Riverside Nursing Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Haven, Michigan.
- Location
- 415 Friant Street, Grand Haven, Michigan 49417
- CMS Provider Number
- 235535
- Inspections on file
- 27
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 48
Citation history
Health deficiencies cited at Riverside Nursing Centre during CMS and state inspections, most recent first.
Staff failed to maintain resident dignity and respect during breakfast assistance for two residents. One resident with traumatic brain injury, quadriplegia, and cognitive communication deficit, who required one-person assistance for feeding, was assisted in bed by a CNA who repeatedly alternated between offering bites of food and scrolling on a cell phone on the overbed table, without meaningful conversation. In the dining room, another resident being assisted with breakfast by a CNA experienced similar behavior, as the CNA fed the resident while intermittently scrolling on a cell phone placed on the table, again with no meaningful interaction. The ADON acknowledged that staff cell phone use while providing resident care was not acceptable.
A resident with adult failure to thrive and a confirmed diagnosis of shingles was placed on contact precautions, with a sign posted at the room entrance directing staff to wear a gown and gloves upon every entry. Despite this, a CNA entered the room and assisted the resident with lunch in bed without wearing any PPE, including gown or gloves. An RN confirmed that staff were expected to follow the posted contact precautions whenever entering the room for any reason.
The facility failed to maintain an active and ongoing water management program to reduce the risk of legionella and other OPPP. The MS reported he had not participated in a Water Management Team meeting, policy review, or risk assessment since starting in the facility, and the Water Management Plan Binder contained no documentation of a team meeting, policy review, or risk assessment within the past 12 months.
Failure to maintain cleanliness and repair of premises and equipment. Surveyors observed food debris on the base of a lift in a hallway that remained present during a later walkthrough, a missing baseboard heater cover in a resident room exposing metal fins, cobwebs and dust on vent covers in a shared bathroom and shower room, peeling wall covering under a hallway mini-split unit, and cobwebs on the kitchen dry storage ceiling. The MS stated cleaning responsibilities were split between resident care staff, housekeeping, and dietary areas.
The deficiency involves multiple failures to ensure resident dignity, respect, and appropriate staff interactions. A cognitively intact resident reported that a CNA initially refused to help her to the bathroom, later assisted her, and then told her not to use the call light for the rest of the night. Another cognitively intact resident with extensive medical conditions and a need for two-person toileting assistance reported becoming bowel incontinent after waiting for her call light to be answered and being told by a CNA, "you stink," which made her feel she did not matter. In a resident group meeting, eight residents unanimously described agency staff as rude and disrespectful, reported staff congregating and talking loudly at the nurses’ station, shutting off call lights without returning, long call light wait times, late medication administration, and staff allowing doors to slam at night, despite a policy affirming residents’ rights to a dignified existence and respectful communication.
The facility failed to ensure safe, consistent pain management and proper controlled drug administration for multiple residents. A cognitively intact resident with chronic pain conditions reported not receiving scheduled hydromorphone and methocarbamol from an agency LPN, despite MAR and narcotic records indicating administration, and described increased pain afterward. The LPN admitted to locking narcotic keys in the med room, pre‑prepping narcotics, and not properly documenting medications, while a regional clinical nurse and another nurse observed poor adherence to controlled substance count procedures. Record review for other residents showed missed or undocumented doses of hydrocodone‑acetaminophen and pregabalin, with discrepancies between Proof of Use forms and MARs and no explanations for withheld doses. During a resident group meeting, several residents reported late or missed scheduled and PRN pain medications, confrontational responses from staff when concerns were raised, and having to attend therapy without timely PRN pain control, particularly citing problems with a male nurse who was no longer employed.
Advance directive planning was not completed or accurately documented for multiple cognitively intact residents. One resident had no evidence of being offered an advance directive during admission and the form was left blank, another had a DNR/medical treatment form but was later listed as Full Code, a third had a DNR order missing required witness and physician signatures, and a fourth had a signed no-CPR form that was not uploaded to the EMR, leaving the chart marked Full Code.
Failure to Notify Provider of Significant Changes in Resident Condition: The facility did not promptly notify the provider of major changes in condition for several residents. Events included SpO2 readings in the 50s for a resident with asthma and epilepsy, repeated hypotension with symptoms for a resident with DM and HTN, duplicate Ativan orders with extra doses given to a resident with anxiety and DS, and multiple critical BG results over 400 mg/dL for a resident with type 1 DM. The record showed missing or delayed provider notification and incomplete documentation of the changes.
Medication administration and monitoring errors occurred for multiple residents. An LPN administered insulin without priming pen needles, insulin was given without required blood sugar checks or was held outside ordered parameters, daily weights were missed or inaccurately documented for a resident with heart failure, and metoprolol was administered or withheld without required BP/HR assessments or documentation. The DON confirmed the errors during interview.
Inconsistent shower assistance was identified for two cognitively intact residents who needed help with personal care. One resident with multiple chronic conditions reported going about two weeks without a shower and said no bed baths were provided when a scheduled shower was missed; the DON found only two showers documented over five weeks and was unsure whether some entries reflected actual showers or bed baths. Another resident with parkinsonism and psychiatric diagnoses reported usually getting only one shower a week instead of two, and the DON found four showers documented over five weeks. In a resident group meeting, multiple residents said showers were often skipped when agency aides were working.
Failure to address and document pharmacy MRR recommendations affected multiple residents. One resident with PTSD, depression, and anxiety continued receiving PRN alprazolam without the ordered stop date after the pharmacist recommended discontinuation or a 14-day limit. Another resident with depression, psychotic disorder, insomnia, and anxiety had repeated PRN lorazepam recommendations that were not timely signed or implemented, with administrations continuing over several months. Two other residents had missing or unsigned pharmacy consult reports, including recommendations to taper and discontinue amitriptyline that were not reviewed or signed.
An LPN administered insulin to two residents with Type 1 DM without priming the insulin pen needles before giving the ordered doses. One resident had an order for insulin aspart before meals, and another had orders for insulin lispro and Lantus Solostar. The LPN stated she did not know the needles had to be primed, and the facility policy stated insulin pens should be primed before administration.
Expired and undated medications were found in a medication room and medication cart. An opened PPD vial was undated in the refrigerator, four bottles of Famotidine were expired, an opened Albuterol inhaler and an opened Wixela inhub inhaler had no open dates, and a Gas Relief bottle was expired. An LPN stated expired meds should not have been available for resident use, and facility policy required checking expiration dates and dating medications with shortened expiration dates.
Improper storage and dating of resident food items. Surveyors observed food in a resident refrigerator without dates showing when it was received and placed there, including cream-based soup, an opened jar of cheese dip, and oatmeal in kitchen dishware. The DS stated dietary staff did not have the key to the refrigerator and freezer and were not responsible for dating or discarding food from the resident refrigerator, despite facility policy requiring cooked food items to be labeled with the resident's name and date of delivery and stored in a resident-designated refrigerator/freezer.
Failure to assess self-administration of medication: A resident with type II DM, major depressive disorder, anxiety disorder, and cognitive communication deficit was found with Flonase nasal spray at the bedside. The resident was unsure why the medication was there, an LPN administered it and returned it to the med cart, and the DON confirmed no self-administration assessment had been completed for the nasal spray.
