Another resident, reliant on enteral feeding, did not receive the required monthly follow-up. The Registered Dietitian acknowledged the oversight, and the Director of Nursing confirmed the expectations for timely assessments and weight measurements.
A medication error rate of 7.41% was identified when an LPN administered incorrect doses of Flonase and provided a PRN breathing treatment without an order to a resident with COPD and asthma. The resident's orders were not followed, leading to the deficiency.
The facility failed to provide two residents with influenza and/or pneumococcal vaccinations and the necessary education. The residents, one with Multiple Sclerosis and Parkinson's Disease and another with Heart Failure, lacked documentation in their EHRs indicating that the vaccines were offered or contraindicated. The DON confirmed that the residents and/or their guardians should have been educated and offered the vaccines, as per the facility's policy.
A facility failed to ensure a resident with Multiple Sclerosis and Parkinson's Disease was provided COVID-19 vaccination and education, leading to potential risk for COVID-19 spread. The resident's records lacked documentation of vaccination or refusal, as confirmed by the Infection Preventionist and DON. Facility policy requires offering the vaccine and documenting education and vaccination status.
The facility had six rooms below ground level, potentially risking water damage. These rooms, observed during a survey, had windows with a line of sight looking up and out. The Housekeeping and Laundry Director confirmed the rooms had been like this for years but were not in use. No water damage was noted.
A resident with a history of stroke and left-sided weakness, requiring a two-person assist for bed mobility, rolled out of bed and sustained a skin tear during a bed bath when only one CNA was present. The CNA was unaware of the two-person assist requirement, leading to the fall and injury.
A resident with Dementia and Hemiplegia was not provided timely incontinence care, resulting in prolonged discomfort and potential skin issues. Despite the facility's policy requiring checks every two hours, the resident was found with a heavily soiled brief and wet bedding, and staff did not attend to the resident until later in the morning.
The facility failed to implement a comprehensive care plan for a resident with vision impairment and chronic urinary tract infections. Despite the resident's history of falls and recent treatment for a UTI, the care plan did not address these issues. Interviews with staff confirmed the absence of necessary care plan entries, and a vision exam indicated severe blurry vision, which was also not included in the care plan.
A facility failed to obtain a timely physician's order for a resident with an ileostomy, resulting in unmet care needs. The resident was admitted with severe cognitive impairment and required specific ostomy care, but the care plan and physician's orders were not initiated until two weeks after admission. The DON confirmed the lack of necessary documentation and monitoring during this period.
Failure to Notify Practitioner of Abnormal Urinalysis Result
Penalty
Summary
The deficiency involves the facility’s failure to notify the ordering practitioner of an abnormal urinalysis result for one resident. The resident was admitted with a history of stroke, resulting in weakness or paralysis on one side of the body, and had difficulty swallowing and speaking. An Interact change-of-condition form documented a change in the resident’s respiratory condition, and the physician ordered blood work and a urinalysis. The urinalysis report later showed elevated white blood cells and more than 100,000 CFU/ml of gram-negative bacteria, indicating a positive result for a urinary tract infection. However, there was no documentation that the physician or nurse practitioner was notified of these abnormal results, and there were no orders showing that the resident was treated for a UTI at that time. Subsequently, the resident was transferred to the hospital for changes in mental status and later returned with diagnoses of pneumonia and UTI. During interviews, the DON confirmed that the urinalysis results were positive for a UTI and acknowledged there was no documentation of physician notification or antibiotic treatment. The physician also confirmed they had not been notified of the abnormal urinalysis results and stated that, although there were no other signs of a UTI besides the urinalysis, they should have been informed. The NHA and DON reported that the facility did not have a specific policy for notifying a physician or extender of an abnormal urinalysis result, but considered such notification to be standard practice.
Failure to Prevent Staff-to-Resident Abuse and Intimidation
Penalty
Summary
A resident with a history of right tibia fracture, lumbar vertebra fracture, and injuries from a motor vehicle accident was admitted to the facility and reported an incident involving an LPN. The resident stated that the LPN did not want to admit her, causing a delay in her admission. The following day, the LPN entered the resident's room and accused her of reporting the LPN, using an aggressive tone that made the resident feel uneasy and fearful. The resident had intact cognition, as indicated by a BIMS score of 14/15. Facility records and interviews confirmed that after being suspended pending investigation, the LPN reentered the building and confronted the resident, despite the expectation that suspended staff leave the premises immediately and not return until notified by a supervisor. The facility's abuse policy requires immediate removal of alleged abusers and protection of residents from all forms of abuse, including intimidation and retaliation. The LPN's actions violated these policies, resulting in a failure to prevent staff-to-resident abuse and to protect the resident from psychosocial harm.
Failure to Report Fracture of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report a fracture of unknown origin to the State Agency (SA) for one resident, as required by both regulation and facility policy. The resident, who had a history of dementia and falls, experienced a fall during therapy, which was documented with no injury or pain at the time. Over a month later, the resident's family requested an x-ray due to complaints of pain, but the x-ray was negative for acute fracture. Subsequently, the resident was sent to the hospital for mental status changes, where a right hip fracture of unknown origin was discovered. There was no documentation of any additional falls after the initial incident in therapy. Interviews with staff revealed that the RN who ordered the x-ray did not inquire about the timing of any new fall, and the DON confirmed that an investigation was initiated but not reported to the SA. The NHA was unaware of the incident until the survey and acknowledged that the fracture should have been reported. The facility's abuse policy requires immediate reporting of injuries of unknown source to the SA, but this was not followed in this case.
Deficient Emergency Preparedness Plan and Risk Assessment Documentation
Penalty
Summary
The facility failed to maintain an Emergency Preparedness plan that was reviewed and updated annually, as required by regulations. Specifically, the facility did not provide evidence of a written, geographically specific risk assessment for hazards identified in their emergency plan. The plan was also required to utilize an all-hazards approach, including consideration of missing residents, but documentation supporting compliance with these requirements was not available for review. During the survey conducted on June 6, 2025, at 2:30 PM, the surveyor requested documentation of the facility-based and community-based risk assessment. The facility was unable to present the required documentation by the time of the survey exit. These findings were confirmed in interviews with both the Maintenance Director and the Corporate Operations Director during the record review process.
