Optalis Health And Rehabilitation Of Grand Rapids
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Rapids, Michigan.
- Location
- 1950 32nd Street Se, Grand Rapids, Michigan 49508
- CMS Provider Number
- 235458
- Inspections on file
- 32
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 34 (2 serious)
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Grand Rapids during CMS and state inspections, most recent first.
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.
Two residents experienced worsening pressure injuries and infection due to the facility’s failure to transcribe, implement, and consistently provide ordered wound care. For one resident with cognitive impairment and incontinence, hospital discharge instructions for existing skin wounds and pressure prevention were not entered into facility orders or care plans, the sacral pressure ulcer was not promptly assessed or care-planned, wound provider orders for daily Manuka dressings and pressure-relief devices were entered incorrectly as every other day, and dressing changes were missed or left soiled for extended periods despite no documented refusals. The resident’s sacral ulcer progressed to a large, foul-smelling unstageable wound associated with sepsis. For another resident with a right heel pressure injury, wound provider notes over several months documented soiled, outdated, and incorrect dressings, deterioration of the unstageable heel ulcer, and concerns for cellulitis and infection, while treatment records showed multiple missed and undocumented dressing changes and incomplete antibiotic and topical treatment implementation. Staff interviews revealed lack of awareness of wound orders, reliance on night shift and agency nurses for dressings, and poor documentation of refusals, contributing to the cited deficiency in pressure ulcer care.
A resident with depression, generalized muscle weakness, impaired walking, and cognitive communication deficit, who was care planned as at risk for falls, was repeatedly observed in bed with the call light not visible and hanging behind the head of the bed near the floor, out of reach. Over multiple observations on consecutive days, staff did not ensure the call light was placed on or near the resident’s body as required. In interviews, CNAs and the ADON confirmed that call lights were supposed to be within residents’ physical reach and acknowledged that the observed placement behind the bed frame near the floor was not acceptable.
A resident with a right heel pressure injury had physician orders for specific wound care regimens and weekly skin evaluations, but records showed multiple missed and refused treatments without corresponding progress notes or PRN documentation, and several weekly skin checks were not completed. A NP twice found the heel dressing grossly soiled, unchanged for several days beyond ordered frequency, and once inconsistent with the ordered dressing type, and also noted that a prescribed topical antibiotic was not available. MARs showed the resident did not receive all ordered doses of oral antibiotics on two separate treatment courses. A TAR entry indicated an LPN had checked the heel dressing, but in interview the LPN stated she was unaware of any dressing despite having documented the check that morning. The ADON acknowledged finding unchanged dressings, missing or inconsistent documentation, and prior concerns from the wound care provider about dressings not being changed as ordered.
A resident with a full code status was found unresponsive and did not receive CPR from the assigned agency RN, who assumed hospice status meant DNR and did not verify the resident's documented wishes. Other staff were aware of the full code status, but no resuscitative efforts or emergency calls were made, resulting in the resident's death without basic life support.
Multiple residents were not protected from physical abuse, including one resident with dementia who was struck by another resident with a history of aggression, and another resident who was hit in the face by an agency LPN during an argument. The facility did not implement a behavior care plan for the aggressive resident prior to the incident and failed to thoroughly investigate the staff-to-resident abuse, collecting only one witness statement despite multiple available witnesses.
Two residents' narcotic medications were misappropriated due to failures in medication tracking, incomplete shift-to-shift controlled substance counts, and lack of proper documentation by nursing staff. Pharmacy and administration records did not account for all received doses, and required signatures and explanations for missing medications were absent, resulting in unaccounted controlled substances.
A resident reported being struck by an agency LPN during an argument related to insulin administration. Multiple witnesses, including a CNA and a family member, observed or heard the altercation, and a police report documented the incident. However, the facility's investigation was incomplete, as not all witnesses were interviewed and documentation was lacking, contrary to the facility's abuse policy.
A resident with complex cardiovascular conditions did not receive medications according to physician orders when an LPN administered Metoprolol and Midodrine together and outside the prescribed time frames. The medications, which have opposing effects on blood pressure and heart rate, were not to be given simultaneously, and one was administered late and not with a meal as ordered. This failure was confirmed by both the LPN and the unit manager.
A resident with chronic lymphedema, heart failure, and constipation did not receive consistent assessment, monitoring, or treatment as ordered. Nursing staff failed to provide timely bowel interventions, resulting in hospitalization for fecal impaction and hyperkalemia. Wound care was not performed per orders, with staff using briefs instead of prescribed dressings when supplies ran out, and there were missed applications of compression stockings and lymphedema boots without proper documentation. Medication administration records showed multiple missed treatments and lack of documentation for refusals.
A resident with multiple urinary and bladder conditions did not receive appropriate care for her Pure Wick external catheter, as staff failed to respond promptly to care requests, left the canister unemptied and uncleaned for extended periods, and lacked clear protocols or education on proper device maintenance. This resulted in inconsistent catheter replacement, inadequate cleaning, and insufficient monitoring, contrary to facility policy and manufacturer guidelines.
Surveyors found that current daily nurse staffing hours were not consistently posted in a prominent and accessible location. Outdated staffing information remained displayed for several days, and staff acknowledged that postings were not updated regularly as required.
A resident with multiple medical conditions on a vegetarian diet did not consistently receive her selected menu items, including missing meals and lack of suitable condiments, due to staff errors in ordering and meal preparation. Dietary staff acknowledged forgetting to order specific items and failing to provide planned meals, leading to resident dissatisfaction and concerns about limited vegetarian options.
A resident with severe dementia, poor safety awareness, and a history of falls was left unsupervised on a bedside commode despite requiring two-person assistance for all ADLs. Staff were not within arm's reach, and the resident fell, sustaining a fractured patella and head injury. Facility records and staff interviews confirmed the resident's need for direct supervision during toileting, which was not provided.
A resident with chronic pain and vascular dementia, who was fully dependent for care, sustained a nondisplaced distal radius fracture of unknown origin. Despite hospital records confirming the injury and facility policy requiring immediate reporting of such incidents, the facility did not report the injury to the state agency or address it in their internal investigation. Interviews revealed that key staff did not review or recognize the x-ray findings, resulting in a failure to follow required abuse and injury reporting procedures.
A resident who was bed bound and dependent on staff for all care was found to have a nondisplaced distal radius fracture during a hospital visit. Despite documentation of the injury in hospital records and the facility's policy requiring investigation of injuries of unknown source, the facility did not identify, investigate, or report the injury, and key staff were unaware of the documented fracture.
A resident at high risk for skin breakdown was not properly assessed or treated for a coccyx wound, despite staff observations and a care plan indicating the need for interventions. No treatment orders were obtained, and the wound worsened, as confirmed during a hospital visit. Facility leadership acknowledged that required wound care protocols were not followed.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in noncompliance with staffing regulations.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific actions or events involved.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident's legal guardian was not properly informed or accommodated to participate in the care planning process following the resident's readmission from a psychiatric facility. Despite policy requiring advance notice and participation, the guardian was unable to attend the care conference due to poor communication from facility staff, and the conference was inaccurately documented as attended.
A resident with significant mobility and coordination issues was unable to access their call light, which was found under the bed and out of reach. The resident, who depended on staff for assistance and was identified as a high fall risk, was observed attempting to stand unassisted and repeatedly calling for help. Facility policy requires call lights to be within reach, but this was not followed, resulting in the resident's inability to request staff assistance.
The facility did not ensure that a resident was protected from being separated from others, their room, or being confined to their room, resulting in a deficiency related to resident rights.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the facility's failure to follow the established care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Staff did not consistently follow Enhanced Barrier Precautions for residents with wounds or indwelling devices, with multiple instances of care being provided without required gowns and gaps in staff knowledge of EBP policy. Additionally, the facility lacked an active water management plan, with stagnant water lines, infrequent flushing, and no routine testing for disinfectant levels, contrary to facility policy.
Surveyors found that medications, including insulin pens and eye drops, were not properly labeled with resident names or open dates, and expired medications were not removed from medication carts. Additionally, a medication cart containing narcotics was left unlocked and unattended in a hallway, contrary to facility policy requiring all medications to be securely stored.