Failure to provide written bed hold notice at hospital transfer. A cognitively intact resident with diagnoses including bile duct obstruction and weakness was transferred to the ER for evaluation and treatment of excessive purulent drainage from a biliary drain, then sent to another hospital for treatment and admission. The EMR did not show written notice of the facility's bed hold policy, and the DON stated the resident was not given the notice when transferred; the policy required the notice at admission and again with emergency transfer.
PASARR Level 1 screenings were not completed timely for two residents with mental health diagnoses. One resident had schizoaffective disorder and severe cognitive impairment, but no new screening was completed after the hospital exemption period expired. Another resident with PTSD, depression, and other behavioral health diagnoses had no PASARR screening in the chart prior to admission, and the later form provided was undated, unsigned, and missing the name and title of the person who completed it.
Failure to Manage and Document Pressure Injuries: A resident with CHF and ongoing skin issues had missed weekly skin assessments, undocumented buttock excoriation, no timely notification to the DON/provider/RP, no care plan update, and no treatment order entered in the MAR until after wound NP review. Later, the resident developed MASD/skin tears to the sacrum/intergluteal cleft, with delayed treatment documentation and inconsistent wound/care plan records.
Incomplete resident records were cited for three residents. One resident with PTSD, depression, and anxiety had no EMR evidence of advance directive discussion or a PASARR Level 1 screening before admission, and the PASARR form later found was undated, unsigned, and missing the preparer’s name and title. Another resident with depression, psychotic disorder with delusions, insomnia, and anxiety had pharmacy consultation reports noted on multiple MRRs but missing from the EMR, with one review left incomplete. A third resident with a biliary drain transfer had no EMR evidence that the bed hold policy was provided at transfer, and the DON confirmed the notice was only given at admission.
The facility did not ensure that a resident received proper care for existing pressure ulcers and failed to implement adequate preventive measures to avoid the development of new ulcers, as observed and documented by surveyors.
The facility did not complete required care conferences or ensure resident and representative participation in care planning, as confirmed by missing documentation and staff interviews. Family members reported lack of communication about care needs and changes, and staff acknowledged irregular scheduling and attendance of interdisciplinary team members at care conferences.
The facility did not ensure effective administration and resource use, resulting in missed care conferences, lack of wound care oversight, insufficient staff orientation and training, and unaddressed resident complaints about late or missed medications. The NHA acknowledged these deficiencies, including the absence of audits and failure to investigate or report potential neglect.
The facility did not designate a physician to serve as medical director, resulting in a lack of oversight for the implementation of resident care policies and coordination of medical care.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
A resident was admitted without a physician's order and was not placed under a doctor's care as required, resulting in noncompliance with admission protocols.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of documentation and information handling practices.
Two residents reported not receiving their afternoon medications during a resident council meeting, but the facility did not follow required procedures to report or investigate the allegations. The DON received the grievances but did not confirm all involved residents or conduct a medication review, and the NHA maintained resident anonymity without further inquiry. The incident was not reported to the State Agency, and the agency LPN on duty was not interviewed.
A resident was not provided assistance to obtain needed vision and hearing services, resulting in a lack of access to appropriate care.
The facility did not provide required orientation or training to agency staff, including two LPNs and a CNA, before they began their shifts. One CNA was unable to access resident information in the EMR and reported not receiving necessary information during shift change. Leadership confirmed that agency staff were not consistently oriented or trained as required by facility policy, and documentation of such training was lacking.
Two CNAs did not receive their required annual competencies and in-service training, including dementia care and abuse prevention, due to the absence of HR staff responsible for these checks. This issue was identified through record review and administrator interview, potentially affecting all 33 residents.
The facility failed to adhere to food safety standards, with issues such as torn cooler gaskets, a malfunctioning plate warmer, improper storage of soy sauce, and unsanitary conditions in the kitchen. Additionally, items in the refrigerator lacked proper date marking, and a staff member did not wash hands after cleaning a cart before returning to food preparation.
The facility failed to maintain a safe and sanitary environment, with issues such as broken blinds, detached footboards, and congested dining areas. Bathrooms had low temperatures, peeling paint, and dusty ventilation. Linen and utility closets were cluttered and dusty, indicating poor maintenance.
A resident with Down syndrome and adult failure to thrive experienced significant weight loss, dropping from 88.8 to 81.4 pounds, without the guardian being informed. The resident's meal intake was inconsistent, and dietary interventions were not consistently administered. The resident's representative was unaware of these issues, and the physician was not notified of the weight loss.
The facility failed to maintain comfortable temperatures and a homelike environment for several residents. A resident was found shivering in bed with room temperatures between 65.5 and 68 degrees Fahrenheit. Another resident reported refusing a shower due to the cold, with no documentation addressing the issue. Other residents also reported feeling cold, with one wearing a jacket to keep warm. The Maintenance Director confirmed the heating system was not functioning properly, indicating a systemic issue.
The facility failed to provide food at a palatable temperature, as observed during a lunch service tour. The Dietary Manager reported issues with the plate warmer, and pre-service temperatures were not recorded. A test tray revealed food temperatures below the desired level, and residents expressed dissatisfaction with the cold and flavorless meals. This indicates a failure to provide food at a safe and appetizing temperature.
The facility failed to consistently provide bedtime snacks to diabetic residents, as evidenced by interviews and snack logs. A resident with diabetes mellitus, weight loss, and weakness reported not receiving snacks consistently, with records showing limited offerings. Another resident with insulin-dependent diabetes had a care plan requiring bedtime snacks to manage blood sugar, yet received them inconsistently. The Dietary Manager was unaware of the number of diabetic residents, leading to inadequate snack provision.
A facility failed to ensure a call light was within reach for a resident with a recent leg amputation, diabetes, and dementia. Observations revealed the call light was placed out of reach on multiple occasions, and staff did not reposition it to be accessible. The resident was unable to reach the call light and was unaware of its location when it was on the floor. A CENA confirmed that staff are expected to ensure call lights are within reach.
A resident reported missing clothing items, including winter boots and a gown, but the facility failed to follow its grievance policy. Despite informing the Administrator, no grievance form was completed, and the issue was not addressed until weeks later. The Activities Director was unaware of the missing items until months after the initial report.
A facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including anxiety, depression, and spondylosis. The care plan lacked focus on these conditions and did not address the resident's cognitive status or ADL needs. The resident experienced significant weight loss, and the nutritional care plan lacked new interventions. The resident's representative was not informed of the weight loss or supplements, and the resident was observed without needed assistance during meals. Additionally, there was no care plan for the resident's seizure-like behaviors or UTI diagnosis.
A resident with chronic health conditions, including diabetes, did not receive necessary foot care due to a lapse in insurance renewal, resulting in missed podiatry visits. The resident was observed with long toenails and expressed dissatisfaction with the lack of care. The care plan required regular foot inspections and podiatrist referrals, which were not fulfilled, leading to the deficiency.
A facility failed to properly secure and store an oxygen tank for a resident. During an observation, a portable oxygen tank was found lying across the arms of a chair in the resident's room, while the resident was not present. The DON acknowledged the improper storage, which was against the facility's policy requiring oxygen cylinders to be secured in racks or by chains.
Two residents experienced significant weight loss due to the facility's failure to monitor and provide adequate nutrition and assistance with meals. One resident, with Down syndrome, lost 8.33% of her weight in less than 30 days, while another resident with dementia received only a fraction of her meals over a month. The facility did not follow its policies on nutritional risk and weight monitoring, leading to inadequate care and lack of communication with the physician and guardians.