Plan Of Correction
E006 Element # 1: The facility emergency preparedness plan was updated using a geographically specific risk assessment. Element # 2: Current residents have the potential to be affected by the deficient practice. The facility Emergency Preparedness plan was reviewed, and necessary updates were made based on the geographically specific risk assessment. Element # 3: The policy, Emergency Operations Plan, was reviewed and deemed appropriate. The maintenance department and IDT were re-educated on the policy, Emergency Operations Plan, with emphasis on a geographically specific risk assessment. Element # 4: The Administrator and/or designee will conduct random audits of the emergency preparedness plan once a week for 1 month, then weekly for 1 month, and then monthly for 3 months to ensure substantial compliance with a geographically specific risk assessment. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Sprinkler System Maintenance and Testing Deficiencies
Penalty
Summary
The facility failed to provide proper maintenance and testing of its automatic sprinkler system as required by NFPA 25. During an inspection, surveyors observed multiple instances of dirty sprinkler heads in various locations, including the Med "C" Nurse Storage Room, Eagle Room, Med "C" Dining Room, Employee Lounge, and Room 107. Additionally, a sprinkler head was found missing an escutcheon ring in the Housekeeping Managers Office, and three sprinkler heads in the corridor by the 1st floor elevator were recessed into the ceiling tile up to the deflector. There were also observations of missing ceiling tiles and a ceiling tile with a large annular space at a light fixture, which could compromise the effectiveness of the sprinkler system. Further deficiencies included combustible stock stored within 18 inches of sprinkler heads in the Business/Activities Office storage cage and the kitchen pantry, which violates clearance requirements for sprinkler systems. These findings were confirmed through interviews with the facility Maintenance Director and the Corporate Operations Director at the time of observation. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
K 353 Element # 1 The sprinkler heads in the Med C Nurse Storage Room, Eagle Room, Med C Dining Room, Employee Lounge and Room 107 were cleaned. The combustible stock on the Business/Activities Storage Cage and in the Kitchen Pantry was removed to be 18 inches from the ceiling and sprinkler heads. The missing ceiling tile in the Janitor Room was replaced. The escutcheon ring on the sprinkler in the Housekeeping Manager's office was replaced. The ceiling tile in the Housekeeping Manager's Office was replaced. The 3 recessed sprinkler heads in the corridor by the 1st floor elevator have been properly installed. Element # 2 Current residents have the potential to be affected by the deficient practice. All sprinkler heads were evaluated to ensure cleanliness and proper installation. Any sprinklers found to be out of compliance will be corrected. All ceiling tiles were evaluated for compliance. Any ceiling tiles that were out of compliance are to be replaced. Element # 3 The maintenance department was re-educated on sprinkler head cleanliness, proper installation of sprinkler heads and missing/broken ceiling tiles. Element # 4 The Administrator and/or designee will conduct random audits of the sprinkler heads and ceiling tiles once a week for 1 month, then weekly for 1 month, and then monthly for 3 months to ensure substantial compliance. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Noncompliance with Gas and Electrical Safety Standards
Penalty
Summary
The facility failed to ensure that equipment using gas or gas-related piping complied with NFPA 54 and that electrical wiring and equipment complied with NFPA 70. During observations, surveyors found two ceiling-mounted light sockets with the bases of broken light bulbs still inside the sockets in the Business/Activities Supply Cage. Combustible stock items were stored within three feet of electrical panels in both the Laundry and Sump Pump Room. Additionally, a Greenfield conduit was found displaced, exposing inner wires at the plug to the relay in the back of a boiler in the North Boiler Room. These deficiencies were confirmed through interviews with the facility Maintenance Director and the Corporate Operations Director at the time of observation.
Plan Of Correction
K 511 Element # 1 The (2) ceiling mounted light sockets in the Business/activities Supply cage with broken light bulbs, were repaired. The items stored in the Laundry Room within 3 of the electrical panel were removed. The Greenfield Conduit in the North Boiler Room was repaired. The combustible items within 3 of electrical panel in the sump pump room were removed. Element # 2 Current residents have the potential to be affected by the deficient practice. The facility's electrical equipment was evaluated to ensure proper maintenance. Any deficiencies found were corrected. Element # 3 The Maintenance Department was re-educated on properly maintained electrical equipment. Element # 4 The Administrator and/or designee will conduct random audits of the emergency preparedness plan x1/week for 1 month, then weekly for 1 month and then monthly for 3 months to ensure substantial compliance with a geographically specific risk assessment. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Disconnected Smoke Detector in Elevator Room
Penalty
Summary
During an observation on June 6, 2025, it was found that the smoke detector in the north elevator room was disconnected from its ceiling mount and was hanging by its wires. This issue was identified during a facility inspection and was confirmed through interviews with both the Maintenance Director and the Corporate Operations Director at the time of observation. The deficiency reflects a failure to ensure the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72 standards. This condition could potentially affect 48 of the 124 residents in the facility in the event of a fire. Records of system acceptance, maintenance, and testing were required to be readily available, but the direct observation of the disconnected smoke detector indicated non-compliance with these requirements.
Plan Of Correction
K 345 Element # 1 The smoke detector in the north elevator room was reconnected to the ceiling mount. Element # 2 Current residents have the potential to be affected by the deficient practice. All smoke detectors in the facility were evaluated to ensure proper mounting to the ceiling. Element # 3 The Maintenance Department was re-educated on proper mounting of smoke detectors. Element # 4 The Administrator and/or designee will conduct random audits of the smoke detectors x1/week for 1 month, then weekly for 1 month and then monthly for 3 months to ensure substantial compliance with properly mounted smoke detectors. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Missing Required Oxygen Prohibition Signage in Hair Salon
Penalty
Summary
The facility failed to comply with NFPA 99 requirements regarding the storage and handling of nonflammable gases. During an observation, it was found that the required cautionary signage, specifically a sign stating "NO OXYGEN ALLOWED" or similar wording prohibiting the use of oxygen, was not displayed in the hair salon. This signage is necessary to alert staff and visitors to the presence of oxidizing gases and to prohibit activities that could increase fire risk. This deficiency was confirmed through interviews with both the facility Maintenance Director and the Corporate Operations Director at the time of the observation. The lack of appropriate signage in the designated area represents a failure to meet established safety standards for gas storage and handling within the facility.
