Optalis Health And Rehabilitation Of Canton
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Michigan.
- Location
- 7025 Lilley Road, Canton, Michigan 48187
- CMS Provider Number
- 235618
- Inspections on file
- 36
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 41 (1 serious)
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Canton during CMS and state inspections, most recent first.
A resident with paraplegia, blindness, muscle weakness, and moderately impaired cognition, who was on Eliquis and care planned for a two-person assist with bed mobility and ADLs, was being changed in bed by a single CNA. The CNA rolled the resident to the far side of the bed, removed her hands, and walked around to the other side, during which the resident rolled off the bed. The CNA acknowledged that the Kardex required a two-person assist and that the resident should have been rolled toward, not away. The resident was hospitalized with a closed head injury, abdominal hematoma, and a closed femur fracture, with ED records documenting a rollover fall from bed during clothing change and subsequent treatment including blood transfusion and pain management.
Surveyors found that staff failed to use required PPE and follow hand hygiene while providing incontinence and hygiene care to two residents on EBP, one with a stage III pressure ulcer and one with a PEG tube, despite facility policy requiring gowns and gloves for such residents. A CNA reported being in a hurry and not noticing EBP signage, and an LPN and the DON confirmed that gowns and hand hygiene between residents were expected. Review of the infection control binder showed no documented infection control program for several months and missing elements such as antibiotic stewardship, staff education and competency checks, environmental audits, outbreak preparedness, hand hygiene/PPE/cleaning audits, McGeer Criteria, and outbreak investigations, and the requested infection control policy was not provided by survey exit.
The facility failed to maintain a continuous Antibiotic Stewardship Program as required by its policy and CDC core elements, including monitoring antibiotic use, tracking resistance, and following McGeer’s criteria and diagnostic testing protocols before initiating antibiotics. The written policy required complete antibiotic orders with indication and stop dates and tracking of adherence to clinical documentation and culture practices. However, during a review with the DON and a corporate nurse, surveyors found that documentation for the Antibiotic Stewardship Program was missing for several months, and an internal audit had already identified inadequate documentation, indicating the program was not properly implemented and had the potential to affect all residents.
A resident with progressive MS, neuromuscular bladder dysfunction, and total dependence for ADLs reported that night-shift staff ignored call lights and verbal calls for help, leaving him in a soiled brief for hours and leading him to call 911 multiple times when he could not reach staff by call light or phone. Police and fire reports documented unanswered calls to the facility, staff unaware of the resident’s needs until prompted by first responders, and nurses observed on personal phones before attending to the resident. The resident stated these concerns were ongoing and had been reported to prior administrators and nursing staff, while the current administrator denied knowledge of the complaints, despite a facility policy guaranteeing freedom from abuse and neglect.
A resident who was totally dependent for ADLs and had progressive MS, neuromuscular bladder dysfunction, and moderate cognitive impairment reported lying in a soiled brief for about four hours after requesting help, ultimately calling 911 twice when staff did not respond and the brief was not changed. The resident also described chronic issues with night-shift call lights going unanswered for over two hours, staff sitting in the hall on their phones, missed bed baths, rude agency CNAs, and staff cursing at patients. Only one grievance form was found documenting these concerns, which noted that staff education would occur, but there was no evidence the education was completed. The DON gave inconsistent statements about awareness of the 911 incident and did not respond to follow-up from external authorities, and the facility did not follow its own grievance policy requiring thorough investigation and resolution of alleged neglect.
The facility failed to develop and revise a comprehensive care plan for a resident with progressive MS, anxiety, MDD, neuromuscular bladder dysfunction, and protein-calorie malnutrition who was cognitively impaired and fully dependent for ADLs. The existing behavior/mood care plan listed general interventions such as medication administration, distraction, offering choices, psych consults, and redirection, and also included an unexplained entry stating the resident "Calls police and Fire Department." Despite multiple documented incidents in which the resident called 911 when night staff did not respond to call lights, the care plan did not include specific interventions to prevent recurrence, did not address the resident’s stated concern about not wanting agency staff to provide care, and did not incorporate reported safety measures or the resident’s hospice status, contrary to the facility’s own care plan revision policy.
Surveyors found that two residents with urinary incontinence were not provided appropriate care when a CNA delayed incontinence care despite a strong urine odor and then was observed removing multiple layers of clothing and two incontinence briefs from each resident, with one brief placed inside another. One resident had multiple comorbidities, moderate cognitive impairment, and a care plan requiring assistance with ADLs and toileting. An LPN and the DON stated that staff are not allowed to double brief and are expected to check and change residents per policy, while a resident reported that staff double brief at night, and the written incontinence policy did not address the use of multiple briefs.
A resident with multiple comorbidities, including CHF, COPD, CKD stage 3, heart failure, and difficulty walking, and with a stage III sacral/coccyx pressure ulcer treated with zinc oxide and alginate, was observed during incontinence care wearing two briefs, with one brief placed inside another. The CNA performing care stated this was not considered double briefing because the inner brief was not closed. The resident’s MDS showed moderate cognitive impairment and an ADL care plan calling for assistance with toileting in bed. The wound care nurse stated that residents with this type of wound should not have multiple briefs due to moisture impeding healing, and the DON confirmed staff are not to double brief and are expected to follow policy for checking and changing residents.
A resident with paraplegia, muscle weakness, legal blindness, and moderately impaired cognition, care-planned for a two-person assist with bed mobility and in-bed toileting, fell from bed and sustained serious injuries while a CNA was changing an incontinence brief alone. The CNA reported rolling the resident away from themselves and that the resident then rolled off the bed while the CNA moved to the other side, and acknowledged having provided this care alone multiple times despite the two-person assist requirement. The CNA stated they had not received training on bed mobility at the facility and were not educated after the fall, while leadership later confirmed that the educator/trainer role had not been fully functioning for several months, contrary to facility policy requiring skills evaluations at orientation and at least annually.
The facility exhibited systemic operational failures, including lack of adequate supervision and transfer assistance that led to a resident fall with fracture and hospitalization, and absence of a system to monitor and coordinate agency and nursing staff competency over several months. There was no consistent infection control program, and staff turnover contributed to confusion on the night shift about who was in charge, with staff directed to call the DON for problems. A resident’s neglect complaints about call lights not being answered for more than two hours were reported to the Administrator and DON without evidence of investigation or reporting to the State Agency. Incontinence care practices included double briefing of two residents, causing strong odor and potential loss of dignity. Multiple reports from residents, families, and local fire/police showed that calls to the facility during the night went unanswered, which surveyors confirmed when calls rang and went to voicemail while phones were not audible to staff. Leadership changes followed an incomplete internal audit and insufficient departmental action and documentation.
A resident with significant communication impairment and a history of stroke was reported by family to have an unexplained lip issue and to be upset about it. The social worker documented the family’s concern and a subsequent visit where the resident pointed to their mouth and indicated a desire to see someone, but no skin or oral assessment was documented in the EHR. An LPN stated they observed a small, dried crack on the resident’s bottom lip but did not document the finding or conduct any interviews. The DON later produced a paper investigation file concluding the resident bit down on a toothbrush during oral care, based solely on an unsigned statement from a single agency CNA, with no additional interviews, assessments, or documentation. These actions did not follow the facility’s abuse policy requiring a timely, thorough, and well-documented investigation of alleged injuries of unknown source.
A resident with a history of recurrent UTIs and abdominal pain had multiple NP orders for a UA with C&S, but staff failed to obtain the specimen in a timely manner. After an initial refusal of straight catheterization documented by an LPN, there was no documentation of further attempts to collect urine despite care plan information showing the resident was usually continent and able to use the toilet with assistance. The NP re-ordered the UA twice before an RN ultimately obtained a clean-catch urine sample using a collection hat in the toilet, highlighting a prolonged delay in following the ordered diagnostic testing.