The facility failed to properly store and label medications according to professional standards. A medication cart inspection revealed 18 loose pills and an undated Basaglar insulin KwikPen prescribed to a resident. The ADON confirmed the loose pills should not have been there, and facility policy requires opened medications to be dated if they have a shortened expiration date.
Failure to Maintain Resident Dignity During Assistance with Meals
Penalty
Summary
The facility failed to honor residents’ rights to dignity and respect during assistance with breakfast, as observed with two residents. One resident, a female with traumatic brain injury, quadriplegia, cognitive communication deficit, and a need for one-person assistance with personal care including feeding, was observed in bed while a CNA stood at her left side and assisted with breakfast. During this interaction, the CNA repeatedly offered bites of food and then looked down and scrolled through a cell phone placed on the overbed table, without engaging the resident in any meaningful conversation throughout the observation period. In a separate observation in the dining room, another resident was seated at a table with her back to the doorway while a CNA sat at the same table assisting her with breakfast. The CNA lifted a utensil with food to the resident’s mouth and then began scrolling on a cell phone placed on the dining room table, again without any meaningful conversation or interaction with the resident. When these observations were shared with the ADON, the ADON stated that staff cell phone use while providing care and assistance to residents was not an acceptable practice.
Failure to Follow Contact Precautions for Resident on Isolation for Shingles
Penalty
Summary
The facility failed to follow its infection prevention and control program by not adhering to posted contact precautions for a resident on isolation for shingles. A face sheet showed that Resident #104 was an adult female admitted with adult failure to thrive, and a physician order summary documented that she was on contact precautions due to a confirmed diagnosis of shingles. A contact precautions sign was posted outside her room instructing staff to wear a gown and gloves with each room entry. However, during an observation, a CNA entered the resident’s room and assisted her with lunch while she was in bed without wearing a gown, gloves, or any PPE, contrary to the posted instructions. During an interview, an RN stated that the expectation for all staff was to follow the posted contact precautions whenever entering this resident’s room for any reason, confirming that the CNA’s actions did not comply with facility expectations and the resident’s ordered precautions.
Water Management Program Lacked Required Review and Documentation
Penalty
Summary
Provide and implement an infection prevention and control program. Based on interview and record review, the facility failed to maintain an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During an interview on 02/09/2026 at 2:30 PM, the Maintenance Supervisor (MS) stated that he had not participated in a Water Management Team meeting, a policy review, or a risk assessment during his employment at the facility, which began in October 2025. Review of the maintenance department's Water Management Plan Binder showed no documentation of minutes from a Water Management Team meeting, policy review, or risk assessment within the past twelve months.
Failure to Maintain Cleanliness and Repair of Premises and Equipment
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises and equipment. On 02/09/2026 at 11:46 AM, surveyors observed food debris on the base of a lift stored in a hallway, including food ground into the mat in the indented area of the base and loose food particles. During a later walkthrough at 2:00 PM with the Maintenance Supervisor, the same food debris was still present on the matting at the base of the equipment. The Maintenance Supervisor stated that general cleaning of equipment was the responsibility of hall resident care staff, and housekeeping would clean the equipment if it could not be cleaned with the wipes provided. Surveyors also observed a baseboard heater cover missing in a resident room, leaving approximately 3 feet of exposed metal fins accessible to residents, with the resident's bed partially blocking the remaining uncovered portion. The Maintenance Supervisor stated the facility was aware of the issue and had made multiple repairs, but the cover would not remain on. Additional observations included cobwebs and dust on vent covers in a shared bathroom and shower room, bubbling and peeling wall covering under a hallway mini-split unit, and cobwebs on the ceiling over the dry storage area in the kitchen. The Dietary staff member stated they were unaware of the cobwebs prior to the discussion, and the Maintenance Supervisor stated housekeeping was not responsible for cleaning in the kitchen area.
Failure to Ensure Resident Dignity, Respect, and Timely Call Light Response
Penalty
Summary
The deficiency involves failures to ensure residents were treated with dignity and respect, including honoring their right to request assistance and to be spoken to respectfully. One cognitively intact female resident with diabetes and hypertension reported that during a night shift she rang her call light for help to use the bathroom, but the CNA who responded initially stated she was not going to help and left the room. The CNA later returned, assisted the resident to the bathroom, and instructed her to use the call light when finished. After returning the resident to bed, the CNA told her not to press the call light for the rest of the night. The facility’s own incident and complaint reports documented the resident’s allegation that the CNA told her she could not assist at that moment, later assisted her, and then told her not to press the call light again. Another cognitively intact resident with multiple significant diagnoses, including acute respiratory failure, chronic kidney disease, type II diabetes, morbid obesity, COPD, difficulty in walking, and a care plan requiring two-person assistance for toileting, reported she became incontinent of bowel after waiting for her call light to be answered the previous night. When staff finally responded, the CNA told her, “you stink,” and the resident reported that such treatment made her feel like she did not mean anything. During a confidential group meeting with eight residents, all participants reported that agency staff often stood at the nurses’ station talking loudly and “goofing around,” did not follow facility protocol, and were rude and disrespectful. Residents reported agency staff answering call lights by saying, “your light’s on, what do you want,” shutting off call lights without returning, long call light response times (up to an hour) on nights with primarily agency staff, and late medication administration. Five of the eight residents also reported that staff allowed doors to slam at night, which they found terrifying. These events occurred despite a facility policy stating residents have the right to a dignified existence, self-determination, and communication.
Failure to Provide Consistent, Properly Documented Pain Management and Controlled Drug Administration
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and to administer controlled pain medications according to provider orders and residents’ goals and preferences. One cognitively intact female resident with acute and chronic respiratory failure with hypoxia, spinal stenosis, low back pain, and asthma had scheduled hydromorphone and methocarbamol ordered every six hours and four times a day, respectively. She reported that on a night when an agency LPN was working, she did not receive her scheduled midnight and early morning pain medications, despite the Medication Administration Record (MAR) and Controlled Substance Proof of Use forms indicating they were given. She stated the LPN attempted to give her medications early around 9:30 PM, claimed her pain pill and muscle relaxer were in the cup, but she did not see them, shook the cup, and believed they were not present. She later reported increased and lingering pain due to not receiving her medications. The facility’s own incident report and staff statements showed discrepancies between documentation and actual access to narcotics. The LPN reported to the oncoming RN and the DON that he had locked the narcotic and med-cart keys in the medication room during the night and did not regain access until after 6:40 AM, which would have prevented timely administration of scheduled narcotics, including the resident’s 6:00 AM hydromorphone. He also told the off‑going RN that he had “prepped all his narcs,” indicating he removed doses and documented them on Proof of Use sheets at the beginning of his shift rather than at the actual time of administration. The DON documented that the LPN later admitted he did not properly document medications he administered and that narcotics were administered late once access to the keys was restored. A regional clinical nurse observed that the LPN did not initially follow required controlled substance count procedures and needed direction to complete them correctly, and a colleague described him as a sloppy nurse with poor practices. Additional record review identified further failures in pain and controlled medication management for other residents. One male resident with hypertensive heart and chronic kidney disease with heart failure had an ordered three‑times‑daily hydrocodone‑acetaminophen regimen; on one date, the afternoon dose was neither dispensed on the Controlled Substance Proof of Use form nor documented as given on the MAR, and there was no documentation explaining the omission. Another male resident with lumbar inflammatory spondylopathy had hydrocodone‑acetaminophen ordered three times daily; on one date, the morning dose was not dispensed per the Proof of Use form, yet all three doses were documented as administered on the MAR, with no documentation of withholding. A female resident with neuropathy had pregabalin ordered three times daily; on one date, the afternoon dose was not dispensed per the Proof of Use form and was left blank on the MAR, again with no documentation for withholding. During a resident group meeting, multiple residents reported that medications, including scheduled and PRN pain medications, were not always administered on time, that staff were confrontational when concerns were raised, and that some residents had to attend therapy without timely PRN pain medication, with several residents specifically citing problems with a male nurse not administering pain medications on time or at all. Facility policies required staff to prepare medications for only one resident at a time, to document removal of controlled substances on Proof of Use sheets as soon as the medication is removed, and to document administration on the MAR or eMAR only after the medication is actually given, with the MAR/eMAR serving as the record of administration. The policies also required proper shift‑to‑shift narcotic counts with both on‑going and off‑going nurses. The nursing textbook cited in the report reinforces that medications should never be documented as given until after administration. The events described, including pre‑prepping narcotics, documenting doses as given when access to narcotics was unavailable, missing doses without explanation, and inconsistent documentation between Proof of Use forms and MARs, demonstrate that these standards and policies were not followed, resulting in missed, late, or unverified pain medication administration for multiple residents. During the confidential resident group meeting, one resident reported that scheduled pain medications were passed late and PRN pain medications were not promptly administered when requested, sometimes taking more than an hour. Three residents reported they had not received pain medications in the past and had reported these issues to management. One resident described having to receive therapy services without PRN pain medication, making participation difficult due to pain. Several residents reported prior problems with a male nurse not administering pain medication on time or at all, and they noted that this nurse was no longer working at the facility. These resident reports, combined with the documented discrepancies in controlled substance handling and administration records, support the finding that the facility failed to ensure consistent, timely, and properly documented pain management services for residents who required such care.