Plan Of Correction
K 923 Element # 1 A No Oxygen Allowed sign was placed on the Beauty Salon door. Element # 2 Current residents have the potential to be affected by the deficient practice. A facility audit was conducted to ensure the proper storage of oxygen cylinders with proper signage related to oxygen are in place. Any found deficiencies were corrected. Element # 3 The maintenance department was re-educated on proper storage of oxygen cylinders with proper signage in place. Element # 4 The Administrator and/or designee will conduct random audits of oxygen storage and proper signage x1/week for 1 month, then weekly for 1 month and then monthly for 3 months to ensure substantial compliance with oxygen storage. Results of the audits will be brought to the QAPI committee. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Infection Control Program and Enhanced Barrier Precautions Deficiencies
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program as required by federal regulations. The Infection Control Preventionist (ICP) had not compiled infection control data for several months, including April and May, and there was no documentation of monthly summaries, infection rates, lists of facility infections, mapping for trends or outbreaks, line listings for antibiotic usage, pharmacy or laboratory reports, departmental surveillance, or staff education for October, November, or December of the previous year. For January, February, and March, only partial data was available, and the line listings did not demonstrate that prescribed antibiotics met McGeer's Criteria. The Director of Nursing acknowledged that the infection control program had not been comprehensively maintained by the previous ICP. Additionally, the facility failed to ensure proper identification and implementation of enhanced barrier precautions (EBP) for residents with indwelling medical devices or wounds. Multiple residents with PICC lines or urinary catheters did not have appropriate EBP signage outside their rooms, and in some cases, EBP orders were missing or delayed in the clinical records. Observations revealed that signage, when present, did not specify which resident in shared rooms was on EBP, leading to confusion and lack of clarity for staff and visitors. Some residents with qualifying conditions for EBP had no signage at all, while others had signage that did not accurately reflect their status. Facility policy required that residents with wounds or indwelling medical devices be placed on EBP upon admission, with physician orders and clear signage indicating the specific resident on precautions. However, the observed practices did not align with these policies, as evidenced by missing or unclear signage, delayed or absent orders, and inconsistent application of EBP. These deficiencies were confirmed through interviews with the ICP and review of facility policies and resident records.
Plan Of Correction
F 880 Infection Control Deficient Practice #1 ELEMENT #1: Infection control program data for April & May 2025 was completed. ELEMENT #2: Current residents have the potential to be affected by the deficient practice. An infection control program that includes preventing, identifying, reporting, investigating, and monitoring and surveillance infections was put into place for June 2025. ELEMENT #3: The policy, "Infection Control Surveillance," was reviewed and deemed appropriate. The policy remains in place. The Infection Preventionist was re-educated on the policy, "Infection Control Surveillance," with emphasis on data collection and tracking. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents with identified and/or potential infections to ensure substantial compliance with infection control data tracking. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025 --- F 880 Infection Control Deficient Practice #2 ELEMENT #1: Enhanced Barrier Precautions were put into place for residents #126, 233, 235, 4, 234, 85, and 30. ELEMENT #2: Current residents requiring Enhanced Barrier Precautions have the potential to be affected by the deficient practice. Current residents requiring Enhanced Barrier Precautions were evaluated to ensure Enhanced Barrier Precaution signage was in place and orders were entered into the electronic medical record. Any resident identified as needing Enhanced Barrier Precautions had proper signage placed and orders entered into the electronic medical record. ELEMENT #3: The policy, "Enhanced Barrier Precautions," was reviewed and deemed appropriate. The policy remains in place. Licensed Practical Nurses and Registered Nurses were re-educated on the policy, "Enhanced Barrier Precautions," with emphasis on proper signage and orders. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents needing enhanced barrier precautions (EBP) to ensure substantial compliance with enhanced barrier precautions, including signage and MD orders. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Delayed Administration of Influenza Vaccines
Penalty
Summary
The facility failed to ensure that seasonal influenza vaccines were offered and administered in a timely manner to five residents reviewed for influenza immunizations. According to the facility's policy, influenza vaccinations should be offered annually between September 1st (or when vaccines become available) and March 31st. However, documentation showed that all five residents received the 2024-2025 influenza vaccine on March 25th, which was at the end of the designated vaccination period. The records indicated that these residents had been admitted or re-admitted to the facility prior to the administration date, but the vaccines were not offered or given at the beginning of the influenza season as required. An interview with the DON revealed awareness that the former Infection Control Preventionist did not offer the vaccine at the start of the 2024-2025 influenza season. The DON stated that the immunizations were administered in March after discovering the oversight. The clinical records for each resident confirmed the delayed administration of the influenza vaccine, with no evidence that the immunizations were offered or provided earlier in the season as per facility policy and federal requirements.
