Regency At Chene
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 2295 E Vernor Highway, Detroit, Michigan 48207
- CMS Provider Number
- 235422
- Inspections on file
- 28
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Regency At Chene during CMS and state inspections, most recent first.
A cognitively intact resident with leukemia and pneumonia, assessed as not at risk for elopement and independent with ADLs, left the facility with family members without any LOA order, care plan, or documentation in the EHR. Staff, including an LPN and a CNA, assumed the resident was on an LOA based on informal comments, did not verify a physician order or sign-out information, and did not recognize or report the absence as a potential elopement until the end of the shift. The receptionist did not recall the resident leaving and did not have the resident identified in the elopement book, and existing signage instructing visitors to sign residents out was not effectively followed, resulting in the facility being unaware of the resident’s whereabouts.
The facility did not provide required information and access to the survey team in a timely manner, including the census, resident list, facility matrix, and WIFI access. Delays were attributed to staff unfamiliarity with the EMR system and incomplete access to clinical records, resulting in the survey team not receiving necessary documentation upon entry.
Several residents who required assistance with personal hygiene did not receive adequate care, including help with facial hair removal, showers, and nail care. One resident with multiple health conditions was observed with excessive facial hair and unclean nails, and reported not receiving scheduled showers due to inability to self-perform. Other residents were observed with long, dirty, or jagged fingernails, despite care plans indicating staff should provide this assistance. Documentation of care was incomplete, and relevant policies were not provided upon request.
Surveyors identified failures in medication storage and labeling, including expired and undated medications found on two medication carts, and unsecured medications left unattended on a cart by an LPN. The DON and unit manager confirmed these actions were not in accordance with facility policy. A resident involved was cognitively intact and recovering from knee surgery with multiple chronic conditions.
Staff were observed handling eating utensils without gloves and serving food with long, unrestrained hair, contrary to hygienic standards. Nursing staff participated in meal service without using required hair restraints, while dietary staff complied with these standards. The DON was unaware of the need for nursing staff to use hair restraints during meal service.
Staff did not consistently follow infection control protocols, including enhanced barrier precautions and proper use of PPE, for residents requiring such measures. In one case, a CNA handled soiled linen without a gown due to missing signage, and in another, a resident's PICC line was left uncovered and without a sterile cap. Additionally, a wound care nurse failed to perform hand hygiene between glove changes during wound care for two residents with complex medical needs.
Multiple residents were observed using wheelchairs with torn and ragged armrests, and several facility areas, including the walk-in freezer and nourishment rooms, had broken tiles, open holes, and unsanitary conditions. Kitchen equipment was found to be non-functional or leaking, and documentation regarding these issues was not provided to administration as requested.
A CNA took a photo of a resident's exposed buttocks with a personal cell phone after the resident expressed concerns about cleanliness following incontinence care. The photo was shown to the resident and an RN, leaving the resident feeling embarrassed, ashamed, and unsafe. The incident was not documented in the medical record, and facility policy prohibiting personal device use and resident photography was violated.
A resident with multiple medical conditions was found with their call light out of reach and hazardous items left at the bedside by family, without any care plan interventions or staff education to address these safety concerns. Staff acknowledged the issues but no documentation or care planning was in place to prevent recurrence.
A resident with end stage renal disease and an AV fistula did not have timely or complete physician orders for dialysis, clear fluid restriction parameters, or restrictions on blood pressure measurements on the arm with the fistula. Staff documented blood pressures on the affected arm and were unclear about the status of special instructions versus medical orders in the EMR, resulting in incomplete guidance for care.
A resident with cerebrovascular disease and vascular dementia was repeatedly observed being transported and seated in a wheelchair without footrests, resulting in poor posture and feet dangling. The resident reported that staff did not replace the footrests after removing them, and an Activities Assistant confirmed transporting the resident without footrests, contrary to facility policy and expectations.
Two residents did not receive pressure ulcer care as ordered by their physicians. In both cases, the wound care nurse failed to use the specified dressings and securement methods during wound care, despite clear orders and care plans. The nurse acknowledged not following the orders when questioned, and the facility's policy requires adherence to physician directives.
A resident with a history of stroke and moderate cognitive impairment was found to have long, thick toenails and dry, flaky skin due to a lack of timely foot care. Nursing staff confirmed the condition, and records showed the resident had not received podiatry services for approximately eight months, despite physician orders and facility policy requiring regular assessment and referral for such care.
A resident with hemiplegia and hemiparesis following a stroke did not receive prescribed splint application or ROM exercises, as staff failed to perform or document these interventions. The resident's splints were found unused, and interviews confirmed that CNAs were not completing the restorative program as ordered, with no documentation of care provided in the medical record.
A resident with impaired cognition and multiple medical conditions was left at risk for accidents due to inaccessible call lights, hazardous cleaning products at the bedside, and lack of staff intervention or family education regarding safety. Staff were aware of the issues but did not document or address them appropriately.
A resident with multiple chronic conditions and on hospice care was observed using an oxygen concentrator with a filter visibly covered in lint and dirt. Staff interviews revealed confusion about who was responsible for cleaning and maintaining the oxygen equipment, and the resident's care plan lacked interventions addressing equipment maintenance. Despite a contract with an outside company for oxygen equipment upkeep, the filter was not cleaned or replaced as required.
A medication cart was left unattended with an open EMR screen displaying a resident's PHI in a hallway, making confidential information visible to unauthorized individuals. An LPN confirmed leaving the cart unsecured, which was not in line with facility policy. The resident involved was recovering from knee surgery and was cognitively intact.
A resident with severe cognitive impairment and a history of acute cerebral vascular insufficiency and dysphagia did not receive routine dental services despite a physician order for evaluation and treatment. The care plan lacked documentation of dental concerns, and the MDS was incomplete for oral/dental status. Staff interviews revealed a lack of awareness and follow-through regarding the resident's dental needs, and dental notes were not available at the time of survey exit.
A resident with dysphagia and self-feeding difficulties was not provided with a physician-ordered scoop plate during meals, despite documentation and care plan requirements. Staff served meals on a regular plate and were unaware of the adaptive equipment order, while the necessary requisition for the scoop plate was not submitted, resulting in the resident not receiving the prescribed assistive device.
Two residents receiving hospice care did not have their comprehensive hospice documentation, including assessments and consents, accessible in their records as required. Nursing staff and management were unable to initially locate these documents, which were later found to be held by the administrator. Both residents had complex medical conditions and required significant assistance with daily activities. The DON acknowledged that hospice documentation should have been available to staff but could not account for its absence, resulting in a lack of coordinated hospice care.