Advance directive documentation was incomplete or not reflected correctly for multiple residents
Penalty
Summary
The facility failed to formulate and complete advance directives in a timely manner for 4 of 17 residents reviewed. Resident 2 was cognitively intact with a BIMS score of 15 and had diagnoses including a compression fracture of the third thoracic vertebra, depression, and generalized muscle weakness. Review of the medical record showed no completed advance directive documentation and no evidence that the resident had been offered the opportunity to formulate one during the admission process. An undated informed health care decisions form in the admission packet was blank, and the Medical Treatment Decisions of Resident form was not completed until almost a month after admission. Resident 4 was cognitively intact with a BIMS score of 15 and had diagnoses including CHF, CKD, and type II DM. The record contained a Do Not Resuscitate Order and Medical Treatment Decisions of Residents form indicating the resident requested no resuscitation, but a later physician order listed the resident as Full Code. Social Services stated she was unsure how the resuscitation status changed and confirmed the resident should have been documented as DNR based on the prior form. Resident 6 was cognitively intact with a BIMS score of 15 and had diagnoses including ESRD with dependence on renal dialysis, acute kidney failure, and CHF. The resident’s DNR order was incomplete because it had only one witness signature and no physician signature, both required to activate the order. Resident 24 was cognitively intact with a BIMS score of 13 and had diagnoses including acute pancreatitis, respiratory failure, and COPD. The EMR listed the resident as Full Code, but Social Services stated a signed Medical Treatment Decisions of Residents form marked no for CPR existed and had not been uploaded into the EMR.
Failure to Notify Provider of Significant Changes in Resident Condition
Penalty
Summary
The facility failed to ensure the provider was immediately notified of changes in resident condition for 4 of 12 residents reviewed. The deficiency involved missed or delayed notification for abnormal oxygen saturation, hypotension, duplicate medication administration, and repeated critical blood glucose results. The report states that the facility did not follow its notification of change policy, which required the resident’s physician and responsible party to be notified when an event occurred or when the resident experienced a change in condition. For one resident with asthma and epilepsy, the record showed oxygen saturations in the 50s were documented in the provider communication log, but there was no nursing note, no vital signs charted for the date of the event, and no call to the provider at the time of the low oxygen reading. The provider later documented that there was a delay in physician notification of an acute change in condition. For another resident with diabetes and hypertension, the record showed manual blood pressures as low as 70/42 with dizziness and lightheadedness, then later 80/60 with headache and fatigue, and then 90/60 and 88/51, but the provider was not notified for further direction on treatment or monitoring. The blood pressure assessments were also not consistently documented in the blood pressure log. For a resident with down syndrome and anxiety disorder, the medication record showed duplicate Ativan orders and administration of extra doses on two days, including a total of 1 mg given instead of 0.5 mg. One nurse did not notify the provider or DON of the duplicate order and did not place the order on hold. The blood pressure log also showed a reading of 73/45 after the extra doses, with no documentation that the provider was notified of the hypotension and change from baseline. For a resident with type 1 diabetes, the blood sugar log showed multiple readings of 447, 456, 500, 504, 511, 519, 539, and values recorded as High, all above the physician notification threshold of greater than 400 mg/dL, but there was no documentation that the provider was notified for any of those critical results.
Medication Administration and Monitoring Errors
Penalty
Summary
The facility failed to ensure medications and treatments were administered and completed according to physician orders for six residents reviewed for nursing professional standards of practice. The report identified errors involving insulin administration, blood sugar monitoring, blood pressure and pulse monitoring before antihypertensive administration, daily weights, and documentation of medication administration or omission. For one resident with Type 1 diabetes, an LPN administered insulin aspart and insulin lispro/insulin Lantus by pen without priming the pen needle first. The LPN stated she did not know the needle had to be primed before administration and said she had never primed an insulin needle. Facility policy stated insulin pens should be primed prior to administering medications, and the RN confirmed that priming an insulin pen needle before dialing the ordered dose was the standard of practice. For another resident with Type 2 diabetes, the record showed multiple instances where Humalog was administered without a documented blood sugar assessment, as well as instances where Humalog was held when the blood sugar was within ordered parameters without a provider order. The blood sugar log also showed several missed meal-time assessments, including no lunch or dinner checks on multiple dates, and the MAR reflected insulin administration despite the missing assessments. For a resident with chronic diastolic heart failure, the order required daily weights, but weights were not obtained on multiple dates. The MAR showed blank entries, repeated prior-day weights, and one entry marked "Other" without a corresponding progress note. For another resident with hypertensive heart and chronic kidney disease with heart failure, metoprolol was held once despite blood pressure and heart rate being within acceptable range, and on later dates the medication was not given because it was unavailable without documentation that the provider or management were notified. For a resident with hypertension and atrial fibrillation, metoprolol succinate was ordered with hold parameters for low systolic blood pressure or heart rate, but the MAR showed the medication was administered on multiple days despite missing assessments or values outside the ordered parameters. The record also showed several dates with no morning or evening heart rate and blood pressure assessments. During interview, the DON confirmed the medication administration errors and the lack of daily weights, and stated that licensed nurses would receive education on administering medication following provider-ordered parameters.
