Regency At Whitmore Lake
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitmore Lake, Michigan.
- Location
- 8633 N Main Street, Whitmore Lake, Michigan 48189
- CMS Provider Number
- 235545
- Inspections on file
- 36
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Regency At Whitmore Lake during CMS and state inspections, most recent first.
A resident who was dependent on staff for bed mobility received catheter and peri care from a CNA using only a one-person assist, contrary to the care plan and Kardex instructions requiring two-person assistance. The CNA rolled the resident away from herself and left the resident close to the edge of the bed without handrails, increasing the risk of falling. The DON confirmed that the care plan required two-person assistance and proper technique, but the CNA had not reviewed the care plan recently.
The facility did not complete the care plan within 7 days of the comprehensive assessment and did not ensure that a team of health professionals prepared, reviewed, and revised the care plan as required.
The facility did not maintain room temperatures within the required 71-81°F range, with multiple areas exceeding this limit. Staff and a resident reported issues with inadequate cooling, old HVAC systems, and portable air conditioners that sometimes tripped circuit breakers. Despite weekly monitoring and use of fans and portable units, surveyors found several rooms and common areas above the regulatory temperature range.
Surveyors found that multiple residents received meals that were often cold, dry, repetitive, and lacking in condiments, with food preferences not consistently honored. Food trays were sometimes left in insulated carts for extended periods, resulting in improper temperatures, and staff did not always follow procedures for tray accuracy. Palatability tests and resident interviews confirmed issues with meal quality, presentation, and portion sizes, affecting residents' willingness to eat and potentially impacting their nutrition.
A resident experienced a delay in receiving their lunch meal, with the tray observed stored in a hallway cart past the usual serving time and not delivered until later by a CNA. This delay was inconsistent with the facility's stated meal service policy and affected up to 116 residents, increasing the likelihood of distress and decreased nutritional intake.
A deficiency was cited due to egress doors being equipped with locks or latches that require a tool or key from the egress side, without meeting the required special locking arrangement standards. The facility did not ensure that all conditions for clinical, security, or special needs locking—such as fail-safe electrical locks and integration with fire protection systems—were met, as observed during the survey.
A deficiency was cited due to corridor doors and doors protecting corridor openings not meeting regulatory requirements for fire and smoke resistance, positive latching hardware, and proper door clearance, as observed during the survey.
A resident with Alzheimer's disease and severe mental impairment was involved in multiple incidents of inappropriate sexual behavior toward female residents. Despite staff attempts to supervise, there was no formal care plan or consistent documentation of one-on-one supervision until after repeated incidents. Staff interviews revealed confusion about supervision requirements, and assignment sheets did not indicate the need for one-on-one monitoring.
A resident with severe cognitive impairment and a history of inappropriate sexual behavior was not consistently provided with one-on-one supervision, despite staff awareness of the need. Staff interviews and documentation review revealed that the supervision plan was not formalized as a physician's order, and assignment sheets did not indicate one-on-one supervision. This lack of clear communication and documentation resulted in repeated incidents where the resident was found unsupervised and engaging in inappropriate behavior with other residents.
The facility failed to prevent and correctly identify pressure ulcers for two residents, leading to misidentification and worsening of their conditions. One resident had a stage III pressure ulcer on the buttock, with incomplete skin assessments and care plans. Another resident had a painful pressure ulcer on the foot and a sacral wound misidentified as unstageable. The facility's interventions were not fully implemented, and staff lacked awareness of the residents' wound conditions.
A facility failed to provide palatable and appropriately temperature-controlled food, affecting 119 residents. Observations showed food items were often served below FDA temperature standards, leading to dissatisfaction. Residents reported meals were cold, unappetizing, and repetitive. Despite temperature audits, issues persisted, indicating inadequate resolution of the problem.
The facility failed to maintain and clean food service equipment, affecting 119 residents and increasing the risk of cross-contamination. Observations revealed soiled can opener assemblies and improperly stored scoops in food bins. Additionally, a loose ventilation grill in the dry storage room was noted. The facility's policies on maintenance and sanitation were not effectively implemented, leading to these deficiencies.
The facility did not reassess its ability to meet resident care needs after changes in resident acuity, including pressure ulcers, falls, and catheter care requirements. The assessment incorrectly listed the Administrator as the Governing Body, and the Administrator was unaware of her accountability to the actual Governing Body.
The facility failed to maintain a clean and safe environment, affecting 119 residents. Observations revealed issues such as a damaged smoking area canopy, porous surfaces in the laundry service area, and multiple maintenance deficiencies throughout the facility, including leaking water valves, broken light covers, and missing atmospheric vacuum breakers in shower rooms. The facility's maintenance policies were not effectively implemented, as evidenced by the lack of specific entries in the work order system for the observed concerns.
A resident with dementia reported abuse by a CNA, but the facility failed to report the allegation to the State Agency. Despite the resident's confusion and inability to identify the perpetrator, the facility's policy requires reporting all abuse allegations, substantiated or not, within specified timeframes. The NHA and SW concluded the abuse was unsubstantiated and did not report it, contrary to policy.
The facility failed to develop and implement comprehensive care plans for two residents with pressure ulcers. One resident had a stage III ulcer and moisture-associated skin damage, with care plan deficiencies in addressing refusals and interventions. Another resident, on hospice care, had pressure ulcers deemed unavoidable, but the care plan lacked interventions for refusals and coordination with hospice. Staff interviews revealed inadequate root cause analysis and documentation, highlighting systemic issues in wound care management.