A resident with intact cognition who required assistance with most ADLs reported that a CNA knew the resident was wet but delayed providing incontinence care for about an hour, then yelled at the resident for several minutes while changing them after the resident requested a clean gown and sheet. The CNA stated they did not have time to obtain the requested items and would return later, leaving the resident feeling degraded, humiliated, anxious, and uncomfortable. The CNA did not return with the clean linens for approximately two more hours, during which the resident remained in urine. During interviews, the resident became tearful when recounting the incident, and facility leadership later confirmed that the conduct constituted verbal abuse and neglect under the facility’s abuse policy.
A resident admitted with frostbitten feet and intact cognition was documented on admission as having frostbite to both feet, but staff did not obtain physician orders or document assessment, monitoring, or treatment of the feet or dressings. A family member reported that the resident arrived with bandages on both feet, reminded staff that the bandages had not been changed, and later found the same original hospital bandages still in place with a foul odor before calling emergency services for hospital transfer. Review of records showed no related orders, no detailed nursing assessments of the feet, and no skin care plan interventions for the foot wounds, despite facility policy requiring evaluation and documentation of skin alterations by a licensed nurse.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of its investigation to the proper authorities as required.
A resident with severe cognitive impairment and a history of agitation was found sleeping with her head on a nurses' station desktop, unsupervised and not positioned with dignity. The RN responsible acknowledged this was not appropriate, and the DON confirmed it did not meet facility standards for resident dignity, despite care plan interventions for supervision and visibility.
A resident was found sleeping in a wheelchair with her head on the nurse's station desk while a Nurse Practitioner was present but not attending to her, and no other staff were in the area. This situation failed to uphold the resident's dignity as required by federal regulations.
A resident with a PEG tube and a history of dysphagia was observed self-administering oral medications without staff supervision, contrary to physician orders specifying administration via PEG tube. The LPN confirmed that the resident had not been assessed for self-administration, and the facility's policy requiring direct observation during medication pass was not followed.
A resident with a PEG tube and a history of dysphagia and aspiration was observed self-administering whole pills orally without staff supervision, despite physician orders specifying medication administration via PEG tube. Staff interviews confirmed the resident was at high risk for aspiration, and there was no assessment or care plan allowing self-administration of medications by mouth.
A resident with a PEG tube and history of dysphagia was observed self-administering oral medications without staff supervision, despite the MAR indicating medications were given via PEG tube. An LPN confirmed the medications were given orally and not as documented, and there was no assessment, care plan, or order for self-administration in the resident's record.
The facility failed to provide adequate shower linens, resulting in an unclean environment. Observations showed insufficient linens, with staff using alternatives like pillowcases. Two residents, one with pressure ulcers and another post-joint replacement, were directly affected, having to reuse or purchase personal supplies. The facility's linen guidelines were not followed, and the NHA was unaware of the shortage.
A resident's wireless earbuds were misappropriated by a facility housekeeper. The resident, in short-term rehab care, used an app to locate the missing earbuds on the housekeeper's cart. An investigation, including security footage review, confirmed the misappropriation, leading to the housekeeper's termination.
The facility failed to provide proper transfer assistance for two residents, resulting in falls. One resident with ovarian cancer fell during a transfer due to inadequate use of a mechanical lift, while another resident with brain cancer fell when staff attempted to walk them to the bathroom instead of using a mechanical lift as required by their care plan.
A resident with ovarian cancer and severe malnutrition did not receive the correct dosage of TPN due to a failure in documentation and administration processes. The resident was supposed to receive two bags of TPN daily but was only receiving one, and missed an entire dose on one occasion. The issue was identified by the resident and a family member, and confirmed by the RD and DON, who noted that the TPN order was not documented in the electronic health record or MAR.
A facility failed to change a resident's PICC line tubing daily as ordered by the physician, increasing the risk of infection. The resident, with ovarian cancer and severe malnutrition, required daily tubing changes for safety monitoring. However, documentation showed that the tubing was not changed on two consecutive days, and the DON confirmed the protocol was not followed.
A facility failed to inform a cognitively impaired resident's representative of a change in condition, missing an opportunity for the representative to participate in medical decisions. The resident had severe cognitive impairment and was dependent on all ADLs. Despite worsening of a pressure ulcer and abnormal lab results, the family was not notified. Interviews with staff confirmed the oversight, which violated the facility's policy on Change in Condition Notification.
A resident with severe cognitive impairment and dependency on all ADLs was not identified as having dentures, leading to inadequate oral care. The facility's admission evaluation incorrectly noted the absence of dentures, and no interventions were in place for denture care. Hospital staff later found the resident's dentures packed with dried food and mold, and the resident's mouth was extremely dry and bleeding. Facility staff were unaware of the resident's dentures, and the facility's oral care policy was not followed.
A resident with a history of urinary retention and multiple fractures experienced a delay in the insertion of a Foley catheter, as ordered by a physician. The order was confirmed by an RN nine hours after being created and executed by an LPN 17 hours later, causing the resident discomfort until the catheter was placed. The facility's policy requires timely execution of physician orders, which was not followed in this instance.
The facility failed to provide adequate nursing staff to meet the needs of 72 residents, with only two nurse aides per floor for 32 residents each. Despite the Facility Assessment indicating a need for more aides, staffing was based on census rather than resident acuity. Interviews with staff and residents revealed the impact of insufficient staffing, such as delays in assistance and missed showers.
The facility did not ensure RN coverage for eight consecutive hours daily, as required. From June 1st to June 3rd, the DON provided coverage due to RN call-offs, which was inappropriate since the DON cannot fulfill this role. This deficiency potentially affected all 72 residents by risking inadequate care coordination.
The facility failed to provide accurate and complete information on Advance Medical Directives (AMD) for eight residents, resulting in their medical care preferences not being followed. Residents or their legal guardians were not informed about formulating an AMD, as required by the facility's policy. This deficiency was identified through interviews and record reviews, revealing a lack of documentation and communication regarding AMDs for residents with varying cognitive abilities.
A resident experienced embarrassment and humiliation after being taken to physical therapy in a wet brief, despite informing the PTA. The resident remained in the wet brief for 45 minutes, and upon returning to his room, found the bed unchanged. Staff interviews revealed a lack of timely response and awareness of the incident, which was reported weeks later.
A resident with multiple health conditions did not receive scheduled showers for over two weeks, despite being cognitively intact and requiring assistance with hygiene. The resident's wife intervened after staff failed to address the issue, and documentation was found to be disorganized and incomplete. Staff interviews revealed a lack of awareness and communication regarding the resident's needs, and the DON acknowledged the deficiency.
The facility failed to communicate effectively with hospice staff, resulting in a resident not receiving a needed Alternating Pressure Relief Mattress. Additionally, the facility inaccurately documented weights for two residents, leading to a significant discrepancy in recorded weight loss for one resident. The hospice staff had difficulty accessing the resident's EHR, and the facility's documentation was incomplete, contributing to these deficiencies.
A resident with cataracts experienced delayed treatment due to the facility's failure to schedule an ophthalmologist appointment, despite multiple requests and a documented order. The resident, who enjoys reading and using an iPad, expressed difficulty seeing. The social worker was unaware of the appointment status, and the nurse practitioner confirmed the appointment should have been made. Facility policies require the social worker to assist in scheduling appointments, which was not followed.
A facility failed to label a tube feeding container and hydration flush bag for a resident with impaired cognition, risking incorrect product and dosage administration. The resident's orders included Glucerna 1.5 and a water flush, but the facility lacked a policy on proper labeling, as confirmed by interviews with the UM and DON.
A facility failed to address a pharmacist's recommendations for a resident's medication regimen, potentially leading to unnecessary medication continuation. The resident, with multiple diagnoses, was on Buspirone and Escitalopram, and the pharmacist recommended a dose reduction of Buspirone. However, these recommendations were not addressed for three months due to documentation errors and lack of communication.