Plan Of Correction
F 883 Influenza & Pneumococcal Immunizations ELEMENT #1 Residents # 28, 24, 26, 19 and 12 continue to reside within the facility and Influenza vaccinations were administered on 3/25/25 with no negative outcomes. Facility infection control was reviewed and there has not been any confirmed cases of Influenza from March through June 2025. ELEMENT #2 Residents residing within the facility will be educated, offered, and vaccinated with the Influenza vaccine for 2025/2026 when made available and dispensed by pharmacy. ELEMENT #3 The policy, Influenza Vaccine was reviewed and deemed appropriate. The policy, Influenza Vaccine remains in place. The Infection Control Nurse was re-educated on the policy, Influenza Vaccine with emphasis on offering vaccinations in a timely manner. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with offering vaccinations. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Implement Dental Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive dental care plan for a resident who required significant dental services. The resident, who was admitted with Parkinson's Disease and had intact cognition, was observed to have crooked and uneven teeth and reported having broken teeth. Although the resident had seen a dentist and had appointments scheduled for oral surgery, there was no evidence in the care plan that addressed the resident's dental needs. Documentation in the medical record indicated plans for a full mouth extraction and the resident's desire for dentures, but these needs were not reflected in the care plan. The resident required substantial to maximal assistance with activities of daily living and had a documented history of poor dental health. Despite multiple dental appointments and referrals, the facility did not develop or implement a dental care plan as required by their own policy and federal regulations. The DON confirmed that the facility should have been aware of the resident's dental issues and that a care plan should have been in place to address these needs.
Plan Of Correction
F 656 Comprehensive Care Plan ELEMENT #1 Resident #19 care plan was updated with a dental care plan. ELEMENT #2 Current residents followed by Health Drive for dental services have the potential to be affected by the deficient practice. Current residents followed by Health Drive were assessed for dental health problems. Any resident identified with dental health problems had a dental care plan reviewed, updated or created. ELEMENT #3 The policy, Care Plan-Comprehensive Revision, was reviewed and deemed appropriate. The policy, Care Plan-Comprehensive Revision remains in place. The IDT was re-educated on the policy, Care Plan-Comprehensive Revision, with emphasis on dental care plans. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits on 5 residents weekly to ensure substantial compliance with dental care plans. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
A resident who was dependent on staff for personal hygiene was observed to have long, jagged, and dirty fingernails with debris, and reported needing their nails cut. The resident stated they had received a bed bath over the weekend, but their fingernails remained untrimmed and unclean over several days of observation. Staff confirmed the resident's nails were long and dirty, and the resident agreed to have them trimmed when asked. The resident's medical record indicated diagnoses including venous insufficiency and chronic ulcers, and a moderate cognitive impairment, requiring dependent assistance for personal hygiene. The care plan specified nail care was to be provided twice a week on shower days and as needed, but there was no documentation of refusals for nail care or bed baths in the electronic medical record for the relevant period.
Plan Of Correction
F 677 ADL Element #1 Resident #41 was provided nail care. Element #2 Current residents have the potential to be affected by the deficient practice. Current residents were assessed for the need of nail care. Any residents without nail care completed were provided nail care and documented in the electronic medical record. Refusals and preferences were documented in the electronic medical record and care plan was updated accordingly. Element #3 The policy, Nail Care Policy, has been reviewed and deemed appropriate. The policy remains in place. CNA s, Licensed Practical Nurses & Registered Nurses were re-educated on the policy for Nail Care Policy with emphasis on routine cleaning and inspection. Element #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with nail care. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Missed Medication Administration and Inadequate PICC Line Care
Penalty
Summary
The facility failed to ensure that a resident received their prescribed neuropathy medication, pregabalin, as ordered by the physician. Upon admission, the resident had an order for pregabalin 75 mg twice daily, but missed 18 out of 21 scheduled doses over a period of approximately ten and a half days. Documentation on the medication administration record indicated the medication was held due to reasons such as awaiting pharmacy delivery, dosage not available in backup, and not in cart. However, the facility's backup medication supply did contain pregabalin in 25 mg and 50 mg tablets, which were not utilized. The Director of Nursing confirmed that staff should have checked the backup supply and followed up with the physician and pharmacy given the prolonged period without medication. The facility also failed to provide proper care and maintenance for PICC lines for two residents. One resident was observed with a PICC line dressing that had multiple layers of tape, with an illegible date, and was unable to recall when the dressing was last changed. Review of the clinical record showed the resident had orders for PICC line flushes, but the medication administration record did not allow staff to sign off on these flushes. Additionally, documentation indicated a dressing change had occurred, but this was not consistent with the observed condition of the dressing. For the second resident with a PICC line, the dressing was observed to be dated from several days prior, despite documentation indicating that dressing changes had been performed more recently. The resident was unsure of when the dressing was last changed and questioned the frequency of required changes. The facility's policy on catheter care did not specify the required frequency for PICC line dressing changes, and national guidelines recommend weekly changes or more frequently if needed.
Plan Of Correction
F 684 Deficient Practice #1 ELEMENT # 1 Resident #30 pregabalin was ordered and received from the pharmacy. ELEMENT # 2 Current residents admitted within the last 7 days, electronic medication administration records were reviewed for medications that were held due to medication unavailability. Any medications identified as unavailable; the pharmacy was contacted to resolve the unavailability. ELEMENT # 3 The policy, Ordering and Receiving Drugs and Biologicals- Emergency Pharmacy Delivery and Emergency Kits, was reviewed and deemed appropriate. The policy, Ordering and Receiving Drugs and Biologicals- Emergency Pharmacy Delivery and Emergency Kits, remains in place. Licensed Practical Nurses & Registered Nurses were re-educated on the policy, Ordering and Receiving Drugs and Biologicals- Emergency Pharmacy Delivery and Emergency Kits, with emphasis on obtaining medications from the emergency back-up supply. ELEMENT # 4 The Director of Nursing and/or designee will conduct random audits of 5 newly admitted residents electronic medication administration records to ensure unavailable medications are being pulled from back up and or reviewed by the physician. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025 F 684 Deficient Practice #2 ELEMENT # 1 Resident #30 & #233 PICC line dressings were changed. ELEMENT # 2 Current residents with PICC lines have the potential to be affected by the deficient practice. Current residents with PICC lines electronic medical records were reviewed to identify residents for PICC line dressing changes. Any residents without dressing changes, were changed and documented in the electronic medical record. ELEMENT # 3 The policy, Catheter Insertion and Care, was reviewed and deemed appropriate. The policy, Catheter Insertion and Care, remains in place. Licensed Practical Nurses and Registered Nurses were re-educated on the policy, Catheter Insertion and Care with emphasis on PICC line dressing changes. ELEMENT # 4 The Director of Nursing and/or designee will conduct random audits of 5 residents with PICC lines to ensure substantial compliance with PICC line dressing changes. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Perform Daily Tube Feed Dressing Changes per Physician Order
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube reported that staff were not changing their tube feed dressing as required. Observation confirmed that the dressing was dated from ten days prior, and a Licensed Practical Nurse (LPN) acknowledged that the dressing had not been changed since that date. The LPN stated that the dressing should be changed daily during the night shift and recognized the risk for infection if the site is not kept clean. Review of the resident's electronic medical record showed a physician order specifying that the enteral tube site should be cleansed with soap and water, rinsed, allowed to air dry, and have split gauze applied, dated, and initialed every night shift. The Director of Nursing (DON) confirmed that the expectation was for nurses to follow these physician orders and that the dressing should have been changed daily. Facility policy also required tube feedings to be managed according to physician orders and current clinical standards of practice.