A facility failed to revise the care plan for a resident with hand and muscle contractures. Despite recommendations for the resident to wear hand and elbow splints, observations showed the splints were not used, and staff interviews revealed inconsistencies in offering the splints. The care plan was not updated following therapy recommendations, leading to a deficiency in care.
A resident with dementia did not receive necessary podiatry care despite multiple requests from a family member over five months. The family member struggled to manage the resident's toenail care due to the nails' thickness and curling. Facility staff interviews revealed a lack of communication and responsibility in arranging podiatry services, with the LPN/Unit Manager acknowledging that the condition should have been documented and addressed during routine assessments.
A resident with hand contractures did not receive prescribed hand splints and positioning wedge to maintain range of motion. Despite care plans indicating the need for these interventions, observations showed the splints were not in use, and the resident reported being left on his back without repositioning. Staff interviews revealed inconsistencies in offering and applying the splints, and the care plan lacked updates following therapy recommendations.
A facility failed to ensure a physician documented the review of medication irregularities for a resident with cognitive impairment. The resident was on Divalproex and experienced mental status changes. The pharmacist recommended monitoring certain levels due to potential adverse effects, but there was no documentation of the physician's response. The DON could not find any documentation or explanation for the lack of physician action.
The facility failed to meet the nutritional needs and preferences of two residents, leading to dissatisfaction with meal consistency and adherence to dietary restrictions. One resident reported inconsistencies in receiving a chef salad and received meals with unwanted barbecue sauce. Another resident, who is underweight, experienced cold meals and missing items from their meal ticket. The Dietary Manager acknowledged issues with food availability and preparation, contributing to these deficiencies.
The facility failed to address pressure ulcers through its QAPI committee, resulting in two residents developing stage III or higher pressure ulcers. The wound nurse did not perform root cause analyses, and the DON did not conduct audits or implement plans to prevent further ulcers. The Administrator acknowledged the lack of a performance improvement plan for pressure ulcers.
A resident's social security debit card was misappropriated by an Activities Aide (AA) who was later arrested and charged with felonies for unauthorized use. The resident, with intact cognition, reported the AA as the last known person to have the card. Unauthorized transactions occurred while the resident was hospitalized, leading to the AA's identification through video footage and transaction records. The incident resulted in the resident's brother managing the card, causing a delay in personal purchases.
A resident with severe cognitive impairment was inappropriately restrained in a long-term care facility. Staff used a foam wedge to prevent the resident from leaving the bed and frequently placed him in a geri-chair, restricting his mobility. The resident, who was active and able to propel himself in a manual wheelchair, was often immobilized for convenience. The Director of Nursing acknowledged the misuse of restraints, which were not medically necessary.
A resident with severe cognitive impairment and a history of falls experienced a delay in receiving a stat x-ray for a hip and femur fracture. Despite staff awareness of the resident's condition and attempts to contact radiology, the x-ray was not completed before the resident was transferred to the hospital. The hospital confirmed fractures requiring surgery. The facility's DON acknowledged the delay and the need for supervision during the resident's unwitnessed fall.
A resident with severe cognitive impairment and a history of falls experienced a major injury due to inadequate fall prevention measures and delayed medical imaging. The resident, who was mobile and able to self-propel in a wheelchair, was often placed in a restrictive geri-chair, leading to restlessness and attempts to exit. Staff were unaware of the purpose of a foam wedge used to prevent the resident from exiting the bed, and there was a significant delay in obtaining a stat x-ray after the resident's family reported swelling and bruising.
A resident with a history of medical conditions experienced a fall and fracture due to inadequate supervision and failure to follow care-planned interventions. The resident was not properly positioned in a shower chair and was left unattended, leading to a fall. The incident was not reported immediately, and the care plan requiring a Hoyer lift was not followed, resulting in increased pain and medication needs for the resident.
A resident with Alzheimer's Disease experienced repeated falls due to inadequate supervision and engagement from staff in a locked unit. Despite the presence of CNAs and an RN, there was a lack of interaction with residents, leading to multiple falls. The facility's interventions, such as medication adjustments and diversional activities, were inconsistently implemented, and there was no thorough analysis of the falls' root causes.
A facility failed to provide adequate supervision and care on a unit for residents with cognitive impairments. A nurse took an extended break without ensuring coverage, leaving only an activities aide with the residents. This resulted in residents being unassisted, with some attempting to leave the unit or access restricted areas. The facility's protocol for staff breaks and coverage was not followed, leading to a deficiency in maintaining professional standards of care.
A facility failed to monitor and document a resident's blood pressure before administering amlodipine, as required by the physician's order. The resident, with severely impaired cognition and hypertension, had no recorded blood pressures in May and June 2024, despite receiving the medication daily. The DON confirmed the lack of documentation and improper order entry, violating the facility's medication administration policy.
Failure to Provide Two-Person Assist for Bed Mobility as Directed by Care Plan
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) provided activities of daily living (ADL) care to a resident who was dependent on staff for bed mobility, as documented in the resident's care plan and Kardex. The care plan specified that the resident required the assistance of two staff members for all bed mobility tasks, including rolling side to side. However, during an observation, the CNA performed catheter and peri care with only a one-person assist, instructing the resident to roll independently and rolling the resident away from herself rather than towards herself. The resident was observed to be very close to the edge of the bed during this process, and there were no handrails present to prevent a fall. Further review of the resident's records confirmed the requirement for two-person assistance with bed mobility. In interviews, the CNA stated she believed the resident was a one-person assist and had last reviewed the care plan three days prior. The Director of Nursing (DON) confirmed that the care plan required two-person assistance and that staff should roll residents towards themselves, not away. The failure to follow the established care plan and facility protocols for bed mobility assistance led to the deficiency.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. Additionally, the care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the surveyor's review of facility practices and documentation.
