Roosevelt Park Nursing And Rehabilitation Communit
Inspection history, citations, penalties and survey trends for this long-term care facility in Muskegon, Michigan.
- Location
- 1300 West Broadway Avenue, Muskegon, Michigan 49441
- CMS Provider Number
- 235549
- Inspections on file
- 21
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Roosevelt Park Nursing And Rehabilitation Communit during CMS and state inspections, most recent first.
Surveyors identified multiple safety failures, including excessively hot water at several resident hand sinks and in a shower room, a missing cold-water handle, and a non-functioning shower call light. Residents reported that the water became very hot and required careful checking before use. An unsecured oxygen tank was found standing at the foot of a bed in a resident room. In addition, a bariatric shower chair of unknown weight capacity collapsed under a morbidly obese resident during a lift transfer, after which staff and the Director of Maintenance acknowledged that there was no preventive maintenance program for shower chairs, no visible manufacturer information or weight limits on the chairs, and confusion among staff about how to determine appropriate weight capacities.
A dependent resident with hemiplegia, severe cognitive impairment, incontinence, and visual deficits was repeatedly observed lying in bed with contracted hands and unused hand splints, no oral care supplies in the room, and persistent white discharge from one eye despite a care plan requiring daily eye/face washing, toothettes BID, and bilateral palm protectors. The resident’s brief was found saturated even though a CNA stated checks and changes were to occur every 2 hours and claimed to have recently changed the brief. The CNA also reported not providing oral care that day and noted the eye discharge had been present for weeks, while staff accounts of how often the resident was assisted out of bed conflicted with the care plan’s direction to encourage daily use of a Broda chair. The resident’s toenails were very long and curled around the toes, further demonstrating missed hygiene and ADL care responsibilities.
Multiple instances of misappropriation of controlled substances occurred, including altered documentation, unaccounted-for doses, and administration of medications outside of prescribed times. An LPN was identified as altering narcotic counts and dispensing medications without proper documentation, affecting several residents. Additional deficiencies included dispensing medications without active orders and lack of required signatures for wastage, with staff failing to follow established procedures for controlled substance management.
A long-term care facility failed to prevent the misappropriation and diversion of narcotic medications for several residents. A nurse was found with unauthorized medications off-site, and discrepancies in medication counts were discovered after another nurse left abruptly. Ongoing issues with controlled medication administration were also identified, with the facility lacking a formal audit system to ensure proper medication handling.
The facility failed to document allegations of abuse made by two residents, resulting in incomplete medical records. One resident, with severe cognitive impairment, reported being pushed by a CNA, while another, moderately cognitively intact, reported being hit. Both cases lacked documentation of physical or psychosocial assessments related to the allegations, and staff interviews revealed an expectation for such documentation, which was not met.
The facility failed to maintain sanitary conditions in the kitchen, with dirty freezer seals and inconsistent refrigeration temperatures. A Raetone unit had a loose door seal and was low on Freon, affecting food safety. Additionally, ready-to-eat foods were improperly date-marked, and thawing procedures were not followed, violating FDA Food Code standards.
The facility failed to implement an effective infection prevention and control program, with inadequate tracking of infections and a lack of investigation during a COVID-19 outbreak. Additionally, the facility did not have an active plan for reducing the risk of Legionella in the plumbing system, with no evidence of regular flushing or testing.
The facility failed to maintain cleanliness and repair, with deteriorating cabinets, unsealed holes, debris in storage areas, and disrepair in the roof and soffit. A family member reported unclean conditions in a resident's room, including an unclean bedside commode and soiled bedding. These issues indicate a lack of consistent maintenance and cleanliness, potentially affecting resident satisfaction.
The facility failed to accommodate the needs and preferences of three residents, including not assisting a resident with mobility issues out of bed, and not responding to call lights in a timely manner. Residents reported long wait times for assistance, particularly during evening shifts, and issues with the distribution of snacks and water. These deficiencies were consistently highlighted in Resident Council Meetings over several months.
The facility was found to have fall hazards due to unsecured rubber mats in a hallway and high hot water temperatures in the central spa and dining room sinks. The clean utility/pantry room was also left unlocked with an unsecured aerosol spray can, posing additional risks. Staff were observed navigating around the hazards without addressing them.
The facility failed to follow proper tube feeding protocols for two residents. One resident's feeding equipment was not properly dated or stored, and the setup lacked necessary labeling. Another resident's head of bed was not elevated to the required degree during feeding, and the feeding setup was also improperly labeled.
