Rivergate Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverview, Michigan.
- Location
- 14141 Pennsylvania, Riverview, Michigan 48193
- CMS Provider Number
- 235516
- Inspections on file
- 33
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Rivergate Terrace during CMS and state inspections, most recent first.
Personal Belongings Moved Out of Resident’s Reach: A resident who was cognitively intact and required assistance with most ADLs had personal items removed from the nightstand by a UM and placed in a closet box, where the resident said they could not be reached independently. The UM acknowledged the items were out of reach, and the DON stated the resident had the right to keep personal items on the nightstand.
Failure to Protect Resident PHI: An LPN left a medication cart computer screen open outside a resident's room, exposing the resident's orders, medications, and diagnoses to staff, residents, and visitors passing by. The LPN said she thought she had closed the screen before leaving for central supply, and the DON later stated the LPN knew better. The resident had multiple diagnoses and was cognitively impaired with impaired speech and ambulation.
Failure to provide ordered splinting and ROM services for two residents with contractures and severe cognitive impairment. One resident with CVA-related hemiplegia had a right resting hand splint order and restorative ROM/splint care planned, but the splint was observed off and the facility had no restorative documentation. Another resident with hand contractures had orders for bilateral palm guards and BUE/BLE ROM, but staff reported restorative care was not consistently provided, and logs showed missed splinting and ROM with no refusals documented.
PEG Tube Placement and Residual Not Verified Before Medication Administration: An LPN administered multiple medications through a resident’s PEG tube without checking tube placement or gastric residual first. The resident had diagnoses including intracranial hemorrhage, dysphagia, gastrostomy, TIA, and cerebral infarction, and was cognitively intact per MDS. The LPN acknowledged the omission, and the DON stated staff are expected to check tube placement before giving medications.
A facility used incorrect isolation signage for two residents with contagious infections, including one resident with C. diff and colonized C. auris and another resident with MRSA and a draining knee wound. Staff and the DON gave conflicting statements about whether Contact Isolation was needed, and one resident’s care plan called for Contact Isolation while the door still displayed EBP. The facility also failed to use required PPE when an LPN administered meds via a PEG tube to a resident on EBP without wearing a gown.
A resident returned from the ED with a right scalp laceration closed with a staple, but staff did not obtain or document specific MD orders for cleansing, monitoring, assessment, or staple removal. The laceration was later observed with a protruding staple, and review of care plans, MAR/TAR, and physician orders showed no interventions or scheduled removal for the staple, despite a provider note referencing the laceration and staple. Leadership interviews confirmed that nursing staff were responsible for securing appropriate orders and follow-up care, and facility policy required staple and suture removal in line with professional standards.
The facility failed to ensure timely review and submission of PASARR forms for residents with mental disorders or intellectual disabilities. Missing PASARR 3878 forms for two residents with dementia and epilepsy were due to physicians not completing them in the OBRA system. Another resident's annual PASARR 3877 and OBRA Level II Evaluation were overdue due to oversight during hospitalizations. Additionally, a resident's PASARR Level II screening was missing from records. These deficiencies could impact residents' care for mental health and dementia needs.
The facility failed to provide wheelchair footrests for two residents, leading to potential injury risks. A resident was observed without footrests during therapy transport, and their family member expressed concern. Another resident was transported to the dining room without footrests, requiring them to lift their feet. Staff acknowledged a shortage of footrests, and the facility lacked a specific policy addressing this issue.
A facility failed to secure a resident's protected health information, leading to potential unauthorized access. A computer on a medication cart was left open to a resident's EMR, visible to passersby for several minutes. The Unit Manager and ADON closed the screen upon noticing the surveyor observing it. The DON confirmed this was a HIPAA violation. The resident had multiple diagnoses, including Memory Deficit and Major Depressive Disorder, and was cognitively intact.
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential unmet care needs. A resident with an indwelling catheter was not educated on its care, another receiving oxygen therapy lacked a care plan for its administration, and a third with a colostomy had no care plan for ostomy care. The Director of Nursing acknowledged these oversights, which were contrary to the facility's policy.
The facility failed to prevent and treat pressure ulcers for two residents. One resident was not repositioned as required, leading to a worsening stage 4 sacral ulcer, with missed dressing changes. Another resident, at high risk for pressure sores, had her heels resting directly on the mattress despite care plan instructions to offload them. Staff interviews revealed a lack of adherence to care plans and facility policies.