Failure to Maintain Safe Ambient Temperatures for Residents
Penalty
Summary
The facility failed to maintain ambient room temperatures within the regulatory range of 71-81 degrees Fahrenheit, affecting 116 residents. Observations and interviews revealed that certain resident rooms and common areas, particularly those exposed to direct sunlight, consistently exceeded the maximum allowable temperature, with readings as high as 88 degrees Fahrenheit. Staff reported that the facility's rooftop air conditioning units were old and insufficient, leading to the use of portable air conditioning units and fans. However, these portable units initially caused circuit breakers to trip, requiring adjustments to their placement. Temperature checks were reportedly conducted early in the morning, before outside temperatures rose, and weekly monitoring was performed by the maintenance director. A resident reported having to unplug personal devices to use a portable air conditioner, which would sometimes trip the circuit breaker. Despite the facility's efforts to supplement cooling with portable units and fans, multiple areas remained above the required temperature range during surveyor checks. Review of the facility's temperature monitoring logs for the previous 75 days did not show any recorded temperatures outside the regulatory parameters, despite surveyor findings to the contrary.
Failure to Provide Palatable, Appetizing, and Properly Tempered Meals
Penalty
Summary
Surveyors identified a deficiency in the facility's food service, specifically related to the palatability, temperature, and presentation of meals provided to residents. Multiple residents reported that food was often served cold, dry, or unappetizing, with specific complaints about hard waffles, cold biscuits and gravy, dry bread, and repetitive menus. Observations confirmed that food trays were sometimes left in insulated carts for extended periods before being delivered, resulting in meals being served at improper temperatures. Temperature checks revealed that hot foods were not consistently maintained at safe temperatures, and cold items such as juice were served above recommended temperatures. Additionally, condiments and food preferences were frequently not honored, with residents receiving items they had previously declined or not receiving requested items such as peanut butter sandwiches or condiments like butter, salt, and pepper. Interviews with dietary staff and review of facility policies revealed that while there were procedures in place for tray accuracy and honoring food preferences, these were not consistently followed. Staff acknowledged that condiments should be included based on tray tickets, but residents routinely reported missing condiments. The dietary manager and registered dietitian indicated that audits to ensure tray accuracy were planned but had not yet been implemented. Bread deliveries were only made once a week, contributing to complaints about stale and hard bread. Food palatability tests conducted by the surveyor further confirmed issues with meal presentation, taste, and portion sizes, with meals described as bland, overcooked, and lacking in visual appeal. The deficiency affected a significant number of residents who rely on the facility for their nutritional needs, with reports of decreased food acceptance and the potential for nutritional decline. Residents expressed dissatisfaction with the quality and variety of meals, and some reported skipping facility meals altogether. The facility's failure to consistently provide palatable, appetizing, and appropriately tempered food, as well as to honor resident preferences and provide necessary condiments, directly contributed to the deficiency cited by surveyors.
Delayed Meal Service and Failure to Meet Resident Preferences
Penalty
Summary
The facility failed to provide timely meal service in accordance with residents' needs, preferences, and requests, as evidenced by observations, interviews, and record reviews. One resident reported that breakfast was served around 9:00 - 9:30 A.M., lunch from 1:00 - 1:30 P.M., and dinner from 6:00 - 6:30 P.M. On the day of observation, the resident's lunch tray was seen stored in an insulated transport cart in the hallway at 1:57 P.M., and was not delivered until 2:04 P.M. by a CNA, who then assisted the resident with feeding. The facility's policy indicated that lunch should be served between 12:00 and 2:00 P.M. This delay in meal delivery affected up to 116 residents who consume food at the facility, increasing the likelihood of delayed meal service, emotional or psychosocial distress, and decreased food acceptance or nutritional decline. The deficiency was identified through direct observation of meal service practices, interviews with residents, and review of facility policies and procedures regarding meal times and the availability of alternative meals and snacks.
Deficiency in Egress Door Locking Arrangements
Penalty
Summary
A deficiency was identified regarding the facility's egress doors, which are part of the required means of egress. The doors were found to be equipped with latches or locks that require the use of a tool or key from the egress side, which is not permitted unless specific special locking arrangements are in place. The report outlines that for clinical needs or security threat locking, only one locking device is allowed per door, and staff must have reliable means for rapid removal of occupants, such as remote control, keyed access, or other reliable methods. Additionally, for special needs locking arrangements, the locks must be electrical and fail-safe, releasing upon power loss, and the area must be protected by both a supervised automatic sprinkler system and a complete smoke detection system, with both systems arranged to unlock the doors upon activation. The report further details that delayed-egress, access-controlled, and elevator lobby exit access locking arrangements are only permitted under specific conditions, such as the presence of approved fire detection and sprinkler systems. The deficiency was cited because the facility did not meet these requirements as evidenced by the survey findings. No specific information about individual residents or their medical conditions is provided in the report.