The facility failed to properly store and label medications in a medication cart and storage room. An LPN was found with a cart containing improperly labeled and undated medications, and a spray bottle with an unidentified liquid. Additionally, a medication storage room had a refrigerator at an incorrect temperature and contained expired medications. A resident was found with unused eye drops left by facility nurses, which she did not administer herself.
The facility failed to provide adequate food options and meal variety for two residents, leading to dissatisfaction and unmet dietary needs. Despite having a system for residents to choose between a main entree and an alternate menu, the process was inconsistently implemented, with some menu items unavailable and repetitive meal options offered. Residents expressed frustration with the lack of variety and the requirement to request alternatives before a specific time.
A facility failed to accurately document the activated medical and financial DPOA for a resident, resulting in the potential for inappropriate delegation of rights. The resident's family members were designated as DPOA, but discrepancies in documentation led to the wrong individual being notified of health status changes. The facility's process for documenting DPOA information was not followed, contributing to the deficiency.
The facility did not provide required Advance Beneficiary Notices (ABN) and Notices of Medicare Non-Coverage (NOMNC) to three residents discharged from a Medicare-covered Part A stay with benefit days remaining. The Nursing Home Administrator and Social Worker confirmed the absence of these notices, which are mandated by facility policy to inform beneficiaries of their rights and potential liabilities.
The facility failed to ensure appropriate antibiotic prescriptions for three residents, leading to inappropriate antibiotic utilization. A resident was prescribed ciprofloxacin without a culture and sensitivity report, another was initially given an ineffective antibiotic for a UTI, and a third resident also lacked culture documentation. The DON confirmed lapses in reviewing reports and monitoring the antibiotic stewardship program.
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, as the IP was also a full-time floor nurse, limiting their ability to focus on infection control duties. The Director of Nursing (DON), who lacked specialized training, covered IPCP duties when the IP was unavailable. This led to inadequate infection surveillance, including a missed COVID-19 outbreak investigation and incomplete Resident Infection Control Logs. The facility's policy required the IP to be employed at least part-time, but the facility assessment did not specify the necessary time for IPCP duties.
Unsafe Water Temperatures, Unsecured Oxygen, and Inadequate Shower Chair Safety
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe water temperatures and functional safety equipment in resident bathrooms and a shower room, as well as failure to secure oxygen equipment and ensure safe, appropriate use and maintenance of shower chairs. During an environmental tour, surveyors measured excessively hot water at multiple resident hand sinks and in a shower room, with temperatures ranging from 120.7°F to 130.3°F at hand sinks and 127.1°F at a shower. Residents reported that the water became very hot and that they had to check the temperature before using it. In the [NAME] Shower Room, the cold-water knob/handle was missing from the bathroom hand sink, and the call light switch on the shower wall was not functioning, as confirmed by the Director of Maintenance (DOM) K. In the boiler room, the temperature valve on the large holding tank read 134°F and the mixing valve read 130°F, which did not match the 120°F temperature DOM K stated he had previously recorded as the outgoing water temperature. The deficiency also includes failure to secure oxygen equipment. During an observation in one resident’s room, an unsecured oxygen tank was found standing alone at the foot of the bed under the window. The Regional Nurse Consultant acknowledged that the oxygen tank should have been secured. This unsecured tank represented an accident hazard in the resident’s immediate environment and reflected a lack of appropriate supervision and environmental safety controls. Another component of the deficiency concerns the facility’s failure to ensure that shower equipment was appropriate for a resident’s weight and maintained in safe condition. Resident R2, a cognitively intact individual with reduced mobility, generalized muscle weakness, morbid obesity, and dependence on staff for bathing and transfers, weighed over 400 pounds at the time of the incident. While being lowered into a bariatric shower chair in the shower room using a mechanical lift, the chair’s leg broke and the chair collapsed, causing the resident to fall to the floor and hit his head. The resident described the chair as made of flimsy, thin PVC piping, appearing small for his size, and reported that it splintered into many pieces. DOM K stated he did not perform preventive maintenance checks on shower chairs, did not know the brand or weight rating of the broken chair, and that the maximum weight limits were not printed on the chairs. Staff interviews revealed confusion and lack of clear knowledge about the weight limits of shower chairs, with some staff believing chairs were color coded by weight capacity but being unable to identify actual limits or find manufacturer information on the chairs themselves. These combined findings show that the facility did not prevent accidents or maintain an environment free from accident hazards in multiple areas: excessively hot water in resident rooms and a shower room, missing sink hardware and a non-functioning shower call light, an unsecured oxygen tank in a resident room, and the use of a shower chair of unknown and unverified weight capacity that collapsed under a bariatric resident during a transfer.
