Optalis Health & Rehabilitation At Leonard
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Rapids, Michigan.
- Location
- 1700 Leonard Street Ne, Grand Rapids, Michigan 49505
- CMS Provider Number
- 235261
- Inspections on file
- 25
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation At Leonard during CMS and state inspections, most recent first.
Menus were not consistently followed during meal service, resulting in several residents receiving incorrect foods or portions. A resident on a diabetic consistent carb diet was served a full banana instead of 1/2 banana, and two residents with NAS or regular diets each received only 1 sausage link instead of 2. Two residents on mechanical soft diets were served carrots without peas despite the meal ticket indicating peas and carrots, and residents in council reported menu inaccuracies were common, especially at dinner and on weekends.
Meal preferences and diet orders were not consistently followed for several cognitively intact residents. A resident with a dairy intolerance was served butter containing milk instead of the ordered substitute and was also missing other requested items, while other residents were missing ordered beverages, fruit, cereal, or condiments. In resident council, all attendees reported concerns that dietary staff were not following meal tickets, and several said the issue had worsened.
Kitchen sanitation and cooling practices were deficient when surveyors found a can opener blade covered in dried debris, debris under the juice machine spouts, a scoop with dried food residue, and staining and debris inside the milk cooler. The DM also stated leftover soup from lunch might be saved for a couple of days; surveyors later found the soup in a reach-in cooler with the lid ajar and a center temperature of 115F, while the DM was unsure when cooling began and did not know the required cooling time-temperature limits.
PPE and equipment cleaning failures were observed with multiple residents. An LPN provided care to a resident on enhanced barrier precautions without gown or gloves and did not clean the BP cuff after use; staff also performed wound care for a resident with an open pressure ulcer without gowns. During COVID-19 isolation care, a housekeeper and an LPN did not follow posted PPE requirements, handled supplies and shared vitals equipment improperly, and left the monitor unattended before using it on another resident. In addition, an oxygen concentrator and a BiPAP mask were repeatedly observed visibly dirty in residents’ rooms.
A cognitively intact resident with muscle weakness, chronic pain syndrome, and an ADL self-care deficit requiring 2-staff assistance was left calling out for help when the DON and an LPN did not ensure her needs were met or her call light was within reach. The resident reported staff often turned off her call light and said they would return but did not always come back, and she felt some staff did not want to care for her because she was "high maintenance." Resident council interviews and meeting minutes also documented repeated concerns that staff turned off call lights and left before resident needs were addressed.
A cognitively intact resident with muscle weakness and chronic pain syndrome was unable to consistently follow her preferred morning routine of eating breakfast in her room and then getting up in time for morning activities. Staff confirmed she often had to wait until late morning or even lunch time because she required two-person assistance, staffing was limited, and other unit priorities delayed her care, causing her to miss or arrive late to activities.
Rooms and bathrooms were not kept clean and in good repair for several residents. A cognitively intact resident reported distress over damaged walls and exposed metal near her bed and sink, while another resident’s room had repeated gouges and missing paint near the HOB. A third resident also had wall damage beside the bed, and staff acknowledged the issue. Shared bathrooms and spa areas were also observed with urine odor, dried soil, buildup, dirty clothes, wet washcloths, and debris under a shower bed mattress.
A resident with muscle weakness and chronic pain syndrome was transferred to the hospital, but the record did not show written bed hold notice was provided at the time of transfer. The NHA and DON reported that the nurse caring for the resident had not given the required notice.
Failure to provide scheduled bathing and hair care for two residents was identified. One resident with impaired mobility required 2-person ADL assistance and reported missing showers or bed baths; CNAs said low staffing prevented timely care, and the DON confirmed missing bathing documentation. Another resident with depression and seborrheic dermatitis was observed with shiny, soiled hair and reported her hair had not been washed for 2 weeks after a staff helper left, despite a care plan for bathing support and medicated shampoo.
A facility failed to follow resident-specific skin integrity care plans for two residents and failed to prevent a pressure ulcer for one resident. One cognitively intact resident developed foot pressure injuries after her feet repeatedly rested against the foot of the bed while staff noted no set boosting schedule and no room change was considered for a longer bed. Another resident with diabetes, dementia, and partial paralysis had an updated order for Prevalon boots when in bed, but the care plan was not updated and staff observed the boots off and stored away instead of being used as ordered.
Improper Administration of Morphine: An LPN prepared a resident’s ordered morphine and placed it in a cup of juice after reporting the resident refused meds, then left the cup on the meal tray while passing meds to other residents. Staff were aware the morphine was being given in juice or milk, but the LPN did not remain with the resident to directly observe the dose being taken, and the MAR was signed as administered.