Three residents with chronic medical conditions were not offered or did not have documentation of being offered COVID-19 vaccinations after 2022, despite facility policy requiring annual offers and documentation. The facility could not provide evidence that these eligible residents received education or offers for the updated vaccine.
The facility did not maintain a fully operational call light system, resulting in several residents experiencing malfunctioning call lights, long response times, and in some cases, call lights being out of reach. Staff and family interviews, as well as direct observations, confirmed ongoing issues with the system, including hallway indicators not activating and repeated maintenance requests that did not resolve the problems.
The facility did not ensure that agency staff received or completed mandatory training on infection prevention and Enhanced Barrier Precautions (EBP). Several agency nurses and a CNA reported not receiving EBP education or being asked to review relevant materials before starting work. One agency RN, unfamiliar with EBP, was preparing to perform wound care without proper protective equipment, highlighting the lack of effective training and verification processes.
A CNA publicly referred to three cognitively impaired residents as "lay backs" while they were seated in geri chairs near the nurses' station, in violation of the facility's dignity policy. The DON confirmed that such language is inappropriate and does not align with expectations for respectful communication with residents.
A resident with severe cognitive impairment and multiple diagnoses was administered several psychotropic medications without documented consent, as required by facility policy. Staff confirmed that no consents were on file prior to administration, and the care plan's intervention to provide education on medication risks and benefits was not documented as completed.
A resident with a history of muscle weakness and hemiplegia was found on the floor with injuries and was sent to the hospital after an unwitnessed fall. The LPN on duty contacted the physician and arranged the transfer but did not notify the resident's DPOA or emergency contact, as confirmed by interviews and documentation review. The facility's policy requires such notification, but it was not completed or documented.
A resident who chose to end skilled therapy services and transition to private pay was not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to inform her of potential financial liability for non-covered services. Although the resident was told her payer source would change, there was no documentation that she was notified of the private pay costs, as confirmed by the Business Office Manager.
The facility did not send required discharge notifications to the LTC Ombudsman for a resident transferred to a psychiatric hospital and failed to provide a bed-hold policy notice to the DPOA of another resident with hemiplegia after hospital transfer. Documentation supporting these notifications was not available, and the omissions were confirmed by the NHA.
A resident with multiple fall risk factors did not consistently have prescribed fall prevention interventions, such as a fall mat and accessible call light, implemented as outlined in the care plan. Observations showed the fall mat was often missing or improperly placed, and the call light was out of reach. Staff confirmed the fall mat was not always returned after meals, resulting in a potential for unmet care needs.
A resident with a history of pressure ulcers developed new and worsening wounds on both heels and toes due to inadequate offloading, insufficient wound care, and lack of cleanliness. Staff were not consistently aware of all wounds, and interventions such as pressure-relieving boots and bed adjustments were not effectively implemented, resulting in preventable skin breakdown.
A resident with a history of muscle weakness and repeated falls was injured after an agency CNA provided bed mobility assistance alone, despite the care plan requiring a two-person assist. The CNA did not review the care plan or consult with staff, leading to the resident falling from the bed and sustaining multiple abrasions.
A resident with end stage renal disease did not receive required post-dialysis assessment and monitoring, as the assigned nurse failed to retrieve and review the dialysis communication form, did not record vital signs, and did not document a progress note after the resident's return from dialysis. The facility's policy for immediate post-dialysis assessment and documentation was not followed.
The facility did not ensure timely follow-up on pharmacist medication regimen review recommendations for three residents, including those with severe cognitive impairment and complex medication regimens. Recommendations to evaluate or discontinue certain medications were not promptly addressed or documented, and required assessments and consents were missing. Staff interviews confirmed lapses in the process for reviewing and implementing pharmacy recommendations, contrary to facility policy.
A resident with Alzheimer's disease, dementia, and hypertension was not properly screened for pneumococcal vaccine eligibility, and there was no documentation that the appropriate vaccine was offered or administered according to CDC guidelines. The resident received two doses of PPSV23, but the facility did not assess or document the need for additional vaccination with PCV20 as required.
A resident with a history of falls and cognitive impairment experienced an unwitnessed fall, after which staff noted abrasions and a progressive decline in condition, including increased blood pressure, somnolence, and loss of independence in activities of daily living. Despite these changes, nursing staff did not promptly escalate care or ensure the on-call provider was fully informed, resulting in a delay in hospital transfer and diagnosis of a significant intracranial hemorrhage.
Multiple residents with histories of falls and cognitive impairment experienced unwitnessed falls, including incidents resulting in serious injuries such as intracranial hemorrhage and spinal fractures. Staff failed to provide adequate supervision, did not implement or update individualized care plan interventions after falls, and did not conduct required interdisciplinary reviews. Care plans were found to be too broad and not descriptive enough for staff to follow, and residents did not consistently receive the assistance or supervision required for their safety.
A resident with significant mobility limitations and a history of falls requested help from a CNA to use the restroom, as outlined in her care plan. The CNA refused to assist, telling the resident she needed to be independent, and did not help with transferring or ambulation, leaving the resident to struggle in pain. The resident described the interaction as condescending and demeaning, and the facility had not provided staff training on communication or customer service in the past year.
A resident with depression reported multiple unresolved concerns, including dietary, dental, podiatry, CPAP, medication, therapy, wound care, and activity issues. Despite raising these concerns with leadership and during a care conference, the resident received no updates or resolutions. Staff interviews revealed confusion about the grievance process, and only one grievance form was found, contrary to facility policy requiring the administrator to oversee and track grievances.
A CNA observed a resident touching another resident inappropriately and reported the incident to an LPN, who redirected the resident and documented the event but did not immediately notify the abuse coordinator as required by policy. Multiple staff interviews confirmed knowledge of the immediate reporting requirement, but the LPN stated unawareness of the policy, resulting in delayed notification to the appropriate personnel and authorities.
The facility did not conduct complete investigations into multiple allegations of abuse and neglect, including incidents involving falls, inappropriate resident contact, and rough care by a CNA. Investigation files were missing key documentation such as staff interviews, clinical assessments, and evidence of follow-up, and administrators were unable to provide details or records supporting their investigative processes.