Noncompliance with Corridor Door Fire and Smoke Resistance Requirements
Penalty
Summary
A deficiency was identified regarding corridor doors and doors protecting corridor openings, which did not meet regulatory requirements for resisting the passage of smoke and fire. The report notes that doors in areas other than required enclosures of vertical openings, exits, or hazardous areas must be constructed of 1 3/4 inch solid-bonded core wood or other approved materials capable of resisting fire for at least 20 minutes, unless the smoke compartment is fully sprinklered, in which case only smoke resistance is required. Additionally, corridor doors and doors to rooms containing flammable or combustible materials must have positive latching hardware, and roller latches are prohibited. The clearance between the bottom of the door and the floor covering must not exceed 1 inch, and there must be no impediment to the closing of the doors. The report also specifies requirements for powered doors, hold open devices, protective plates, Dutch doors, and door frames. The deficiency was cited due to noncompliance with one or more of these requirements, as evidenced by the survey findings.
Failure to Timely Revise Care Plan for Resident's Sexual Behaviors
Penalty
Summary
The facility failed to revise and implement a comprehensive care plan addressing a resident's sexual behaviors following a significant incident. The resident, who had Alzheimer's disease and was deemed incompetent to make medical decisions, exhibited severe mental impairment as indicated by low BIMS scores. On one occasion, the resident was found in bed with a female resident, with his hand down her pants. Although staff attempted to keep the resident separated from female residents and initiated one-on-one supervision, this intervention was not formalized through a physician's order or documented in the care plan. There was no clear communication or documentation to ensure all staff were aware of the supervision requirement. Subsequent incidents occurred, including the resident being found naked in bed with another female resident, again without evidence of one-on-one supervision being in place. Interviews with staff revealed confusion and lack of awareness regarding the supervision status, and assignment sheets did not reflect any one-on-one supervision for the resident. The care plan was not updated to address the resident's sexual behaviors and the need for one-on-one supervision until after these incidents had occurred, indicating a failure to timely revise the care plan in response to the resident's behaviors.
Failure to Provide One-on-One Supervision for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide one-on-one supervision for a resident with severe mental impairment and a diagnosis of Alzheimer's disease, despite documented incidents of inappropriate sexual behavior with other residents. The resident had a Brief Interview for Mental Status (BIMS) score indicating severe impairment and was deemed incompetent to make medical decisions. Progress notes revealed that staff had been attempting to keep the resident separated from female residents, but the resident was found in bed with a female resident on multiple occasions, including incidents where inappropriate sexual contact occurred. Although a plan for one-on-one supervision was mentioned in progress notes, it was not formalized as a physician's order, and there was no consistent documentation or communication to ensure all staff were aware of the supervision requirement. Interviews with staff indicated a lack of clarity and documentation regarding the implementation of one-on-one supervision. Some staff members were unaware of the supervision requirement, and assignment sheets did not reflect that one-on-one supervision was in place for the resident. Additionally, behavior monitoring logs and daily assignment sheets lacked documentation of the resident's behaviors and supervision status. The absence of clear orders, documentation, and communication led to repeated incidents where the resident was unsupervised and engaged in inappropriate behavior with other residents.
Failure to Prevent and Identify Pressure Ulcers
Penalty
Summary
The facility failed to prevent and correctly identify pressure ulcers for two residents, leading to misidentification and worsening of their conditions. Resident 101, who had a spinal cord injury and contractures, was observed to have a stage III pressure ulcer on the right buttock, which was initially documented as new. However, the facility's documentation was inconsistent, with no granulation observed in the wound photos, and the resident's skin assessments were incomplete, missing several months. The care plan for Resident 101 did not address the moisture-associated skin damage (MASD) or the stage III pressure ulcer, and the resident's refusals of care were not adequately managed or documented. Resident 108, who had been residing in the facility since October 2024, reported having a painful pressure ulcer on the right foot and another on the buttock. The facility's documentation showed inconsistencies in staging the sacral wound, which was initially identified as unstageable but was later observed to be a stage IV wound. The care plan for Resident 108 did not address the resident's refusals to reposition or coordinate care with Hospice, despite the resident's high risk for skin breakdown due to malnutrition and terminal diagnosis. The facility's interventions were not fully implemented, and there was a lack of documentation on the coordination of care with Hospice. Interviews with staff revealed a lack of awareness and understanding of the residents' wound conditions and the appropriate staging of pressure ulcers. The wound care nurse and the Director of Nursing did not perform root cause analyses or develop plans to prevent further pressure ulcers. The facility's failure to conduct regular skin assessments, update care plans, and implement effective interventions contributed to the deterioration of the residents' pressure ulcers.
Deficiency in Food Quality and Temperature Control
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled food to its residents, affecting 119 individuals. Observations and interviews revealed that food items were often served at temperatures below the standards set by the 2022 FDA Model Food Code. For instance, during meal service, items such as hamburgers, mashed potatoes, and broccoli were recorded at temperatures below the required 135°F, leading to dissatisfaction among residents. Additionally, beverages like apple juice were served at temperatures above the recommended 41°F, further contributing to the issue. Residents expressed dissatisfaction with the quality and temperature of the food. Several residents reported that meals were often cold, unappetizing, and lacked flavor. Some residents mentioned that the food was tough and difficult to cut, while others noted that the meals were repetitive and of poor quality. Interviews with residents revealed that these concerns had been ongoing, with some residents stating that they had raised these issues with the dietician, but little had changed. The facility's dietary management practices were also scrutinized. The Dietary Manager and Registered Dietician acknowledged receiving complaints about cold food and had instituted temperature audits. However, the audits revealed consistent issues with food temperatures, as documented in the Test Tray Audit Worksheet. Despite these audits, residents continued to report dissatisfaction with the food, indicating a lack of effective resolution to the problem. The facility's failure to address these concerns adequately resulted in a deficiency in providing palatable and safe meals to its residents.