A resident with a history of falls, cognitive impairment, and high elopement risk exited the facility unsupervised after exhibiting increased exit-seeking and wandering behaviors. Despite repeated door alarms and staff awareness of the resident's agitation, no increased supervision was implemented, and the resident was able to leave through an alarmed exit, descending multiple stairs to a parking lot without assistance.
The facility failed to maintain food safety standards, with observations of unsanitary conditions in the kitchen, improper food storage, and staff not adhering to hand hygiene protocols. Issues included lack of soap and towels at the hand sink, exposed raw burger patties, and outdated or unlabeled food items. Staff were observed not washing hands after glove changes and consuming personal drinks without proper hygiene measures.
The facility failed to implement Enhanced Barrier Precautions and ensure proper use of PPE during resident care, as observed with several residents requiring such precautions. Staff inconsistently wore gowns and gloves during high-contact activities, such as transfers and personal care, despite clear indications of EBP requirements. Additionally, the facility did not maintain equipment and surfaces to prevent bacterial harborage, with issues like leaking fixtures and non-cleanable shelving contributing to potential contamination risks.
The facility failed to update care plans for two residents using assistive devices, resulting in inaccurate care plans. One resident with chronic pain and foot drop was observed using PRAFO braces without corresponding care plan interventions. Another resident with paralysis and muscle atrophy used a hard AFO, also lacking care plan documentation. Staff interviews revealed a lack of communication and documentation, with therapy recommendations not incorporated into care plans.
The facility failed to assist two residents with personal hygiene and clothing changes. One resident, with cognitive impairment and muscle atrophy, was observed disheveled and wearing the same clothes over consecutive days, while another resident with physical limitations reported not being offered shaving assistance for two weeks. Staff interviews revealed inconsistencies in providing expected care during shower days.
A resident with venous ulcers did not receive consistent wound care as per physician orders, leading to a missed treatment. Despite having a care plan for skin integrity, the facility staff failed to adhere to the treatment schedule, with a nurse documenting a missed treatment due to the resident sleeping. Interviews revealed that staff were expected to complete treatments within their shift or communicate any issues, but this protocol was not followed.
A resident with muscle wasting and atrophy was not provided with necessary splints to prevent worsening contractures due to a lack of communication and documentation in the care plan. Staff were unaware of the resident's need for splints, and one splint was found to be broken, highlighting a failure in implementing care plan interventions.
A resident with a tracheostomy experienced breathing difficulties due to inadequate respiratory care. Despite visible distress and an empty oxygen tank, an LPN failed to provide necessary suctioning or replace the oxygen tank, leaving the resident at risk. The resident's medical history included chronic respiratory failure and pneumonia, and orders for suctioning and oxygen were not followed. The incident was not documented, highlighting a deficiency in the facility's care.
A facility failed to provide or correctly use adaptive feeding equipment for a resident with dysphagia, leading to potential risks. The resident, who required a Provale cup to manage swallowing difficulties, was observed with inappropriate drinking vessels like a Styrofoam cup with a straw. Despite staff education on the necessity of the Provale cup, the deficiency persisted, indicating non-compliance with prescribed adaptive equipment needs.
A resident fell and sustained a serious injury due to improper use of a sit-to-stand mechanical lift by a CNA who did not follow the care plan requiring a two-person assist and proper use of straps. The resident was hospitalized and underwent surgery for a distal left femoral fracture.
Menus Not Followed Consistently During Meal Service
Penalty
Summary
Menus were not consistently followed for multiple residents who were served incorrect foods or incorrect serving sizes compared with their diet orders and the facility’s menu spreadsheets. Resident #26 had a diabetic consistent carbohydrate diet order and, during breakfast service, was served a full banana even though the meal ticket and menu spreadsheet indicated she should have received 1/2 a banana. Resident #50 had an NAS diet order and was served only 1 sausage link at breakfast even though the meal ticket and menu spreadsheet indicated 2 sausage links; she reported it was irritating not knowing if her meals would be delivered with everything she was supposed to get. Resident #55, who had a regular diet order, was also served only 1 sausage link instead of 2 and reported his meals were served with inaccuracies approximately 60 percent of the time. Resident #3 had a diabetic consistent carbohydrate, mechanical soft diet order and was served lunch with diced cooked carrots but no peas, even though the meal ticket indicated peas and carrots. The facility’s menu spreadsheet for that meal had been changed the prior afternoon to peas and carrots instead of guacamole, but the tray line had two pans of carrots and no separate pan of peas. The dietary manager stated the facility only had carrots and did not have any peas to prepare or serve. Resident #63, who was on a mechanical soft diet, was also served lunch with only diced cooked carrots and no peas despite the meal ticket indicating peas and carrots. During a confidential resident council interview, 9 of 11 residents reported the menus were not consistently followed and said dinner meals and weekend meals were the worst for menu inaccuracies. Resident council minutes also identified kitchen running out of menu items as an area for improvement. Facility staff described a tray-line process in which tickets were reviewed while meals were plated, but the registered dietitian confirmed that missed items could occur due to a breakdown in communication between dietary staff. The report also noted that on one lunch service, the facility substituted tater tots for curly fries and tapioca pudding for rice pudding because extra products were available, and puree residents were given tomato soup instead of the menu items because the main entrée had not been prepared for puree texture.