The facility failed to monitor blood glucose levels per physician orders for a resident with Type 2 Diabetes and Sepsis, resulting in the resident being sent to the hospital with elevated blood sugar levels and diabetic ketoacidosis (DKA). Interviews with staff confirmed that the monitoring should have occurred, but it was not documented.
The facility failed to report an allegation of abuse for a resident with moderate cognitive impairment. The resident alleged that a heavy woman tried to wake her up, describing the experience as feeling like 'a bull laid on me.' Despite the facility's policy requiring immediate reporting of abuse allegations, the Nursing Home Administrator did not report the incident to the State Agency, as she did not find the allegation substantiated within the 2-hour investigation window.
The facility failed to investigate an allegation of abuse for a resident with moderate cognitive impairment. The resident alleged that a heavy woman tried to wake her up, describing the experience as feeling like 'a bull laid on me.' The investigation lacked a documented interview of the LPN involved, and the Nursing Home Administrator confirmed that only a verbal interview was conducted and not documented.
Failure to Provide Two-Person Assist and Safe Bed Mobility During In-Bed Care
Penalty
Summary
The deficiency involves the facility’s failure to follow the care plan and Kardex requirements for a two-person assist and safe bed mobility techniques during in-bed care, resulting in a resident fall with serious injury. The resident had multiple diagnoses including chronic kidney disease, legal blindness, atherosclerotic heart disease, heart failure, spinal stenosis, muscle weakness, DVT, and paraplegia, and was receiving Eliquis. The resident’s BIMS score indicated moderately impaired cognition. The care plan and Kardex specified a two-person assist for ADLs, bed mobility, toileting in bed, and bathing/showering, and identified the resident as at risk for falls due to muscle weakness, paraplegia, encephalopathy, and blindness. Despite these documented needs, the resident was being changed in bed by a single CNA. During the incident, the CNA reported changing the resident’s incontinence brief alone and stated that she had changed this resident alone several times because she was the only aide assigned to that hall at the time, which had a census of 12 residents with one CNA and one nurse. The CNA rolled the resident to the other side of the bed and then took her hands off the resident to walk around to the other side, at which point the resident threw a leg over and rolled off the bed. The CNA acknowledged that the Kardex indicated a two-person assist and that the resident should have been rolled toward her rather than away. The resident was sent to the hospital, where records documented a fall from bed during clothing change, with final diagnoses including acute kidney injury, fall, closed head injury, abdominal hematoma, and a closed fracture of the femur, along with imaging showing a left deep subcutaneous hematoma over the left hip and a distal femoral fracture requiring blood transfusion and pain management.
Failure to Implement Enhanced Barrier Precautions and Maintain a Comprehensive Infection Control Program
Penalty
Summary
Surveyors identified a failure to follow Enhanced Barrier Precautions (EBP) and basic infection prevention practices during direct resident care. On 4/15/2026 at 6:28 AM, CNA B was observed changing the incontinent brief and performing hygiene care for resident R519, who was on EBP for a stage III pressure ulcer to the sacrum/coccyx, without wearing a gown as required by the facility’s EBP policy. CNA B changed gloves after providing hygiene care but did not perform hand hygiene with sanitizer or soap and water before donning new gloves, and then immediately proceeded to provide hygiene care to resident R520. At 6:37 AM, CNA B was observed providing incontinence care to R520, who was on EBP due to having a PEG tube, again without wearing a gown. In an interview at 6:45 AM, CNA B stated they were in a hurry and did not see the EBP signs on the room doors. At 6:47 AM, LPN C acknowledged observing CNA B perform hygiene care on both residents without proper PPE and stated that a gown should have been worn for EBP residents. The DON later confirmed that staff are expected to wear appropriate PPE, including gowns, for residents on EBP and to perform hand hygiene between residents. Review of the facility’s EBP policy, revised 2/6/2026, showed that gowns and gloves were required for residents with wounds and feeding tubes, which applied to R519 and R520. On 4/16/2026 at 9:55 AM, review of the facility’s infection control program with the DON and Corporate Nurse K revealed that there was no documented infection control program in the facility’s infection control binder from 9/1/2025 through 4/1/2026. The DON stated they were not employed at the facility during that time, and Corporate Nurse K reported that an internal audit on 4/6/2026 had identified that, despite having several individuals in the Infection Preventionist (IP) role, they had not carried out core IP responsibilities of identifying, investigating, monitoring, and reporting infections. The infection control binder lacked documentation for multiple required components, including an antibiotic stewardship program, staff education and competency checks, environmental audits, emergency preparedness for outbreaks, audit tools for hand hygiene, PPE, and cleaning, McGeer Criteria for infection surveillance, and outbreak investigations. When the infection control policy was requested from the DON at 10:12 AM on 4/16/2026, it was not provided by the time of survey exit.
Failure to Maintain Continuous Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a continuous Antibiotic Stewardship Program as required by its own policy and CDC core elements, resulting in a lapse in monitoring and documentation of antibiotic use. The facility’s written policy, dated 02/04/2026, states that staff and medical practitioners are responsible for ensuring antibiotics are requested and provided only when a bacterial infection is identified and for only the necessary duration. The policy outlines goals such as improving appropriate antibiotic utilization, reducing resistance, reducing adverse drug events, reducing unnecessary antibiotics, and improving resident outcomes. It also specifies that the facility will follow CDC core elements, including leadership commitment from the DON, Infection Preventionist, Medical Director, and Consultant Pharmacist, use of McGeer’s criteria to determine infection, completion of diagnostic testing per McGeer’s criteria before starting antibiotics, reporting diagnostic results that do not meet criteria to the practitioner, and ensuring antibiotic orders include name, dose, route, frequency, indication, and stop date. The policy further requires tracking measures such as adherence to clinical evaluation documentation, cultures obtained before starting or changing antibiotics, and completeness of antibiotic orders. During a review of the Antibiotic Stewardship Program with the DON and a corporate nurse, surveyors found missing documentation in the program for the period from September 1, 2025, through April 1, 2026. This gap indicated that the program was not in effect or not properly implemented during that timeframe. When asked about the absence of an Infection Preventionist during that period, the DON stated they were not employed at the facility at that time and could not explain why the antibiotic stewardship program was not in effect. The corporate nurse reported that an audit conducted on April 6, 2026, had already identified inadequate documentation for the Antibiotic Stewardship Program, confirming that the program had not been properly implemented for that period, with the potential to affect all residents in the facility.
Failure to Respond to Dependent Resident’s Calls for Care Leading to 911 Involvement
Penalty
Summary
Surveyors found that the facility failed to protect a resident from neglect when staff did not respond to the resident’s calls for assistance, leading the resident to call 911 multiple times for help with basic care needs. During an early-morning observation, the resident reported that staff sat in the hallway, slept, and talked on their phones at night and did not respond to call lights at the front desk or nursing station. In a subsequent interview, the resident stated that agency staff did not answer call lights, that calls to the nursing station and front desk went unanswered, and that the problem was ongoing and had been reported to two prior administrators and a nurse who were no longer employed. The resident described the care on the midnight shift as bad, with nurses and aides ignoring residents. Police and fire department reports corroborated that the resident called 911 on multiple occasions after being unable to obtain assistance from facility staff. On one night, the resident reported lying in a soiled brief for approximately four hours after requesting help around 8:30 p.m., with no staff response despite use of the call light and verbal calls for help with a roommate. The police report documented that the resident called 911 twice hours apart because staff did not respond, that fire department and dispatch calls to the facility went unanswered, and that upon arrival staff were unaware the resident needed assistance. Fire personnel observed nurses on their personal phones and then saw staff change the resident’s soiled brief only after being prompted. Another police case report documented a later service call from the same resident reporting that staff were not answering him. The resident had progressive multiple sclerosis, neuromuscular bladder dysfunction, bladder calculus, recurrent urinary issues, and was totally dependent on staff for all ADLs, with moderate cognitive impairment, and the facility’s abuse policy stated residents have the right to be free from abuse and neglect. The administrator denied knowledge of the resident’s concerns about unresponsive nursing and agency staff.