Deficiencies in Food Service Equipment Maintenance and Sanitation
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 119 residents and increasing the likelihood of cross-contamination and bacterial harborage. During an initial tour of the food service area, it was observed that two can opener assemblies and their mounting brackets were soiled with accumulated and encrusted food residue. The Dietary Manager acknowledged the issue and indicated that staff would clean and sanitize the equipment. Additionally, clear plastic scoops used for dry food products like flour and oatmeal were stored improperly within the food product storage bins, contrary to the 2022 FDA Model Food Code requirements. Further observations revealed that the dry storage room's return-air-ventilation grill was loose, with five of six mounting screws missing, which could compromise the facility's physical integrity. The facility's policies on maintenance and repairs, as well as dietary cleaning and sanitation, were reviewed, indicating that malfunctions and repair needs should be reported promptly, and that the kitchen should be maintained to minimize microorganism growth. However, these policies were not effectively implemented, leading to the noted deficiencies.
Failure to Reassess Facility Needs and Involve Governing Body
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment that included input from the Governing Body and did not reassess the facility's ability to meet resident care needs following a change in resident acuity status. The last assessment was conducted on 7/16/2023 and was valid through 7/15/2024. However, within the last 30 days, the facility experienced seven pressure ulcers requiring treatment, 42 resident falls with two resulting in major injuries, and 13 residents requiring catheter care. Despite these changes, the facility did not reassess its capacity to meet these care needs. Additionally, the assessment incorrectly listed the Administrator as the Governing Body, rather than the owner, CEO, or other legally responsible individuals. The Administrator was unaware that she was accountable to the Governing Body and not the Governing Body herself.
Facility Maintenance Deficiencies Affect Resident Safety and Cleanliness
Penalty
Summary
The facility failed to maintain a clean and safe environment, affecting 119 residents, as evidenced by multiple deficiencies observed during an environmental tour. The outdoor smoking area canopy was found to be worn, warped, and missing, allowing weather elements to enter the space. A resident reported that the canopy had been in poor condition for the entire three years of their stay. Additionally, the laundry service area had issues such as a porous folding table surface, cracked light lens covers, and non-functional light assemblies, which could lead to bacterial harborage and decreased air quality. Further observations revealed numerous maintenance issues throughout the facility, including leaking water valves, broken light covers, and non-functional light assemblies in soiled utility rooms. The occupational therapy/physical therapy area had a corroded microwave oven, and the staff/visitor restroom had deteriorated caulking. The nurses' station restroom had an ill-fitting commode seat, and the PPE storage room had flooring issues. Shower rooms were missing atmospheric vacuum breakers, and several areas had cracked or missing tiles, contributing to potential cross-contamination risks. The facility's maintenance department policies were reviewed, revealing a lack of specific entries related to the observed maintenance concerns in the Direct Supply TELS Work Orders for the last 85 days. This indicates a failure in the ongoing monitoring and reporting system for necessary repairs, as outlined in the facility's maintenance and housekeeping policies. The environmental services supervisor acknowledged the issues and indicated plans to contact maintenance for repairs, but the deficiencies remained unaddressed at the time of the survey.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency involving a resident with moderate cognitive impairment due to dementia. The resident reported being physically and verbally abused by a Certified Nursing Assistant, and the Nursing Home Administrator (NHA) and Social Worker (SW) were notified. Despite the resident's inability to provide a physical description or name of the alleged perpetrator, the SW interviewed the resident and their spouse, concluding that the abuse was not substantiated due to the resident's confusion. Consequently, the incident was not documented in the clinical record nor reported to the State Agency. During interviews, the SW indicated that the decision not to report was made by the NHA, who also confirmed the incident was not reported because it was deemed unsubstantiated. However, the facility's policy requires reporting all allegations of abuse to the State Agency within specified timeframes, regardless of substantiation. The NHA acknowledged that the facility frequently self-reports to the State Agency, even when abuse is unsubstantiated, but could not explain why this particular incident was not reported. The facility's policy mandates that the results of any investigation, substantiated or not, be reported to the State Agency within five working days, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their skin integrity needs. Resident 101, who had a spinal cord injury and contractures, developed a stage III pressure ulcer on the buttocks, which was not adequately addressed in the care plan. The care plan was outdated and did not include interventions for the resident's moisture-associated skin damage (MASD) or the pressure ulcer. Additionally, the resident's refusals of care, such as turning and repositioning, were not documented or addressed in the care plan. Resident 108, who was on hospice care and had a high risk for skin breakdown, developed pressure ulcers on the right foot and sacrum. The facility's documentation indicated that these pressure ulcers were unavoidable due to the resident's malnutrition and terminal diagnosis. However, the care plan did not include interventions to address the resident's refusals to reposition or coordinate care with hospice services. The facility also failed to document interventions such as off-loading bony prominences and using positioning devices, which were noted in other documents but not in the care plan. Interviews with facility staff revealed a lack of root cause analysis and documentation regarding the residents' pressure ulcers. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) involved in wound care did not perform thorough assessments or document discussions about the residents' wounds in Quality Assurance Performance Improvement (QAPI) meetings. The Director of Nursing (DON) acknowledged the lack of audits and root cause analysis to ensure the healing of current wounds and prevention of further wounds, indicating systemic issues in the facility's approach to wound care management.