Plan Of Correction
F 693 Tube Feeding Element #1: Resident #69 dressing was changed. Element #2: Current residents with gastrostomy tubes have the potential to be affected. Current residents with gastrostomy tubes were assessed to ensure that dressings were changed. Any dressing not in place or in need of change was completed. Current residents with gastrostomy tubes' electronic medical records were reviewed to ensure that dressing change orders were in place. Any resident without orders for dressing change orders was entered into the electronic medical record. Element #3: The policy, Tube Feeding - Formula Administration, Flushing, and Unclogging, has been reviewed and deemed appropriate. The policy remains in place. Registered Nurses & Licensed Practical Nurses were re-educated on the policy for Tube Feeding - Formula Administration, Flushing, and Unclogging, with emphasis on gastrostomy tube dressings. Element #4: The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with tube feeding dressing changes. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Coordinate Dialysis Fluid Restrictions
Penalty
Summary
The facility failed to ensure proper coordination of care between the facility and the contracted dialysis center for a resident with end stage renal disease (ESRD) who required hemodialysis. Despite physician orders specifying "No bedside water and one beverage per meal tray" per the dialysis clinic, the resident was repeatedly observed with a 20 oz. cup of water or ice at the bedside, which the resident could access and consume. Documentation from the dialysis center indicated ongoing concerns about excessive fluid intake, including notes that the resident was gaining more fluid than could be removed during dialysis, and specific requests to reduce fluid intake and monitor liquid foods and snacks. The care plan and Kardex did not reflect the fluid restriction order, and interventions included encouraging fluid intake, which conflicted with the dialysis center's instructions. Interviews with facility staff, including an LPN/Unit Manager and the DON, confirmed that the fluid restriction was not communicated or implemented in the resident's care plan or Kardex, and that the necessary coordination with the dialysis center and facility registered dietitian had not occurred. The DON acknowledged the need for consultation between the facility RD and the hemodialysis center, which had not been done. No additional documentation or information was provided by facility leadership during the exit conference regarding this deficiency.
Plan Of Correction
F 698 Dialysis Fluid Restrictions ELEMENT #1 A fluid restriction order was entered into the electronic medical record for Resident #15. ELEMENT #2 Like residents that receive dialysis treatment; electronic medical records were reviewed to ensure that residents needing fluid restrictions had orders entered into the electronic medical record. Any resident identified to need fluid restrictions had orders entered into the electronic medical record. ELEMENT #3 The policy, Fluid Restrictions was reviewed and deemed appropriate. The policy, Fluid Restrictions remains in place. Registered Nurses, Licensed Practical Nurses and Registered Dietician were re-educated on the policy, Fluid Restrictions, with emphasis on residents receiving dialysis treatment and fluid restrictions. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents receiving Dialysis treatments to ensure substantial compliance with fluid restrictions if ordered. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when prescription medication was found unsecured at a resident's bedside during a morning medication pass. An LPN discovered a cup containing two pills (Faxiga and Levothyroxine) on the resident's bedside table, with no knowledge of who placed them there. The resident, who has a history of chronic obstructive pulmonary disease, dementia, psychotic disorder, schizoaffective disorder, major depressive disorder, type two diabetes mellitus, and generalized anxiety, was observed reaching for the medication and stated that pills are often left at the bedside because staff claim they cannot wake her up. The resident's records indicated moderately impaired cognition and no completed self-administration assessment. Facility policy requires all medications to be stored in locked compartments or under the direct observation of the person administering them. The DON confirmed that leaving medication at the bedside is unsafe and against facility policy, as it could allow unauthorized access. The medication in question was scheduled for administration at 6 a.m. and should not have been left unattended at the resident's bedside.
Plan Of Correction
F 761 Medication Storage ELEMENT #1: Medication was removed and properly disposed of from Resident #21's room. ELEMENT #2: Current residents have the potential to be affected by the deficient practice. Current residents' rooms were evaluated for proper medication storage. Any medications not properly stored were properly stored and/or disposed of. ELEMENT #3: The policy, Medication and Treatment Cart Storage policy, was reviewed and deemed appropriate. The policy remains in place. Licensed Practical Nurses & Registered Nurses were re-educated on the policy, Medication and Treatment Cart Storage, with emphasis on proper medication storage. ELEMENT #4: The Director of Nursing and/or designee will conduct random audits of 5 residents' rooms to ensure substantial compliance with medication storage. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Provide Timely Dental Services
Penalty
Summary
A deficiency occurred when a resident with Parkinson's Disease, who required substantial to maximal assistance with activities of daily living and had intact cognition, did not receive timely dental care. The resident had a history of broken teeth and had been waiting for dentures for an extended period. Medical records showed that the resident was referred for full dental extractions and had multiple oral surgery appointments scheduled, but the procedures were not performed. After the last missed appointment, no new appointment was scheduled. Interviews revealed that each time the resident was taken to an appointment, the family did not show up, resulting in cancellations. Staff did not follow up to reschedule the procedure or ensure the resident received the necessary dental care. The DON confirmed that staff should have scheduled another appointment and could have accompanied the resident for assistance, acknowledging that the resident did not receive dental care in a timely manner. The facility's policy required assistance in obtaining routine and emergency dental care, which was not met in this case.