Meal Preferences and Diet Orders Not Consistently Followed
Penalty
Summary
The facility failed to ensure that resident food preferences, allergies, and intolerances were consistently honored for multiple residents reviewed for dining. Resident #26, who was cognitively intact, reported that meal tickets were not followed consistently. During breakfast observation, her tray ticket indicated she should receive 6 ounces of coffee and 8 ounces of sugar-free punch, but neither beverage was served and milk was the only beverage provided with the meal. Resident #1, who was cognitively intact, had a regular diet order with no milk, and his nutrition care plan documented milk as a dislike, lactose intolerance, and no snacks with milk per his request. He reported the facility served dairy-containing items in error about once per meal and said staff were not following his meal ticket. During breakfast observations, his ticket indicated a margarine pat and later a peanut butter packet, but he was served salted butter containing milk instead of margarine and did not receive the peanut butter packet. Resident #24, who was cognitively intact, was observed at breakfast with a meal ticket indicating a banana, but no banana was served. Resident #50, who was cognitively intact and had a NAS diet order with regular texture and thin consistency, was observed at breakfast with a meal ticket indicating cream of wheat, no added salt, and specified creamer and sugar packets. Her tray was served with an added salt packet and without the cream of wheat, and she reported having to request additional creamer and sugar. On another breakfast observation, her ticket indicated frosted flakes and no salt packet, but she was served a different cereal and a salt packet. During a confidential resident council interview, all 11 residents in attendance reported concerns that meal ticket preferences were not being followed, and several said the problem had gotten worse recently.
Kitchen Sanitation and Cooling Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area after surveyors observed multiple sanitation issues during a kitchen tour with the Dietary Manager. The can opener on the preparation table had a blade covered in dried red debris, the underside of the juice machine had accumulations of debris where the spouts were mounted, one clean mechanical scoop had dried food debris in the ladle portion, and the inside of the milk cooler showed increased accumulation of white and yellow staining and debris on the bottom and sides. The Dietary Manager acknowledged the debris on the juice machine and stated it should be cleaned daily. During the same survey, the Dietary Manager stated that some items from lunch service might be saved if there was enough and indicated that the soup would probably be kept for another couple of days. Later, surveyors found a 12-quart container of Lemon Chicken and [NAME] soup from lunch in the two-door reach-in cooler with the lid ajar for venting, and the soup temperature was 115F in the center of the container. The Dietary Manager stated the soup had been saved after lunch but was unsure when cooling started and was unsure of the time-temperature frequency for proper cooling, stating only that it needed to get down to 41F. The report cited the 2022 FDA Food Code requirements for clean food-contact surfaces and for cooling cooked TCS food within the required time and temperature limits.
PPE, Shared Equipment, and Respiratory Device Cleaning Failures
Penalty
Summary
The facility failed to ensure proper use of PPE for enhanced barrier precautions and transmission-based precautions, failed to clean shared resident equipment, and failed to clean respiratory equipment for multiple residents. These failures were observed during resident care, room cleaning, and equipment use, and involved staff entering rooms, handling wound care, using shared monitoring equipment, and leaving respiratory devices visibly soiled in resident rooms. Resident #39 had an indwelling medical device and a care plan that directed staff to wear a gown and gloves during high-contact resident activities. During an observation, an LPN assisted the resident with repositioning and took a blood pressure reading without wearing a gown or gloves. After leaving the room, the LPN placed the blood pressure cuff on the medication cart without cleaning it. Resident #5 had a stage 3 pressure ulcer to the right shoulder, but the care plan did not include enhanced barrier precautions. During wound care, the UM and wound care NP removed the dressing, cleaned the wound, measured it, and took photos, but neither staff member wore gowns during the treatment. The UM stated the facility had not initiated enhanced barrier precautions because the wound drainage was not the type that would require precautions, and confirmed the resident had an open wound. Resident #17 was on airborne and contact precautions for active COVID-19 infection, with signage on the door directing staff to wear an N95 or higher-level respirator, gown, gloves, and eye protection. During observations, a housekeeper entered the room without goggles, left and re-entered the room multiple times while wearing the same PPE, kept the room door open, and handled supplies from a hallway cart with unwashed hands before putting on new gloves. An LPN later entered the room with a portable vitals monitor without goggles or a face shield, then left the monitor unattended in the hallway and later used the same shared monitor on another resident before parking it near the medication cart again. Staff interviews confirmed that PPE should have been worn and that shared equipment should have been disinfected after use. Resident #30 had an oxygen concentrator in the room that was visibly covered with dried splatters, dirt, dust, debris, and material resembling food crumbs on repeated observations. The respiratory therapist stated the concentrator was dirty, had sent a picture to the equipment company, and did not clean it or notify facility staff. Resident #50 had BiPAP orders and used the device nightly, but the BiPAP face mask remained visibly soiled with white debris and red flakes over several days while stored in the room. The resident reported staff helped with the mask, and the RT confirmed that visibly soiled BiPAP or CPAP masks should be cleaned before the scheduled weekly cleaning.