A facility failed to properly store an oxygen cylinder in a resident's room, creating a potential fire hazard. An oxygen tank was found leaning against a dresser instead of being secured in a metal carrier. A respiratory therapist confirmed the improper storage, and the Environmental Director acknowledged the deviation from the facility's safety protocols, which require tanks to be stored in a metal carrier or cage.
A resident with an indwelling urinary catheter experienced unresolved UTIs due to inadequate care at the facility. The catheter was not securely anchored, and the tubing was improperly positioned. Despite orders for catheter care and a urology consult, the facility staff failed to change the entire catheter system as needed and did not schedule the consult, leading to the resident seeking emergency care.
A resident with severe cognitive impairment was not administered oxygen as prescribed, resulting in a low pulse oximetry reading. Observations revealed the oxygen tubing on the floor and the concentrator not properly connected. The facility's policy on oxygen administration was not followed, leading to the deficiency.
A facility failed to ensure proper PPE use for a resident under enhanced-barrier precautions and did not follow aseptic techniques for IV line management. Staff were observed performing hygiene care and medication administration without required PPE, and an LPN connected an IV-line without using a sterile cap, contrary to facility policies.
A resident with Alzheimer's Disease, identified as at risk for elopement, managed to leave the facility unsupervised by following a visitor through the front door. The receptionist, responsible for monitoring the entrance, was distracted and did not notice the resident leaving. The facility's door setup allowed the resident to exit without detection, despite prior assessments and a care plan in place to prevent such incidents.
A resident with dementia and osteoporosis suffered a leg fracture due to improper transfer by CNAs who did not use the required mechanical lift, contrary to the care plan and facility policy. The resident was hospitalized following the incident, which revealed a lack of adherence to established transfer procedures.
A cognitively impaired resident at risk for elopement exited an LTC facility unsupervised, following an activities aide distracted by a cell phone. The resident, diagnosed with dementia and a history of wandering, was outside for two minutes before being returned by the Director of Rehab. The incident highlighted lapses in supervision, as the aide and receptionist failed to notice the resident's exit.
Personal Belongings Moved Out of Resident’s Reach
Penalty
Summary
The facility failed to ensure that R169’s personal belongings were kept within reach. On 3/24/26, R169 was observed sitting in a specialized wheelchair in the bedroom and was alert, oriented to person, place, and situation. R169 stated that Unit Manager F removed personal items from the nightstand because the State was in the building and said the items were moved because it looked messy. R169 reported that the belongings had been placed in a box in the closet and were not reachable there, explaining that when the items were on the nightstand they could be reached easily and independently. At 3:35 p.m., R169’s belongings, including shampoo, deodorant, shaving cream, and body lotion, were observed in a box on the closet floor. R169 said the items had been on the top of the closet and asked staff to place the box on the floor, but also stated the items would not be easily accessible without staff assistance. Unit Manager F stated the belongings were not supposed to be on the nightstand and moved them to the closet, acknowledging they would not be easily accessible and were out of R169’s reach. The DON stated R169 had the right to have personal items on the nightstand and did not know why they were moved to the closet and out of reach. R169’s record showed diagnoses including dysphagia, adjustment disorder with anxiety, bipolar disorder, schizoaffective disorder, malignant neoplasm of female breast, and above the right leg amputation, with a BIMS of 15 and assistance needed with most ADLs.
Failure to Protect Resident PHI
Penalty
Summary
The facility failed to keep one resident's personal and medical records private and confidential when an LPN left a medication cart computer screen open outside a resident's room in the Therapy Department. The screen displayed the resident's written orders, medications, and diagnoses, and it remained visible to anyone passing by while the LPN left the area to go to central supply. During this time, a respiratory therapist, a wound care nurse, a housekeeper, and three residents escorted by guests passed the cart. When the LPN returned, the screen was closing automatically, and she stated that she thought she had closed it but had not. The DON was later informed and stated that the LPN had already reported the incident herself and that she knew better. The resident whose information was visible had diagnoses including bacteremia, MSSA infection, anxiety disorder, depression, hypertensive heart disease with heart failure, myositis, COPD, cognitive communication deficit, severe morbid obesity, and hyperlipidemia, and the admission MDS indicated the resident was cognitively impaired with impaired speech and ambulation.