A resident with multiple medical conditions and severe cognitive impairment did not receive the Pneumococcal and Influenza vaccines despite having signed consent forms. There was no documentation of vaccine administration in the medical record, and the facility could not provide the influenza vaccination policy when requested.
A resident admitted with acute pancreatitis and found to be cognitively intact did not receive a comprehensive MDS assessment within the required timeframe, with the assessment overdue by more than 120 days. The MDS nurse did not provide information about alerts for late assessments, and the DON indicated that policy should have been followed.
A resident with multiple chronic conditions did not receive any scheduled medications during an evening medication pass, and there was no documentation of administration or vital signs for that shift. Staff interviews confirmed the medications were not given, and the MAR was left blank, contrary to facility policy requiring proper administration and documentation.
A resident with multiple chronic conditions did not receive scheduled medications during an evening shift, and the MAR was left blank with no documentation from nursing staff. Facility staff, including the DON and an LPN, were unable to determine which nurse was assigned to the resident due to incomplete records and limitations in the electronic scheduling system.
A resident with a PEG tube did not receive the prescribed enteral feeding or water flush due to unlabeled and undated feeding and water bags, and an unprogrammed water flush rate. The resident's PEG tube insertion site was improperly cared for, with no dressing or abdominal binder applied. The facility's Enteral Nutrition policy was not followed, leading to this deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound and PEG tube. Staff provided care without wearing required gowns, and there was no signage or PPE supply cart available. The Director of Nursing acknowledged the lapse, despite staff being in-serviced on EBP. The resident's records indicated a physician's order for EBP, but the facility's policy was not followed, risking infection spread.
Two deficiencies were identified in respiratory care practices. The first involved a resident requiring mechanical ventilation who did not have an emergency tracheostomy readily accessible. During an observation, staff were unable to promptly locate a spare tracheostomy, leading to a delay in emergency care. The second deficiency was related to the failure to label and date oxygen tubing for a resident receiving oxygen therapy. The tubing was found to be unlabeled and undated, with the resident unable to recall the last change, posing a potential risk of respiratory infections.
The facility failed to maintain sanitary conditions in the kitchen, with soiled non-food contact surfaces and debris on equipment. Additionally, a meal test tray revealed improper food temperatures, with macaroni and cheese, collard greens, and fried chicken holding below the required 135 degrees F. These deficiencies could potentially affect 143 residents who receive meal services.
The facility failed to maintain the garbage storage area in a sanitary condition, with exterior trash dumpsters observed with open lids and surrounding trash and debris. Staff indicated this was a recurring issue after trash pickup. The facility's waste disposal policy and the 2017 U.S. Public Health Service Food Code were not adhered to.
The facility failed to ensure the 2nd floor wireless nurse call light system was effectively utilized by staff or had consistently functioning centralized monitor screens. A resident's bedside nurse call device was found frayed and taped over, and the nurse's station did not have an audible alarm. Further observations revealed that the computer monitors at various nurse's stations were either not displaying notifications or were turned off, leading to potential delays in response times and unmet resident care needs for 47 residents.
A resident was not dressed in their personal clothing, causing verbal frustration and impaired mental and psychosocial well-being. Despite reporting the issue to social services, no action was taken, and the resident's closet had limited clothing. The facility's policy mandates dressing residents in their desired clothing, but this was not followed.
The facility failed to ensure a call light was within reach for a resident with severe cognitive impairment and multiple medical conditions, and did not provide a wheelchair for another resident with a fractured hip. Both deficiencies resulted in unmet care needs, as confirmed by staff and multiple observations.
The facility failed to update PASARR forms for a resident with bipolar disorder and paranoid personality within the required 30-day period. The resident's MDS assessment indicated cognitive impairment and antipsychotic medication use. Staff interviews revealed that a new PASARR should have been completed 25 days after admission but was only done on the day of the survey. The DON confirmed that the Social Worker is responsible for PASARRs and that they should be reviewed on admission and sent for Level II evaluation if needed.
The facility failed to revise care plans in a timely manner for two residents, leading to deficiencies in their care. One resident's care plan did not address new wounds, and another resident's care plan was not updated after the removal of an indwelling catheter.
The facility failed to implement an appropriate discharge plan for a resident who had been in the facility for two months and expressed a desire to return home. Despite being alert and capable of making independent decisions, the resident was not receiving therapy and was left without a clear discharge plan. Staff interviews revealed a lack of communication and coordination regarding the resident's discharge.
The facility failed to provide adequate nail care, scheduled showers, and assistance with transfers out of bed for two residents. One resident had long, dirty fingernails despite being dependent on personal hygiene assistance, while another resident reported not being offered scheduled showers or assistance to get out of bed for three months, resulting in unkempt and greasy hair with a foul odor.
The facility failed to adequately assess and monitor wounds for a resident with a pertinent diagnosis of acquired absence of right and left leg above the knee. Despite the wounds being reported, there was no documentation of assessment, measurement, or monitoring, and no care plan was initiated, contrary to the facility's policy.
A resident was observed using broken reading glasses due to the facility's failure to provide vision services. Despite several requests to social services, the resident had not received assistance in obtaining new prescription glasses, which had been lost two years ago. The resident's medical record indicated intact cognition and a history of dementia, anxiety, and falls.
The facility failed to follow infection control standards during medication administration for a resident with Type 2 Diabetes. An LPN did not use a barrier for the glucometer, failed to clean it properly, and neglected hand hygiene, leading to potential cross-contamination risks.