Failure to Revise Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to appropriately revise the care plan interventions for one resident, identified as R101, who had been residing at the facility since April 2023. R101 had diagnoses including contractures of the right and left hand and muscles. A care plan dated January 2025 indicated that R101 had contractures in bilateral ankles, wrists/hands, and elbows, with interventions to provide assistive devices such as hand and elbow splints. However, observations on multiple occasions in March 2025 revealed that R101 was not wearing the prescribed splints, and they were found lying on the over-bed table instead. R101 reported that the splints no longer fit because staff did not put them on, and a washcloth was observed in R101's left hand instead of the splints. Interviews with staff, including a CNA, LPN, and a Certified Occupational Therapy Assistant (COTA), revealed inconsistencies in the implementation of the care plan. The CNA mentioned that R101 was offered the splints every two hours but may refuse them, while the LPN was unaware of how often the splints were offered. The COTA stated that R101 was evaluated in March 2025, and it was recommended that R101 wear bilateral hand/wrist splints since November 2024. However, the COTA was not informed of any refusal by R101 to wear the splints. The care plan had not been updated with new interventions following the therapy's recommendations in March 2025, indicating a failure to revise the care plan appropriately based on the resident's current needs and therapy recommendations.
Failure to Provide Podiatry Care for Resident
Penalty
Summary
The facility failed to provide necessary podiatry care for a resident diagnosed with dementia, who was admitted with moderate cognitive impairment. The resident's family member, who visited daily, expressed frustration over the facility's inaction despite multiple requests for podiatry services over approximately five months. The family member had been attempting to manage the resident's toenail care themselves, despite the difficulty due to the thickness and curling of the nails. During an observation, the resident's second toenail was noted to be excessively long and curled under the toe, covering the pad of the toe. Interviews with facility staff revealed a lack of communication and responsibility regarding the arrangement of podiatry services. The social worker claimed no responsibility for arranging ancillary services and did not acknowledge the family's requests. The medical records staff confirmed receiving a request for podiatry care from the family member about a month prior but had not ensured the resident was seen by a podiatrist. The LPN/Unit Manager was unaware of the resident's need for podiatry care and acknowledged that the nursing staff should have documented and addressed the condition of the resident's toenails during routine assessments.
Failure to Implement Prescribed ROM Interventions for Resident
Penalty
Summary
The facility failed to ensure that a resident, who had been diagnosed with contractures of the right and left hands and muscles, received appropriate care to maintain or improve range of motion. The resident, who had been residing at the facility since April 2023, was observed on multiple occasions without the prescribed hand splints and positioning wedge in place. The care plan and CNA Kardex indicated that the resident should have been provided with right and left hand splints and elbow splints, but these were not being utilized. The resident reported that staff never turned him, and he was always on his back, with the wedge meant for repositioning left unused on the bedside table. Interviews with staff revealed inconsistencies in the application of the splints. A CNA mentioned that the resident was offered the splints every two hours but may refuse them, although no specific reason was provided for the resident's refusal. The LPN was unaware of how often the splints were offered, and the COTA stated that the resident should have been wearing the splints since they were recommended in November 2024. The therapy plan of treatment recommended the use of resting hand and elbow extension splints for four hours on and four hours off to improve passive range of motion, but the care plan had not been updated with these recommendations.
Failure to Document Physician Review of Medication Irregularities
Penalty
Summary
The facility failed to ensure that the attending physician documented the review of identified medication irregularities, the actions taken, or the rationale for not making changes to the medications for a resident. The resident, who was admitted for long-term care and resided in the facility's secured dementia unit, had a low score on the Brief Interview for Mental Status, indicating cognitive impairment. The Monthly Medication Review noted that the resident was receiving Divalproex and had experienced recent mental status changes, including agitation and anxiety. The pharmacist recommended monitoring serum ammonia concentration and valproic acid levels due to potential adverse effects, but the physician did not document any response to these recommendations. During an interview, the Director of Nursing (DON) explained the process for handling pharmacist recommendations, which involved electronic delivery, printing, and placement in a binder for the physician or nurse practitioner to review and sign. However, the DON was unable to find any documentation from the provider regarding lab orders for valproic acid or any agreement or disagreement with the pharmacist's recommendations. The provider's signed pharmacy recommendation was also missing, and the DON could not explain why the physician had not addressed the recommendation.
Failure to Meet Residents' Nutritional Needs and Preferences
Penalty
Summary
The facility failed to meet the nutritional needs and food preferences of two residents, R28 and R117, as observed during a survey. Resident 28 expressed dissatisfaction with the inconsistency in receiving a chef salad, which was supposed to be a regular part of their meal plan. Despite having a standing order for a chef salad, R28 reported receiving it only about once a week, and sometimes it was just plain lettuce without the desired toppings. Additionally, R28 received a meal with barbecue sauce, which was listed as a dislike on their meal ticket, indicating a failure to adhere to dietary restrictions. Resident 117, who has a history of depression, anxiety, COPD, and congestive heart failure, was found to be underweight with a BMI of 13.6. R117 reported that meals were often served cold and did not match the items listed on their meal ticket, such as side salad, fresh grapes, and nutritional juice. The resident also noted that the meal cart sat in the hallway for extended periods before trays were distributed, contributing to the cold meals. Despite having standing orders for certain items, these were not consistently provided, and the resident expressed frustration over the lack of oversight in meal preparation and delivery. The Dietary Manager acknowledged issues with food availability and preparation, citing instances where fresh produce was not available and substitutions were not communicated to residents. The manager also confirmed that certain items, like grapes, were out of stock, and admitted that the staff might have rushed meal preparation, leading to errors in fulfilling residents' meal preferences. The facility's policy on food preferences was not effectively implemented, resulting in residents not receiving appropriate meals as per their dietary needs and preferences.