Failure to Provide Ordered Splinting and ROM Services
Penalty
Summary
The facility failed to apply splinting devices and perform range of motion (ROM) exercises as care planned for two residents with limited ROM and contractures. One resident had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment, and dependence for ADLs. That resident had an order for a right resting hand splint to be applied for 4 hours in the morning and removed in the evening, with assessment of pain, circulation, and skin integrity, and the care plan included restorative passive ROM for both upper and lower extremities and splint application for the right hand to manage contracture. The resident was observed in bed with the right-hand splint on the bedside table on one occasion and later observed again without the splint in place. The facility did not have documentation of restorative services for that resident when requested. The restorative nursing program entries for the resident were revised, but the Nursing Home Administrator stated the facility did not have documentation of restorative services for the resident. The second resident had diagnoses including contracture of the left hand and pain in both hands, severe cognitive impairment, and dependence for ADLs. That resident had an order for bilateral palm guards to be applied for 4 to 6 hours as tolerated and care plan interventions for bilateral upper extremity active ROM and bilateral lower extremity passive ROM. The resident was observed with a palm protector on the bedside table and later with one hand protected while the other hand was not wearing the palm protector. A CNA stated she did not apply splints or perform ROM exercises and that restorative staff performed that care, while the restorative aide stated the residents did not receive restorative services when she was pulled to the floor to work and when the facility was short staffed. Review of the restorative logs showed the resident’s bilateral palm guards and ROM program were not performed during multiple weeks, with no refusals documented.
PEG Tube Placement and Residual Not Verified Before Medication Administration
Penalty
Summary
The facility failed to verify PEG tube placement and assess gastric residual before administering medications through a PEG tube for one resident, R185, who was observed receiving multiple crushed medications via the tube. On 3/26/26 at 8:56 AM, an LPN administered Potassium chloride 15 ml, oxybutynin chloride 5 mg, Coreg 12.5 mg, metoclopramide 10 mg, sulfasalazine 500 mg, apixaban 5 mg, folic acid 1 mg, and losartan potassium 25 mg through the PEG tube without checking tube placement or gastric residual. When interviewed immediately afterward, the LPN acknowledged that placement and residual were not checked before medication administration. The DON later stated that staff are expected to check tube placement before giving medications. Record review showed that R185 was admitted with diagnoses including intracranial hemorrhage, dysphagia, gastrostomy, transient ischemic attack, and cerebral infarction, and the resident’s quarterly MDS indicated a BIMS score of 15 out of 15, showing the resident was cognitively intact. The facility’s Medication Administration Through External Tube policy, revised 11/15/24, stated that feeding tube placement should be confirmed per facility policy.
Incorrect Isolation Signage and PPE Use
Penalty
Summary
The facility failed to use proper signage for two residents with contagious infections. For one resident, an Enhanced Barrier Precaution sign was posted even though the resident’s record showed an order for Enhanced Barrier Precautions related to colonized Candida auris and laboratory results showing Clostridioides difficile. The resident’s progress note also documented ongoing oral vancomycin for C. diff with loose stool that continued but was less frequent. During interview, infection prevention staff stated the resident should have been on Contact Isolation for C. diff, and the DON later stated the resident should have been on Contact Isolation as well. For the same resident, the care plan was revised to Contact Isolation with instructions to wear gowns and mask when changing linens and to place soiled linens in biohazard bags, but at the time of observation there were no linens in biohazard bags and no trash marked biohazard. The resident was observed in bed while a family member sat at the bedside and adjusted the blanket. The family member stated they had not been told of any special precautions. The facility also failed to maintain correct isolation signage for another resident. That resident’s door initially displayed an Enhanced Barrier Precaution sign, then the sign was changed to Contact Isolation after staff stated the resident had MRSA. The resident’s record showed diagnoses including MRSA, bacteremia, diabetes, edema, congestive heart disease, total knee replacement, and a wound with drainage. The DON stated the resident was not on isolation precautions while in the hospital and did not need Contact Isolation, and also stated the resident did not have MRSA, despite the admitting diagnosis and physician order for rifampin for MRSA. The facility additionally failed to don appropriate PPE for a resident on Enhanced Barrier Precautions. An LPN administered medications via the resident’s PEG tube without wearing a gown, even though the Enhanced Barrier Precaution sign was posted on the door. The LPN acknowledged that a gown should have been worn for the medication administration. The resident had diagnoses including intracranial hemorrhage, dysphagia, gastrostomy, transient ischemic attack, and cerebral infarction, and the facility policy identified feeding tubes as an indwelling medical device requiring gown and gloves during high-contact care.