Failure to Follow LOA Procedures Resulting in Unmonitored Resident Departure
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate supervision and follow its Leave of Absence (LOA) policy for a cognitively intact resident, resulting in the resident leaving the building with family without the facility’s knowledge of their whereabouts. The resident had been admitted with leukemia and pneumonia, had intact cognition per the MDS, and was independent with ADLs including ambulation. An elopement risk assessment completed prior to the incident indicated the resident was not at risk for elopement. However, there was no physician order, no care plan, and no documentation in the electronic health record authorizing or describing an LOA for this resident at the time they left the facility. On the evening in question, the resident was seen on the front door camera properly dressed and walking out of the facility with several family members at approximately 6:00 PM. The receptionist did not recall seeing anything unusual and did not remember seeing the resident leave, despite a sign at the exit instructing visitors to sign residents out when leaving. The facility did not have information on who the resident left with, where they were going, or how long they would be gone, and the resident was not listed in the receptionist’s elopement book. The resident did not return to the facility as expected, and the next morning it was reported in the morning meeting that the resident had not come back from what staff believed was an LOA. Staff interviews revealed that both nursing and CNA staff assumed the resident was on an LOA without verifying orders or documentation. An LPN stated that a CNA had told her the resident went on an LOA with family, but she did not check for an LOA order, did not confirm who the resident was with, and did not report the resident’s absence until the end of her shift. A CNA reported that when she went to pick up the resident’s dinner tray, the resident was not in the room and had earlier been with several visitors; she assumed the resident had gone somewhere with them and did not recognize the situation as a potential elopement, nor did she initiate an elopement response. The facility’s LOA policy required physician orders, care planning, sign-out/sign-in procedures, and implementation of elopement protocol if a resident left without the facility’s knowledge and whereabouts were unknown, but these procedures were not followed in this case.
Failure to Provide Timely Survey Information and Access
Penalty
Summary
The facility failed to provide timely and required information to the survey team upon entry and during the annual recertification survey, affecting all residents. Upon arrival, the survey team leader requested a facility census, resident list, and matrix from an RN, but these were not provided. Subsequent requests for the same information, as well as WIFI access, were made to the DON and NHA, with the full set of documents and access not provided until over an hour after entry. The WIFI access provided did not function throughout the survey, further impeding the process. The entrance conference worksheet, which outlines the required timeframes for document provision, was sent to the NHA, and the entrance conference was conducted, with the NHA confirming familiarity with the electronic file sharing platform. Delays continued as the NHA reported not having full access to the clinical portions of the EMR, and the DON was new and still acclimating to the system. Additional required documents, such as hospice agreements and dialysis contracts, were not provided within the required timeframe and had to be requested again. The DON later acknowledged that any unit manager should have been able to provide a census upon surveyor entry and agreed that the survey team was not provided timely documentation upon entry.
Failure to Provide Adequate Assistance with Personal Hygiene and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living, specifically in the areas of personal hygiene, for several residents who were unable to perform these tasks independently. One female resident was observed with excessive facial hair and dark matter under her fingernail, and reported not receiving scheduled showers due to pain from arthritis, which she could not manage without help. Documentation of her showers was incomplete or missing, and there was no record of her refusing care or assistance with facial hair removal. Her medical history included rheumatoid arthritis, dysphagia, diabetes with neuropathy, hypertension, acute kidney failure, and spinal stenosis, all of which contributed to her need for assistance with personal hygiene. Three other residents were observed with long, jagged, or dirty fingernails, and in some cases, debris under the nails. Interviews with staff and review of records confirmed that these residents required assistance with personal hygiene due to severe or moderate cognitive impairment, paraplegia, or hemiplegia following a stroke. The facility's care plans and Kardexes indicated that staff were to observe and trim nails on shower days, but observations and interviews revealed that this was not consistently done. There was no documentation in the electronic medical records of refusals of care for these residents. The Director of Nursing confirmed that CNAs were expected to check and provide nail care on shower days and during regular care, but this was not consistently documented or performed. Additionally, when requested, the facility was unable to provide the relevant policies for activities of daily living, shower, and nail care by the time of survey exit.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication management within the facility. During an inspection of two medication carts, expired and undated medications were found, including an expired vial of Humulin R insulin, an opened and undated vial of Lantus insulin, expired Vitamin E pills, and expired Fish Oil pills. When questioned, the registered nurse present was unable to provide an explanation for the presence of expired and undated medications. The Director of Nursing confirmed that staff are expected to follow facility policy, which requires medications to be dated and discarded per manufacturer guidelines. Additionally, a medication cart was found left unattended in a hallway with three prescribed medications unsecured on top of the cart. The LPN responsible admitted to leaving the cart and medications unattended while attending to a resident's vital signs. The unit manager and DON both confirmed that facility policy requires medication carts to be locked and that no medications should be left unattended or on top of the cart. The resident involved was cognitively intact and had a history of osteoarthritis, recent knee replacement, borderline diabetes, lipidemia, and hypertension.
Failure to Follow Hygienic Practices During Meal Service
Penalty
Summary
Surveyors observed that staff failed to follow hygienic practices during meal service, specifically in the handling and serving of food and utensils. Nursing staff were seen wrapping silverware in napkins and placing them on tables after washing their hands, but they touched the eating portions of the utensils without wearing gloves. Additionally, staff with long, loose hair were observed serving and assisting residents with food and beverages without using hair restraints, as required by professional standards and the 2013 Food Code. These practices were noted during multiple meal services in both the first and second-floor dining areas, involving approximately 30 residents at one time. The dietary manager confirmed that all dietary staff wore appropriate hair restraints, but the nursing staff, who also participated in meal service, did not. The Director of Nursing was unaware of the requirement for nursing staff to use hair restraints while assisting with meal service. The lack of proper glove use and hair restraints by nursing staff created the potential for food contamination during the observed meal services.
Failure to Follow Infection Control Protocols and Hand Hygiene Standards
Penalty
Summary
Staff failed to follow enhanced barrier precautions (EBP) and use appropriate personal protective equipment (PPE) for residents requiring infection control measures. In one instance, a certified nursing assistant (CNA) removed soiled linen from a resident on EBP without wearing a gown, as required. The CNA was unaware of the resident's EBP status due to the absence of a precautionary sign on the door. The infection control registered nurse later placed the sign, and interviews revealed that staff were expected to verify EBP status through the electronic medical record (EMR) or Kardex system. The resident involved had significant medical conditions, including end-stage renal disease and bacteremia, and a physician order for EBP was present in the EMR prior to the incident. The facility's EBP policy was requested but not provided at the time of the interview. Another deficiency was observed when a resident with a peripherally inserted central catheter (PICC) line was found in physical therapy with the line uncovered and lacking a sterile cap. The director of nursing (DON) acknowledged that the PICC line should have been covered with a sterile cap after each use, as outlined in the facility's policy for PICC line care. The policy specified that an end cap should be placed on the connector to reduce the risk of vascular-associated infections. The resident had a history of osteoarthritis, contracture, pain, and a surgical wound. Additionally, the facility failed to ensure proper hand hygiene during wound care for two residents. The wound care nurse was observed repeatedly removing gloves and donning new ones without performing hand hygiene between glove changes while providing wound care to residents with surgical wounds and pressure ulcers. The DON confirmed that staff would be re-educated on hand hygiene. The facility's hand hygiene policy emphasized the importance of hand washing to prevent healthcare-associated infections. The residents involved had complex medical histories, including recent surgeries, amputations, and pressure ulcers.