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 Transcribe, Implement, and Consistently Provide Ordered Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer care and to prevent worsening of existing pressure injuries for two residents. For one resident with metabolic encephalopathy, hospital discharge paperwork and a handwritten note from hospital staff documented existing skin issues, including a right hip wound and incontinence-associated dermatitis, with specific wound care instructions such as cleansing, Xeroform and foam dressings on a set schedule, frequent turning and repositioning, heel offloading, and use of barrier creams. These instructions were not transcribed into the facility’s physician orders, treatment records, or care plans upon admission. The admission skin assessment documented only a right hip surgical site and did not record any open wounds or refusals for skin assessment, and there were no sacral wound orders or treatments documented for several days after admission. The pressure ulcer care plan for the sacrum was not developed until two weeks after admission, and the incontinence and skin care plans did not reflect the resident’s need for frequent incontinence care or any refusals of care. Subsequent assessments and documentation for this resident showed inconsistent and delayed recognition and treatment of a sacral pressure injury. A new sacral pressure ulcer was first documented days after admission as a Stage 3 pressure ulcer, with measurements and moderate drainage, and wound care orders were initiated the following day. A wound provider later assessed the sacral wound as an unstageable pressure ulcer, noted heavy drainage, and ordered daily dressing changes with Manuka dressing, an APM bed, heel protectors, offloading, and frequent incontinence changes. However, the provider’s daily dressing order was incorrectly entered as every other day, and the TAR showed missed or undocumented treatments, including no documented dressing change on a scheduled day and no PRN wound care orders. Staff interviews revealed that the resident was very hard to reposition, required two-person assistance, was incontinent, and did not refuse care, and CNA documentation showed no refusals of incontinence care. A CNA reported finding a large sacral dressing that was foul-smelling and urine-soaked, notifying an LPN twice, and observing that the dressing remained unchanged for many hours; another LPN later changed the dressing without cleansing the wound. The resident’s change in mental status and suspected sepsis from the coccyx wound were documented only shortly before transfer to the hospital, where the sacral ulcer was described as a large, foul-smelling, unstageable pressure sore with black eschar and sepsis secondary to the sacral decubitus ulcer. For a second resident with a right heel pressure injury, the facility failed to provide consistent wound care as ordered, resulting in deterioration and infection of the heel wound. The pressure ulcer care plan identified a right heel pressure injury and called for wound care per physician orders and weekly skin evaluations, but wound provider notes over several months documented that dressings were grossly soiled, left in place far beyond the ordered change frequency, and not consistent with the prescribed products. The wound provider repeatedly noted missed dressing changes, wrong dressings, deterioration of the wound, strong odor, and concerns for cellulitis and infection, and ordered systemic and topical antibiotics and more frequent dressing changes. Review of physician orders and treatment records showed multiple missed and refused treatments across three months, with no corresponding progress notes or documentation of PRN wound care or re-attempts after refusals. Staff interviews indicated that some nurses, including agency staff, were unaware of the resident’s wound or dressing orders, that dressing changes were typically assigned to night shift, and that the resident did not usually refuse care, despite multiple refusals being recorded without supporting narrative documentation. These actions and omissions led to worsening of the resident’s unstageable right heel pressure injury and required antibiotic interventions for infection. The facility’s internal nursing leadership acknowledged awareness of ongoing issues with wound care not being completed as ordered for multiple residents, including missed dressing changes, incomplete documentation, and lack of availability of ordered wound care products. The ADON, who managed wounds, reported not reviewing the first resident’s hospital discharge paperwork until after the wound had already worsened and acknowledged that wound orders from the hospital should have been entered on admission. She also reported discovering months earlier that other residents were not receiving ordered wound care and that she and the unit manager had been monitoring for missed treatments. The DON confirmed that there were no documented refusals of incontinence or wound care for the first resident and that she was aware of prior problems with wound care not being completed. The administrator reported that wound-related QAPI discussions had focused only on the number of wounds, not on missed or incomplete wound care, indicating that the documented failures in assessment, order transcription, treatment implementation, and monitoring directly contributed to the cited deficiencies in pressure ulcer care for both residents.
Failure to Keep Call Light Within Reach of a Bedbound Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach as required by the resident’s care plan and facility expectations. The resident was a female with diagnoses including other recurrent depressive disorders, generalized muscle weakness, difficulty in walking, and cognitive communication deficit, and had a care plan focus of being at risk for falls due to a history of falls. The care plan, revised on 11/9/25, included an intervention to orient the resident to her surroundings and the use of the call light, initiated on 4/24/25. On multiple observations over two consecutive days, the resident was seen in bed with her call light not visible and hanging on the bottom of the bed frame behind the head of the bed near the floor, out of her reach. This positioning of the call light was documented at 9:27 AM, 11:07 AM, and 2:54 PM on 3/4/26, and again at 8:49 AM on 3/5/26. In interviews, CNAs and the ADON consistently reported that call lights were supposed to be within physical reach of residents, placed on or near their body so they could touch and activate them, and confirmed that it was not acceptable for the call light to be behind the resident on the bed frame near the floor. One CNA reported she had just found the resident’s call light in that inaccessible location and confirmed the resident did use her call light sometimes.
Incomplete and Inaccurate Wound Care Documentation for Heel Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and treatment documentation for a resident with a right heel pressure injury. The resident was admitted with weakness and falls and had an active care plan for a right heel pressure injury requiring wound care per physician orders and weekly skin evaluations. Review of physician orders and treatment records from December through February showed multiple missed and refused wound care treatments without corresponding progress notes or documentation of PRN wound care, despite orders specifying every other day, then daily wound care, and checks of dressing placement. The care plan also called for weekly full skin checks, but several of these were not completed on specified dates. The Unit Manager stated she was aware of issues in December and January with wound dressings not being changed and incomplete documentation, and confirmed that refusals of wound care in February were not supported by progress notes or documentation of re-attempts. The Nurse Practitioner reported that on two separate visits, the resident’s right heel dressing was grossly soiled, had not been changed for several days beyond the ordered frequency, and did not match the ordered dressing type on one occasion. The NP documented concern for cellulitis, ordered oral antibiotics, and later added a topical antibiotic and daily dressing changes when the wound deteriorated, but on a subsequent visit again found a soiled dressing that had not been changed as ordered and noted the topical antibiotic was not available. Medication records showed the resident did not receive all ordered doses of oral antibiotics in both December and January. Additionally, a Treatment Administration Record entry showed that an LPN documented checking the placement of the right heel dressing, but in interview that LPN stated she was not aware of a wound dressing on the resident, despite having documented the check that same morning. The ADON acknowledged finding the resident’s dressing not changed, missing documentation, and documentation indicating dressings had been changed more than once in the past, and was aware that the wound care provider had previously been upset about dressings not being changed as ordered.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
A deficiency occurred when nursing staff failed to initiate cardiopulmonary resuscitation (CPR) for a resident who was found unresponsive, despite the resident having a documented full code status. The assigned agency RN did not perform CPR upon discovering the resident unresponsive and without vital signs, and instead pronounced the resident deceased. The nurse stated she was informed the resident was on hospice and did not recall the code status, leading to no resuscitative efforts being made. Other staff, including CNAs, were aware of the resident's full code status and expected that CPR should have been started, but no action was taken to initiate a code or call emergency services. The resident involved had a history of hereditary ataxias, dysphagia following cerebral infarction, and Parkinson's disease, and was admitted to hospice services with a clear advance directive indicating full cardiopulmonary resuscitation. Despite this, the care plan did not document the code status or advance directives, and the nurse relied on verbal information about hospice status rather than verifying the resident's documented wishes. The nurse did not check the medical record or care plan for code status before deciding not to initiate CPR. Interviews with staff revealed a lack of clarity and communication regarding the resident's code status, with some staff assuming hospice status equated to a do-not-resuscitate (DNR) order. The facility's policies required CPR to be initiated for full code residents unless a DNR order was present and documented. The failure to follow these policies and verify the resident's code status resulted in the resident not receiving basic life support prior to death.
Removal Plan
- All resident charts were audited to confirm code status based on Resident/POA wishes.
- Facility licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- Agency licensed staff were provided with in-service education. Education included ensuring CPR was initiated for residents identified as full codes, a resident on hospice does not mean DNR code status, location of code status preference in resident records, and review of facility cardiac arrest emergency management policy.
- The Director of Nursing will ensure that all staff received in-service education and completed education was documented prior to working their next assigned shift.
- The Director of Nursing/Designee will monitor all booked shifts for Agency licensed staff for completion of assigned required in-service education and completed education was documented prior to working the scheduled shift.
- The medical director was notified.
- The Director of Nursing held mock CPR drills with nursing staff on each shift.
- Director of Nursing will conduct mock CPR drills monthly on each shift.
- Information from the drills will be reviewed for recommendations at QA&A committee meetings monthly.
- An Ad-Hoc QAPI meeting was held to review findings and action plan.
Failure to Protect Residents from Abuse and Inadequate Investigation of Incidents
Penalty
Summary
The facility failed to protect residents from both resident-to-resident and staff-to-resident physical abuse, as evidenced by multiple incidents involving three residents. One incident involved a resident with Alzheimer's disease and dementia who was struck in the mouth by another resident with a known history of aggression and behavioral disturbances. Documentation and interviews revealed that the aggressive resident had exhibited repeated episodes of anger, verbal and physical aggression, and difficulty with redirection in the weeks leading up to the incident. Despite these documented behaviors, there was no behavior care plan implemented prior to the altercation, and staff supervision was reported as insufficient, particularly when staffing levels were low or when unfamiliar staff were present on the unit. Another incident involved a cognitively intact resident who reported being struck in the face by an agency LPN during an argument about the administration of an insulin injection. Multiple interviews with staff and witnesses confirmed that a physical altercation occurred, with the resident sustaining a bloody lip and both parties engaging in yelling and physical contact. The LPN admitted to pushing the resident's hands away after being poked in the chest, and a police report classified the event as a simple assault. The facility's investigation into this incident was incomplete, as only one written witness statement was collected and not all available witnesses were interviewed. The facility's abuse prevention policy requires ongoing assessment, care planning, and monitoring of residents with behavioral issues, as well as immediate reporting and investigation of abuse allegations. However, the facility did not implement appropriate interventions or supervision for residents with known aggressive behaviors, nor did it conduct a thorough investigation into the staff-to-resident abuse incident. These failures resulted in residents being exposed to physical harm and not being protected from abuse as required by facility policy and regulatory standards.