Inconsistent Shower Assistance and ADL Care
Penalty
Summary
The facility failed to consistently provide ADL assistance, specifically showers, for residents who were unable to complete this care independently. Resident #17, who had diagnoses including acute respiratory failure, chronic kidney disease, type II diabetes mellitus, morbid obesity, COPD, difficulty walking, and need for assistance with personal care, had a care plan to keep her clean and dry and minimize skin exposure to moisture. Although she was cognitively intact with a BIMS score of 15, she reported that she had not received a shower in about two weeks and that a scheduled shower was missed because staff said there was not enough time. She also stated that no bed baths had been substituted during that period. The DON reviewed shower documentation and found only two showers over a five-week span, with uncertainty about whether some documentation reflected actual showers or bed baths because of inconsistent staff signatures. Resident #18, who had parkinsonism, bipolar disorder, anxiety disorder, and need for assistance with personal care, was also cognitively intact with a BIMS score of 15 and had a pressure ulcer care plan directing staff to keep her clean and dry and minimize skin exposure to moisture. She stated she was supposed to receive two showers a week but usually only got one, and that the last shower she received was on 2/3/26. The DON reviewed records showing four showers over a five-week span and noted that the expectation was two showers a week or resident preference. In a confidential group meeting with eight residents, six reported that when agency aides were working, showers were skipped, and residents stated agency staff were often sitting at the nurses' station instead of completing care. Residents also stated they felt they should not have to beg to get a shower.
Failure to Address and Document Pharmacy Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacist medication regimen review recommendations were addressed and documented for multiple residents. For one resident with PTSD, depression, and anxiety, the pharmacist recommended discontinuing PRN alprazolam or adding a stop date not to exceed 14 days from initiation, and the physician accepted the recommendation, but the physician order record did not show the medication was discontinued or given a stop date. The medication administration record showed the resident continued receiving PRN alprazolam for 21 days after initiation, with no stop date listed. For another resident with depression, psychotic disorder with delusions, insomnia, and anxiety, the pharmacist recommended adding a stop date for PRN lorazepam no more than 14 days from initiation, but the report was not signed or acknowledged by the physician or designee. A later pharmacist recommendation repeated the need for a stop date or discontinuation, and the physician accepted it and noted to add a stop date. The resident’s physician orders showed consecutive PRN lorazepam orders over an extended period, and the MAR documented multiple administrations of lorazepam across several months before the original recommendation was addressed and a stop date was initiated. For two additional residents, the facility could not produce pharmacy medication irregularity reports when requested. One resident with type II diabetes mellitus, hypertension, chronic respiratory failure, and weakness had irregularities noted in multiple months, but the September, October, and December pharmacy reports could not be located. Another resident with depression, insomnia, and chronic respiratory failure had irregularities noted in October and December, and the facility located consultation reports recommending tapering and discontinuing amitriptyline related to a fall, but both recommendations were not reviewed or signed. The resident remained on an active order for amitriptyline 50 mg daily, and the DON stated the completed pharmacy consult reports were still being located.
Insulin Pen Needles Were Not Primed Before Administration
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders without errors for 2 of 7 residents observed during the medication administration task, resulting in a medication error rate of 10.34% (3 errors out of 29 opportunities). Resident #17, a female with Type 1 Diabetes, had an active order for insulin aspart U-100 before meals. During observation, an LPN prepared and administered the insulin but did not prime the insulin pen needle or expel insulin into the needle to ensure patency. When interviewed, the LPN stated she did not know she had to prime the insulin needle before administration and said she administers her own insulin and has never primed the needle. Resident #5, a female with Type 1 Diabetes, had active orders for insulin lispro 100 units/mL, 4 units twice daily, and Lantus Solostar U-100 insulin, 15 units once daily, both per insulin pen. During observation, the same LPN prepared and administered both insulins to the resident without priming either pen needle or expelling insulin into the needles to ensure patency. The regional nurse stated that the standard of practice is to prime an insulin pen needle prior to dialing the ordered amount of insulin during administration, and the facility policy on injection technique stated that insulin pens should be primed prior to administering medications.
Expired and Undated Medications Found in Medication Storage and Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles and stored without expired medications being available for resident use. During an observation of the medication room, an opened Tuberculin Purified Protein Derivative vial was found in the refrigerator opened and undated, and four bottles of Famotidine 20 mg tablets were found with an expiration date of January 2026. During an observation of the medication cart, an opened Albuterol inhaler with 196 puffs remaining had no date showing when it was opened, a Gas Relief 125 mg bottle was expired with an expiration date of 1/2026, and an opened Wixela inhub inhaler with 39 puffs remaining had no date indicating when it was opened. In interview, an LPN stated the expired medications should not have been in the medication storage room and available for resident use. Review of the facility’s General Dose Preparation and Medication Administration policy stated staff should check medication expiration dates and enter the date opened on medications with shortened expiration dates. Review of the House Stock Policy stated house stock medications should be stored in the original manufacturer’s container with the medication name, strength, expiration date, and lot number clearly visible.
Improper Storage and Dating of Resident Food Items
Penalty
Summary
The facility failed to maintain best practices for the storage of foods brought to residents by family and other visitors. During observation and interview on 02/09/2026 at 10:32 AM, the Dietary Supervisor stated they did not have the key to the refrigerator and freezer and had to go to the nurse's station to obtain it before opening the doors. The Dietary Supervisor also stated dietary staff were not responsible for dating food or discarding food from the residents' refrigerator. In the resident refrigerator, surveyors observed a cream-based soup with only the room number on the container, an opened jar of Tostitos cheese dip, and oatmeal in kitchen dishware, all without a date showing when the food was received and placed in the refrigerator. Record review of the facility policy, Foods Brought in to Resident Education Material, stated cooked food items will be labeled with the resident's name and date of delivery and, if refrigeration or freezing is needed, the items will be placed in a resident designated refrigerator/freezer.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to properly assess one resident for self-administration of medications. The resident was admitted with diagnoses including type II diabetes mellitus, major depressive disorder, anxiety disorder, and cognitive communication deficit. During an observation, the resident was found with a bottle of Flonase nasal spray at the bedside, and when asked, the resident stated she was unsure why it was there. An LPN then administered the Flonase as ordered and placed it into the medication cart. Review of the physician order showed Flonase Allergy Relief spray ordered as one spray in each nostril every morning, and the record showed no diagnosis for use of Flonase. The LPN stated the nasal spray should have been in the medication cart and was unsure how long it had been at the bedside. The DON later reported that the resident did not have a self-administration assessment completed for the Flonase nasal spray. Facility policy stated residents may not self-administer medications until the IDT determines they are safe to do so and which medications may be self-administered.
Failure to Provide Written Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide a resident with written notice of the facility's bed hold policy when the resident was transferred to the hospital emergency room. R27 was a cognitively intact resident with a BIMS score of 15 and diagnoses including obstruction of the bile duct and weakness. An interdisciplinary team note documented that R27 was transferred to the hospital emergency room for evaluation and treatment of excessive purulent drainage from the biliary drain and was then transferred to another hospital for treatment, management, and admission. A review of R27's electronic medical record from 1/6/26 to 2/12/26 did not show that the facility provided written notice of the bed hold policy at the time of the hospital transfer. During interviews, the DON stated the surveyor could not locate the written notice and later stated the facility did not give R27 written notification of the bed hold policy when she went to the emergency room, explaining that the policy was only given when the resident was admitted to the facility. The facility's bed hold policy stated the policy would be provided at admission and again with any emergency transfer from the community.