Failure to Respond to Call Lights and Meet Resident Needs
Penalty
Summary
The facility failed to provide care and services that promoted dignity and respect for Resident #39, a cognitively intact resident with muscle weakness, chronic pain syndrome, and an ADL self-care deficit related to impaired mobility who required assistance from two staff members for ADLs. During observation, the resident was calling out for help from bed, and the DON entered the room, told the resident someone would come help, and left without obtaining assistance from the LPN or CNA on the hall. The resident’s call light was not on when the DON left, and the resident later reported that she had asked to be straightened up in bed and was left waiting for help. The resident continued to yell for help, and an LPN who was nearby did not check on her. When the surveyor entered the room, the resident was lying in bed leaning over the side near her tray table, and her call light was on the ground under the bed and out of reach. The resident stated she was yelling because she did not have her call light. On another observation, the resident spilled water on the floor around her bed and again yelled for help. An LPN entered, told the resident she would turn on the call light so someone could clean it up, and left the room. When the LPN returned later, the call light was off but the water had still not been cleaned up. The resident reported that some staff did not care for her or want to take care of her because she was "high maintenance," explaining that she needed two staff for ADL care and therefore required more staff time. She also reported that staff would often turn off her call light and say they would return but would not always come back, and that staff sometimes forgot to give her a call light so she had to yell out for help. A CNA reported that staff often turned off call lights without addressing residents’ needs and that residents had complained about having to turn their call lights back on. Resident council interviews and meeting minutes also documented repeated concerns that staff turned off call lights, left before needs were met, and returned only after residents had to call again.
Failure to Honor Resident’s Preferred Morning Routine
Penalty
Summary
The facility failed to honor Resident #39’s preferences for customary routines and activities. Resident #39 was admitted with diagnoses including muscle weakness and chronic pain syndrome, and her MDS assessment showed a BIMS score of 15/15, indicating she was cognitively intact. Her care plan included assistance with ADLs due to impaired mobility and assistance/escort to activities because of physical limitations and weakness in a wheelchair. Resident #39 stated that she preferred to eat breakfast in her room and then get up for the day so she could attend morning activities, which usually began at 10:00 AM. She reported that she often was not able to get up until 10:00 AM to 12:00 PM and believed staff sometimes waited to provide her care because she required two staff members for assistance. During observation, staff entered her room at 10:16 AM to assist with morning care. Multiple staff members confirmed that Resident #39 frequently had to wait to get up because she required two-person assistance and staffing was difficult. Staff reported that call-ins, the need to pick up breakfast trays, other residents needing two-person assistance, and residents leaving for dialysis contributed to delays. Staff also confirmed that Resident #39 sometimes had to wait until lunch time to get up and that she occasionally missed or arrived late to morning activities because she was waiting for staff.