Failure to Prevent Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medications for two residents, resulting in missing controlled substances and incomplete documentation. During the discharge process for one resident, discrepancies were identified in the narcotic card and sheet counts, with three cards missing and no documented explanation for their removal. The agency RN involved could not account for the missing medications or provide details on the disposition of the blister packs and count sheets. The controlled substance shift inventory sheets were not properly completed, with missing signatures and blank sections where explanations should have been provided. One resident was admitted for a respite stay under hospice care and had orders for hydrocodone-acetaminophen. Pharmacy records indicated a specific quantity of medication was received, but the medication administration record only documented the administration of three tablets during the stay. The controlled substance inventory showed a reduction of three cards without corresponding documentation or explanation. The former DON confirmed that the medications and count sheets were missing and could not be located after an internal investigation. A second resident, admitted with multiple injuries and prescribed oxycodone, also had missing narcotic medications. Pharmacy records and medication administration records did not account for all tablets received, and witness statements confirmed that medications for both residents were unaccounted for. Interviews with staff revealed that the required shift-to-shift controlled substance counts were not consistently signed by both incoming and outgoing nurses, contrary to facility policy. The facility's policy required immediate reporting and documentation of unresolved discrepancies, which was not followed in these instances.
Failure to Thoroughly Investigate Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving one resident. The resident reported that during an argument with an agency LPN, he was struck by the nurse after he pushed the LPN. The incident occurred after the resident requested an insulin injection in the dining area, which the LPN refused, leading to a confrontation in the resident's room. Multiple witnesses, including a CNA and a family member, reported hearing or observing the altercation, with one CNA noting the resident had a bloody lip and stating that both the resident and LPN admitted to physical contact. A police report also documented the incident, with the LPN admitting to slapping the resident's hand away after being poked in the chest. Despite these accounts, the facility's investigation was incomplete. The interim DON only collected a written statement from one CNA and did not interview all staff or witnesses present during the incident, including another CNA and a family member who directly observed or heard the altercation. The facility's abuse policy requires a thorough investigation, including interviewing all involved persons and witnesses, but this was not followed. As a result, the incident of staff-to-resident physical abuse was not fully identified or documented, and there was a potential for additional abuse to go unrecognized.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for a resident with multiple cardiovascular diagnoses, including paroxysmal atrial fibrillation, pulmonary embolism, popliteal vein thrombosis, hypertension, heart failure, and hypotension. The resident had physician orders for Midodrine to be given with meals for hypotension, to be held if systolic blood pressure was greater than 130, and for Metoprolol to be given once daily for cardiac arrhythmia, to be held if systolic blood pressure was less than 100, diastolic blood pressure less than 60, or heart rate less than 55. The orders also specified that Midodrine and Metoprolol should not be administered at the same time per the cardiologist. Observation and interviews revealed that an LPN administered both Metoprolol and Midodrine together at 9:39 AM, with the Midodrine being given late (scheduled for 8:00 AM) and not with a meal as ordered. The LPN acknowledged the error, stating that medication administration was difficult due to frequent interruptions. The unit manager confirmed that the medications were administered together, contrary to the physician's order, and explained that the medications have opposing effects on blood pressure and heart rate. The failure to follow the physician's orders and professional standards resulted in the resident not receiving medications as intended.
Failure to Provide Consistent Assessment, Monitoring, and Treatment for Resident with Complex Needs
Penalty
Summary
A resident with a complex medical history, including chronic lymphedema, morbid obesity, heart failure, chronic constipation, and hyperkalemia, experienced multiple failures in care delivery. The facility did not consistently assess, monitor, document, or provide treatment according to professional standards and physician orders. The resident reported significant pain from constipation and requested an enema, which was refused by nursing staff despite her history of fecal impaction. She was later hospitalized for fecal impaction and dangerously high potassium levels. Hospital records confirmed severe constipation, hyperkalemia, and the need for disimpaction and urgent medical intervention. The resident also reported that wound care was not being provided as ordered. She had open, weeping areas on her legs due to lymphedema, and facility staff used incontinence briefs instead of prescribed wound dressings when supplies ran out. The resident stated that she often had to clean her own wounds, and there were periods when the wound nurse did not assess her skin as scheduled. Documentation and interviews confirmed missed applications of compression stockings and lymphedema boots, with no progress notes indicating resident refusal. Supply orders for wound care were not consistently maintained, leading to lapses in appropriate wound management. Review of the Medication Administration Records (MAR) revealed multiple missed treatments, including compression stockings and lymphedema boots, without documentation of resident refusal. There were also inconsistencies in the administration and documentation of bowel management interventions, such as enemas and laxatives. Staff interviews indicated a lack of communication and follow-through regarding supply shortages and resident care needs. These failures resulted in the resident's hospitalization and ongoing issues with wound care, bowel management, and monitoring of critical lab values.
Failure to Provide Proper External Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a female resident using a Pure Wick external urinary catheter. The resident, who had diagnoses including acute cystitis with hematuria, overactive bladder, neuromuscular dysfunction of the bladder, and was a carrier of carbapenem-resistant enterobacterales (CRE), reported that staff did not respond promptly to her requests for assistance. She described being left in feces for extended periods, sometimes up to five hours, and noted that the Pure Wick device was not always functioning properly, leading to leakage and the need for additional pads. The resident also had to instruct CNAs on how to properly reattach tubing and clean the canister, indicating a lack of staff competency and adherence to proper procedures. Observations and interviews revealed that the Pure Wick canister was often left full or over halfway full, and staff did not consistently empty or clean it as required. The resident reported that the canister had not been cleaned for two or three days at times, and staff were not coming in to provide care until late in the evening. The Unit Manager acknowledged there were no specific orders or protocols in the resident's record regarding cleaning the Pure Wick canister, when to empty it, or when to replace the canister and tubing. Additionally, there was no documentation of staff education or resident monitoring related to the use and care of the Pure Wick system, despite the resident's history of multiple urinary tract infections and CRE. Review of facility policy and manufacturer guidelines confirmed that the Pure Wick external catheter should be replaced every 8 to 12 hours or immediately if soiled, and that canisters and tubing should be cleaned and disinfected at least daily and replaced every 60 days. However, the facility's practice did not align with these standards, as staff were not consistently following the required procedures for replacement, cleaning, and monitoring. The Director of Nursing was unable to confirm whether staff were ensuring timely replacement of the external catheter or proper documentation, and there was a lack of clear protocols and staff education regarding the care of the Pure Wick system.
Failure to Post Current Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that current daily nurse staffing hours were posted in a prominent location readily accessible to residents, staff, and visitors. Observations on multiple dates revealed that outdated staffing information was displayed, with staffing hours from previous days remaining posted for extended periods. On several occasions, the most current staffing hours were not posted as required, and the information available was several days old. The postings were located in a glass-enclosed bulletin board behind the entryway and reception area, but due to a missing key, updated postings were taped to the outside of the enclosure rather than placed inside. Interviews with facility staff confirmed that the responsibility for posting staffing hours had recently transitioned from one staff member to another. The new scheduler acknowledged that the postings were not being updated regularly and admitted that the current day's staffing hours had not yet been posted at the time of the surveyor's inquiry. The Nursing Home Administrator also confirmed that staffing hours were supposed to be posted daily and recognized that the postings were not current during the surveyor's visit.