Failure to Maintain Safe and Sanitary Environment Due to Broken Equipment and Unsanitary Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of broken and unsanitary equipment and areas. Several residents were observed using wheelchairs with torn and ragged armrests, and one resident's wheelchair had uneven armrests. In the kitchen area, the walk-in freezer had approximately 5-6 missing floor tiles at the threshold, creating an indentation and a visible gap at the bottom of the freezer door, which led to ice accumulation and safety concerns. Delivery staff required assistance to move goods into the freezer due to the broken tiles. The Dietary Manager stated the threshold had been missing for over a year, and the Maintenance Manager indicated repairs were in process. Additionally, a double-deck steamer was non-functional, and a leaking faucet in the dish room caused water to overflow the sink. The nourishment rooms on both the first and second floors were found to be soiled and littered with paper and debris. The first-floor nourishment room had cracked floor tiles around the sink, creating an uneven surface, while the second-floor nourishment room had a 6x6 inch open hole in the wall, which was covered by a garbage can. The Dietary Manager reported that dietary staff monitored the nourishment rooms three times daily, but cleaning was the responsibility of housekeeping. Requested documentation regarding the broken equipment and safety concerns was not submitted to the Administrator by the time of the survey exit.
Violation of Resident Dignity and Privacy Due to Unauthorized Photograph
Penalty
Summary
A certified nurse assistant (CNA) failed to treat a resident with dignity and respect by taking a photograph of the resident's exposed buttocks using a personal cell phone. The incident occurred after the resident expressed concern about not feeling clean following incontinence care. The CNA, in response, took out their phone, asked the resident if they wanted to see a picture, and then took and showed the photo to the resident. The CNA also showed the photo to a registered nurse (RN) present at the time. The resident reported feeling embarrassed, ashamed, nervous, and scared as a result of this action. The resident involved had a history of multiple medical conditions, including hypertension, heart failure, diabetes, morbid obesity, asthma, peripheral vascular disease, epilepsy, obstructive sleep apnea, lymphedema, and anxiety. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The care plan for the resident included interventions to encourage participation in self-care, provide positive reinforcement, and maintain a calm approach due to anxiety. Despite these interventions, the incident was not documented in the resident's medical record, and there was no evidence of psychosocial follow-up or documentation by staff regarding the resident's emotional state after the event. Facility policy explicitly prohibits the use of personal electronic devices, including cell phones, in resident care areas and strictly forbids taking photographs of residents. The CNA admitted to knowing that having a phone on the floor and taking pictures of residents was against policy. The lack of documentation and follow-up in the medical record, as well as the violation of privacy and dignity policies, contributed to the deficiency identified during the survey.
Failure to Develop and Implement Care Plan Interventions for Resident Safety
Penalty
Summary
The facility failed to develop and implement care plan interventions to monitor and prevent accidents for a resident, resulting in a potentially unsafe environment. During observations, the resident's call light was found on the floor and out of reach, and the resident was unaware of its location while expressing feeling unwell and requesting assistance. The bed was positioned at its highest height, further increasing the risk of accident. Staff acknowledged that the call light was out of reach after care had been provided, and it was noted that someone had just left the room without ensuring the call light was accessible. Additionally, hazardous items such as hydrogen peroxide and comet cleaner were found on the resident's bedside table on separate occasions. Staff indicated that the resident's family frequently brought in items and left them without informing staff, and there was no documentation of interventions, education, or care planning to address this ongoing behavior. The care plan did not include any measures to address the family's actions or to prevent unsafe items from being left with the resident, despite the resident's medical history of rheumatoid arthritis, dysphagia, lower back pain, diabetes mellitus with neuropathy, hypertension, acute kidney failure, and spinal stenosis.
Failure to Ensure Timely and Complete Dialysis Orders and Fluid Restriction Parameters
Penalty
Summary
A resident with end stage renal disease and dependency on dialysis was found to lack timely and complete physician orders for dialysis services. Observation revealed the resident had multiple cups of liquid and a large bottle of juice at the bedside, while the electronic medical record (EMR) did not contain a physician order for dialysis or clear directives regarding fluid restrictions. Additionally, there were no orders restricting staff from obtaining blood pressures on the resident's left arm, which contained an arteriovenous (AV) fistula used for dialysis. Documentation showed that blood pressures were recorded on the left arm on several occasions despite the presence of the AV fistula. Interviews with facility staff, including an LPN and the DON, confirmed the absence of a dialysis order in the medical orders section of the EMR and uncertainty about whether special instructions in the EMR qualified as medical orders. The facility's policy required a physician order for hemodialysis and monitoring of fluid restrictions for dialysis residents, but these requirements were not met for this resident. The lack of clear and accessible orders and directives created the potential for missed treatment, compromised vascular access, and inadequate fluid management.
Failure to Use Wheelchair Footrests During Resident Transport
Penalty
Summary
The facility failed to ensure that wheelchair footrests were in place during transportation and to assist with proper seated posture for a resident. On multiple occasions, the resident was observed sitting in a wheelchair without footrests, with her feet dangling and in a slouched position, both while stationary and while being transported by an Activities Assistant. The resident reported that staff often removed the footrests and did not replace them. The Activities Assistant acknowledged transporting the resident without footrests and stated that footrests should be used to prevent injury. Review of the resident's medical record indicated a history of cerebrovascular disease and vascular dementia, with moderate cognitive impairment and a need for dependent assistance with mobility. The Director of Nursing confirmed that footrests should be used during transportation and for positioning to ensure safety. Facility policy also stated that footrests should be down when the wheelchair is moving to prevent injury.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with physician orders and standards of clinical practice for two residents. For one resident with a left above-the-knee amputation and additional wounds on the right foot, the wound care nurse did not follow the physician's order for wound dressing. Specifically, the nurse used an ACE wrap instead of the ordered kerlix to secure the dressing on the right foot. The resident's care plan included interventions to follow facility protocols for impaired skin integrity, but these were not adhered to during observed wound care. For another resident with a history of a gunshot wound, paralysis, and an unstageable sacral pressure ulcer, the wound care nurse also failed to follow the physician's wound care order. The nurse did not secure the sacrococcyx wound with border gauze as ordered, instead applying only Maxorb AG and ABD dressing. Both incidents were observed directly, and the wound care nurse acknowledged not following the physician's orders when questioned. The facility's policy requires treatments to be rendered in accordance with specific physician orders, which was not done in these cases.