Failure to Obtain and Implement Orders for Scalp Laceration and Staple Care
Penalty
Summary
Surveyors identified that the facility failed to consistently assess and monitor a scalp laceration for one resident. Observation showed the resident had an intact laceration on the right side of the scalp with one staple protruding, and the resident could not recall when or why the staple was placed. Record review revealed the resident had an unwitnessed fall that resulted in a right scalp laceration and transfer to the ED, after which the resident returned to the facility. A subsequent physician/PA/NP note documented that the resident had a fall with head trauma and laceration, that a staple was intact, and that it should be removed as directed, with continued supportive care and monitoring of mentation. Further record review showed that none of the resident’s care plans contained interventions for cleansing, monitoring, or assessing the laceration, and there was no documented order specifying a date or plan for staple removal. The MAR and TAR for the relevant months contained no physician orders for laceration care or assessment, and physician orders over the same period did not include any orders for laceration care or staple removal. In interviews, the ADON acknowledged that a physician order should have been obtained and documented for care, monitoring, and timely removal of the staple, and the NHA stated that nursing staff were responsible for ensuring appropriate orders and follow-up care were obtained and implemented. The facility’s policy stated that skin staple, suture, and clip removal would be provided in accordance with professional standards of practice.
Deficiency in PASARR Documentation for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure timely review, revision, and submission of Preadmission Screening and Annual Resident Review (PASARR) forms for residents with mental disorders or intellectual disabilities. Specifically, the facility did not have the required PASARR 3878 forms for residents R22 and R52, who had diagnoses of dementia and epilepsy. The absence of these forms was due to the physicians not completing and signing them in the OBRA system, despite being aware of the process. Resident R175's records lacked an annual PASARR 3877 and the required OBRA Level II Evaluation, which was overdue. The Social Service Director acknowledged the delay, attributing it to the resident's multiple hospitalizations and the oversight during readmissions and discharges. This oversight resulted in the absence of necessary documentation for residents with mental illness diagnoses, including schizoaffective disorder and bipolar disorder. Resident R190's records showed a completed PASARR Level I screening, but the required Level II screening was missing. The Social Work Assistant was unable to locate the Level II documentation in the electronic medical record. These deficiencies indicate a failure to maintain accurate and timely PASARR documentation, potentially affecting the residents' receipt of appropriate care and services for their mental health and dementia needs.
Failure to Provide Wheelchair Footrests for Residents
Penalty
Summary
The facility failed to provide wheelchair footrests for two residents, resulting in a potential risk for injury to their lower extremities. Resident R93 was observed without footrests on their wheelchair during transportation to therapy, and their family member expressed concern about the absence of footrests, which were necessary for safe mobility at home. The clinical record indicated that R93 was readmitted with diagnoses including dementia and was totally dependent on staff for ambulation and transfer, being unable to propel themselves in the wheelchair. Similarly, Resident R86 was observed being transported to the dining room without footrests, requiring the resident to lift their feet repeatedly. R86, who had a moderate cognitive impairment and was wheelchair dependent, was unable to recall the last use of footrests. An anonymous staff member acknowledged the shortage of footrests, which had been a concern since June 2024. The Director of Nursing and the Administrator confirmed the lack of a specific policy addressing footrests, and a check of the residents' rooms revealed no available footrests.