Failure to Address Resident Grievances and Delayed Response to Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and resolve a resident’s grievances regarding delayed responses to call lights and incontinence care, as well as failure to follow its own grievance policy. A resident with progressive multiple sclerosis, neuromuscular bladder dysfunction, protein-calorie malnutrition, anxiety disorder, major depressive disorder, and moderate cognitive impairment (BIMS 10/15) was totally dependent on staff for all ADLs. The resident reported that on one evening they lay in a soiled brief for approximately four hours after requesting assistance around 8:30 P.M., with no staff response. At 10:55 P.M. the resident called 911 for assistance, resulting in a response from the police and fire departments, but the resident’s brief was still not changed and only a blanket was provided. The fire department left at 11:38 P.M., and the resident called 911 again at 12:12 A.M. to report the same unresolved situation. The resident also stated that staff sit in a chair in the hallway at night, sleep, and talk on their phones, and that staff do not respond to calls to the desk or nursing station. The resident reported having raised concerns about delayed or absent call light responses with two previous administrators and another former employee, though they could not recall exact dates. Review of concern forms from November 2025 to the present produced only one documented grievance from this resident dated 1/16/2026, listing multiple issues: waiting over two hours for call lights to be answered on the midnight shift, nurses and CNAs being on their phones while performing care, agency CNAs being rude, going two weeks without a bed bath on Thursdays when a specific CNA was assigned, and staff cursing at patients when upset. The documented resolution stated that education would take place on the specific concerns and that the resident’s concerns were valid, but the administrator later reported there was no evidence that the planned staff education occurred. The facility’s written grievance policy designates the administrator as grievance officer responsible for receiving, tracking, and investigating concerns, maintaining confidentiality, and issuing written grievance decisions, and requires that alleged violations of neglect be reported and investigated; however, the report from local police/fire regarding the 3/15/26 incident noted that the former DON initially claimed to be unaware of the incident, later stated she had been told while half asleep, and then did not respond to follow-up calls or emails, indicating the grievance process was not carried through to conclusion as required by policy.
Failure to Revise Comprehensive Care Plan for Resident With Repeated 911 Calls
Penalty
Summary
Surveyors found that the facility failed to develop and revise a comprehensive care plan for a resident with progressive multiple sclerosis, bladder calculus, anxiety disorder, neuromuscular bladder dysfunction, adjustment disorder, major depressive disorder, adjustment insomnia, and protein calorie malnutrition. The resident was moderately cognitively impaired per the MDS and totally dependent on staff for all ADLs. A care plan initiated on 8/4/2025 addressed risk for changes in behavior and mood related to anxiety and major depressive disorder, with a goal that the resident would accept care and medications as prescribed. Interventions listed included administering medications per physician orders, an entry stating “Calls police and Fire Department,” distraction techniques, offering choices, psychiatric consults as ordered, and redirection as needed. Record review showed that the resident had a history of calling the police and fire department when the midnight shift did not respond to call lights, with three such calls reported, the last on 3/30/26. Despite this pattern, the care plan did not include specific interventions to prevent recurrence of these calls, nor did it contain revisions reflecting that the resident was receiving hospice services. Nursing notes by the DON documented that, when interviewed about one of the incidents, the resident’s only concern was not wanting agency staff to provide care, and safety measures were reported to be in place; however, there was no corresponding care plan or interventions addressing these safety measures. During interview, the social worker could not explain why “calling the police/fire department” appeared as an intervention, and facility leadership provided no additional information. The facility’s own policy required ongoing assessment and care plan revision when residents’ conditions or outcomes changed, but this was not reflected in the resident’s care plan.
Improper Urinary Incontinence Care and Double Briefing of Residents
Penalty
Summary
Surveyors identified a failure to provide appropriate urinary incontinence care when a strong smell of urine and a sticky floor were noted in a shared room occupied by two residents. An LPN acknowledged noticing the odor and sticky floor. A CNA brought incontinence supplies into the room, left them, and did not return to begin incontinence care for one resident until approximately 45 minutes later. During care, the resident was found wearing two incontinence briefs: a white brief over a green brief. The CNA stated this was not considered double briefing because the inner brief was not closed. This resident had a history of acute respiratory failure with hypercapnia, chronic kidney disease stage 3, adjustment disorder with mixed anxiety and depressed mood, heart failure, difficulty in walking, and an MDS showing moderate cognitive impairment, with a care plan indicating an ADL self-care deficit and a goal to receive needed assistance with ADLs, including toileting with 1–2 person assist in bed. The same CNA then provided incontinence care to the roommate and was observed removing multiple layers of clothing and two white incontinence briefs, one inside the other. The LPN stated that staff are not allowed to double brief residents, and the DON later confirmed that staff should not double brief and were expected to check and change residents according to policy. One resident reported that staff double brief residents at night. Review of the incontinence care policy showed it did not address the use of multiple briefs. These observations and interviews showed that two residents were being managed with multiple incontinence briefs at the same time, contrary to staff statements that double briefing was not allowed and without clear guidance in the written policy.
Improper Incontinence Management for Resident With Stage III Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and incontinence management for a resident with a stage III pressure injury. During early morning observations, a CNA entered the resident’s room with incontinence supplies, left them, and later returned to perform incontinence care. When incontinence care was provided, the resident was found wearing two incontinence briefs: a white brief with a green brief placed inside. The CNA stated this was not considered double briefing because the inner brief was not closed. The resident’s care plan indicated an ADL self-care deficit related to muscle weakness, impaired physical mobility, COPD, CHF, and low back pain, with a goal to receive necessary assistance for ADLs and an intervention specifying 1–2 person assist for toileting in bed. The wound care nurse reported that the resident had a stage III pressure ulcer located on the sacral/coccyx area, with treatment ordered as zinc oxide with alginate. The wound care nurse stated that residents with this type of wound should not have multiple incontinence briefs applied because additional moisture can impede healing. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11 out of 15 and diagnoses including acute respiratory failure with hypercapnia, chronic kidney disease stage 3, adjustment disorder with mixed anxiety and depressed mood, heart failure, and difficulty in walking. The DON confirmed that staff should not double brief residents and that staff were expected to check and change residents according to facility policy.
Failure to Ensure CNA Competency and Adherence to Two-Person Assist Leading to Resident Fall With Injury
Penalty
Summary
The facility failed to ensure that CNAs had appropriate training, demonstrated skills, and confirmed competency to safely provide care, which resulted in a fall with injury for one resident. The resident was admitted with diagnoses including legal blindness, atherosclerotic heart disease, spinal stenosis, muscle weakness, and paraplegia, and had a BIMS score indicating moderately impaired cognition. The resident’s Kardex specified a two-person assist for bed mobility and toileting in bed. On the date of the incident, an LPN documented that staff notified the nurse of a fall during a brief change and that, upon entering the room, the nurse observed the resident on the floor lying on the right side. The resident was subsequently hospitalized with a closed head injury, abdominal hematoma, and a closed femur fracture. During an interview, the CNA who provided care at the time of the fall stated that they were changing the resident’s brief alone, despite the Kardex indicating a two-person assist. The CNA reported rolling the resident to the far side of the bed, away from themselves, and that the resident then threw a leg over and rolled off the bed while the CNA walked to the other side. The CNA acknowledged having changed this resident alone several times and stated they were the only aide on that hall. The CNA also stated they had not received training at the facility on bed mobility, did not know if there was a trainer at the facility, and received no education or feedback after the fall. The DON later stated that the resident should have been rolled toward the CNA and that the Staff Educator/Trainer position had not been fully functioning for several months, despite a facility policy requiring skills evaluations at orientation, annually, and as needed, with records maintained by Human Resources.