Failure to Address Pressure Ulcers in QAPI Committee
Penalty
Summary
The facility failed to identify the need for an action plan for pressure ulcers through its Quality Assurance Performance Improvement (QAPI) committee. During an onsite survey, it was found that two out of six residents reviewed had developed facility-acquired pressure ulcers at stage III or higher. The facility's policy requires the QAPI committee to meet regularly to develop and implement plans to correct quality deficiencies, but this was not done for pressure ulcers. The wound nurse, LPN K, admitted to not performing a root cause analysis for the pressure ulcers and only verbally discussing the residents' wounds in QAPI meetings without documentation. The Director of Nursing (DON B) stated that she assisted the wound care nurses in obtaining necessary equipment but did not conduct audits or root cause analyses to prevent further pressure ulcers. The Administrator acknowledged that the QAPI committee was working on assessing residents' risk for skin breakdown but had not identified residents with current pressure ulcers or developed a performance improvement plan. There were no audits or assessments available for residents with pressure ulcers, indicating a lack of systematic approach to address and prevent pressure ulcers in the facility.
Failure to Prevent Misappropriation of Resident's Debit Card
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's belongings, specifically a social security debit card, which resulted in feelings of loss of independence and potential mistrust. The resident, who had intact cognition, reported that an Activities Aide (AA) had assisted him with an online purchase and was the last known person to have possession of his debit card. The resident was informed by the police that the AA was arrested and charged with felonies for unauthorized use of the card. The resident expressed a desire for restitution rather than punishment for the AA, as the incident led to his brother managing the card, causing a delay in his ability to make personal purchases. The facility's investigation revealed that the resident's debit card was missing after he returned from a hospital stay. The police were notified, and a report was filed. The investigation showed unauthorized transactions, including online gaming purchases and fast-food orders, made while the resident was hospitalized. The police identified the AA as the perpetrator through video footage and transaction records. Despite the facility's initial inability to substantiate the misappropriation, the police investigation confirmed the AA's involvement, leading to his arrest and termination from the facility.
Inappropriate Use of Restraints on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which were imposed for convenience rather than medical necessity. The resident, who had severe cognitive impairment and required assistance for mobility, was observed attempting to exit his bed independently. A foam wedge was placed under the fitted sheet, seemingly to prevent the resident from leaving the bed, which restricted his mobility. Staff members, including a CNA and an LPN, were unsure of the purpose of the wedge, indicating a lack of clear communication and understanding of its use. The resident had a history of falls and was known to be active, often propelling himself around the unit in a manual wheelchair. However, staff frequently placed him in a geri-chair, which he could not propel, further restricting his movement. The resident's care plan included interventions to prevent falls, such as positioning him in view of staff, but these were not effectively implemented. Interviews with staff and family members revealed that the resident was often kept in the geri-chair to prevent him from moving, and a standard chair was used to immobilize the geri-chair's footrest, indicating the use of restraints for convenience. The Director of Nursing acknowledged that the wedge should be used for positioning and that the resident should be allowed to move freely in a manual wheelchair when awake and active. Despite this, the resident was often restrained in a geri-chair, and there was no work order for the chair, suggesting it may have been broken. The facility's actions and inactions led to the inappropriate use of restraints, restricting the resident's mobility and potentially impacting his physical and psychosocial well-being.
Delay in X-ray Leads to Untimely Treatment for Resident's Fracture
Penalty
Summary
The facility failed to obtain a timely x-ray for a resident, resulting in a delay in treatment for a hip and femur fracture. The resident, who had severe cognitive impairment and was a known fall risk, experienced multiple falls within the facility. Despite interventions to position the resident in view of staff, the resident continued to fall, including an unwitnessed fall on 9/20/24. Following this fall, significant bruising and swelling were observed, and a stat x-ray was ordered on 9/24/24. However, the x-ray was not completed promptly. The nursing staff noted the resident's condition, including swelling and inability to move the left leg, and contacted the radiology service for a status update. Despite these efforts, the x-ray service did not arrive until after the resident was transferred to the hospital on 9/25/24. The hospital confirmed the resident had a femoral shaft fracture and a chronic femoral neck fracture, requiring operative fixation. Interviews with staff revealed that the resident was often restless and attempted to get out of bed, leading to the use of a wedge to prevent falls. The Director of Nursing acknowledged the delay in obtaining the x-ray and the need for staff supervision during the resident's unwitnessed fall. The interdisciplinary team was discussing the concerns regarding the delay in obtaining the x-ray.