Failure to Provide Timely and Adequate Foot Care
Penalty
Summary
A deficiency was identified when a resident with a history of epilepsy, hemiplegia, and hemiparesis following a stroke was found to have long, thick toenails and dry, flaky skin on their feet. The resident, who had moderate cognitive impairment and required dependent assistance for personal hygiene, reported that their nails were not being adequately cared for. Observations by nursing staff confirmed the condition of the resident's feet, and it was noted that the resident had not seen a podiatrist for approximately eight months, despite having a physician's order for podiatry evaluation and treatment as indicated. Review of the resident's care plan indicated that staff were to observe finger and toenails on shower days to determine if trimming was needed, but there was no documentation of care refusals or evidence that this was being consistently done. The facility's policy required referrals to ancillary providers based on individualized needs, but the resident's last podiatry visit was significantly delayed. The deficiency was attributed to the facility's failure to provide timely and adequate foot care, including appropriate podiatry services, for the resident.
Failure to Provide and Document Required Splint Application and ROM Exercises
Penalty
Summary
A deficiency was identified when a resident with a history of epilepsy, hemiplegia, and hemiparesis following a stroke was not provided with the required application of splints and range of motion (ROM) exercises as ordered. Observations showed the resident in bed without the prescribed splints, and the splints were later found stored in a dresser drawer. The resident reported that staff were not applying the splints, stating that they were too busy. Interviews with a CNA and a registered nurse confirmed that splints were not being applied and ROM exercises were not being performed. The registered nurse indicated that CNAs were responsible for these tasks, but there was no restorative nurse or aides assigned to the program at that time. A review of the resident's electronic medical record revealed no documentation of splint application or ROM exercises, nor any record of refusals, for several weeks. The resident's care plan and Kardex included specific instructions for splint use and ROM exercises, but these interventions were not carried out or documented. The facility's policy required daily documentation of restorative care and interventions, but this was not followed for the resident in question.
Failure to Prevent Accident Hazards and Ensure Supervision
Penalty
Summary
A resident was found to be at risk for accidents due to multiple lapses in safety and supervision. On two separate occasions, the resident's call light was not within reach—once entangled in linens and another time on the floor—leaving the resident unable to summon assistance when feeling unwell. Additionally, the resident's bed was observed at its highest position, and the resident was unable to lower it independently. Staff acknowledged that the call light should always be accessible and that the resident required a Geri chair due to issues with the wheelchair armrests and risk of sliding out. Potentially hazardous products, including hydrogen peroxide and Comet household cleaner, were found at the resident's bedside. Staff indicated these items were likely left by the resident's family, who frequently brought in various items without notifying staff. There was no documentation of staff educating the family about safety or addressing the issue, and the unit manager was unaware of the situation. The resident had significant medical conditions, including impaired cognitive function, incontinence, and required assistance with activities of daily living.
Failure to Maintain Sanitary Oxygen Equipment for Resident
Penalty
Summary
The facility failed to ensure that respiratory equipment, specifically an oxygen concentrator and its components, was maintained in a sanitary manner for a resident receiving oxygen therapy. Observations revealed that the oxygen tubing was dated and changed, but the oxygen concentrator's filter was visibly covered with lint and dirt, which was confirmed by the surveyor upon inspection. Interviews with staff, including a hospice aide and a nurse, indicated confusion and lack of clarity regarding responsibility for the maintenance and cleaning of the oxygen equipment. The hospice aide stated she was only responsible for placing the oxygen back on the resident after care, while the nurse deferred responsibility to maintenance. The care plan for the resident did not include interventions related to the maintenance or cleaning of the oxygen equipment or its filter. The resident involved had multiple significant medical diagnoses, including atrial fibrillation, hypertensive heart disease with heart failure, type 2 diabetes mellitus, lymphedema, venous insufficiency, dementia, and acute respiratory failure with hypoxia. The resident was moderately cognitively impaired, frequently incontinent, and required extensive assistance with mobility and transfers. Despite a contract with an outside company to maintain oxygen equipment, the filter on the resident's oxygen concentrator was not cleaned or replaced as required, and there was no documentation or clear delegation of responsibility for this task in the resident's care plan or facility records.
Unsecured Medication Cart Exposes Resident PHI
Penalty
Summary
A medication cart on unit 300 was observed left unattended with the electronic medical record (EMR) screen open, displaying a resident's protected health information (PHI) in a hallway accessible to staff and residents. The cart was not secured, and the EMR was visible to unauthorized individuals. The LPN responsible for the cart confirmed leaving it unsecured with PHI visible, acknowledging this was not in compliance with facility protocol. The unit manager and Director of Nursing both confirmed that staff are expected to lock the cart and secure the EMR screen when not in use, as per facility policy. The resident whose PHI was exposed had been admitted for operative recovery from a total left knee replacement and had a history of borderline diabetes, lipidemia, and hypertension. The resident was cognitively intact at the time of the incident. Facility policies reviewed stated that residents' privacy must be safeguarded and that medication carts should be locked at all times when not in use or not within constant vision.
Failure to Provide Routine Dental Services for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide routine dental services to one resident with severe cognitive impairment and a history of acute cerebral vascular insufficiency and dysphagia. The resident was observed to be edentulous and unable to communicate about his oral health needs. Despite a physician order for a dental evaluation and treatment, there was no documentation in the care plan addressing dental concerns or the absence of teeth. The Minimum Data Set (MDS) for the resident did not have the oral/dental status completed. Interviews with facility staff revealed that the social worker was unaware of the resident's dental needs, even though a physician order was present. The DON acknowledged that the resident should have been seen by a dentist and confirmed that the social work department was responsible for arranging dental appointments. Dental notes for the resident were requested but not provided by the time of survey exit. Facility policy indicated that referrals to ancillary providers should be made based on identified needs, but this process was not followed for the resident in question.