Failure to Honor Resident Food Choices and Menu Consistency
Penalty
Summary
The facility failed to ensure that a resident's food choices were consistently obtained and honored, resulting in dissatisfaction with meal services and the potential for inadequate food or fluid intake. The resident, who had a complex medical history including iron deficiency, slow transit constipation, mixed irritable bowel syndrome, lymphedema, CHF, morbid obesity, recurrent UTI, hypertension, depression, and a history of pressure injuries, was on a regular vegetarian diet and was supposed to be offered food and beverage selections with substitutes as requested. Despite this, the resident reported not receiving planned menu items on multiple occasions, such as the Christmas lunch meal and lentil meatloaf, and expressed frustration over the lack of suitable vegetarian options and necessary condiments for her meals. Interviews with dietary staff and the registered dietician revealed that errors in ordering and meal preparation contributed to the resident not receiving her selected meals. The dietary manager admitted to forgetting to order specific items, and the registered dietician confirmed that some preferred items were not available from the supplier, requiring alternative discussions with the resident. The resident also reported feeling that she was expected to supply her own food due to the limited vegetarian options available, and staff acknowledged lapses in providing the correct menu items as ordered.
Failure to Provide Supervision During Toileting Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, abnormal gait, chronic pain, and a history of falls was left unsupervised on a bedside commode. The resident was dependent on two staff members for all activities of daily living and was unable to make her needs known or use a call light. Despite these needs, the resident was left alone on the commode after a shift change, with staff only nearby outside the room and not within arm's reach. The incident was discovered when a registered nurse heard a loud noise and found the resident lying on the floor in front of the commode. The resident sustained a closed comminuted fracture of the left patella and a closed head injury, as confirmed by hospital records. Interviews with staff and the resident's guardian confirmed that the resident should not have been left unattended due to her cognitive and physical limitations, and that her care plan required staff to anticipate her needs and provide safety and comfort. Facility documentation, including the fall risk assessment and care plan, indicated the resident was at high risk for falls, had poor safety awareness, and required staff assistance for toileting. The facility's ADL policy also required appropriate support for residents unable to carry out activities independently. The failure to provide direct supervision during toileting led to the resident's unwitnessed fall and subsequent injuries.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically in relation to an injury of unknown origin sustained by a resident. The resident, who had chronic pain, vascular dementia, and was dependent for all activities of daily living, was found to have a nondisplaced distal radius fracture after being transferred to the hospital. The hospital records indicated swelling, tenderness, and pain in the resident's left arm, with imaging confirming a concerning lucency in the distal radius. Despite these findings, the facility did not report the injury of unknown origin to the state agency as required by their abuse policy and federal regulations. The facility's internal investigation into the incident did not address the injury of unknown origin, even though the hospital records noting the fracture were present in the facility's incident folder. Interviews revealed that the administrator and medical director did not review or recognize the x-ray findings indicating a possible fracture. The administrator confirmed that such an injury should have been reported to the state agency but was unable to explain why this was not done. The family member of the resident also reported concerns about the injury, noting the resident's inability to self-inflict such harm due to being bedbound and dependent on staff for care. The facility's abuse policy required immediate reporting of any allegations or reasonable suspicions of abuse, neglect, or injuries of unknown source to the state agency and other authorities. However, the injury was not reported as required, and the investigation did not address the injury of unknown origin. This failure to report and investigate the injury in accordance with policy and regulatory requirements constituted the deficiency identified by surveyors.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to identify and thoroughly investigate an injury of unknown origin for a resident who was dependent on staff for all activities of daily living due to chronic pain, vascular dementia, and multiple amputations. The resident was re-admitted to the facility following a lengthy hospitalization and was noted to be bed bound, requiring total assistance from staff. During a subsequent hospital visit, the resident was found to have a nondisplaced distal radius fracture, as confirmed by x-ray findings in the hospital records. Family members and staff interviews indicated that the resident had been in pain and exhibited swelling in the affected arm, but the source of the injury was not clear, and the resident was unable to communicate the cause due to cognitive and language barriers. Despite the presence of hospital records in the facility's incident investigation folder that documented the injury, the facility did not address or investigate the injury of unknown origin in its report to the State Agency or as part of its internal investigation. The Director of Nursing and the Nursing Home Administrator both confirmed that they were unaware of the fracture documented in the hospital records, and the hospital x-ray findings were not fully reviewed by the facility's medical director or administration. The facility's investigation focused on allegations of neglect and abuse but did not include a review or investigation of the resident's wrist injury, even though the resident was entirely dependent on staff for care and unable to self-inflict such an injury. The facility's abuse policy required a timely, thorough, and objective investigation of all alleged violations, including injuries of unknown source, and mandated reporting to the State Agency. However, the investigation did not identify or address the injury, did not include a review of all relevant medical records, and did not determine the cause or extent of the injury. As a result, the injury of unknown origin was not investigated as required by facility policy and regulatory standards.
Failure to Assess, Monitor, and Treat Pressure Ulcer Results in Worsening Wound
Penalty
Summary
A resident with reduced mobility and type 2 diabetes was identified as being at high risk for skin breakdown, as indicated by a Braden score of 11. The resident's care plan included multiple interventions for skin integrity, such as the use of an alternating pressure mattress, barrier cream, regular turning and repositioning, and daily skin monitoring. Despite these interventions being listed, the care plan was not updated upon the resident's re-admission, and there was a lack of follow-through in implementing and documenting appropriate wound care interventions. On assessment, the resident was found to have a wound on the coccyx, initially documented as moisture-associated skin damage (MASD) with incontinence-associated dermatitis (IAD). The wound was present on admission, but no treatment orders were obtained or implemented for this wound. Staff interviews revealed that both nursing assistants and nurses observed an open area on the coccyx, described as red and larger than a quarter, but the nurse who assessed the wound did not notify the provider or obtain specific treatment orders. Instead, a barrier cream and gauze were applied without clear documentation of the type of cream used, and the provider was not informed to establish a formal treatment plan. Further review showed that the wound worsened, as documented during a subsequent hospital visit, where multiple chronic shallow pressure ulcers were noted, and the coccyx wound was described as much worse than previously observed. The wound care provider confirmed not having assessed the resident, and the facility's own guidelines required provider-ordered treatments for wounds, which were not followed. The Director of Nursing and Assistant Director of Nursing acknowledged that treatment orders were missed and that the wound care team had not seen the resident as expected.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or events involved. No further information about the circumstances, individuals affected, or observations made by surveyors is included in the report.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information or ensuring proper documentation of resident records were not followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Involve Responsible Party in Care Planning
Penalty
Summary
The facility failed to inform and accommodate a resident's responsible party (RP), who is also the legal guardian, in the development and implementation of the resident's person-centered care plan. The resident, who has diagnoses including unspecified dementia, major depressive disorder, and schizoaffective disorder, was readmitted to the facility from a psychiatric hospital. The care plan indicated that the RP should be kept informed of changes in health and medical status to assist with ongoing care planning and decision-making. However, the RP reported that communication from the facility had declined since a change in ownership, and she was not being given the opportunity to participate in care planning as required. The RP had arranged to attend a scheduled care conference in person, but was told by the facility's social worker to cancel, with the promise of a phone call at the scheduled time. The social worker called earlier than scheduled, and when the RP missed the call and attempted to return it, she received no response. The care conference was documented as attended by the RP, but the RP stated she did not participate and was not contacted afterward despite leaving messages. The facility's policy requires advance notice and participation of the resident or RP in care planning, which was not followed in this instance.
Call Light Not Accessible to High Fall Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's call light was within reach, as required by facility policy. The resident, who had diagnoses including lack of coordination, epilepsy, muscle weakness, and difficulty walking, was dependent on staff for toileting, personal hygiene, and required substantial assistance with dressing. During an observation, the resident was found sitting at the edge of his bed, appearing weak and shaky while attempting to stand up unassisted. The resident repeatedly stated he needed help but was unable to use his call light because he did not know where it was. It was observed that the call light was under the bed and out of the resident's reach. In an interview, a registered nurse confirmed that the resident was a high fall risk and had recently experienced unwitnessed falls in the facility. The nurse also stated that the resident typically used his call light for assistance. Review of the facility's call light policy indicated that staff are responsible for ensuring call lights are plugged in, functioning, and within reach of residents. The failure to provide the resident with access to the call light resulted in the resident's inability to call for staff assistance.