PASARR Level 1 Screenings Not Completed Timely
Penalty
Summary
The facility failed to complete PASARR Level 1 screenings timely for 2 residents with mental health diagnoses. One resident was admitted with schizoaffective disorder, bipolar type, and type II diabetes. The resident’s MDS showed a BIMS score of 4, indicating severe cognitive impairment, and the resident had received an antipsychotic and an antidepressant during the assessment period. The resident had a PASARR Level 1 screening dated 09/22/2025 marked as a hospital exemption discharge, but there was no new PASARR Level 1 screening completed after the 30-day exemption period passed. For the second resident, the face sheet listed diagnoses including PTSD, depression, anorexia nervosa-binge eating/purging type, and a personal history of other mental and behavioral disorders. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. Review of the EMR and admission packet audit did not show that a PASARR Level 1 screening had been completed prior to admission, and the audit form was left blank for the PASARR task. The DON could not locate the screening in the medical record and later provided an undated, unsigned copy that lacked the name and title of the person who completed it. Social Services stated the resident did not have a PASARR Level 1 screening completed prior to admission and that the facility had asked the hospital to complete it when the resident arrived from an out-of-state hospital. The screening later loaded into the EMR was completed by an RN after admission, was unsigned, and lacked identifying information for the person who completed it. The State Operations Manual states that all applicants to Medicaid-certified nursing facilities must be screened for possible serious mental disorders, intellectual disabilities, and related conditions prior to admission.
Failure to Manage and Document Pressure Injuries
Penalty
Summary
The facility failed to implement its pressure injury/wound management policy for three residents with alterations in skin integrity. Resident #21 had diagnoses including chronic diastolic heart failure and was on a weekly skin assessment order. The record showed a left lower extremity ulcer with treatment in place on 12/18/25, but no weekly skin assessments were completed on 12/25/25 or 1/1/26. On 1/8/26, the skin assessment documented excoriation on both buttocks with barrier cream applied to open areas, but there was no documentation that the DON, provider, or emergency contact were notified, the care plan was not updated, and no new treatment orders were implemented for the documented barrier cream use. For Resident #21, follow-up skin assessments were also missing on 1/14/26, 1/19/26, and 1/21/26. On 1/27/26, the skin assessment documented sacrum/coccyx skin tears and bilateral intergluteal cleft involvement, and a nursing progress note described moisture-associated skin tears to the right and left intergluteal cleft with wound NP evaluation planned. However, the order summary showed no treatment was initiated from 1/27/26 through 1/29/26, and the MAR contained no documentation of treatments during that period. The DON later reported that treatment had been initiated when the breakdown was identified, but it was not ordered in the MAR until after the wound consultant assessment on 1/30/26. The record also showed inconsistencies in wound documentation and ongoing order management. On 1/30/26, the wound NP identified the intergluteal cleft areas as MASD to the sacrum, updated measurements, and ordered cleansing with normal saline or wound cleanser and hydrocolloid dressing three times weekly and as needed. On 2/6/26, the wound note stated the right sacral area was improving and the left sacral area had healed, but the care plan still reflected active MASD to the left sacrum and healed MASD to the right sacrum, creating a discrepancy. The treatment order remained ongoing through survey exit without modification to reflect the change or resolution documented on 2/6/26.
Incomplete Resident Records and Missing Required Documentation
Penalty
Summary
The facility failed to maintain complete medical records for 3 of 12 sampled residents. For one resident with PTSD, depression, and anxiety, the electronic medical record did not contain documentation showing that advance directives were addressed or that a PASARR Level 1 screening had been completed before admission. When the DON was notified, she stated she would look through file folders and boxes in her office for missing documents. The facility later produced an undated and unsigned PASARR Level 1 screening that lacked the name, title, date, time, and signature of the person who completed it, and the form was loaded into the record after the resident had already been admitted. The DON also stated that an advance directives form was completed only after the missing documentation could not be located. For another resident with depression, psychotic disorder with delusions, insomnia, and anxiety, the pharmacist’s drug regimen review forms showed multiple dates when irregularities or recommendations were noted, but the resident’s EMR did not contain the corresponding pharmacy consultation reports. One review date also had no indication whether the medications were reviewed at all because the form was left incomplete. During interview, the DON confirmed that the pharmacy consultation reports were in boxes and file folders in her office and had not been scanned into the resident’s medical record. The facility’s medication regimen review policy stated that readily available copies of MRRs should be maintained on file as part of the resident’s permanent health record. For a third resident with obstruction of the bile duct and weakness, the EMR did not show that the facility provided written notice of the bed hold policy when the resident was transferred to the hospital emergency room for excessive purulent drainage from a biliary drain and subsequent transfer to another hospital. The DON initially said she would look for the paperwork, then later stated the facility did not give written notification at the time of transfer and only provided the bed hold policy at admission. She produced a copy of the policy that had been given on admission and confirmed it had not been scanned into the medical record. The facility’s bed hold policy required the social worker or designee to provide the policy at admission and again prior to transfer due to hospitalization or therapeutic leave, with signed copies maintained in the resident’s file.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents at risk for pressure ulcers did not consistently receive necessary interventions or monitoring to address existing wounds or prevent further skin breakdown.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed and that residents or their representatives participated in the development and implementation of person-centered care plans. For three of four residents reviewed, there was no evidence of required care conferences being held, including upon admission and quarterly as mandated. One family member reported ongoing concerns about a resident's need for an eye doctor appointment and new glasses, stating that despite repeated communication with the social worker, no action was taken by the facility, leading the family member to arrange the appointment independently. The same family member also expressed concerns about not being notified in a timely manner regarding medication changes and falls. Review of electronic medical records confirmed the absence of documentation for care conferences for multiple residents, with staff interviews corroborating that care conferences were not held as required and that the responsibility for organizing them had shifted between staff members. The social worker, DON, and NHA all acknowledged that care conferences were not conducted regularly, and that not all interdisciplinary team members attended when they did occur. The lack of care conferences and documentation affected all residents in the facility.
Failure to Administer Facility Resources and Oversight of Resident Care
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to meet the needs of all 33 residents. The Nursing Home Administrator (NHA) acknowledged that quarterly resident care conferences had not been conducted or attended by all Interdisciplinary Team (IDT) members, and there was no documentation of these conferences being completed. Additionally, the facility lacked oversight of skin assessments and wound care after the contract with an external wound care company ended, with no clear plan for ongoing wound care oversight. The NHA also reported that audits or monitoring of resident care and services were not being performed to ensure compliance, except for a one-time audit following a facility-reported incident involving a resident not receiving dressing changes as documented by nursing staff. Further deficiencies included inconsistent orientation and policy review for agency staff, with no evidence that agency staff received proper orientation or reviewed facility policies before starting their shifts. Certified Nursing Assistants (CNAs) were not receiving their required annual trainings due to the absence of a Human Resources staff member. During a resident council meeting, multiple residents reported receiving medications late or not at all, but the NHA did not investigate or report these allegations of neglect, nor did she speak with the nurse involved. The facility's policy required the administrator to ensure ongoing medical care and oversight, but these requirements were not met as described in the findings.
Failure to Designate a Medical Director
Penalty
Summary
A deficiency was identified due to the facility's failure to designate a physician to serve as the medical director. This physician is responsible for the implementation of resident care policies and the coordination of medical care within the facility. The absence of a designated medical director resulted in noncompliance with regulatory requirements for oversight of resident care policies and medical care coordination. No additional details regarding specific residents, staff, or events were provided in the report.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Failure to Obtain Physician Order and Oversight at Admission
Penalty
Summary
A deficiency was identified when a resident was admitted without obtaining a doctor's order for admission and without ensuring that the resident was under a physician's care. The required process to secure a physician's order and oversight at the time of admission was not followed, resulting in noncompliance with regulatory requirements.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices related to the handling and documentation of resident medical records. The report notes that the required standards for protecting confidential information and maintaining accurate, complete records were not met.