Failure to Provide Prescribed Adaptive Eating Equipment
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, obesity, and self-feeding difficulties was not provided with the prescribed adaptive eating equipment, specifically a scoop plate, as ordered by the physician and indicated on the care plan. The resident was observed being fed by staff using a regular plate instead of the adaptive equipment, despite the tray card and physician order specifying the need for a scoop plate. Staff interviews revealed a lack of awareness regarding the therapy recommendations and the physician's order for the scoop plate. The dietary aide confirmed that the resident previously received meals with a scoop plate, but the new order on the tray card was not matched with the actual provision of the equipment due to the absence of a requisition for purchase. Further review showed that the registered dietitian was unaware of the order and discovered that therapy had not submitted the necessary requisition to obtain the scoop plate. The facility's policy required adaptive equipment to be provided based on comprehensive assessment, but this process was not followed, resulting in the resident not receiving the prescribed adaptive device. The resident's medical record indicated multiple diagnoses, including acute respiratory failure, dysphagia, and muscle weakness, and the MDS assessment showed moderate cognitive impairment and a need for one-person assistance with ADLs.
Failure to Maintain Accessible Hospice Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that relevant hospice documentation was accessible for two residents who were receiving hospice services. For one resident, the nurse was unable to locate the comprehensive assessment, consent for hospice benefits, or the hospice comprehensive plan of care in the designated Hospice Notebook. The unit manager and social worker were also initially unaware of the location of these documents, and it was later revealed that the administrator had them. The documents showed that the resident had been admitted to hospice, but there was a possible lapse in service as indicated by the dates on the comprehensive assessment benefit period. The resident had multiple diagnoses, including atrial fibrillation, heart failure, diabetes, lymphedema, venous insufficiency, dementia, and acute respiratory failure, and required extensive assistance with daily activities. For the second resident, the hospice comprehensive assessment was not included in the electronic health record until a later date, despite the resident being admitted to hospice care earlier. This resident also had significant medical conditions, including acute cystitis, dysphagia, severe malnutrition, pressure ulcer, vascular dementia, aphasia, and major depression, and required maximal assistance for most activities of daily living. The Director of Nursing confirmed that the hospice documentation should have been accessible in the residents' records but was unable to explain why it was missing. The lack of accessible hospice documentation resulted in a lack of coordination of comprehensive services and care for both residents.
Failure to Administer and Document Pneumococcal and Influenza Vaccines
Penalty
Summary
The facility failed to administer both the Pneumococcal and Influenza vaccines to one resident, despite having obtained signed consent for these vaccinations. Documentation provided by the Infection Control RN confirmed that the resident had signed to receive both vaccines, but there was no evidence in either the vaccination book or the electronic medical record that the vaccines were actually administered. The Director of Nursing acknowledged the absence of documentation for vaccine administration, even though the expectation was that residents who sign consent forms would receive the vaccines. The resident involved had multiple significant medical conditions, including a history of stroke, chronic obstructive pulmonary disease, hypertension, generalized anxiety, major depressive disorder, dysphagia, and aphasia. The resident was also noted to be severely cognitively impaired. Facility policy required documentation of vaccine administration, including the injection site, in the medical record, but this was not completed. Additionally, the facility was unable to provide the influenza vaccination policy when requested during the survey.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for one resident who was admitted with a diagnosis of acute pancreatitis and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15. Review of the resident's electronic medical record showed that the MDS assessment was overdue by more than 120 days. During interviews, the MDS nurse did not respond when asked about receiving alerts for late assessments, and the DON stated that the MDS nurse should follow the facility's policy for MDS assessments.
Failure to Administer and Document Scheduled Medications
Penalty
Summary
A deficiency occurred when a resident did not receive any of their scheduled medications during an evening medication pass. The resident, who had diagnoses including hypertension, heart disease, and diabetes, reported not receiving their medications, which included insulin and a blood pressure pill, on the specified evening. Review of the Medication Administration Record (MAR) confirmed that none of the medications scheduled for that time were signed out, and there was no documentation of vital signs or blood sugar checks for that shift. The resident's subsequent vital signs and blood sugar were within normal limits the following morning, but the lack of medication administration and documentation was evident for the evening in question. Interviews with facility staff, including the LPN and DON, revealed that neither could initially determine who was assigned to the resident during the shift, and the MAR remained blank for all scheduled medications. The LPN later identified as assigned to the resident stated they did not recall working that assignment and confirmed that if the MAR was blank, the medications were not given. The facility's policy requires medications to be administered according to physician orders and documented on the MAR, which was not followed in this instance.
Incomplete Medical Records and Unclear Nurse Assignment for Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident reviewed for medication administration. On the evening of February 6th, the resident did not receive any of their scheduled medications, and the Medication Administration Record (MAR) for that shift was left blank with no signatures or documentation from nursing staff. The resident, who had diagnoses including hypertension, heart disease, and diabetes, reported not receiving medications and was unable to identify the nurse assigned to them that evening. The resident's electronic health record also lacked progress notes, vital signs, and blood sugar results for the relevant shift. Upon review, facility staff, including an LPN, nurse manager, and the Director of Nursing (DON), were unable to determine which nurse was assigned to the resident during the shift in question. The facility's electronic scheduling system only indicated which nurses were scheduled and clocked in, but did not specify unit assignments. The nurse identified as possibly assigned to the resident could not recall working with the resident or on that unit and stated that if the MAR was blank, the medications were not administered. The Nursing Home Administrator and DON confirmed there was no accurate way to determine the nurse assignment for that shift due to lack of documentation.
Failure to Provide Appropriate PEG Tube Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a PEG tube, resulting in the resident not receiving the prescribed amount of enteral feeding or water. During an observation, it was noted that the tube feeding bag was unlabeled and undated, with no indication of when it was hung. The water flush bag was also unlabeled and full, indicating that the resident did not receive any water flushes. The infusion pump showed that the tube feeding rate was set at 75 ml/hr, but the water flush rate was not programmed, resulting in a rate of 0 ml/hr. Licensed Practical Nurse (LPN) B acknowledged the error, stating that the water flush was not programmed, and the resident did not receive any water the previous night. Additionally, the resident's PEG tube port had broken, requiring a hospital visit for a new tube insertion. However, LPN B could not provide details on when the tube feeding and water were restarted or how much the resident received. The infusion pump indicated that only 705 ml of tube feeding had been infused, with no start date or time available. The resident's PEG tube insertion site was found open to air with a small amount of reddish drainage, and the required 4 x 4 split gauze was not properly adhered. The abdominal binder, ordered for PEG tube securement, was also not applied. The Director of Nursing (DON) confirmed the resident did not receive the prescribed enteral feeding or water flush and acknowledged the lack of labeling on the feeding and water bags. The facility's Enteral Nutrition policy requires labeling and specific orders for enteral feeding, which were not followed in this case.