Rooms and Bathrooms Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure resident rooms were kept clean and in good repair for Resident #21, Resident #22, and Resident #30. Resident #21 was cognitively intact with a BIMS score of 15/15 and was independent with self-propelling her wheelchair up to 50 feet. During observation, her room walls were noted to be in disrepair, with multiple dime-sized holes, deep gouges, scraped-off paint exposing drywall, and an area near the sink with extensive scrapes and peeling paint. Exposed metal corner bead was visible in several areas from the floor to about 3 feet high, and Resident #21 stated she did not like the condition of the walls and found them depressing. Resident #21 also reported concern about the exposed metal corner near her sink because she wore clothing that left her legs exposed and her skin broke open easily. In the shared bathroom between rooms [ROOM NUMBERS], dried brown drops were observed on wall tiles behind the toilet, a strong urine odor was present, and thick brown buildup was noted around the toilet base sealant. On a later tour, the same bathroom remained soiled with additional dried brown drops on the tiles and the same buildup around the toilet base. The Housekeeping Manager confirmed resident bathrooms should be cleaned daily. Resident #22 had severe cognitive impairment with a BIMS score of 7 and was observed in bed with the wall near the head of the bed showing approximately 10 areas of gouges and missing paint, including scratches and an area of missing paint about 8 inches long by half an inch wide. The condition remained unchanged on a later observation. Resident #30 was cognitively intact with a BIMS score of 13/15 and stated the wall beside the bed did not look good and should be painted. Observations and interviews with Maintenance and the DON confirmed the wall had gouges and peeling or missing paint, and staff described beds being moved into walls during care in the small rooms. Additional tours found multiple rooms with gouges and scratches near the head of the bed, and the spa areas contained wet washcloths, dirty clothes, and debris under the shower bed mattress.
Failure to Provide Written Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to ensure that proper discharge notifications were completed for Resident #39, resulting in the resident not receiving written notice of bed hold when transferred from the facility to the hospital. Resident #39 was originally admitted with diagnoses including muscle weakness and chronic pain syndrome, and the electronic medical record showed the resident was transferred to the hospital on 1/16/26. Review of the record did not locate documentation of written notice of bed hold for that transfer. During interview, the Nursing Home Administrator and Director of Nursing reported that the nurse caring for Resident #39 on the day of transfer had not given the resident written notice of a bed hold. The report also states that the facility identified the failure to provide the written notice and clarified that the Admissions Coordinator was responsible for initiating contact with the hospital and/or responsible party within 24 hours of transfer.
Failure to Provide Scheduled Bathing and Hair Care
Penalty
Summary
The facility failed to provide appropriate ADL care, including showers and hair washing, for two residents who were dependent on staff assistance. One resident had an ADL self-care deficit related to impaired mobility, required assistance from two staff members, and had a care plan directing ADL assistance, bathing or showering as preferred, and sponge baths when a full bath or shower could not be tolerated. During interview, the resident stated she did not always receive adequate ADL care and missed showers or bed baths at times, and her hair was observed to be disheveled and greasy. Bathing documentation for this resident showed limited completed showers and bed baths across the reviewed months, with refusals also documented, and the shower sheets reflected only a few showers and bed baths over that period. CNAs reported that when staffing was low, residents who required longer assistance did not get showers or bed baths, and that this resident required two-person assistance and a long shower, making it difficult to complete her care when fewer than five CNAs were on day or evening shift. The DON reviewed the bathing documentation and confirmed the facility was missing documentation to verify the resident was receiving scheduled twice-weekly showers or baths or refusals. A second resident had diagnoses including adjustment disorder with depressed mood and seborrheic dermatitis, a BIMS score of 15/15, and a care plan calling for bathing or showering as preferred and medicated shampoo. The resident was observed with shiny, soiled hair, distinct comb lines, and hair sticking together, and reported that her hair had not been washed in two weeks and that she was bothered by its condition. She stated a staff member who had previously helped wash her hair had left, and her hair remained dirty, oily, and itchy; she later reported her scalp was very itchy before her hair was washed the evening prior to the interview. The shower record showed she received assistance with showering four times during the month reviewed.
Failure to implement pressure injury care plans and protect residents from skin breakdown
Penalty
Summary
The facility failed to implement resident-specific comprehensive care plans for two residents and failed to prevent the development of a pressure ulcer for one resident. Resident #13 was admitted with limitations in activities due to disability and had a BIMS score of 15/15, indicating cognitive intactness. Her care plan included interventions for ADL self-care deficit and, after pressure injury formation was identified, frequent turning and repositioning. Wound orders were in place for intact blisters on both 5th metatarsal areas, and later documentation noted the left foot wound was deteriorating with the superficial layer lifting. During multiple observations, Resident #13 was found lying in bed with her feet directly against the foot of the bed while wearing Prevalon boots. She reported that she developed pressure ulcers on her feet because she was too tall for the bed and her feet would lie directly on the foot of the bed. Staff interviews confirmed that she had developed both wounds at the facility because her bed was too small for her, that boosting was not done on a set schedule, and that the facility had not considered moving her to a room that could accommodate a larger bed. The wound care nurse practitioner also confirmed that the left foot wound was deteriorating and that the treatment order needed to be updated because the blister had detached. Resident #52 had diagnoses including diabetes, traumatic brain dysfunction, arthritis, non-Alzheimer's dementia, and partial paralysis of the right arm and leg, and was dependent on staff for ADLs. His MDS indicated he was at risk for pressure ulcers, and his care plan addressed skin integrity with interventions including elevating heels off the bed surface and Prevalon boots on at all times. However, the record later showed the order changed to Prevalon boots on when in bed for pressure relief at bedtime, and the care plan did not include this updated order. Observations showed the boots were not on the resident, with the boots found on the closet floor during one observation and the resident in bed or in his wheelchair without them during others. Staff stated he did not need to wear the boots, and the unit manager acknowledged that therapy discontinued the order but the care plan was not updated.