Failure to Protect Residents from Unwarranted Separation or Confinement
Penalty
Summary
A deficiency was identified regarding the protection of residents from separation, including separation from other residents, their own rooms, or confinement to their rooms. The report notes that the facility failed to ensure that each resident was protected from such separation or confinement, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular residents or their medical conditions at the time of the event.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from facility staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Enhanced Barrier Precautions and Water Management Protocols
Penalty
Summary
Facility staff failed to implement Enhanced Barrier Precautions (EBP) according to facility policy and CDC guidance for three out of four residents reviewed. In one instance, a nurse performed nephrostomy care and flushed nephrostomy tubes for a cognitively intact female resident with multiple comorbidities, including obstructive uropathy and wounds, without donning a gown as required. The resident reported that staff inconsistently wore gowns during her care. The nurse stated she did not believe a gown was necessary unless there was splashing, despite facility policy requiring gown and glove use for high-contact care. Another resident with chronic kidney disease and a hemodialysis catheter was repositioned and checked for wounds by a CNA who wore gloves but not a gown, under the mistaken belief that the resident was no longer on precautions, despite active EBP orders. A third resident with a stage 3 pressure ulcer received wound care from a nurse who wore gloves but not a gown and was unaware of EBP requirements, having not received facility education on the policy. Additionally, the facility did not maintain an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in premise plumbing. Multiple janitors' sinks and spa tubs throughout the facility were observed with issues such as brown or discolored water, stagnant water lines, and lack of flushing schedules. Some sinks did not dispense water from certain handles, indicating stagnant lines, and some tubs and sinks were not regularly used or flushed. The Director of Facilities confirmed that not all areas were on a flushing schedule and that the facility did not routinely test for residual disinfectants in the water supply, despite having a test kit available. Review of facility policies confirmed that EBP requires gown and glove use for high-contact activities for residents with wounds or indwelling devices, and that the water management program requires control measures, testing protocols, and documentation for water safety. However, staff interviews and observations revealed gaps in knowledge, inconsistent implementation of precautions, and lack of adherence to water management protocols.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors observed multiple instances where medications and biologicals were not properly labeled, dated, or stored in accordance with facility policy and professional standards. On the 400 hall medication cart, a bottle of nitroglycerin was found with an expired discard date, and two opened insulin pens (Lantus and Humalog) lacked open dates. Additionally, an opened lidocaine cream was missing both a resident name and an open date. Nursing staff confirmed that all medications should be labeled with the resident's name and the date opened, and that expired medications should be removed from the cart. On the 300 hall cart, two opened bottles of Genteal tears eye drops were found without resident names or open dates, and an opened insulin pen was missing an open date, making it unclear if it was safe to use. Staff interviews confirmed these labeling and dating requirements were not met. Further, an unlocked medication cart was observed in the hallway near the 300 Hall, with the narcotic drawer pulled open and no staff present to supervise. The cart was later secured by a nurse, who confirmed that medication carts should be locked when not in use. Review of the facility's policy indicated that all medications and biologicals are to be stored in locked compartments to ensure safety and security, which was not adhered to during the observations.
Failure to Offer and Document COVID-19 Vaccination for Eligible Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccinations were offered to eligible residents, as required by their policy and CDC/FDA guidelines. Specifically, three residents with significant medical histories, including conditions such as stroke, Alzheimer's disease, anemia, diabetes, and high blood pressure, did not have documentation in their medical records indicating that they were offered or administered COVID-19 vaccinations beyond 2022. For two residents, the last recorded COVID-19 vaccinations were in October 2022 and March 2022, respectively, with no further information about subsequent offers or administration. For the third resident, there was no documentation of any COVID-19 vaccination being offered or administered at all. Interviews with the Infection Preventionist confirmed that COVID-19 vaccinations are supposed to be offered upon admission and annually as the vaccine changes, but no additional documentation could be provided to show that these three residents were offered the vaccine after 2022. At the time of the survey, all three residents were eligible to receive the COVID-19 vaccination, but the facility lacked evidence that the required education and offer of vaccination had occurred as per policy.
Failure to Maintain Functional Call Light System for Residents
Penalty
Summary
The facility failed to ensure a fully functioning call light system was available and operational for all residents, specifically affecting four residents out of eighteen reviewed. Multiple residents reported that their call lights were either not working properly or not being answered in a timely manner. Observations confirmed that in several cases, the call light would activate inside the resident's room but would not trigger the hallway indicator to alert staff, and in some instances, the call light remained on even after staff attempted to turn it off. Additionally, some residents reported that their call lights were placed out of reach, preventing them from calling for assistance when needed. Interviews with residents revealed ongoing issues with the call light system, including long wait times for staff response and instances where no one responded at all. One resident reported waiting approximately two hours for assistance, while another stated that the call light system in her room frequently did not work and was often out of reach. Family members and roommates corroborated these accounts, noting repeated problems with the call light system and the need for residents to call out for help when the system failed. Facility staff, including the Director of Facilities and the DON, acknowledged awareness of the call light system's deficiencies. The facility had previously attempted to use cell phones as part of the system, but these were not functioning properly and were discontinued. The monitoring screen for call lights had also been placed in a location not visible to staff at the nurse's station until recently. Work orders confirmed repeated maintenance requests for the malfunctioning call light system in affected rooms, but issues persisted, resulting in residents' needs potentially going unmet.
Failure to Provide Mandatory Infection Control and EBP Training to Agency Staff
Penalty
Summary
The facility failed to implement an effective infection prevention and control training program, specifically regarding Enhanced Barrier Precautions (EBP), for agency staff. Record review and interviews revealed that four out of five staff members reviewed did not receive or complete required education on EBP prior to working shifts. The Infection Preventionist stated that agency staff were expected to review a binder containing EBP policies at the facility entrance, but there was no process in place to verify or document that this education was completed. Agency staff reported either not being informed about the binder, not receiving any EBP education, or only being asked to review unrelated materials such as the narcotic binder. Additionally, an agency RN preparing to perform wound care was unaware of the need to wear a gown and was not familiar with EBP, stating that she had not received any relevant education from the facility. This lack of training and verification created the potential for cross-contamination and the spread of infection among a vulnerable population, as staff were not adequately prepared to follow infection control protocols.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that three residents were treated with dignity and respect, as required by policy. During an observation, a CNA referred to residents with the label "lay backs" in a public hallway while pointing to three residents who were seated in geri chairs near the nurses' station. This comment was made in the presence of other staff and residents, and the Director of Nursing later confirmed that such language is not appropriate and does not align with facility policy, which mandates respectful communication and addressing residents by their preferred names. The residents involved had significant cognitive impairments, including diagnoses of major depressive disorder, anxiety disorder, Alzheimer's disease, and dementia. Two of the residents were moderately cognitively impaired, while one had severely impaired cognitive skills and was unable to participate in a mental status interview. The incident was observed and documented by surveyors, and attempts to interview the CNA involved were unsuccessful prior to the survey exit. The facility's own dignity policy emphasizes the importance of promoting residents' well-being and self-worth, which was not upheld in this instance.
Failure to Obtain Psychotropic Medication Consent Prior to Administration
Penalty
Summary
The facility failed to obtain consent for psychotropic medications prior to administration for one resident with severe cognitive impairment. The resident, who had diagnoses including dementia, depression, and anxiety, was unable to clearly verbalize needs and frequently refused care. Despite being prescribed multiple psychotropic medications such as Lexapro, Risperidone, Trazodone, and Ativan, there was no documentation of signed or verbally discussed consents for these medications prior to their administration. Record review confirmed the absence of psychotropic medication consents, and staff interviews verified that no consents were on file before a specified date. The resident's care plan included interventions to provide education on the risks and benefits of these medications, but there was no evidence that this was carried out as required by facility policy. This resulted in the resident and/or their representative not being fully informed about the medications being administered.