Plan Of Correction
F 791 Dental Services ELEMENT #1 Resident #19 had a dental appointment made for 6/24/25. ELEMENT #2 Current residents followed by Health Drive have the potential to be affected by the deficient practice. Current residents followed by Health Drive were assessed for additional dental service needs. Any resident in need of dental services was referred to Health Drive. Any resident needing additional dental care, an appointment was made for. ELEMENT #3 The policy, Dental Services has been reviewed and deemed appropriate. The policy, Dental Services remains in place. The social work department and ward clerks were re-educated on the policy, Dental Services with emphasis on follow-up dental appointments. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with dental services being scheduled. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Failure to Provide Ordered Tube Feed Dressing Changes and Accurate Documentation
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube reported that staff were not changing their tube feed dressing as required. Upon observation, the tube feed dressing was found to be dated from over a week prior, indicating it had not been changed daily as ordered. The resident confirmed that the dressing had not been changed, and a Licensed Practical Nurse (LPN) verified that the dressing should be changed every night shift to reduce the risk of infection. Further review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed discrepancies. The records indicated that wound care and bandage changes had been documented as completed on several days when, in fact, the last dressing change had occurred much earlier. The LPN acknowledged that these entries were incorrect and stated that documentation should only occur after care has been provided. The LPN also reported discussing the issue of falsification of records with the Registered Nurse (RN) who had made the entries. The resident's medical history included dysphagia and the presence of a gastrostomy tube, with physician orders specifying daily site care and dressing changes. The Director of Nursing (DON) confirmed that the facility's expectation is for medical records to be accurate and for residents to receive the treatments as ordered. The failure to provide daily dressing changes and the inaccurate documentation led to the identified deficiency.
Plan Of Correction
F 842 Accurate Medical Record ELEMENT #1 Resident #69 dressing was changed and properly documented in the electronic medical record. ELEMENT #2 Current residents with enteral tubes have the potential to be affected by the deficient practice. Current residents with enteral tubes dressings were evaluated to determine if they were changed timely. Any dressing not changed was changed and appropriately documented in the electronic medical records. ELEMENT #3 The policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, and the policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, has been reviewed and deemed appropriate. The policy, Tube Feeding- Formula Administration, Flushing, and Unclogging, remains in place. Registered Nurses & Licensed Practical Nurses were re-educated on the policy for Tube Feeding- Formula Administration, Flushing, and Unclogging with emphasis on enteral tube dressing changes and documentation. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with enteral tube dressing changes and documentation. 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. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025
Verbal Abuse Incident Involving Resident and CNA
Penalty
Summary
The facility failed to prevent verbal abuse for a resident, resulting in staff-to-resident verbal abuse. The incident involved a resident who was readmitted to the facility with multiple diagnoses, including chronic respiratory failure, quadriplegia, and major depressive disorder. The resident was cognitively intact, as indicated by a BIMS score of 15/15, and was dependent on staff for toileting and hygiene. The incident occurred when the resident activated the call light for assistance, and the Certified Nurse Aide (CNA) initially responded but did not return promptly, leading to a delay in care. When the CNA returned after being called from a lunch break, the resident requested additional cleaning, which the CNA refused, leading to a verbal altercation. The CNA used derogatory language towards the resident, calling her a "Fucking bitch" and telling her to "wipe your own ass." This exchange was overheard by a floor nurse, who reported the incident to a supervisor. The CNA was subsequently terminated from employment following the incident. Interviews with the resident, the CNA, and nursing staff confirmed the occurrence of verbal abuse. The resident described the CNA's attitude and refusal to provide adequate care, while the CNA denied the allegations, claiming the resident cursed first. However, the floor nurse corroborated the resident's account, having overheard the abusive language. The facility's investigation confirmed the verbal abuse, which violated the facility's abuse policy that prohibits verbal abuse, including harassment and insulting language.
Failure to Provide Proper Bed Frame Extender Leads to Resident Fall
Penalty
Summary
The facility failed to provide a proper bed frame extender for a resident, resulting in the resident rolling out of bed during patient care. The incident involved a resident with a history of acquired absence of the right leg below the knee, spinal stenosis, and lumbar radiculopathy. The resident, who had intact cognition and required partial to moderate assistance with toileting, was observed in a 42-inch bed without the necessary bed frame extenders. During an interaction with a CNA, the resident rolled out of bed because the mattress slipped off the bed frame, which lacked extenders to secure it. The incident report indicated that the resident slipped out of bed while being repositioned by a CNA, as the mattress did not fit securely within the bed frame. The CNA confirmed that the mattress flipped and the resident began sliding out of bed. Maintenance records showed that the bed did not have the required extenders at the time of the incident, and the Director of Nursing acknowledged that the absence of extenders contributed to the fall. The facility's Fall Management Guidelines identified extrinsic factors, such as the physical environment, that could increase the risk of falls.
Improper Sanitization for C. diff Infection
Penalty
Summary
The facility failed to ensure the use of a proper sanitizing product to kill Clostridium difficile (C. diff), a bacteria that can cause diarrhea, potentially affecting all residents. On June 25, a resident in a specific room was placed on transmission-based precautions due to a C. diff infection. Despite signage indicating the need for such precautions, a housekeeper entered the room without donning appropriate personal protective equipment, except for gloves, and used a multi-purpose cleaner, Xcelente, instead of bleach, which is required to kill C. diff spores. The housekeeper was unaware of the need to use bleach until informed later. The Infection Preventionist confirmed that bleach is necessary to kill C. diff spores and expressed concern about the potential spread of the infection due to improper cleaning. The Housekeeping Supervisor acknowledged that the wrong product was used, and the Nursing Home Administrator expected the correct products to be used. During the exit conference, no additional documentation or information was provided by the Nursing Home Administrator or the Director of Nursing.