Inadequate Infection Control Practices for Resident with Wound and PEG Tube
Penalty
Summary
The facility failed to ensure appropriate infection control practices related to Enhanced Barrier Precautions (EBP) for a resident with a wound and PEG tube. During an observation, the resident was found lying in bed with visibly soiled clothing and a soiled gauze dressing in the bed. Licensed Practical Nurse (LPN) and Certified Nursing Assistant (CNA) entered the room to provide incontinence care without wearing gowns, which are required under EBP for residents with wounds and indwelling medical devices. The staff acknowledged the need for gowns but had to leave the room to obtain them, as there was no signage or PPE supply cart available in or near the resident's room. The Director of Nursing (DON) confirmed the lapse in following EBP, noting that the staff had been in-serviced on the precautions but failed to implement them correctly. The resident's electronic health record indicated a physician's order for EBP due to the presence of a PEG tube and wound. The facility's policy mandates the use of EBP for residents with wounds or indwelling medical devices, requiring signage and readily available PPE. However, these measures were not in place, leading to the potential for the spread of infection.
Deficiencies in Respiratory Care: Emergency Tracheostomy and Oxygen Tubing Management
Penalty
Summary
The facility was cited for two deficient practices related to respiratory care. The first deficiency involved the failure to ensure an emergency tracheostomy was readily accessible for a resident (R138) who required mechanical ventilation. During an observation, it was noted that R138 did not have an emergency trach visible in their room, and staff members were unable to locate one promptly. Despite R138's history of respiratory failure and the need for a tracheostomy, there was no spare tracheostomy at the bedside, leading to a delay in accessing emergency care when needed. The second deficiency identified was the failure to label and date oxygen tubing for a resident (R48) receiving oxygen therapy. The observation revealed that R48's oxygen tubing connected to the concentrator was unlabeled and undated, with the resident unable to recall the last time the tubing was changed. Staff members acknowledged the importance of labeling and dating oxygen tubing to track usage and ensure cleanliness, highlighting the potential risk of respiratory infections associated with unclean tubing.
Sanitary Conditions and Food Temperature Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which resulted in an increased potential for cross-contamination of food and foodborne illness. Observations revealed soiled non-food contact surfaces, including ventilation filters above the fryer, the top and sides of the fryer, the sides of the oven next to the fryer, the grates of the flat top grill, and the six-burner oven's stainless steel backsplash. Additionally, the number ten can opener's cutting blade at the cook prep station was observed with visible debris and metal shavings. The flooring throughout all the facility's nourishment rooms was also found to have an accumulation of dust and debris. The Dietary Director acknowledged that these areas were not being cleaned sufficiently and timely, despite the kitchen's cleaning policy stating that these areas should be cleaned three times a day after each meal. No additional cleaning schedule documenting verification of the daily cleaning tasks was provided for review. The facility also failed to maintain proper food temperatures during meal service. A meal test tray revealed that the macaroni and cheese and collard greens were holding at a temperature of 105 degrees F, and the fried chicken at 100 degrees F, which is below the required 135 degrees F for hot holding. The Dietary Director and staff acknowledged the issue and mentioned the need for additional insulated meal carts and a functioning plate warmer to prevent meals from sitting too long before being served. This failure to maintain proper food temperatures could potentially affect 143 residents who receive meal services.
Improper Garbage Disposal and Sanitation
Penalty
Summary
The facility failed to ensure that the garbage storage area was maintained in a sanitary condition, which increased the potential for the harborage and feeding of pests. During a tour of the facility, the surveyor observed exterior trash dumpsters with lids in the open position and a variety of trash, debris, and used fryer oil surrounding the area. Staff E mentioned that the area often looks like this after trash pickup, and the doors are left open. The facility's waste disposal policy, dated April 2015, stated that outside dumpsters should be maintained in a clean manner, not overflowing, and with lids closed at all times. This was not adhered to, as observed by the surveyor. The 2017 U.S. Public Health Service Food Code also directs that receptacles and waste handling units should be kept covered with tight-fitting lids or doors if kept outside the food establishment, which was not followed in this instance.
Inconsistent Functioning of Nurse Call System
Penalty
Summary
The facility failed to ensure the 2nd floor wireless nurse call light system was effectively utilized by staff or had consistently functioning centralized monitor screens. During an environmental tour, a resident's bedside nurse call device was found frayed and taped over, and upon testing, it was observed that the nurse's station did not have an audible alarm, although the call light was flashing on a computer monitor. A Registered Nurse admitted that the sound was turned off because it was always going off. The Maintenance Director was unaware of the issue and mentioned that the system alarms at each nurse's station on the computer screen and through speakers, but no wireless pagers were used to notify staff of resident needs. Further observations revealed that the computer monitors at the 800, 500, and 600 hall's nurse's stations were either not displaying notifications or were turned off. The Maintenance Director had to reset and reattach cords to the monitors to get them functioning again. Additionally, a Registered Nurse expressed a preference for keeping the monitor off. Bells were available for use on each resident floor as an alternative notification method, but the primary nurse call system was not consistently operational, leading to potential delays in response times and unmet resident care needs for 47 residents.
Failure to Maintain Resident Dignity by Not Providing Personal Clothing
Penalty
Summary
The facility failed to maintain the dignity of a resident (R16) by not dressing them in their personal clothing. On multiple occasions, R16 was observed wearing clothes that did not belong to them, which caused the resident verbal frustration and impaired their mental and psychosocial well-being. R16 reported that their personal clothes had been missing for about two weeks, and despite informing social services, no action was taken. The resident's closet was observed to have limited clothing, and the assigned CNA confirmed that they had to dress R16 in miscellaneous clothes from the laundry that belonged to other residents. R16 was admitted to the facility with diagnoses including dementia, diabetes mellitus type two, malignant neoplasm of the stomach, and major depressive disorder. The resident was cognitively intact with a BIMS score of 14/15 and required extensive assistance with ADLs, including dressing. The facility's policy on Resident Dignity & Personal Privacy mandates that residents should be dressed in their desired clothing, but this was not adhered to in R16's case. The DON confirmed that it should take only one day to wash and return residents' clothes, indicating a failure in the facility's processes.