Failure to Notify DPOA of Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's durable power of attorney (DPOA) or emergency contact after the resident experienced a fall and was transferred to the hospital. The resident, who had a history of muscle weakness and hemiplegia following a cerebral infarction, was found on the floor next to her bed with a large bruise on her right knee and a bump and bruise on the left side of her forehead. The LPN on duty initiated neurological assessments, contacted the on-call provider, and arranged for the resident to be transported to the hospital due to concerns about a possible head injury. However, there was no documentation that the resident's DPOA was notified of the incident or the hospital transfer. Interviews with the family member, LPN, DON, and regional nurse consultant confirmed that the DPOA was not contacted regarding the fall and subsequent hospital transfer. The facility's own policy requires notification of the resident's designated representative in the event of an accident or incident resulting in injury and requiring physician intervention or transfer. Review of the incident report and progress notes did not show evidence of such notification, and the family member only learned of the incident after being contacted by the hospital.
Failure to Issue SNF ABN for Non-Covered Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to a resident who transitioned from Medicare-covered skilled care to private pay after choosing to discontinue therapy services. Documentation showed that the resident was informed on her last covered day that her payer source would change to private pay, but there was no record of an SNF ABN being issued to notify her of potential financial liability for non-covered services. The Business Office Manager confirmed that the resident should have received an ABN but did not, and there was no documentation indicating the resident was informed of the private pay costs.
Failure to Provide Required Discharge and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide required discharge notifications and bed-hold policy information for two residents during the discharge process. For one resident with a history of anxiety and depression, the State Long-Term Care (LTC) Ombudsman did not receive notification of the resident's discharge to a psychiatric hospital. The Nursing Home Administrator (NHA) was unable to provide documentation that notifications were sent to the ombudsman's office, and the resident was not listed on the facility's discharge log for the relevant month. Interviews and record reviews confirmed that the required notification was not completed. For another resident with muscle weakness and hemiplegia following a cerebral infarction, the facility did not provide the resident's Durable Power of Attorney (DPOA) with written notice of the bed-hold policy when the resident was transferred to the hospital. The NHA confirmed that the bed-hold notice was not provided. These failures were identified through interviews, record reviews, and correspondence with the LTC Ombudsman.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions for a resident identified as being at risk for falls due to multiple factors, including medication side effects, debility, poor oral intake, ataxia, impaired safety awareness, visual impairment, and osteoporosis. The resident's care plan included specific interventions such as keeping the call light within reach and ensuring a fall mat was placed next to the bed. However, during multiple observations, the fall mat was either missing, improperly positioned, or folded against the wall, and the call light was found out of the resident's reach. Staff interviews confirmed that the fall mat was often moved to accommodate the bedside table during meals and was not consistently returned to its proper position afterward. A CNA acknowledged that staff frequently forgot to replace the fall mat after the resident finished eating, resulting in the resident being left without the prescribed fall prevention intervention. These lapses in following the care plan created a potential for unmet care needs for the resident.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident with a history of unstageable pressure ulcers to the heels was not provided with adequate care and services to prevent the development and worsening of pressure injuries. The resident was observed multiple times with his feet pressed against the footboard of a bed that was too short, resulting in wounds on both heels and toes. The resident reported pain and that his feet were not being cleaned as needed, and observations confirmed the presence of open, bleeding, and scabbed wounds on his heels and toes, as well as soiled pressure-relieving boots and bedding. Nursing and agency staff were not consistently aware of all the resident's wounds, with some staff unaware of wounds on the toes and wound care orders not covering all affected areas. Wound assessments and documentation showed a lack of timely identification and treatment of new or worsening wounds, including a newly developed unstageable pressure injury to the right heel and scabbed, bleeding toes. The resident's care plan included the use of foam heel suspension boots and offloading, but these interventions were not consistently or effectively implemented, as evidenced by the resident's ongoing contact with the footboard and the condition of his feet. Record review indicated that the resident had a history of pressure injuries to both heels and toes, with recommendations for offloading and repositioning. Despite these recommendations, the resident continued to experience preventable skin breakdown due to inadequate offloading, insufficient wound care, and lack of cleanliness. The failure to provide necessary care and services consistent with professional standards resulted in the development of new pressure injuries and the potential for further harm.
Failure to Follow Care Plan for Bed Mobility Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of muscle weakness and repeated falls was not provided the care as outlined in his care plan. The resident required assistance from two staff members for bed mobility, as documented in his care plan and Kardex. However, on the date of the incident, an agency CNA provided care alone and attempted to move the resident in bed without the required second staff member present. During this process, the resident fell from the bed, resulting in abrasions to his face, knees, and a bleeding wound on his toe. The incident report and interviews confirmed that the CNA did not review the care plan or Kardex prior to providing care and did not consult with nursing staff or other personnel before proceeding. The resident was found on the floor, partially under the bed, after the fall. The DON confirmed that the CNA was alone in the room at the time of the incident, which was not in accordance with the resident's care plan requirements for a two-person assist during bed mobility.
Failure to Monitor and Document Post-Dialysis Care
Penalty
Summary
The facility failed to ensure appropriate post-dialysis assessment and monitoring for a resident with end stage renal disease who required hemodialysis. The resident's care plan included interventions such as monitoring for signs and symptoms of infection, renal insufficiency, bleeding, and other complications, as well as specific instructions not to draw blood or take blood pressure in the arm with a graft. Despite these interventions, there was no evidence that the resident was assessed or monitored upon return from dialysis on multiple occasions. The dialysis communication form was not immediately retrieved or reviewed by the assigned nurse, and vital signs were not recorded regularly, with the most recent entry being a month prior to the incident. Progress notes for the days the resident returned from dialysis were also missing. Interviews with staff revealed that the nurse assigned to the resident was unfamiliar with the resident and did not receive or review the dialysis communication form. The Director of Nursing confirmed that the form was later found in the resident's wheelchair pocket and acknowledged that the nurse did not monitor the resident or document a progress note after dialysis. The facility's policy required immediate retrieval of the dialysis communication form, assessment of the resident's stability, and documentation in the medical record, none of which were followed in this instance.
Failure to Address Pharmacist Medication Review Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure a prompt response to the registered pharmacist's monthly medication regimen review (MRR) recommendations for several residents, resulting in recommendations not being addressed in a timely manner. For one resident with severe cognitive impairment and diagnoses including dysphagia and dementia, the pharmacist repeatedly recommended evaluation and possible discontinuation of Nystatin-Triamcinolone cream and Acidophilus, as their continued use was not supported. Although the provider agreed with the recommendations, there was no documentation of timely follow-up or physician review, and the medications were not discontinued until much later than when the recommendations were signed. Another resident with severe cognitive impairment and multiple psychotropic medications did not have required Abnormal Involuntary Movement Scale (AIMS) assessments documented, and the facility was unable to produce MRR irregularity reports for review. Interviews revealed that the process for reviewing and implementing pharmacy recommendations had not been followed for at least two months, with reports not being reviewed or acted upon in a timely fashion. Additionally, medication consents were not on file for this resident prior to a certain date. A third resident with Alzheimer's disease and major depressive disorder had a pharmacist recommendation to evaluate the continued need for Vitamin B-12 and Lipitor due to terminal status, but there was no evidence that the physician or provider reviewed or responded to this recommendation. Interviews with facility staff confirmed a lack of awareness and follow-up regarding these recommendations. The facility's policy required that physicians document review and action on any pharmacist-identified irregularities by their next mandatory visit, but this process was not followed for the residents in question.
Failure to Screen and Document Pneumococcal Vaccination Eligibility
Penalty
Summary
The facility failed to ensure that a resident was properly screened for eligibility to receive pneumococcal vaccinations and to document the administration or offer of the vaccine in accordance with facility policy and CDC guidelines. Review of the resident's medical record showed no documentation of screening for pneumococcal vaccination eligibility, and no record that the resident was offered the vaccine as recommended. Although a consent for vaccination was signed in 2022, there was no clear documentation of follow-up screening or administration of the appropriate pneumococcal vaccine. Further review revealed that the resident received two doses of the same pneumococcal polysaccharide vaccine (PPSV23) on separate occasions, but there was no evidence that the facility assessed the need for additional or different pneumococcal vaccines as per current recommendations. The lack of documentation and screening resulted in the resident not being offered the Prevnar 20 (PCV20) vaccine in a timely manner, as required by CDC guidelines for adults of her age and vaccination history.