Failure to Properly Complete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure the proper completion of Advance Directive information for a resident, which could potentially result in the resident's medical care preferences not being followed. The resident had a Do Not Resuscitate (DNR) order, which was signed by the guardian and later by the physician and two witnesses. However, the dates of the signatures by the witnesses did not match the date of the guardian's signature, as required by the facility's policy. The policy mandates that the DNR form must be fully completed and signed by the resident or their legal representative, two witnesses, and a physician for it to be valid. Until then, the resident is considered Full Code by default. The resident in question had mild cognitive impairment with a BIMS score of 13 out of 15.
Failure to Complete Annual OBRA Level II Evaluation
Penalty
Summary
The facility failed to complete an annual OBRA Level II Evaluation for one of the seven residents reviewed for PASARRs, which could result in unmet mental health services. The clinical record review revealed that the resident was initially admitted and later readmitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, bipolar disorder, and major depressive disorder. A Minimum Data Set assessment documented moderate cognitive impairment. The most recent Level II PASARR was dated 3/21/23, and it was due for renewal on 3/21/24. However, the facility did not submit a new Level II PASARR as required. During a review with the Social Worker, it was noted that the local community mental health services had modified the document on 3/21/23, indicating the need for a new submission. The Nursing Home Administrator stated that PASARRs should be completed upon admission, a change in condition, and annually. The facility's document titled PASARR, dated April 2022, indicated that the nursing facility is responsible for ensuring that PAS and ARR processes are completed appropriately and timely. No additional documentation or information was provided by the Nursing Home Administrator and Director of Nursing during the exit conference.
Deficiencies in Wound Care and Medication Management
Penalty
Summary
The facility failed to provide wound care according to treatment orders for a resident with skin conditions. The resident, who had a diagnosis of Parkinson's Disease and a history of falls, was observed with outdated bandages on his left forearm and right hand. An LPN admitted to not changing the bandages as required and inaccurately documenting that the wound care was performed. The Unit Manager and Director of Nursing confirmed that the wound care was not provided as per the physician's orders and that documentation should reflect actual care provided. The facility also failed to follow up on pharmacist recommendations in a timely manner for a resident with multiple diagnoses, including moderate protein-calorie malnutrition, type 2 diabetes, and heart failure. The pharmacist had recommended changes to the resident's medication regimen, which were agreed upon by the physician, but these changes were not implemented promptly. The Director of Nursing acknowledged that the determination of the pharmacist's recommendations should be completed within seven days, but this was not adhered to. Additionally, the facility did not consistently hold antihypertensive medication per physician's order and failed to check blood pressure prior to administration for two residents. One resident, who had severe cognitive impairment and was diagnosed with persistent atrial fibrillation and hypotension, was administered Midodrine without checking blood pressure, contrary to the physician's order to hold the medication if systolic blood pressure was above 130. The Director of Nursing confirmed that blood pressure should have been taken prior to each administration, but this was not done on several occasions.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to consistently implement interventions to prevent the development of pressure wounds for a resident, identified as R19, who was at high risk for pressure ulcer development. Observations revealed that R19's left heel was frequently resting directly on the sheeted mattress, despite the care plan indicating the need for heel lift boots to be worn while in bed. Interviews with staff, including LPNs and CNAs, indicated inconsistencies in the application of these interventions, with some staff noting that R19 did not like to wear the boots, while others stated that R19 was compliant with wearing them. There was no documentation of attempts to apply the boots or any refusals by R19. R19 had a history of severe cognitive impairment, dysphagia following cerebral infarction, vascular dementia, and severe protein-calorie malnutrition, which increased the risk of pressure ulcer development. The resident had a previous pressure sore on the left heel and was identified as having a Stage 3 pressure ulcer on the left lateral calf. The care plans included interventions such as elevating heels and using heel lift boots, but these were not consistently followed, as evidenced by the observations and interviews conducted during the survey. The facility's policy on skin and wound care, which included the use of the Braden Scale to assess pressure ulcer risk, was not adequately implemented for R19. The Director of Nursing acknowledged that R19's foot should not be lying directly on the bed due to vascular concerns, yet there was no documentation of interventions related to refusals to elevate feet or wear protective boots. The lack of consistent implementation of the care plan and failure to document refusals contributed to the deficiency identified by the surveyors.
Failure to Monitor Nutritional Status of High-Risk Residents
Penalty
Summary
The facility failed to obtain weekly weights and perform timely nutrition reviews for two residents who were at high nutritional risk. Resident #1, who had diagnoses including moderate protein-calorie malnutrition, type 2 diabetes mellitus, and heart failure, was identified as having fluctuating weight due to various health conditions. Despite a recommendation for weekly weight monitoring starting from 5/28/24, only one weight was recorded between 5/28/24 and 6/25/24. The resident's care plan also noted inadequate oral intake and a dislike of food, with interventions including weekly weights, which were not consistently followed. Resident #19, with severe cognitive impairment and reliant on enteral feeding due to dysphagia, was also at high nutritional risk. The last nutrition assessment for this resident was completed on 3/27/24, and there was no monthly follow-up as required for high-risk residents. The Registered Dietitian acknowledged the oversight in both cases, noting that the recommendations for weekly weights and monthly follow-ups were not adhered to. The Director of Nursing confirmed that the Registered Dietitian was expected to see patients timely and that weight measurements should have been conducted for Resident #1.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to administer medications accurately, resulting in a medication error rate of 7.41%. During a medication pass, an LPN administered medications to a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, dementia, and asthma. The LPN gave two sprays of Flonase in each nostril instead of the prescribed one spray per nostril. Additionally, the resident requested a PRN breathing treatment, which the LPN provided, despite the absence of a PRN order for Albuterol. Upon review, it was confirmed that the resident did not have a PRN order for Albuterol, and the LPN acknowledged the error in administering the incorrect dose of Flonase. The Director of Nursing emphasized the importance of checking the Medication Administration Record to ensure the correct dose and presence of an order before administering medications. The facility's Medication Administration policy outlines the necessity of adhering to the rights of medication administration, including the right dose and right medication.