Systemic Operational Failures Affecting Quality of Care and Life
Penalty
Summary
The facility failed to administer operations in a way that ensured effective and efficient use of resources to maintain residents’ highest practicable physical, mental, and psychosocial well-being. During an abbreviated survey conducted in the early morning hours, surveyors identified multiple deficiencies, including failure to provide adequate supervision, transfer assistance, and interventions to prevent a resident fall that resulted in a fracture and hospitalization. From September 2025 through April 2026, there was no system or designated individual to consistently monitor, assess, and coordinate the competency and skill level of agency staff and nursing personnel. There was also no consistent infection control program during this same period, resulting in missed opportunities to prevent the spread of infections. Staff turnover and poor resource utilization were evident on the midnight shift when staff could not identify which nurse was in charge and repeatedly identified each other, and first-floor nursing staff reported they had been instructed to call the current DON if any problem arose. An allegation of neglect was reported to the Grievance Officer/Administrator by a resident on 1/16/2026, and two additional incidents for the same resident were reported to the DON on 3/19/2026 after the resident called local fire/police stating nursing staff failed to respond to the call light for more than two hours. There was no evidence these allegations were investigated or reported to the State Agency, despite a 1:1 meeting with the Grievance Officer who documented resolution. Incontinence care practices were inconsistent with best practices, including double briefing of two residents, which produced an unpleasant odor in the second-floor halls and posed a potential loss of dignity. Multiple incidents were reported by residents, local fire/police, and family members that calls to the facility during the midnight shift went unanswered; this was verified when surveyors made calls on and off-site that rang and went to voicemail without staff answering, and a call placed while at the first-floor nursing station was not audible. The Maintenance Director verified the phones were on but not audible to staff. A corporate nurse reported an internal audit on 4/6/2026 could not be completed and resulted in termination of department leadership due to insufficient action and documentation. During an interview with corporate and facility leadership, the current Administrator and DON stated the previous Administrator and DON had been terminated and that they were unable to address the concerns presented by the State Agency, and no additional information was provided by the time surveyors exited the facility.
Failure to Thoroughly Investigate Alleged Lip Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of an injury of unknown origin to a resident’s lip. The resident had a history of stroke with right-sided hemiparesis and aphasia and was documented on the MDS with a BIMS score of 0/15, indicating they were rarely understood or unable to complete the mental status interview. A family member contacted the social worker to report concerns about the resident’s care over a weekend and specifically that the resident had something on their lip and was upset about it. During this call, the Nursing Home Administrator, who is also the abuse coordinator, became aware of the concern. Subsequently, the social worker documented a wellness visit with the resident, noting that when asked about how they were doing following the incident, the resident repeatedly pointed to their mouth and nodded yes that they wanted to see someone regarding the incident. However, there was no documented skin assessment or oral assessment in the electronic health record related to the lip injury, and no additional progress notes describing the condition of the resident’s mouth, lips, or oral cavity. The social worker stated that they did not assess the inside of the resident’s mouth, indicating that such an assessment would be for nursing to perform. The nurse unit manager LPN reported that they had looked at the resident’s mouth and observed a small, dried crack on the bottom lip that appeared chapped, but confirmed there was no progress note or documentation of this assessment and that no interviews or investigation were conducted by them. The DON later stated that an investigation had been completed and kept in a paper file, concluding that the resident bit down on a toothbrush during oral care, causing a small crack or split on the bottom lip that looked like chapped lips rather than an injury. The DON reported interviewing only one CNA, an agency staff member, whose unsigned witness statement described the lip slit occurring during oral care; no other staff or resident interviews, additional assessments, or documentation were completed. This limited and poorly documented response did not meet the facility’s own abuse policy requirements for a timely, thorough, and objective investigation of alleged injuries of unknown source, including comprehensive interviews, observations, record review, and complete documentation.
Failure to Obtain Ordered Urinalysis in a Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and NP orders for a urinalysis (UA) with culture and sensitivity (C&S) for a resident with a history of recurrent UTIs and complaints of abdominal pain. The resident was admitted with multiple diagnoses including a history of UTI. On 2/5/26, the NP ordered a UA with C&S. On 2/6/26, an LPN documented that the resident refused straight catheterization and that a urine sample could not be obtained. There was no documentation of any further attempts to obtain the ordered UA and C&S at that time, despite the resident’s care plan indicating they were usually continent of urine and able to use the toilet with 1–2 person assist, and a care plan for dehydration related to UTI that included obtaining labs as ordered and reporting abnormal results. Nineteen days later, on 2/24/26, the NP re-ordered the UA and C&S, but there was still no documentation that a urine sample was collected. On 3/1/26, the NP again re-ordered the UA and C&S, and on that same day an RN documented that a UA was collected and sent to the lab using a clean-catch method with a collection hat placed in the toilet. Interviews with nursing staff confirmed that attempts had been made to obtain urine via straight catheterization, that the resident declined this method, and that there were progress notes indicating the resident could urinate in a toilet with assistance. The unit manager could not explain why a clean-catch method was not used earlier, and the Nursing Home Administrator acknowledged that the urine sample was not collected in a timely manner.
Failure to Protect Resident From Verbal Abuse and Neglect During Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse and neglect by a CNA. The cognitively intact resident, who had a BIMS score of 15/15 and required assistance with most ADLs, reported that on the day of the incident the CNA entered the room, placed a brief in the room, and was aware the resident was wet and needed assistance but did not provide care for approximately one hour. When the CNA returned, the resident requested a clean gown and flat sheet due to being wet with urine. The resident stated the CNA began yelling, saying the resident should have requested those items earlier, that she did not have time to obtain them, and that she would change the resident quickly and return later with the requested items. The resident reported the CNA yelled for about five minutes while providing care, which caused the resident to cry and feel degraded, humiliated, anxious, and uncomfortable. The resident further reported that the CNA did not return with the requested clean gown and flat sheet for approximately two hours, during which time the resident remained anxious and uncomfortable while sitting in urine. During follow-up interviews, the resident became tearful when recounting the incident and expressed sadness about being treated in that manner and wishing to be able to care for herself. Record review confirmed the resident’s need for assistance with daily hygiene and grooming. Facility leadership, including the DON and Nursing Home Administrator, reported that an investigation was conducted and that abuse was substantiated, and both acknowledged that yelling at residents constitutes verbal abuse and that making the resident wait so long for needed incontinence care and linens constituted neglect. The facility’s abuse policy states residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.
Failure to Assess and Document Care for Resident With Frostbitten Feet
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals by not adequately assessing, monitoring, or documenting the condition of a resident’s frost-bitten feet. The resident was admitted with diagnoses including pain in both feet and frostbite of the feet, and the admission evaluation documented frostbite to both feet under the integumentary section. The resident’s BIMS score indicated intact cognition. A family member reported that the resident was admitted with bandages on both feet and that during a visit the day after admission, nursing staff were reminded that the bandages had not been changed. On the following morning, the family member again found both feet still wrapped in the original hospital bandages, which had a bad stench, and after staff did not respond in a timely manner, emergency services were called and the resident was transported to the hospital. Record review showed there were no physician orders to assess, monitor, or provide care for the resident’s bilateral feet, and no documentation in progress notes from admission through the date of transfer describing the feet, assessing them, or monitoring them. Medication and treatment administration records contained no related physician orders, and skilled nursing notes either omitted any assessment of the feet or only noted that dressings were present, without further description. The resident’s skin care plan contained no interventions for monitoring, assessment, or treatment of the feet. The DON stated that the resident had no dressings applied at admission, that the feet should have been assessed and monitored regardless of any bandage, and later acknowledged that nursing staff should have thoroughly examined and documented the bandages and notified the physician so that treatment orders could be obtained. Facility policy required that skin alterations be evaluated and documented by a licensed nurse using the admission or readmission evaluation.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Resident Dignity Not Maintained During Supervision Lapse
Penalty
Summary
A resident with severe cognitive impairment, altered mental status, and a history of restlessness and agitation was observed sleeping at the nurses' station with her head resting directly on the desktop. The registered nurse responsible for her care acknowledged that this positioning was not optimal and did not maintain the resident's dignity, stating that the resident should have been returned to her room to sleep in her bed. The nurse was not in a position to directly supervise the resident at the time she was observed, and another nurse practitioner present stated she was not responsible for the resident but had been helping to keep her calm. The resident's care plan included interventions such as encouraging her to be in common areas when awake, increasing the frequency of checks, and ensuring she was up in a wheelchair in visible fields when rambling. Despite these interventions, the resident was left unsupervised and allowed to sleep in a public area in a manner that did not promote dignity or respect, as required by facility policy. The Director of Nursing confirmed that this did not meet the facility's standards for maintaining resident dignity and that alternative arrangements were available for such situations.