Delayed Identification and Treatment Following Unwitnessed Fall
Penalty
Summary
A resident with a history of falls, dementia, and previous intracranial hemorrhage experienced an unwitnessed fall in the facility's bathroom. The resident was found on the floor by a CNA, with abrasions noted on the elbows, knees, and later, the forehead. The resident denied hitting his head and initially did not report pain, but over the following days, staff documented significant changes in condition, including increased blood pressure, facial grimacing, refusal to eat, increased need for assistance with activities of daily living, and increased somnolence. Despite these changes, the resident was not immediately sent to the hospital. Nursing staff communicated with the on-call provider, a Physician Assistant (PA), about the resident's symptoms, but the PA was not made fully aware of all the changes, such as the increased blood pressure and the full extent of the resident's decline. The PA ordered a chest x-ray due to a cough and instructed continued monitoring, but did not assess the resident in person or via telehealth. The LPN caring for the resident did not advocate for hospital transfer, relying on the provider's judgment, and was unsure if the PA knew the fall was unwitnessed. The provider later stated that, had he been aware of the full clinical picture, he would have considered a virtual assessment and possible hospital transfer. It was only after the Assistant Director of Nursing reviewed the communication and recognized the significant change in condition that the resident was sent to the hospital, where a significant intracranial hemorrhage was diagnosed. Interviews with staff revealed gaps in assessment, communication, and escalation of care following the unwitnessed fall, resulting in a delay in identifying and treating the resident's acute change in condition.
Failure to Provide Adequate Supervision and Update Care Plans After Falls
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent falls and injuries for multiple residents, as well as to implement and revise care plan interventions following falls. One resident with a history of falls, dementia, and moderate cognitive impairment experienced multiple unwitnessed falls, including one resulting in a multicompartmental acute intracranial hemorrhage. The care plan for this resident included broad interventions such as keeping the bed in a low position and offering frequent toileting, but these were not specific or descriptive enough for staff to follow. Staff interviews revealed a lack of clarity regarding the frequency of checks and toileting, and staff were unable to report when the resident was last assisted or checked. After falls occurred, no new interventions were added to the care plan, and the interdisciplinary team did not meet to review or revise interventions. The Director of Nursing and Nursing Home Administrator confirmed that care plan interventions were too broad and that post-fall reviews and care plan updates did not occur as required by facility policy. Another resident with Alzheimer's disease, repeated falls, and impaired mobility also experienced multiple unwitnessed falls, including incidents resulting in T3 and T8 vertebral fractures. The care plan for this resident was not updated after each fall, and immediate interventions to ensure safety were not implemented. Staff documentation and interviews indicated that the resident frequently attempted to self-transfer, did not consistently use assistive devices, and was not provided with interventions such as frequent rounding, signage, or reminders to use a walker. The care plan lacked specific interventions such as non-slip socks or a fall mat, despite these being used at times. The Director of Nursing acknowledged that interventions were not developed following each fall, and that immediate interventions should have been created to minimize risk. A third resident with a history of joint replacement and falls reported that staff did not provide the required assistance with transfers and toileting, despite being care planned as a one-person assist. The resident described being told by a CNA to be independent and was left to struggle without help, raising concerns for her safety. The Director of Therapy and Director of Nursing confirmed that the expectation was for staff to provide support or supervision for transfers and ambulation, especially for a resident with recent joint surgery. The facility's failure to provide adequate supervision, update care plans, and implement individualized interventions after falls contributed to the risk of further accidents and injuries.
Failure to Promote Resident Dignity and Provide Required Assistance
Penalty
Summary
A deficiency was identified when a resident with a history of right hip replacement, muscle weakness, difficulty walking, necrosis of the bone, and a history of falls requested assistance from a CNA to use the restroom. The resident's care plan specified the need for one-person assistance with a four-wheeled walker for locomotion, toilet use, and transfers. Despite this, when the resident called for help, the CNA told her she needed to learn to be independent and stood by without providing the requested assistance, even as the resident struggled to ambulate and expressed being in pain and concerned for her safety. The resident reported feeling that the CNA's response was condescending and demeaning, and that she was left to struggle without the necessary support, which caused her frustration and disappointment. The facility administrator confirmed that there had been no communication or customer service training for staff in the past twelve months. The incident was substantiated through interviews and record review, demonstrating a failure to provide an environment that promoted resident dignity and respect as required.
Failure to Resolve Resident Grievances and Follow Grievance Policy
Penalty
Summary
The facility failed to resolve a resident's concerns and did not follow its grievance policy, resulting in unresolved issues and the resident feeling frustrated and neglected. The resident, who had a diagnosis of depression, reported multiple ongoing concerns including inadequate accommodation of a vegetarian diet, lack of access to dental and podiatry care, issues with CPAP cleaning, inconsistent medication administration, missed therapy interventions, inconsistent wound care, missed bed baths, and delays in MRI scheduling. These concerns were discussed in a care conference and communicated to facility leadership, but the resident reported no updates or resolutions. Interviews with staff revealed a lack of awareness and understanding of the facility's grievance process. Several staff members, including CNAs and LPNs, were unable to describe the process for handling resident grievances or completing grievance forms. The resident reported never having a grievance form completed with her and was unaware of the facility's grievance process. The Director of Nursing and Social Worker were also unaware of the status of the resident's concerns or their own responsibilities in addressing them. The Nursing Home Administrator (NHA) was identified as the Grievance Officer per facility policy but was unable to provide updates on the resident's concerns and stated she was not responsible for following up on grievances. Only one grievance form was found, despite multiple concerns being raised. The facility's policy required the administrator to oversee the grievance process, receive and track concerns, and issue written decisions, but these steps were not followed for the resident's grievances.
Failure to Immediately Report Allegation of Abuse to Abuse Coordinator
Penalty
Summary
The facility failed to implement its policy and procedures regarding abuse and neglect when staff did not immediately report an allegation of abuse to the abuse coordinator. Specifically, a certified nursing assistant (CNA) witnessed a resident entering another resident's room and touching her breast area while she was calling out for help. The CNA reported the incident to an LPN, who redirected the resident and documented the event in a progress note, but did not immediately notify the abuse coordinator or administrator as required by facility policy. The incident was later reported to the state agency several hours after it occurred. Interviews with multiple staff members confirmed that they were aware of the requirement to report allegations of abuse immediately to the abuse coordinator, who was identified as the nursing home administrator. However, the LPN involved stated that they were unaware of the policy to report to the administrator and only documented the incident in the resident's record. The failure to follow the established reporting protocol resulted in a delay in notifying the appropriate personnel and authorities about the abuse allegation.
Failure to Conduct Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and neglect involving four residents. In one case, a resident with a history of falls was found on the bathroom floor with an abrasion and later diagnosed with a hemorrhage. The investigation file lacked critical components such as resident outcomes, documentation of family or agency notification, staff interviews, hospital record reviews, and a conclusion or corrective actions. The administrator was unable to provide details about the incident, the investigation process, or any measures taken to prevent recurrence. In another incident, a resident was observed touching another resident inappropriately. The investigation file included some documentation, such as staff statements and a five-day follow-up report, but did not contain assessments by physicians or social workers, evidence of ensuring the victim's sense of safety, or analysis of the root cause. Staff interviews revealed a history of inappropriate behavior by the alleged perpetrator and concerns about the adequacy of supervision and the thoroughness of investigations. The administrator could not provide documentation of assessments or daily safety checks and was unable to explain the investigation process or preventive measures. A third case involved a resident alleging rough care by a CNA. The investigation included interviews with other residents, some of whom reported negative experiences with the CNA. However, the investigation file did not include relevant clinical records, care plans, or documentation of follow-up interviews. The resident who made the allegation reported that the administrator did not complete the interview and that no staff followed up with her. The administrator was unable to provide documentation of additional interviews or evidence of care plan updates. The facility's abuse policy requires thorough and objective investigations, but the documentation and actions taken did not meet these standards.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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