Failure to Report and Investigate Alleged Neglect of Medication Administration
Penalty
Summary
The facility failed to follow its policies and procedures regarding the reporting of alleged neglect when two residents, including one identified as R8, complained during a resident council meeting about not receiving their afternoon medications. The Abuse Prevention Program Policy requires that all alleged or suspected violations, including neglect, be reported immediately to the Administrator or Director of Nursing, and subsequently to the State Survey Agency and other authorities as required by law. However, after the resident council meeting where the complaints were raised, there was no immediate follow-up or investigation into the allegations, and the incident was not reported to the State Agency as required. Interviews revealed that the Director of Nursing received the grievances but did not confirm the identity of one of the residents or conduct a full medication review. The Nursing Home Administrator was initially unaware of the complaints and later stated that the residents' anonymity was maintained due to fear of retaliation, resulting in no direct questioning or investigation of the residents involved. There was also no documentation of a medication review for the affected residents, and the agency nurse who was on duty at the time of the alleged neglect had not been interviewed regarding the incident. These actions and inactions led to the deficiency cited in the report.
Failure to Assist Resident with Access to Vision and Hearing Services
Penalty
Summary
A resident was not assisted in gaining access to necessary vision and hearing services. The facility failed to ensure that the resident received support to obtain these services, resulting in the resident not having access to appropriate vision and hearing care as required.
Failure to Provide Orientation and Training to Agency Staff
Penalty
Summary
The facility failed to provide required training and orientation to agency staff prior to the start of their shifts, as evidenced by interviews and record reviews. An agency CNA reported not receiving any training or orientation before her first shift and was unable to locate a resident in the electronic medical record system when asked about the resident's use of hearing aids. The CNA stated she did not receive necessary information during shift change and was unfamiliar with the facility's systems. Additionally, review of two agency nurse employee files showed no documentation of training or orientation provided by the facility. The binder presented by the Nursing Home Administrator as evidence of training contained only materials from a previous unrelated education session and not current orientation records for agency staff. Further interviews with facility leadership confirmed that agency staff were not consistently receiving training or orientation before starting work. The Regional Nurse acknowledged the lack of appropriate training for agency staff and stated that a more formal education process was supposed to be in place. The Nursing Home Administrator admitted that, although a binder with policies existed for agency staff to review, this process was not being followed consistently. Facility policy required all newly hired licensed nurses and direct caregivers to receive job-specific orientation and competency testing prior to assignment, but this was not documented or observed for the agency staff in question.
Failure to Complete Annual CNA Competencies and Training
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) received their required annual competencies and in-service training, including education in dementia care and abuse prevention. Review of employee files showed that these CNAs had not completed their continuing annual competencies. During an interview, the Nursing Home Administrator stated that the responsibility for completing annual skills checks belonged to the Human Resource (HR) staff, but the facility did not have an HR staff member at the time of the survey. This deficiency was identified through both interview and record review and has the potential to affect all 33 residents residing in the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety, as observed during a kitchen tour. The two-door True cooler had ripped and torn gaskets, and the plate warmer was not functioning properly, holding plates at only 88F. Additionally, a bottle of soy sauce was improperly stored at room temperature despite instructions to refrigerate after opening. The kitchen also had plumbing issues, with a leaking faucet and water line, and the ice machine was found with slimy debris and leaking onto the floor. Further observations revealed unsanitary conditions, including clean utensils with dried food debris, and a juice machine with sticky debris on the spouts. The dining room refrigerator contained items without proper date marking, such as a peanut butter and jelly sandwich, hot dogs, tuna salad, and Thanksgiving leftovers, which were not labeled with discard dates. Bulk containers of flour and sugar had scoops stored with handles in the product, violating food safety standards. During lunch service, a staff member failed to wash hands after cleaning a cart and before returning to food preparation, which is against the FDA Food Code requirements. These deficiencies indicate a lack of adherence to food safety protocols, potentially leading to foodborne illness among residents consuming food from the facility's kitchen.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as observed in multiple areas. In the living area of bed 14-2, there were broken window blinds, a detached footboard lying on the floor atop an APM machine, and a strip of molding pulled off the wall. The east hall dining room was congested with a hoyer lift, wheelchairs, vitals machines, and totes containing Christmas decorations, impeding safe movement. In the bathroom of a resident room, the temperature was notably low, paint was peeling, the toilet paper holder was dysfunctional, and the ventilation cover was dusty. Additionally, the light fixture contained small dark objects. During a facility tour, clean linen closets were found with excess accumulation and items stored on the floor, including socks, briefs, and washcloths, along with dust. The utility closet lacked vinyl base cove molding, leading to wall deterioration. Other utility closets had items like disposable silverware on the floor, with dust debris and cobwebs present. Linen closets near another resident room also had socks, cobwebs, and dust accumulation at the bottom, indicating a lack of proper maintenance and cleanliness throughout the facility.
Failure to Notify Guardian of Resident's Significant Weight Loss
Penalty
Summary
The facility failed to notify the guardian of a resident, who was admitted with diagnoses including fracture, Down syndrome, and adult failure to thrive, about significant changes in her condition. The resident experienced an 8.33% weight loss in less than 30 days, with her weight dropping from 88.8 pounds to 81.4 pounds. Despite this significant weight loss, there was no documentation indicating that the guardian was informed. The resident's electronic medical record showed inconsistent meal intake, with several days where no meals were documented, and dietary interventions such as Med Pass and Mighty Shakes were ordered but not consistently administered. Interviews revealed that the resident's representative was unaware of the weight loss, dietary supplements, or missed meals. The registered dietician confirmed that the resident required assistance with meals and that her weights appeared stable, but acknowledged that the physician was not notified of the significant weight loss. The facility's failure to communicate these critical changes to the guardian represents a deficiency in the notification of changes policy.
Facility Fails to Maintain Comfortable Temperatures for Residents
Penalty
Summary
The facility failed to maintain comfortable temperatures and a homelike environment for five residents, as observed and reported during a survey. Resident R10 was found shivering in bed, wrapped in blankets, with the room temperature between 65.5 and 68 degrees Fahrenheit. The hallway thermostat was not providing a reading, and the Maintenance Director confirmed the heating system was not functioning properly. R10's room also had a peeling baseboard and a dusty air vent. Similarly, R3 reported her room was cold and had refused a shower due to the low temperature, with no documentation in her electronic medical record addressing the cold environment or missed showers. Other residents, including R13, R29, and R4, also reported feeling cold in their rooms. R13 was observed wearing a jacket to keep warm, while R29 and R4 were bundled in blankets. The Maintenance Director verified that the room temperatures were below the set thermostat levels, indicating a systemic issue with the facility's heating system. These observations and interviews highlight the facility's failure to provide a safe, comfortable, and homelike environment for its residents.