Improper Administration of Morphine
Penalty
Summary
The facility failed to follow professional standards of practice for medication administration for a resident with unspecified dementia and severe cognitive impairment, as shown by a BIMS score of 00/15. The resident had a care plan addressing behavioral concerns related to dementia and was ordered morphine sulfate oral solution 20 mg/mL, 0.25 mL by mouth three times daily for chronic pain. During a medication administration observation, an LPN prepared the morphine dose and placed the syringe into an 8-ounce cup of cranberry juice after reporting that the resident refused medications and that hospice had obtained an order to give the morphine in juice. The LPN then placed the cup on the resident’s breakfast tray on the meal cart rather than taking it to the resident’s room and remaining with the resident during administration. The LPN marked the morphine as administered in the MAR and then left the medication cart to pass medications to other residents while the resident was eating and drinking in her room. The observation and interviews showed that CNA staff were aware the resident was receiving medication in juice, and one CNA stated the resident drank all of the cranberry juice before the LPN returned to check on her. Another CNA reported that nurses sometimes put the resident’s morphine in milk, while a different CNA said she had no knowledge that medications were being placed in the resident’s drinks. The UM stated the resident had not been assessed to self-administer medications and that nurses were expected to follow the rights of medication administration and supervise residents while they took medications. The DON stated she was not aware that nurses were administering morphine in cups of juice or milk and that nurses were supposed to observe residents when administering medications.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Elopement
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, delusional disorder, Parkinson's disease, and Alzheimer's disease, who was assessed as a high risk for wandering and elopement, exited the facility unsupervised. The resident had been actively exit seeking and displaying increased agitation and wandering behaviors for at least two days prior to the incident. Despite these behaviors, staff did not implement increased supervision or additional interventions beyond closing doors and attempting redirection. The resident was able to leave the facility through a dining room exit door, which led to a series of steep concrete stairs and a parking lot. On the night of the incident, staff observed the resident wandering the halls, testing doors, and expressing a desire to leave the facility. The resident was given PRN pain and anti-anxiety medications and was believed to be resting in bed shortly before the elopement. However, the resident managed to exit her room, traverse the facility, and open the dining room exit door, which triggered an alarm. Staff responded to the alarm and found the resident outside in the parking lot, having descended multiple flights of stairs without her walker, in cold weather conditions. Interviews with staff revealed that the resident had been exhibiting increased exit-seeking behaviors, including setting off door alarms and attempting to leave through various exits. Staff assignments and coverage were limited due to short staffing, and staff were not present on the resident's hall at the time of the elopement. The resident had a recent history of unwitnessed falls and was not considered safe to ambulate unsupervised, yet no increased supervision was implemented during the period of heightened exit-seeking behavior.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. At the only hand sink in the kitchen, there was no soap or paper towels available, which are essential for proper hand hygiene. The Food Services Director acknowledged the absence of soap, stating it had run out and needed to be replenished from the basement. Additionally, a box of raw burger patties was found open and exposed in the freezer, contrary to food safety standards that require food to be stored in covered containers to prevent cross-contamination. Further observations revealed unsanitary conditions in various areas of the kitchen. The door gasket seals on a two-door unit and the milk cooler were found with an accumulation of black debris. The dish machine area had debris on its top surfaces and wet debris underneath. A mechanical scoop hanging above the three-compartment sink was found with dried-on food debris, indicating a failure to maintain clean food-contact surfaces. In the pantry, several food items were improperly labeled or outdated, including salsa without a label or date, a mac and cheese product past its best-by date, and various other items that exceeded safe consumption dates. During meal service, a staff member was observed not washing hands after changing gloves and using a wiping cloth to clean gloves, which is against food safety protocols. Another staff member drank from a personal drink and returned to the serving line without washing hands or changing gloves. These actions violate the FDA Food Code, which mandates handwashing after certain activities to prevent contamination. The report highlights multiple deficiencies in food safety practices that could potentially lead to foodborne illness among residents.