Failure to Secure Resident's Protected Health Information
Penalty
Summary
The facility failed to properly secure protected health information for a resident, resulting in the potential for unauthorized disclosure and access. During an observation, a computer on a medication cart was found open to a resident's Electronic Medical Record (EMR) on the Blue unit. The computer screen was visible for approximately five minutes, during which several residents and staff were present in the hallway. The Unit Manager and Assistant Director of Nursing noticed the surveyor observing the open computer screen and subsequently closed it. The Unit Manager confirmed that the resident's medical record was accessible to anyone passing by. The Director of Nursing acknowledged that leaving a computer open with resident information visible is a violation of HIPAA. The resident involved was admitted to the facility with diagnoses including Memory Deficit following a stroke, Cognitive Communication Deficit, Generalized Anxiety, Major Depressive Disorder, Epilepsy, and Repeated Falls. The resident's Minimum Data Set (MDS) Admission assessment indicated they were cognitively intact.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in potential unmet care needs and lack of coordination of care. Resident R91, who was admitted with an indwelling urethral catheter, was not provided with a care plan addressing the catheter. Despite being cognitively intact and requiring supervision for personal hygiene and toileting, R91 was not educated on catheter care, and the Director of Nursing acknowledged the absence of a necessary care plan. Resident R85, who was receiving oxygen therapy for asthma and chronic obstructive pulmonary disease, also lacked a care plan for oxygen administration. Although the resident was observed receiving a nebulizer treatment and oxygen, the care plan did not reflect the physician's order for oxygen therapy. A Licensed Practical Nurse confirmed the oversight and acknowledged the need for a care plan. Resident R206, who had a colostomy, was observed with a leaking ostomy bag, yet there was no care plan for ostomy care. The resident, who was severely cognitively impaired and non-verbal, had orders for ostomy care every three days and as needed. The Director of Nursing confirmed that a care plan should have been in place for the colostomy, highlighting a failure to adhere to the facility's policy for comprehensive care plans and revisions.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development or worsening of pressure injuries for two residents, R206 and R155. R206 was observed lying on their back for extended periods without the use of a positioning wedge, despite having a care plan that required frequent repositioning to avoid pressure on the sacrum. The resident had a large unstageable sacral pressure ulcer that was present upon admission, which later progressed to a stage 4 ulcer. The facility's records showed that the pressure ulcer treatments were not documented as administered for two consecutive days, and the dressing was not changed as ordered, leading to a saturated dressing with drainage. R155, who was at high risk for developing pressure sores, was observed multiple times with her heels resting directly on the mattress, contrary to her care plan that required offloading of heels while in bed. Despite the resident's complaints of pain and requests for support under her feet, staff failed to consistently provide the necessary support to elevate her heels. Interviews with staff revealed a lack of awareness or adherence to the care plan requirements for heel elevation. The facility's policy on skin integrity and pressure ulcer prevention was not followed, as evidenced by the lack of consistent repositioning and failure to implement protective measures against pressure, friction, and shear. The Director of Nursing acknowledged the lapses in care, including the failure to change R206's dressing and the need for R155's heels to be offloaded to prevent skin breakdown.
Improper Storage of Oxygen Cylinder Creates Fire Hazard
Penalty
Summary
The facility failed to ensure proper storage of an oxygen cylinder in a resident's room, creating a potential fire hazard. During an observation, three oxygen tanks were found in the room of a resident, with one tank leaning against a dresser and not secured in a metal carrier. At the time, one resident was not present, and the other resident in the room stated that the oxygen tank was not for them and they did not pay attention to it. A respiratory therapist confirmed that the tanks were not stored according to safety protocols, emphasizing the flammable nature of the tanks and the necessity for them to be stored in a metal carrier. The Environmental Director was informed of the unsafe storage practice and confirmed that the facility's policy requires oxygen tanks to be stored in a metal carrier or cage to prevent safety issues. The facility's policy on oxygen administration and storage specifies that tanks should not be fastened to a resident's bed and must be installed on a stable, wheeled dolly or portable stand. Additionally, tanks in storage rooms should be chained to the wall or installed on a stable dolly or floor stand. This incident highlights a deviation from the facility's established safety protocols for oxygen tank storage.
Inadequate Catheter Care Leads to Unresolved UTIs
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling urinary catheter, leading to multiple unresolved urinary tract infections (UTIs). The resident, who had been admitted with urinary retention and a UTI, was observed with a catheter that was not securely anchored, and the tubing was improperly positioned. Despite physician orders for catheter care every shift and to secure the catheter with an anchoring device, these instructions were not followed, contributing to the resident's ongoing health issues. The resident's medical records indicated that a urinalysis confirmed a UTI, and the resident experienced gross hematuria and urinary obstruction. However, the facility staff failed to change the entire catheter system as clinically indicated, opting instead to change only the collection bag. This decision was contrary to the facility's policy and the nurse practitioner's verbal orders, which specified changing the entire catheter system in cases of obstruction and infection. Additionally, the facility did not schedule a urology consult as ordered by the physician, further delaying appropriate treatment for the resident's condition. The lack of adherence to established guidelines and physician orders resulted in the resident's condition not being properly managed, leading to the resident and their family seeking emergency medical care outside the facility.