Resident Dignity Not Maintained at Nurse's Station
Penalty
Summary
A deficiency was identified when a resident was observed sleeping at the Beck nurse's station, seated in a wheelchair with her head resting directly on the desk. At the time of observation, a Nurse Practitioner was present in the nurse's station but was seated in a different area, facing away from the resident and actively typing on a computer. No other staff members were present in the area during this time. The incident was noted during a review focused on respect, dignity, and the right of residents to retain and use personal possessions, as outlined in §483.10(e). The facility failed to maintain the dignity of the resident by allowing her to sleep in a public and potentially undignified manner at the nurse's station without staff engagement or intervention.
Failure to Supervise Medication Administration and Follow Physician Orders
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed self-administering oral medications without staff supervision. The resident, who has a PEG tube, was seen walking out of his room holding a medication cup with approximately four pills, dropping one on the floor, picking it up, and returning it to the cup before ingesting the remaining pills. The resident was not supervised during this process, despite facility policy requiring direct observation during medication administration. The resident's electronic health record did not contain an assessment for self-administration of medications, a care plan for self-administration, or a physician's order permitting self-administration. Further review of the physician's orders indicated that all prescribed medications were to be administered via the PEG tube, not orally. The LPN involved acknowledged that supervision should have occurred and that the resident had not been formally assessed for self-administration. The DON confirmed that the resident was not assessed for self-medication and should have been supervised. Facility policy also specifies that medications must remain under the direct observation of the person administering them during medication pass, which was not followed in this instance.
Failure to Administer Medications via PEG Tube and Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident with a PEG tube and a history of dysphagia, cerebral ischemia, and recurrent aspiration was observed self-administering whole pills orally without staff supervision. The resident was seen walking out of his room holding a medication cup with several whole pills, dropping one on the floor, picking it up, and then returning to his room to swallow the pills. The resident's medical record indicated that all prescribed medications were ordered to be administered via PEG tube, and there was no assessment, care plan, or physician order permitting self-administration of medications by mouth. Interviews with staff, including an LPN and the SLP, confirmed that the resident was at high risk for aspiration and that medications should have been given via PEG tube as ordered. The SLP noted that the resident coughed when attempting to swallow pills and was at risk for silent aspiration. The facility's policy required verification of physician orders and monitoring for aspiration during tube feeding, but these procedures were not followed in this instance, resulting in the resident receiving medications by an incorrect route and without adequate supervision.
Failure to Accurately Document and Supervise Medication Administration
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed independently taking oral medications from a medication cup without staff supervision. The resident, who had a PEG tube in place, dropped a pill on the floor, picked it up, and returned it to the cup before ingesting the remaining pills. The resident stated he was taking his pills, and there was no staff present to supervise the administration. Interview with an LPN revealed that the resident was given several medications in pill form to take orally, and the LPN acknowledged not supervising the resident during administration. Review of the resident's electronic health record showed no assessment, care plan, or order for self-administration of medications. Additionally, the Medication Administration Record (MAR) inaccurately documented that the medications were administered via PEG tube, contrary to the actual oral administration observed. The Director of Nursing confirmed the inaccuracy in the MAR and stated that documentation should reflect the actual treatment provided.
Linen Shortage Leads to Unclean Environment
Penalty
Summary
The facility failed to provide adequate shower linens, such as towels and washcloths, for its residents, resulting in an unclean and uncomfortable environment. Observations and interviews revealed that the facility had insufficient linens, with some units having zero towels and washcloths available. Staff members reported having to use alternative items like pillowcases and cut-up gowns to clean residents due to the shortage. The Housekeeping Director acknowledged the lack of linens, attributing it to staff shortages and ongoing laundry processes, while the Nursing Home Administrator (NHA) was unaware of the linen issues and claimed that staff did not communicate their needs effectively. Two residents, identified as R112 and R113, were directly affected by the linen shortage. R112, who had pressure ulcers and other medical conditions, reported purchasing personal supplies due to the facility's inadequacy. R113, who had undergone joint replacement and experienced difficulty walking, stated they were given only one washcloth, which they had to reuse for several days. Both residents' care plans indicated the need for assistance with daily hygiene, which was compromised by the lack of available linens. The facility's Linen Supply Guidelines required regular replenishment of linens, but these guidelines were not followed, leading to the deficiency. The NHA could not explain the shortage despite the inventory process and suggested that CNAs were discarding and cutting up linens. The facility's policy on maintaining a homelike environment emphasized the importance of clean and sanitary conditions, which were not met due to the linen shortage.
Misappropriation of Resident's Property by Facility Employee
Penalty
Summary
The facility failed to protect a resident's personal property from theft by an employee, resulting in the misappropriation of the resident's wireless earbuds. The incident involved a resident who was in the facility for short-term rehabilitation care and was alert and oriented. The resident reported to the Director of Nursing (DON) that their Apple AirPods were missing after they left their room for activities. Upon returning, the resident used an app to locate the earbuds, which were found on a housekeeper's cleaning cart. The resident informed the housekeeper, who then returned the earbuds and was instructed to report the incident to a supervisor. The facility conducted an investigation, which included reviewing security camera footage. The footage showed the housekeeper entering the resident's room and placing something at the bottom of the cleaning cart. The housekeeper, who had been employed at the facility for a short period, was interviewed and subsequently suspended pending the investigation. The investigation substantiated the allegation of misappropriation, leading to the termination of the housekeeper. The facility's policy on abuse, updated in May 2023, states that residents have the right to be free from misappropriation of property.
Failure to Ensure Proper Transfer Assistance
Penalty
Summary
The facility failed to ensure proper transfer assistance for two residents, leading to accidents. Resident R102, who had diagnoses including ovarian cancer and severe protein-calorie malnutrition, experienced a fall during a transfer back to bed. The care plan for R102 required one-person assistance with a two-wheeled walker and gait belt. However, during the incident, R102's knees buckled, and she fell to the floor. The CNA and RN involved in the transfer did not use a mechanical lift, as required by the facility's policy, and instead manually lifted R102, which was not in accordance with the guidelines. Resident R103, diagnosed with brain cancer and a history of repeated falls, also experienced a fall due to inadequate assistance. R103's care plan required a full mechanical lift for transfers, but staff attempted to walk R103 to the bathroom, resulting in a fall. The DON confirmed that R103 should have been transferred with two-person assistance and a mechanical lift. The facility's policy on fall management was not followed, as the staff did not use the mechanical lift for either resident, leading to the deficiencies noted in the report.