Failure to Provide Call Light and Wheelchair
Penalty
Summary
The facility failed to ensure a call light was within reach for one resident (R43) and a wheelchair was provided for another resident (R108), resulting in unmet care needs. R43, who has severe cognitive impairment and multiple medical conditions including dysphagia, chronic obstructive pulmonary disease, and hemiplegia, was observed lying in bed without a call light within reach. R43 expressed discomfort and the need for assistance to be repositioned. The facility's policy and R43's care plan both indicated that call lights should be within reach to ensure safety and assistance, but this was not adhered to, as confirmed by the LPN and the Director of Nursing (DON). R108, who was admitted with a fractured hip and no cognitive impairment, reported not having a wheelchair to get up. Multiple observations confirmed the absence of a wheelchair in R108's room. The Therapy Manager and the DON both acknowledged that it is the facility's responsibility to provide necessary mobility aids such as wheelchairs and walkers. Despite this, R108 was left without a wheelchair, which is essential for mobility and emergency situations. These deficiencies highlight the facility's failure to accommodate the needs and preferences of its residents as required by their policies and care plans.
Failure to Update PASARR Forms for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Annual Resident Review (PASARR) forms were reviewed, revised, and sent to the local state agency for evaluation of intellectual or developmental disability needs for one resident. The resident was admitted with diagnoses including bipolar disorder and paranoid personality, but the PASARR Level I screen from the hospital was not updated within the required 30-day period. The resident's Minimum Data Set (MDS) assessment indicated cognitive impairment and the use of antipsychotic medication. Interviews with facility staff revealed that a new PASARR should have been completed 25 days after admission, but it was only completed on the day of the survey. The Director of Nursing confirmed that the Social Worker is responsible for completing PASARRs and that they should be reviewed on admission and sent for Level II evaluation if needed.
Failure to Revise Care Plans in a Timely Manner
Penalty
Summary
The facility failed to revise care plans in a timely manner for two residents, leading to deficiencies in their care. Resident R18, who had bilateral above-the-knee amputations and two open wounds on the bottom back side of the right leg, did not have an updated care plan addressing these wounds. The care plan still included outdated interventions for previous conditions and had not been revised to reflect the current state of the resident's health. The Director of Nursing confirmed that the care plans should have been updated to include the new wounds and that the previous interventions should not have been documented as active. Resident R121, who was admitted with an indwelling catheter, had the catheter removed in March, but the care plan was not updated to reflect this change. The care plan still indicated the presence of the catheter, despite physician orders to discontinue it. The facility's policy on care planning requires that care plans be developed, reviewed, and revised based on comprehensive assessments, but this was not followed in the cases of R18 and R121.
Failure to Implement Appropriate Discharge Plan
Penalty
Summary
The facility failed to implement an appropriate discharge plan for a resident (R79) who had been in the facility for two months and expressed a desire to return home. Despite being alert, oriented, and capable of making independent decisions, the resident was not receiving therapy and was left without a clear discharge plan. The resident's clinical record indicated a goal to return to the community, but no active discharge planning was documented. Progress notes showed initial discussions about discharge plans, but no follow-up actions were taken, and no physician orders for discharge were present in the medical record. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge. The Therapy Manager was unaware of why the resident had not been discharged, and the Social Worker was not informed of the resident's desire to leave until the day of the interview. The facility's policy on discharge planning, which mandates that discharge planning should start at the time of admission, was not followed, resulting in the resident's prolonged stay and unmet needs.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate nail care, scheduled showers, and assistance with transfers out of bed for two residents. Resident R100 was observed with long fingernails and debris underneath, despite being dependent on personal hygiene assistance. There was no documentation indicating that R100 preferred long nails or had refused nail care. Observations over multiple days confirmed that R100's nails remained untrimmed and dirty. The Assistant Director of Nursing confirmed that residents' nails should be cleaned and trimmed unless otherwise preferred by the resident, which was not the case for R100. Resident R13 reported not being offered scheduled showers or assistance to get out of bed for the past three months. Observations revealed R13's hair was unkempt, greasy, and had a foul odor, with a knot that required cutting out. The resident's care plan indicated a need for assistance with various ADLs, including bathing and transfers, but there was no documentation of noncompliance with scheduled showers or getting out of bed. A review of the scheduled shower task showed missed opportunities for showers, marked as not applicable. The Director of Nursing confirmed that residents should be offered showers first and that refusals should be documented and care planned, which was not done in R13's case.
Failure to Adequately Assess and Monitor Wounds
Penalty
Summary
The facility failed to provide adequate assessment and monitoring of wounds for one resident (R18) out of three residents reviewed for wound care management. During an observation and interview, it was noted that R18 had two open wounds on the bottom back side of the right leg. The wounds were first reported on 4/7/24, but there was no documentation of assessment, measurement, or monitoring of the wounds after that date. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the wounds were not measured or documented as required by the facility's policy. The resident, who had a pertinent diagnosis of acquired absence of right and left leg above the knee and required substantial assistance with Activities of Daily Living (ADLs), did not have a care plan initiated for the wounds. The facility's policy on skin management mandates that new areas of skin impairment should be reported and assessed promptly, with weekly evaluations until resolved. However, this protocol was not followed, leading to a deficiency in wound care management for R18.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to provide vision services for a resident, resulting in inadequate eyewear. During an observation and interview, the resident was seen wearing broken reading glasses held together with tape. The resident reported that the prescription glasses had been lost about two years ago and that several requests had been made to social services for assistance in obtaining new glasses. The resident's electronic medical record indicated a history of dementia, anxiety, and falls, with intact cognition as per the latest Minimum Data Set (MDS) assessment. Social services staff confirmed that they were unaware of the resident's need for new glasses and stated that the resident would be scheduled to see an optometrist in the future. The Director of Nursing confirmed that it was the responsibility of the social services department to assist residents with such ancillary needs. The lack of timely assistance resulted in the resident using inadequate eyewear for an extended period.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to adhere to infection control standards during the administration of medication to a resident diagnosed with Type 2 Diabetes. An LPN entered the resident's room with blood glucose supplies in hand and placed the glucometer on the resident's bed without using a barrier. After performing the blood glucose test, the LPN did not clean the glucometer, did not perform hand hygiene, and placed the used glucometer back in the medication cart. The LPN acknowledged the failure to clean the glucometer properly and admitted to using an alcohol swab instead of the required disinfectant wipe. The Director of Nursing confirmed that the glucometer should be cleaned with a disinfectant wipe after each use and that alcohol wipes are not acceptable. The facility's policies on glucometer decontamination and hand washing were reviewed, indicating that the glucometer should be placed on a clean surface, cleaned with a disinfectant wipe, and hand hygiene should be performed after glove use. The LPN's actions were inconsistent with these policies, leading to a potential risk of cross-contamination and infection among residents.
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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