Failure to Administer Prescribed Oxygen
Penalty
Summary
The facility failed to administer oxygen as prescribed to a resident, resulting in a low pulse oximetry reading of 82%. The resident, who had severe cognitive impairment and was non-verbal, was observed multiple times over a 5.5-hour period without the prescribed oxygen via nasal cannula. The oxygen tubing and nasal cannula were found on the floor, and the oxygen concentrator was turned on but not properly connected to the resident. The resident's electronic health record indicated a prescription for continuous oxygen at 4 liters per minute, but this was not adhered to, as evidenced by the lack of oxygen administration during the observations. The resident's pulse oximetry reading remained low until a stat respiratory treatment was administered. The facility's oxygen administration policy requires specific liter flow orders and the use of humidifiers for flows of 4 liters or greater, which were not followed in this case. The Director of Nursing acknowledged the failure to administer oxygen per the physician's orders, and the facility's staff was educated on the issue following the incident.
Inadequate PPE Use and IV Line Management
Penalty
Summary
The facility failed to ensure appropriate use of personal protective equipment (PPE) for a resident under enhanced-barrier precautions. During an observation, a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN) entered the resident's room and performed hygiene care and medication administration without donning the required PPE, such as gowns and gloves. The facility's policy indicated that PPE should be worn during high-contact care for residents with wounds or indwelling medical devices, which was not adhered to in this instance. Both the CNA and LPN acknowledged the oversight after reviewing the enhanced barrier precautions sign and the facility's policy. Additionally, the facility failed to implement proper preventative measures for a resident receiving IV antibiotics. An LPN was observed connecting an IV-line without using a sterile cap, contrary to the facility's policy on maintaining aseptic techniques. The policy required that a new sterile end cap be placed on the administration set after medication administration if it would be used again within 24 hours. The Assistant Director of Nursing and the Director of Nursing both acknowledged the lapse in following the policy, which could potentially lead to infection due to poor sterile technique.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as R912, who was at risk for elopement due to cognitive impairment and a history of exit-seeking behavior. On the day of the incident, R912, who was diagnosed with Alzheimer's Disease, managed to walk out of the facility unsupervised by following a visitor through the front door. The receptionist, responsible for monitoring the entrance, was distracted while replacing coffee cups and did not notice the resident leaving. The facility's layout included a series of doors, with the second set requiring activation by the receptionist to open. However, the third set of doors leading to the resident's living area was not locked and could be easily opened. This setup contributed to the resident's ability to exit the facility without being detected. The resident was later returned by another visitor without injury. Prior assessments had identified R912 as being at risk for elopement, and a care plan was in place, including frequent monitoring and inclusion in an 'elopement book' at the front desk. Despite these measures, the lapse in supervision allowed the resident to leave the facility, highlighting a failure in the implementation of the elopement prevention policy at the time of the incident.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure adequate assistance during a mechanical lift transfer for a resident, resulting in a fracture of the right lower leg and subsequent hospitalization. The resident, who had a history of dementia, Alzheimer's disease, osteoporosis, and a previous fracture, was observed with a soft cast on the right lower leg. The care plan indicated that the resident required a mechanical lift with two-person assistance for transfers. However, on a specific day, two CNAs transferred the resident without using the mechanical lift, instead opting for a manual transfer method. This action was contrary to the care plan and the facility's policy, which mandates the use of mechanical lifts for non-ambulatory patients. Interviews with staff revealed discrepancies in the accounts of the transfer process. One CNA admitted to not being aware of the requirement for a mechanical lift and acknowledged not consulting the care guide. The facility's policy on the Limited Lift Program emphasized the necessity of using mechanical lifting devices and having two associates present during transfers. Despite this policy, the CNAs involved did not adhere to the established procedures, leading to the resident's injury. The incident highlights a failure in following the care plan and facility policy, resulting in harm to the resident.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident, identified as R701, who was at risk for elopement. On the day of the incident, R701 exited the facility unsupervised through the main entrance, following an activities aide who was distracted by a cell phone. The resident was outside the facility for approximately two minutes before being brought back inside by the Director of Rehab, with no reported injuries. R701 had been admitted to the facility with diagnoses including dementia, a history of falling, anxiety, and a psychotic disorder with hallucinations. The resident's care plan, initiated five days prior to the incident, identified them as at risk for elopement due to wandering behavior. Despite this, the resident managed to exit the facility, indicating a lapse in the supervision and monitoring protocols that were supposed to be in place. The incident was compounded by the failure of staff to adequately monitor the resident. The activities aide, who was not on break, was preoccupied with a cell phone and did not notice the resident following them outside. Additionally, the receptionist, responsible for monitoring the main entrance, was distracted by conversations with staff and guests, allowing the resident to pass unnoticed. This series of oversights led to the resident's unsupervised exit from the facility.
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A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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