Failure to Administer Correct TPN Dosage
Penalty
Summary
The facility failed to ensure the correct administration of Total Parenteral Nutrition (TPN) for a resident diagnosed with ovarian cancer and severe protein-calorie malnutrition. The resident, who had intact cognition, was supposed to receive two bags of TPN daily to meet her nutritional needs but was only receiving one bag per day and missed an entire dose on one occasion. This discrepancy was identified when the resident and a family member reported the issue, indicating that the TPN had not been administered correctly since a specific date. The Registered Dietitian (RD) and the Director of Nursing (DON) confirmed that the TPN order was not documented in the electronic health record or the Medication Administration Record (MAR). The DON revealed that the TPN administration was never transcribed onto the MAR, and the nursing staff failed to document the administration in the progress notes. Additionally, the facility staff were administering TPN bags containing lipids but not the clear TPN bags, resulting in the resident not receiving the prescribed amount of TPN.
Failure to Change PICC Line Tubing as Ordered
Penalty
Summary
The facility failed to consistently change the PICC line tubing according to the physician's order for a resident who was receiving parenteral nutrition, which increases the risk of infection. The resident, who was admitted with diagnoses including ovarian cancer and severe protein-calorie malnutrition, had a care plan indicating the need to change the IV tubing daily as per physician orders. However, a review of the resident's Treatment Administration Record revealed that the nursing staff did not document the tubing change on two consecutive days. The Director of Nursing confirmed that the protocol to change the tubing daily was not followed, and no additional documentation was provided to support that the tubing had been changed on those days.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to inform a cognitively impaired resident's representative of a change in condition, which resulted in a missed opportunity for the representative to participate in medical decisions. The resident, identified as R902, was admitted with diagnoses including dementia, pressure ulcers, and chronic kidney disease. The Minimum Data Set indicated severe cognitive impairment, and the resident was dependent on all Activities of Daily Living. A Skin and Wound Evaluation revealed that the resident's pressure ulcer had worsened to a Stage III, but documentation only noted that the patient was notified, not the resident's representative. Further review of the resident's records showed abnormal lab results and the initiation of IV fluids, yet there was no indication that the family was informed of these changes. Interviews with facility staff, including an LPN, an RN, and the Director of Nursing, confirmed that the resident's family should have been notified of the worsening condition and interventions. The facility's policy on Change in Condition Notification mandates that the resident's designated representative be informed of changes in medical or mental condition, which was not adhered to in this case.
Failure to Provide Adequate Oral Care for Resident with Dentures
Penalty
Summary
The facility failed to identify and provide adequate oral care for a resident with dentures, leading to a deficiency in the care of Activities of Daily Living (ADLs). The resident, who was admitted with diagnoses of dementia, pressure ulcers, and chronic kidney disease, was documented as being dependent on all ADLs and had severe cognitive impairment. Despite this, the facility's admission evaluation incorrectly noted that the resident did not have dentures, and there were no interventions in the care plan or Kardex to address denture care. The deficiency was discovered when a hospital employee observed the resident's dentures packed with dried food and mold. Hospital records indicated the resident's mouth was extremely dry, crusting, and bleeding, with mold appearing plaque buildup on the tongue, hard palate, and dentures. Interviews with facility staff revealed a lack of awareness regarding the resident's dentures, and the Director of Nursing stated that oral care should be provided on every shift for dependent residents. The facility's policy required oral care to be provided with morning and nighttime care and as needed, which was not adhered to in this case.
Delayed Execution of Physician's Order for Urinary Catheter
Penalty
Summary
The facility failed to follow a physician's order in a timely manner for a resident who required an indwelling urinary catheter. The resident, who had a history of urinary retention and other urological issues, was admitted with multiple fractures and required maximum assistance for mobility and toileting. On a specific date, the physician ordered the insertion of a Foley catheter due to the resident's inability to urinate independently. However, the order was not confirmed until approximately nine hours later by an RN, and the catheter was not inserted until about 17 hours after the order was created. Interviews with the nursing staff revealed that the order was passed from one shift to the next without being executed promptly. The LPN who eventually inserted the catheter noted that the resident expressed relief and had a significant urine output immediately after the procedure. Both the Medical Director and the Director of Nursing acknowledged that the standard practice is to carry out physician orders as soon as possible, and the delay in this case was unexplained. The facility's policy on physician orders emphasizes the importance of timely execution according to professional standards.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 72 residents, as observed during a survey. On the second floor, there were only two nurses and two nurse aides for 32 residents, while the first floor had two nurse aides for 32 residents. Interviews with staff, including a Unit Manager and an LPN, revealed that the usual staffing level was two nurse aides per floor, which was insufficient given the number of residents requiring two-person assistance for care needs. The Facility Assessment indicated that there should be one aide per eight residents, suggesting a need for more aides than were present. The Nursing Home Administrator and Director of Nursing confirmed that staffing was based on census rather than resident acuity, which led to inadequate staffing levels. The Director of Nursing acknowledged that the staffing was not sufficient according to acuity, and the Staffing Coordinator mentioned that more aides could be scheduled with approval. Interviews with CNAs and residents highlighted the impact of insufficient staffing, such as delays in assistance and missed showers. The facility's policy stated that staffing should be based on residents' care plans, but this was not reflected in practice.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN), excluding the Director of Nursing (DON), was on duty for eight consecutive hours a day, seven days a week. This deficiency was identified through interviews and record reviews, revealing that there was no RN coverage from June 1st through June 3rd. During this period, the DON had to step in to provide coverage due to call-offs, which was later identified as inappropriate since the DON cannot fulfill the role of an RN for this requirement. This lack of RN coverage had the potential to affect all 72 residents in the facility by possibly leading to inadequate coordination of emergent or routine care.
Failure to Provide Information on Advance Medical Directives
Penalty
Summary
The facility failed to provide accurate and complete information regarding Advance Medical Directives (AMD) for eight residents, resulting in their preferences for medical care not being followed. The report highlights that residents or their legal guardians were not fully informed about how to formulate an AMD, which is a legal document that allows individuals to specify their end-of-life care decisions in advance. This deficiency was identified through interviews and record reviews, revealing that the facility did not ensure residents or their legal representatives were aware of their rights to request, refuse, or discontinue treatment. For instance, one resident, who had a legal guardian, was marked as a full code in the Electronic Health Record (EHR) without any documentation indicating that information about AMDs was provided to either the resident or the guardian. Another resident, admitted with a Do Not Resuscitate (DNR) order from the hospital, was also marked as a full code without any documentation of discussions or information provided to the family regarding AMDs. The facility's policy required that information about AMDs be provided upon admission, but this was not consistently followed. Several residents with varying cognitive abilities, ranging from intact cognition to severe impairment, were found to have no documentation of AMD discussions or forms in their records. Interviews with social workers and reviews of clinical records confirmed the lack of documentation and communication regarding AMDs. The facility's policy stated that information should be provided to residents or their legal representatives, but this was not adequately implemented, leading to the deficiency.
Resident Dignity Compromised Due to Inadequate Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R21, who was taken to physical therapy while wearing a wet brief. R21 reported the incident occurred on 6/21/24, when he informed the Physical Therapy Assistant (PTA) G of his condition, but no assistance was provided to change his brief. Instead, PTA G requested two nurse aides to change the linen on R21's bed before he returned to his room. However, upon returning to his room, R21 found the bed still had the same soiled linen, and he was left in a wet brief for approximately 45 minutes, leading to feelings of embarrassment and humiliation. R21 expressed his distress during an interview, stating that he felt disrespected and humiliated by the experience. Interviews with staff revealed discrepancies in the handling of the incident. PTA G denied being informed by R21 about the wet brief but confirmed requesting the linen change. CNA B confirmed that R21 was wet upon returning from therapy and required assistance. The Unit Manager (UMH) and Director of Nursing (DON) were unaware of the incident until weeks later, with a Concern Form being submitted to the Administrator and Physical Therapy Manager on 7/7/24. The facility's policy on dignity emphasizes care that promotes residents' well-being and self-esteem, which was not upheld in this instance.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide scheduled showers for a resident, identified as R21, who was admitted with multiple health conditions including heart failure, chronic kidney disease, and diabetes mellitus. Despite being cognitively intact with a BIMS score of 14 out of 15, R21 required assistance with transferring and hygiene. The resident reported not receiving a shower for two and a half weeks post-admission, leading to frustration and prompting his wife to intervene by giving him a shower herself. The resident had communicated his concerns to a corporate liaison, but the promised shower was not provided, and he continued to receive only bed baths. The investigation revealed that the Nurse Aide's Task Assignment for R21 did not include shower days, and the Shower Logbook was disorganized, with missing documentation for scheduled showers. Interviews with staff, including a CNA and the Unit Manager, indicated a lack of awareness and communication regarding the resident's unmet needs. The Director of Nursing acknowledged the incomplete and disorganized state of the shower documentation and confirmed that all residents should receive two showers a week, which was not adhered to in R21's case. The deficiency was further highlighted by the absence of a documented Concern Form related to the missed showers, despite the resident's wife reporting the issue to the Unit Manager.