Failure to Prevent Falls and Delay in Medical Imaging
Penalty
Summary
The facility failed to develop and implement effective interventions to prevent falls for a resident, resulting in a fall with a major injury. The resident, who had severe cognitive impairment and required assistance for transfers, was observed attempting to get out of bed independently. The only measure in place to prevent the resident from exiting the bed was a foam wedge, which was not properly positioned. Staff members, including a CNA and an LPN, were unaware of the purpose of the foam wedge, indicating a lack of communication and understanding of the resident's care plan. The resident had a history of falls, with multiple incidents reported in the months leading up to the major injury. Despite these falls, the interventions listed in the care plan were inadequate, such as encouraging positioning near staff in the day room. The resident was known to be mobile and able to self-propel in a wheelchair, yet was often placed in a geri-chair, which restricted movement and contributed to the resident's restlessness and attempts to exit the chair. The use of a standard chair to immobilize the geri-chair's footrest further limited the resident's ability to move safely. Additionally, there was a significant delay in obtaining a stat x-ray after the resident's family reported swelling and bruising, which was indicative of a fracture. The x-ray was ordered but not completed in a timely manner, leading to a delay in the resident's transfer to the hospital for appropriate care. Interviews with staff revealed a lack of consistent supervision and inadequate fall prevention strategies, contributing to the resident's fall and subsequent injury.
Failure to Ensure Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure the safety and proper supervision of a resident, resulting in a fall and subsequent injury. The resident, a cognitively intact female with a history of cerebral vascular accident and other medical conditions, was not properly positioned in a shower chair by a CNA. The CNA left the resident unattended to seek assistance, during which time the resident began to slide forward and was lowered to the floor. Despite the fall, the resident was moved back into the shower chair and the shower was completed without notifying a nurse or conducting an immediate assessment. The incident was not reported to the nursing staff until approximately two hours later when the resident's husband alerted the nurse to the resident's pain. The resident was found to have a swollen left knee and was later diagnosed with a left distal femur fracture. The facility's care plan, which required a Hoyer lift for transfers, was not followed, and the incident report lacked a thorough investigation. The resident experienced increased pain and required additional pain medication following the fall. Interviews with staff revealed a lack of adherence to the facility's fall management policy, which mandates that residents not be moved after a fall until assessed by a nurse. The CNA involved in the incident was terminated, and the facility acknowledged past non-compliance with fall supervision. Despite the facility's policy and staff education on fall prevention, the incident highlighted deficiencies in communication and adherence to care plans.
Failure to Prevent Repeated Falls Due to Lack of Supervision
Penalty
Summary
The facility failed to implement effective interventions to prevent repeated falls for a resident with Alzheimer's Disease, who was reviewed for accidents and supervision. The resident, who had severely impaired cognition and a history of falls, was observed multiple times in the day room without adequate supervision or engagement from staff. Despite the presence of staff, including CNAs and an RN, there was a lack of interaction with the residents, which was noted during several observations by the surveyor. The resident had a history of ten falls since March 2024, with incidents occurring in various locations such as the day room, hallway, and her room. The falls were often related to the resident's behavior of moving furniture or attempting to stand unassisted. Although some interventions were documented, such as medication adjustments and providing diversional activities, there was no in-depth analysis of the root causes of the falls or consistent implementation of interventions. For instance, a recommended chair by the exit door was not observed during the surveyor's visits. The Director of Nursing acknowledged the need for more engagement and interaction with residents to prevent falls but did not provide a response regarding the evaluation of staffing needs or the implementation of interventions. The facility's fall management policy emphasized identifying hazards and implementing interventions to minimize falls, but the observations and documentation indicated a failure to adhere to this policy effectively.
Inadequate Supervision and Care on Unit 3
Penalty
Summary
The facility failed to ensure adequate care and supervision on Unit 3, which housed residents with cognitive impairments, including a resident with Alzheimer's Disease who had a history of falls and impaired cognition. On the day of the incident, a complaint was submitted regarding the absence of staff on the unit, which was observed by a family member returning a resident from an overnight leave of absence. The family member noted that there was no nurse present to receive the resident's medications, and the only visible staff was an activities aide in the day room. This lack of supervision led to residents being unassisted, with some attempting to leave the unit or access restricted areas. The investigation revealed that the assigned Registered Nurse (RN) for Unit 3, RN 'F', had taken an extended break without ensuring proper coverage. RN 'F' combined her lunch and two 15-minute breaks, leaving the unit for approximately an hour without informing another nurse or handing over the medication cart keys. During her absence, the Certified Nursing Assistants (CNAs) assigned to the unit were also not present, as one CNA had left to inform another unit of her departure time, leaving only the activities aide with the residents. This lack of coordination and communication among staff resulted in inadequate supervision and care for the residents. The Director of Nursing (DON) confirmed that the facility's protocol was not followed, as RN 'F' did not report her extended break to another nurse or ensure the medication cart was accessible. Additionally, CNA 'K' did not remain on the unit or seek assistance from another nurse when the family expressed concerns. The failure to adhere to established protocols for staff breaks and coverage led to a deficiency in maintaining professional standards of care and supervision for the residents on Unit 3.
Failure to Monitor Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to monitor and document blood pressures for a resident with hypertension, which was necessary to ensure the proper administration of prescribed medication. The resident, who had severely impaired cognition, was admitted with a physician's order for amlodipine, a medication to be held if the systolic blood pressure was less than 100 mmHg. However, the Medication Administration Record for May and June 2024 showed no documentation of the resident's blood pressure, despite the medication being administered daily since the order was given. Interviews and record reviews revealed that the Director of Nursing acknowledged the lack of consistent documentation of the resident's blood pressures in the clinical record. The order was not properly entered to ensure monitoring before administering the medication. The facility's policy on medication administration required vital signs to be taken prior to administering doses when applicable, but this was not followed, leading to the deficiency.
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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