Failure to Provide Palatable and Safe Food Temperatures
Penalty
Summary
The facility failed to provide food at a palatable temperature to residents, as observed during a lunch service tour. The Dietary Manager (DM) reported that the plate warmer had not been functioning properly since he started a month ago, with plates being only 88F. The DM also noted that the plate warmer only has an on and off switch, and no other equipment besides thermal covers is used to ensure hot food delivery. Additionally, the DM discovered that pre-service temperatures for the meal were not recorded, leaving the actual temperatures of the hot food unknown before service began. A test tray was plated and delivered with hall trays, and upon examination, the food temperatures were found to be below the desired level: chicken at 119F, vegetables at 116F, and rice at 111F. Residents expressed dissatisfaction with the food, describing it as cold, flavorless, and unappetizing. One resident reported that they do not get to choose meals ahead of time and must wait for an alternative if they do not like the initial offering. These observations and resident interviews indicate a failure to provide food at a safe and appetizing temperature, potentially leading to decreased food consumption and nutritional decline.
Inconsistent Provision of Bedtime Snacks for Diabetic Residents
Penalty
Summary
The facility failed to consistently provide bedtime snacks to four residents, all of whom had pertinent diagnoses related to diabetes. Resident #17, a male with diabetes mellitus, weight loss, and weakness, reported not being consistently offered a bedtime snack. The snack log indicated he was offered a snack on only four evenings over a month. Resident #5, a female with insulin-dependent diabetes, also reported inconsistent snack offerings, with the log showing she received a snack on eight evenings. Her care plan specifically included the provision of a bedtime snack to manage her blood sugar levels. Resident #12, another female with insulin-dependent diabetes, was unsure if she was consistently offered a bedtime snack, with records showing she received one on three evenings. Resident #133, a male with diabetes mellitus and dementia, expressed that he did not consistently receive snacks and was often hungry before bed, with the log indicating he was offered a snack only once. Interviews with the Administrator and Dietary Manager revealed a lack of communication and documentation regarding which residents required snacks, with dietary staff unaware of the number of diabetic residents and relying on a limited supply of snacks.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident #133, a male with a recent amputation of the left leg below the knee, diabetes mellitus, and dementia. During an observation, the call light touch pad was found on the over bed table in the upper right-hand corner, out of reach for the resident. The resident confirmed that the call light had been in that location since he woke up and was unable to reach it. In a subsequent observation, staff were seen leaving the resident's room without ensuring the call light was accessible, as it remained out of reach. Another observation found the call light attached to a blanket on the floor, out of sight and reach of the resident, who was unaware of its location. A certified nurse aide indicated that staff are expected to ensure essentials, including call lights, are within reach each time they enter a resident's room.
Failure to Address Resident Grievances for Missing Items
Penalty
Summary
The facility failed to adhere to its grievance policy regarding missing items for a resident, identified as R183. The policy, last reviewed in January 2024, mandates prompt action to resolve grievances and to keep residents informed of progress. However, R183 reported missing several clothing items, including winter boots, pants, shirts, and a gown, and was told by staff that the items would eventually appear. Despite informing the Administrator, who requested receipts that R183 did not have, no formal grievance form was completed to address these concerns. The Resident Council Minutes from July 2024 documented R183's missing items, along with similar issues reported by two other residents. However, these grievances were not properly recorded or addressed until mid-August, when they were transferred to missing item sheets and given to the laundry/housekeeping supervisor. The Activities Director, who was not present at the July meeting, was unaware of R183's missing items until December. The Nursing Home Administrator confirmed that no form had been filled out to address R183's concerns, indicating a lapse in the facility's grievance handling process.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple diagnoses, including fracture, Down syndrome, adult failure to thrive, anxiety, depression, dorsalgia, and spondylosis. The care plan did not address the resident's anxiety, depression, dorsalgia, or spondylosis. Additionally, there was no activity care plan, no cognitive status interventions, and incomplete ADL care plans reflecting the resident's dependence and needs for incontinence, toileting, bathing, and dressing. The resident experienced significant weight loss, with an 8.33% decrease in less than 30 days, and there was a lack of documented weights and meal intake records. The resident's nutritional status care plan was initiated but lacked new interventions despite significant weight loss. The resident's representative reported not being informed of the weight loss or supplements and noted the resident's need for 1:1 assistance with meals, which was not consistently provided. The resident was observed sitting without assistance in the dining room, and staff only prompted her to eat. The resident also had a history of behaviors resembling seizures when upset or scared, but there was no care plan for seizures or behaviors. After a hospital visit, the resident was diagnosed with a UTI, but no meaningful interventions were added to the toileting care plan following this diagnosis.
Failure to Provide Adequate Foot Care
Penalty
Summary
The facility failed to provide adequate foot care for a resident, identified as R13, who was admitted with chronic diastolic heart failure, diabetes, and chronic obstructive pulmonary disease. During an observation, R13 was found in his room with long toenails and contracted toes, expressing dissatisfaction with the length of his toenails and noting he was supposed to see a podiatrist but had not yet done so. Interviews revealed that R13 was on the list to see a podiatrist, but due to a lapse in insurance renewal, he missed the podiatry visit when the service was last available at the facility. The resident's care plan included regular foot inspections and referrals to a podiatrist for nail trimming, but these actions were not completed as required, leading to the deficiency.
Improper Storage of Oxygen Tank
Penalty
Summary
The facility failed to safely secure and store an oxygen tank for a resident, identified as R183, during an observation and interview conducted on December 2, 2024, at 9:51 AM. At the time of the observation, R183 was not present in her room, and her personal belongings, including a coat and a bag, were placed on a chair. A portable oxygen tank was also observed lying across the arms of the chair. The Director of Nursing (DON) was informed of the improper placement of the oxygen tank and acknowledged that it should not be stored in that manner. A review of the facility's Oxygen Storage policy, last reviewed in January 2024, indicated that oxygen cylinders must be secured in racks or by chains.
Failure to Monitor and Provide Nutrition Leads to Resident Weight Loss
Penalty
Summary
The facility failed to adequately monitor and provide nutrition and assistance with meals for two residents, R30 and R29, leading to significant weight loss and inadequate meal intake. R30 was admitted with diagnoses including Down syndrome and adult failure to thrive, requiring 1:1 assistance with meals. Despite this, R30 experienced an 8.33% weight loss in less than 30 days, with inconsistent meal provision and lack of documentation for receiving prescribed nutritional supplements. The facility did not notify the physician or the resident's guardian about the significant weight loss, and staff were observed not providing the necessary assistance during meals. R29, diagnosed with dementia and osteoporosis, also faced issues with meal provision, receiving only a fraction of the meals over a month. Despite orders for dietary supplements due to weight loss concerns, there was no documentation of these being administered. Observations revealed R29 missed meals, and the Registered Dietician was unaware of the lack of meal documentation and provision. The facility's policies on nutritional risk and weight monitoring were not followed, as evidenced by the lack of timely assessments, documentation, and communication with the interdisciplinary team. The Registered Dietician did not notify the physician of significant weight changes, and the facility failed to implement appropriate interventions for residents at nutritional risk, as outlined in their policies.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to adhere to professional standards for storing and labeling medications, as observed during a survey. During an inspection of a medication cart, 18 loose pills of various shapes and colors were found, each representing a medication prescribed to a resident. The Assistant Director of Nursing (ADON) acknowledged that these loose pills should not have been present. Additionally, a Basaglar insulin KwikPen prescribed to a resident in bed 12-2 was found without a date indicating when it was first opened and used. The facility's policy requires that once any medication is opened, the date should be recorded on the primary medication container if the medication has a shortened expiration date once opened, following manufacturer guidelines.
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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