Deficiencies in Hospice Communication and Weight Documentation
Penalty
Summary
The facility failed to effectively communicate and collaborate care with hospice staff for a resident receiving hospice services, resulting in the resident not receiving an Alternating Pressure Relief Mattress (APM). The resident's family member reported that the APM, intended for comfort care, had not been received despite being ordered by hospice a month prior. Observations confirmed that the resident was using a regular bariatric mattress, while the APM was found outside the resident's room. The facility's records showed a lack of documentation from hospice regarding the APM order, and a care conference did not include hospice participation or documentation of the APM order. The Director of Nursing (DON) revealed that hospice staff documented communications in a physical binder at the nurse's station, which was found to be blank. The Maintenance Director confirmed the APM was delivered but was the wrong size for the resident's bed, and there was no communication with hospice to rectify the issue. The hospice nurse was unaware of the mattress size issue and cited difficulties in communication due to lack of access to the resident's Electronic Health Record (EHR). Additionally, the facility failed to accurately obtain and document weights for two residents, leading to a significant discrepancy in recorded weight loss for one resident. The resident's records showed an implausible weight loss of 127.4 pounds in one month, which was not supported by the resident's condition or dietary intake. Interviews with the resident, Registered Dietician, and Physician confirmed the weight loss was not possible and attributed the error to inaccurate weight measurements. Another resident's weight was also inaccurately recorded due to improper positioning during weighing, which was corrected upon re-evaluation.
Failure to Schedule Ophthalmologist Appointment for Resident
Penalty
Summary
The facility failed to schedule an ophthalmologist appointment for a resident, identified as R12, who was reviewed for vision services. This resulted in a delay in treatment for R12's cataracts. On July 9, 2024, R12 was observed in bed with several reading materials and an iPad, expressing difficulty in seeing due to cataracts and stating that multiple requests for an eye doctor appointment had not been fulfilled. R12's Electronic Health Record indicated a history of stroke and chronic obstructive pulmonary disease, with intact cognition as per the Minimum Data Set. A progress note from June 5, 2024, documented R12's complaint about worsening cataracts, and an order for an ophthalmology appointment was made on June 9, 2024, with the ophthalmologist's contact information provided. Despite these steps, there was no documentation of an appointment being made. On July 10, 2024, the social worker, SW K, was unaware of any appointment being scheduled and acknowledged the lack of follow-up after reviewing R12's records. Nurse Practitioner Z confirmed that the appointment should have been made, as the necessary information was included in the order. The facility's policy on Hearing and Vision Services and Consultations outlines the responsibility of the social worker to assist in making appointments and arranging transportation, which was not adhered to in this case.
Failure to Label Tube Feeding and Hydration Containers
Penalty
Summary
The facility failed to properly label a tube feeding container and a hydration flush bag for a resident, leading to the potential for administering the incorrect product and dosage. During an observation, it was noted that a bottle of Glucerna, a liquid nutrition formula, and a hydration bag were not labeled with essential information such as the date started, the resident's name, or the physician's order for infusion. This oversight was identified for one resident who was under review for nutrition. The resident involved had a pertinent diagnosis of gastrostomy status and impaired cognition, with a Brief Interview for Mental Status (BIMS) score of 5 out of 15. The resident's physician orders specified the use of Glucerna 1.5 at a rate of 70 ml per hour and a flush order of 50 cc of water every hour via auto flush. Interviews with the Unit Manager and Director of Nursing confirmed that the containers should have been labeled before administration to ensure the correct resident received the proper dosage. However, the facility was unable to provide a policy or procedure guideline on labeling tube feeding and hydration containers by the end of the survey.
Failure to Address Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to respond timely to the pharmacist's Medication Regimen Review (MRR) recommendations for a resident, resulting in the potential continuation of unnecessary medications. The resident, who had diagnoses including major depressive disorder, heart failure, generalized anxiety disorder, and morbid obesity, was on medications such as Buspirone and Escitalopram. The pharmacist had recommended a gradual dose reduction of Buspirone, as per federal guidelines, to ensure the resident was on the lowest possible dose. However, these recommendations were not addressed for three consecutive months. The Director of Nursing (DON) confirmed that the pharmacy reports and recommendations for the resident were not documented in the electronic medical record (EMR) due to an error. The pharmacist explained that irregularities are documented in the EMR, but detailed reports are emailed to the facility. The facility's policy requires that findings and recommendations from the pharmacist be reported to the DON and attending physician, but this process was not followed, leading to the deficiency.
Failure to Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to obtain blood glucose levels per physician orders for a resident (R901) who had been admitted with diagnoses including Sepsis, Type 2 Diabetes, and Severe Sepsis with Septic Shock. Despite physician orders for blood sugar checks twice a day, there were no documented blood glucose levels in the resident's electronic health record. This oversight resulted in the resident being sent to the hospital with elevated blood sugar levels greater than 800 and evidence of diabetic ketoacidosis (DKA). The resident's care plan had included interventions for blood sugar testing, but these were not followed, leading to unmonitored blood glucose levels. Interviews with facility staff, including a Registered Nurse (RN), Unit Manager, and the Director of Nursing (DON), confirmed that blood glucose levels should have been monitored per physician orders, especially given the resident's use of Total Parenteral Nutrition (TPN). The DON acknowledged that the blood sugar monitoring order was not prompted for documentation, and the physician had to call to report the lack of monitoring. The facility's Parental Nutrition Administration policy also required routine monitoring of glucose levels for residents receiving TPN, which was not adhered to in this case.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse for one resident (R502) out of four residents reviewed for abuse. R502, who has a moderate cognitive impairment with a BIMS score of 8/15, alleged that a heavy woman tried to wake her up around 8:00 AM, describing the experience as feeling like 'a bull laid on me.' The investigation revealed that LPN A was providing care to R502, including taking her blood pressure and administering two breathing treatments. The timeline of events from the facility's cameras showed LPN A entering and exiting R502's room multiple times between 8:22 AM and 8:29 AM to provide care and medication. Despite the allegation, the Nursing Home Administrator (NHA) did not report the incident to the State Agency, as she did not find the allegation substantiated within the 2-hour investigation window. The facility's policy mandates that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes be reported immediately to the Administrator and the State Agency. Specifically, allegations involving abuse or serious bodily injury must be reported within two hours, while other allegations must be reported within 24 hours. The NHA acknowledged that it is her expectation that all allegations of abuse should be reported within the required timeframe, yet this protocol was not followed in the case of R502.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse for one resident (R502) of four residents reviewed for abuse. R502, who has a moderate cognitive impairment with a BIMS score of 8/15 and medical diagnoses including encephalopathy and aphasia, alleged that a heavy woman tried to wake her up around 8:00 AM, describing the experience as feeling like 'a bull laid on me.' The facility's investigation report noted that LPN A was providing care, including taking R502's blood pressure and administering two breathing treatments. However, the investigation lacked a documented interview of LPN A's account of the incident. The Nursing Home Administrator confirmed that only a verbal interview was conducted and not documented.
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A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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