Failure to Implement Enhanced Barrier Precautions and Maintain Sanitary Conditions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and ensure the use of Personal Protective Equipment (PPE) when providing direct care to residents, as observed in multiple instances. For Resident #9, who required EBP due to a urinary catheter and tube feeding, staff members were observed assisting with transfers without wearing gowns or gloves, despite signs indicating EBP requirements. Interviews with staff revealed a lack of understanding and inconsistent practices regarding when PPE should be worn, particularly during transfers. Similarly, Resident #35, who was on EBP due to unhealed surgical wounds, was transferred by CNAs who did not wear gowns, only gloves. The CNAs engaged in direct contact with the resident during the transfer process, including adjusting clothing and changing a soiled shirt, without adhering to the full PPE requirements. This inconsistency in PPE usage was also noted with Resident #24, who had multiple chronic ulcers and a urinary catheter, and Resident #10, who had a catheter and required assistance with personal care. In both cases, staff did not don gowns during high-contact activities such as repositioning and transferring. Additionally, the facility failed to maintain equipment and surfaces in a manner that would reduce the risk of bacterial harborage. Observations revealed issues such as a leaking hopper sprayer, a slow leak behind a toilet causing discoloration, and the use of press board shelving in the central supply room, which is not easily cleanable. These deficiencies in maintaining sanitary conditions further increased the risk of contamination and infection spread within the facility.
Failure to Update Care Plans for Assistive Devices
Penalty
Summary
The facility failed to update and revise the person-centered care plans in a timely manner for two residents, resulting in an inaccurate reflection of their current status and needs. Resident #3, diagnosed with chronic pain syndrome, muscle weakness, back pain, diabetes with neuropathy, and osteoporosis, was observed wearing bilateral PRAFO braces due to foot drop. However, there was no focus or intervention for these devices in the care plan, nor was there an order for the device. Despite multiple observations confirming the use of the PRAFO devices, the care plan remained unchanged, and the CNA was unaware of the intervention due to its absence in the care guide. Similarly, Resident #25, with a history of paralysis, stroke, heart failure, and muscle atrophy, was observed using a hard AFO on the left lower leg. The care plan for this resident also lacked any focus or intervention for the AFO, and there was no order for the device. Interviews with staff, including the CNA, DPT, and UM, revealed a lack of communication and documentation regarding the use of these devices, as therapy recommendations were not incorporated into the care plans. The DON was unaware of the absence of these interventions in the care plans, indicating a breakdown in the process of updating and revising care plans based on residents' current needs and therapy recommendations.
Failure to Assist Residents with Personal Hygiene and Clothing Changes
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in the areas of personal hygiene and changing clothes. Resident #13, who was moderately cognitively impaired and had muscle wasting and atrophy, was observed on multiple occasions to be disheveled, with messy hair and long chin hairs, and wearing the same clothes over consecutive days. Despite the care plan indicating a need for assistance with daily care needs, there was no documentation of shaving being offered, and the resident expressed a desire for help with shaving and changing clothes daily. Resident #54, who had significant physical limitations due to muscle wasting, paralysis, and other conditions, reported not being offered assistance with shaving for two weeks. Observations confirmed that the resident remained unshaven despite having shower days scheduled. Interviews with staff, including a CNA and RN, revealed an expectation that shaving should be offered during shower days, but this was not consistently done. The Director of Nursing also confirmed that shaving should be completed during showers if residents desired it.
Failure to Implement Consistent Wound Care Interventions
Penalty
Summary
The facility failed to consistently implement venous ulcer interventions, monitoring, and treatments as per physician orders for a resident with wounds. The resident, who was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and peripheral vascular disease, had a care plan that included specific interventions for skin integrity and wound care. Despite these orders, the facility did not adhere to the prescribed treatment schedule, resulting in a missed wound care treatment. Interviews with facility staff revealed inconsistencies in the execution of wound care treatments. The former unit manager expressed concerns about nurses not completing wound treatments, while a registered nurse incorrectly reported that the resident did not have any wounds. The unit manager confirmed that the resident had wound care orders that were not followed, as a treatment scheduled for a specific date was missed because the resident was sleeping, and the nurse did not attempt to complete the treatment later or communicate the missed treatment to the next shift. The director of nursing and other staff confirmed that it was unacceptable to skip treatments due to a resident sleeping and emphasized the expectation for nurses to complete all treatments within their shift or communicate any issues. The director also noted that there were sufficient staff available to assist with treatments if needed, indicating that the missed treatment was due to a lack of adherence to protocol rather than staffing issues.