Failure to Provide Daily ADL, Hygiene, and Positioning Care for a Dependent Resident
Penalty
Summary
Failure to provide daily care and assistance with ADLs occurred for a dependent resident with hemiplegia, vascular dementia, severe cognitive impairment, and visual deficits. Surveyors observed the resident repeatedly lying in bed over two consecutive days, with contracted hands and hand splints not applied as care-planned, instead left on a table or bedside. The resident’s care plan documented urinary incontinence with a check-and-change schedule, bilateral palm protectors to be applied in the morning and removed in the evening, daily washing of eyes and face, and use of toothettes twice daily for oral care, as well as staff assistance and encouragement to get the resident up in a Broda chair daily. Despite this, observations showed the resident remained in bed throughout multiple time points, with no oral swabs or toothettes visible in the room, and with a noticeable white discharge in the left eye on several occasions. Interviews further supported that required daily care was not consistently provided. The resident’s guardian reported concerns about lack of oral care, the resident staying in bed all day, and not attending preferred religious activities. A CNA stated the resident was to be checked and changed every two hours but, when asked to check the resident’s brief, found it saturated, despite having claimed to have changed it earlier via entry through the adjoining bathroom. The CNA acknowledged not providing oral care that day and confirmed there were no oral glycerin swabs readily accessible in the room. The CNA also confirmed the eye discharge had been present for a couple of weeks and that the resident typically only got out of bed on two days per week, which conflicted with the RN’s statement that the resident was scheduled to be out of bed three days per week and with the care plan’s approach to encourage daily out-of-bed activity. The resident’s toenails were observed to be very long and wrapped around the tips of the toes, and the eye discharge remained evident during multiple observations, indicating lapses in basic hygiene and ADL care as outlined in the care plan.
Failure to Prevent and Monitor Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for multiple residents, as evidenced by altered documentation and unaccounted-for doses of narcotic medications. For one resident, the Controlled Substances Proof of Use sheet showed repeated alterations in the quantity remaining, with bold overwriting of numbers to obscure previous entries. This resulted in discrepancies where more tablets were dispensed than ordered, and the documentation was manipulated to hide the actual count. Staff interviews confirmed that an agency LPN was responsible for altering the narcotic count and that these changes were not immediately detected during shift exchanges, as the counts were verbally confirmed rather than visually verified against the medication sleeves and documentation. Another resident's records revealed that an additional dose of a controlled medication was dispensed outside of the prescribed times, with no corresponding entry in the electronic medication administration record (eMAR) or the resident's electronic medical record. The missing documentation and the lack of a scheduled administration at that time indicated that the medication was unaccounted for. Further audits of medication carts did not reveal additional discrepancies, but the incident was substantiated as misappropriation based on the available evidence. Staff statements indicated that the LPN involved had a history of similar issues at other facilities. Additional deficiencies were identified for other residents, including the dispensing of controlled substances without active orders, administration of medications outside of prescribed times, and lack of required documentation for medication administration and wastage. In several cases, doses were dispensed and not recorded in the eMAR, and there was no second nurse signature to verify wastage of unused medication. Interviews with nursing staff and review of facility policies confirmed that these actions did not follow professional standards or facility procedures for controlled substance management, leading to unaccounted-for medications and the potential for ongoing diversion.
Medication Misappropriation and Diversion in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation and diversion of narcotic medications for several residents, leading to a deficiency in safeguarding resident property. In one incident, a registered nurse (RN E) was found in possession of medications belonging to a resident (R8) during a police traffic stop. The medications included 17 vials of Promethazine and a hydrocodone capsule, which were not authorized for removal from the facility. The facility confirmed the misappropriation of these medications, as they were found off-site and in the possession of RN E without proper authorization. In another incident, discrepancies in the medication count were discovered after RN D abruptly left the facility without completing the required medication count. This resulted in missing doses of Norco for two residents (R7 and R3) and Tramadol for another resident (R4). The facility's investigation was inconclusive due to RN D's refusal to cooperate, including failing to submit to a drug test and provide a statement. Despite the evidence of missing medications and RN D's abrupt departure, the facility was unable to definitively conclude that RN D diverted the medications. Additionally, ongoing discrepancies in controlled medication administration were identified for three residents (R3, R4, and R5), with missing documentation for the administration of medications such as Lorazepam, Tramadol, and Oxycodone-Acetaminophen. The facility lacked a formal audit system to ensure proper medication administration and reconciliation, and the Director of Nursing (DON) had not implemented a comprehensive review process to address these discrepancies. The facility's failure to monitor and investigate these issues adequately contributed to the deficiency in protecting residents' medications from misappropriation and diversion.