Failure to Provide Vaccination and Education
Penalty
Summary
The facility failed to ensure that two residents, identified as R37 and R60, were provided with influenza and/or pneumococcal vaccinations and the necessary education regarding these immunizations. During an interview with the Infection Preventionist, it was revealed that there was no documentation in the Electronic Health Records (EHR) for these residents indicating that the vaccines were offered or contraindicated. R37, who was admitted with diagnoses of Multiple Sclerosis and Parkinson's Disease, and R60, admitted with a diagnosis of Heart Failure, both lacked documentation of being offered the vaccines or any refusal thereof. The Director of Nursing confirmed that both residents and/or their guardians should have been educated and offered the vaccines. The facility's policy, revised on March 1, 2022, states that residents should be offered the influenza vaccine annually between October 1 and March 31, and pneumococcal vaccines as recommended by the CDC upon admission, with documentation reflecting the education provided and details regarding the immunizations.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, was provided with COVID-19 vaccination and education, which resulted in a potential risk for the development and spread of COVID-19 among vulnerable residents. The deficiency was identified during an interview and record review conducted on 6/28/2024, where the Infection Preventionist (IP) reported that R37 did not have documentation of a current COVID-19 immunization or refusal. R37 was admitted with diagnoses of Multiple Sclerosis and Parkinson's Disease, yet there was no documentation indicating that the COVID-19 vaccine was offered or contraindicated. On 7/2/2024, the Director of Nursing (DON) confirmed that R37 should have been educated and offered the COVID-19 vaccine. The facility's policy, revised on 3/1/22, states that residents will be offered the COVID-19 vaccine, and documentation should reflect the education provided and details regarding whether or not the resident received the vaccine.
Deficiency in Room Level Compliance
Penalty
Summary
The facility failed to provide resident bedrooms that are at or above ground level in six of the 70 rooms, specifically rooms 101, 103, 105, 107, 109, and 111. During an environmental tour, it was observed that these rooms were below grade level, with windows that had a visual line of sight looking up and out, indicating that the ground leveled out at the base of the windows. An interview with the Housekeeping and Laundry Director revealed that these rooms had been in this condition for several years but are no longer in use. No water damage was observed in these rooms during the survey.
Inadequate Supervision During Bed Bath
Penalty
Summary
The facility failed to provide adequate supervision during the delivery of care for a resident, resulting in the resident rolling out of bed and sustaining a skin tear. The resident, who had a history of stroke with left-sided weakness, required a two-person assist for bed mobility. However, during a bed bath, only one CNA was present, and the resident rolled out of bed when attempting to assist the CNA by pulling on the headboard. This incident led to the resident falling onto the floor and sustaining a skin tear on the left knee, although x-rays showed no fractures or other injuries. The CNA involved in the incident admitted to being unaware that the resident required a two-person assist, as they did not usually work that set. The facility's records, including the Minimum Data Set (MDS) and Kardex, clearly indicated the need for two-person assistance for bed mobility. The Nurse Manager and other staff confirmed that the resident was assessed to need two-person assistance and acknowledged that the CNA did not follow the care plan, leading to the fall and injury.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R102) who was admitted with diagnoses including Dementia and Hemiplegia affecting the left non-dominant side. The resident, who had no cognitive impairment as per a recent MDS assessment, reported having a wet brief and not being changed since midnight. Observations confirmed that the resident's brief was heavily soiled, and the bed pad and draw sheet were wet. Certified Nursing Assistant (CNA) A did not check and change the resident until 9:33 a.m., despite the resident's report of needing assistance and the facility's policy requiring checks approximately every two hours or as needed. Interviews with CNA A and the Assistant Director of Nursing (ADON) revealed that staff were expected to check residents for incontinence at the beginning of their shift and every few hours thereafter. However, CNA A admitted to not checking the resident until later in the morning. The facility's Peri Care policy, which mandates incontinent care assistance based on resident request and regular checks, was not followed, leading to the resident experiencing prolonged discomfort and potential skin issues due to the wet and soiled brief.
Failure to Implement Comprehensive Care Plan for Vision and UTI
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with vision impairment and chronic urinary tract infections. The resident, who had a history of falls and was recently treated for a urinary tract infection, reported ongoing issues with a burning sensation in the bladder and had new glasses that improved vision. Despite these issues, the care plan did not address the resident's vision deficit or recurrent urinary tract infections. The resident had fallen nine times since November, and the care plan lacked entries for these concerns. Interviews with the Director of Nursing, Nursing Home Administrator, and MDS Coordinator confirmed the absence of care plan entries for the resident's vision and urinary tract issues. A vision exam form in the resident's chart indicated severe, constant blurry vision in both eyes, but this did not trigger a care plan entry. The facility's policy requires a comprehensive, person-centered care plan with measurable objectives and timetables, which was not implemented for this resident.
Failure to Obtain Timely Physician's Order for Ileostomy Care
Penalty
Summary
The facility failed to obtain a physician's order in a timely manner for a resident (R201) with an ileostomy, resulting in unmet care needs. R201 was admitted with diagnoses including hemiplegia, hemiparesis, and ileostomy status. Despite the resident's severe cognitive impairment and need for specific ostomy care, the facility did not have a care plan for the ileostomy at the time of admission. The physician's orders for ostomy care were not initiated until 2/29/2024, leaving a gap from the admission date on 2/15/2024 without proper documentation and monitoring of the ileostomy. The Director of Nursing (DON) confirmed that the admitting nurse should have initiated a care plan for the ileostomy care and monitoring. The lack of a care plan and delayed physician's orders meant that the resident's ileostomy went without necessary care and monitoring for an extended period. This included the absence of documentation and output monitoring, which are critical for assessing the condition of the stoma and ensuring the ileostomy bag is secure. The DON acknowledged the importance of these measures to prevent complications such as redness, bloody content, and ensuring the bag's secure placement.
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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