Failure to Implement Care Plan for Contracture Management
Penalty
Summary
The facility failed to implement care plan interventions to prevent the worsening of contractures for a resident, resulting in the potential for worsening of contractures. The resident, who was moderately cognitively impaired and had a history of muscle wasting and atrophy, was observed with a contracted left hand. The resident reported that she used to wear a splint on her hand and arm, but staff had not put them on her lately, despite her preference to wear them. The care plan and orders for the resident did not include any orders for splints or braces for her left hand, although there were pictures and instructions for applying the splint in her room. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for splints. The Director of Rehab indicated that the resident was supposed to wear a modified splint for 2-4 hours daily, but therapy staff relied on nursing staff to enter orders, which were not present in the resident's chart. The therapy communication book listed the resident as needing splints, but nursing staff were unaware of this requirement. The Unit Manager and a CNA were unaware of the resident's need for splints, and it was discovered that one of the splints was missing a piece, rendering it unusable. The Director of Nursing acknowledged the oversight in ensuring the resident wore her splints daily due to therapy staff not entering their own orders or care plans.
Inadequate Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident with a tracheostomy, leading to breathing complications and a risk of infection. The resident, who had a history of stroke, traumatic brain injury, chronic respiratory failure, and pneumonia, was observed struggling to clear phlegm from his throat while seated in his wheelchair. Despite the resident's visible distress and inability to clear his airway, a Licensed Practical Nurse (LPN) walked past without offering assistance and later returned only to check the resident's oxygen saturation, which was at 97 percent, but did not replace the empty oxygen tank or provide suctioning. The resident continued to experience difficulty breathing, and the LPN left the room to finish her break without addressing the resident's immediate needs, such as replacing the oxygen tank or suctioning the tracheostomy site. The resident's medical record showed no documentation of this event, and interviews with other staff members revealed that the resident should have been monitored closely due to his history of aspiration pneumonia and continuous coughing. The Director of Nursing (DON) and Unit Manager (UM) both acknowledged that the LPN should have taken immediate action to address the resident's respiratory distress. The resident expressed fear during the incident, and it was noted that he had been hospitalized multiple times for pneumonia and sepsis. Orders for suctioning and oxygen administration were not followed, as evidenced by the lack of suctioning recorded in the Medication Administration Record (MAR) and the empty oxygen tank. The failure to provide timely and appropriate respiratory care, as well as the lack of documentation, contributed to the deficiency identified in the facility's care for this resident.
Failure to Provide Correct Adaptive Feeding Equipment
Penalty
Summary
The facility failed to provide or correctly use adaptive feeding equipment for a resident with dysphagia, resulting in the potential for decreased independence in consuming food and fluids and weight loss. The resident, who has a swallowing disorder, was observed multiple times with inappropriate drinking equipment, such as a Styrofoam cup with a straw, despite having orders for a Provale cup only. The care plan and dietary meal slips specified the use of a Provale cup to manage the resident's swallowing difficulties and prevent aspiration. Interviews with staff, including a CNA and a Speech Language Pathologist, revealed that the resident was at increased risk of aspiration and required the Provale cup to control the bolus size when drinking fluids. Despite this, the resident was consistently provided with inappropriate drinking vessels, indicating a failure in adhering to the prescribed adaptive equipment needs. The Speech Language Pathologist confirmed that the facility had educated staff and the resident on the necessity of using the Provale cup, yet the deficiency persisted.
Failure to Safely Transfer Resident Resulting in Serious Injury
Penalty
Summary
The facility failed to safely transfer a resident, resulting in a fall and serious injury. Resident #101, who was cognitively intact with a BIMS score of 14, was being transferred using a sit-to-stand mechanical lift by a CNA. The CNA did not follow the care plan, which required a two-person assist and the use of chest and leg straps. During the transfer, the resident let go of the grips, slid out of the sling, and fell to the floor, resulting in a distal left femoral fracture that required surgery. The resident reported that the straps were not buckled around her chest or legs, causing the sling to slide up her back and squeeze her lungs, leading to her fainting and falling hard onto the floor. The incident report confirmed that the CNA was alone during the transfer and did not follow the care plan instructions. The resident was immediately sent to the hospital, where she underwent surgery to repair the fracture and was discharged five days later. Interviews with staff revealed that the resident was not wearing appropriate footwear during the transfer, which is required for safe use of the sit-to-stand lift. The CNA involved was suspended and later terminated for failing to adhere to the facility's policies and procedures related to mechanical lifts. The facility's policy on mechanical lifts mandates that two staff members assist with transfers, ensuring the sling is properly placed for support. The facility identified that the failure to follow this policy led to the resident's fall and injury.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