Deficiency in Documentation of Resident Allegations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in the potential for providers not having an accurate and complete picture of the residents' stay. For one resident, identified as R2, the facility's records did not document an allegation made by the resident that a CNA had pushed her. Despite the resident's severe cognitive impairment and multiple diagnoses, including delusional disorders and PTSD, there was no documentation of physical or psychosocial assessments related to the allegation. Additionally, the social services notes and assessments conducted did not specify the reasons for the visits or assessments, such as whether they were routine or related to the incident. Similarly, for another resident, identified as R4, the facility's records failed to document an allegation that someone had hit her. R4, who was moderately cognitively intact, also had no documentation of physical or psychosocial assessments related to her allegation. The social services notes and assessments for R4 did not indicate the reasons for the visits or assessments, leaving a gap in the documentation of care provided following the resident's report of abuse. Interviews with facility staff, including the Nursing Home Administrator and the Director of Nursing, revealed that there was an expectation for nurses to document such allegations in the residents' progress notes. However, upon review, no such documentation was found in the electronic medical records of either resident. This lack of documentation was acknowledged by the Director of Nursing, who noted the need for improvement in this area. The absence of documentation related to the allegations was not rectified by the time of the survey's completion, highlighting a deficiency in the facility's record-keeping practices.
Sanitation and Temperature Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, the top portion of the door seals of a two-door Traulson freezer was found with an accumulation of crumbs and dirt debris. This issue persisted during a revisit, indicating a lack of proper cleaning and maintenance. Additionally, the internal thermometer of a Raetone refrigeration unit showed inconsistent temperatures, and a whole tomato inside the unit was found to be at an unsafe temperature. The door seal of the unit was loose, allowing light to be seen from inside, which could compromise the unit's ability to maintain safe temperatures. Further inspection revealed that the Raetone refrigeration unit was low on Freon and had icing on the thermostat, affecting its functionality. Despite these issues, potentially hazardous food was not immediately discarded or moved, as confirmed by the Dietary Supervisor. It was only after a vendor's intervention that the unit was emptied. Additionally, the facility failed to properly date-mark ready-to-eat foods, with several items found open and without discard dates, or held past their discard dates, in the hallway utility pantry. The facility also did not adhere to proper thawing procedures for time/temperature control for safety food. Frozen nutritional drinks were found in a bowl of water in the rinse compartment of a three-compartment sink, and a box of frozen nutritional drinks and ice cream was left in ambient air outside of refrigeration. These actions and inactions demonstrate a failure to comply with the 2017 FDA Food Code, which outlines necessary standards for maintaining food safety and preventing foodborne illnesses.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by inadequate tracking and surveillance of infections among residents. Three residents were identified as having been prescribed antibiotics, but their information was not accurately reflected in the Resident Infection Control Log. Additionally, the facility did not conduct a thorough investigation or implement preventative measures during a COVID-19 outbreak, failing to document essential details such as contact tracing, notifications, and interventions. The facility's infection control program was found lacking in several areas, including the absence of a comprehensive outbreak investigation and management plan. The documentation provided did not include critical information such as the notification of the Medical Director, Health Department, staff, residents, and families about the outbreak. Furthermore, there was no evidence of daily active surveillance or implementation of transmission-based precautions to prevent the spread of infection. Additionally, the facility did not have an active plan for reducing the risk of Legionella and other opportunistic pathogens in the plumbing system. The Maintenance Director was unaware of the facility's water management plan, and there was no evidence of regular flushing or testing of the water system. The facility's Water Pathogen Risk Reduction policy was not dated, and there was no indication that a water management team was in place to monitor and address potential risks.
Facility Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises, leading to potential contamination and decreased resident satisfaction. During a tour of the utility pantry, it was observed that the cabinets were deteriorating due to water damage, and a large hole in the wall behind a stainless-steel panel was not sealed, allowing potential pest entry. In the storage room containing nursing and tube feeding supplies, excess debris and trash were found on the floor, and a light shield was hanging down. Additionally, a light shield cover was missing in the service hall storage room. The back portion of the roof and soffit was in disrepair, providing open access to the attic space. Several wall-mounted air conditioning units in the hallways had an accumulation of black spotted debris. A family member expressed concerns about the cleanliness of a resident's room, reporting that the bedside commode was often not cleaned, resulting in a strong odor of urine and feces. The family member also noted that the resident's bedding was not changed regularly, leaving it visibly soiled and malodorous. Despite voicing these concerns to management, improvements were inconsistent. These observations and interviews highlight the facility's failure to maintain a clean and safe environment for residents, staff, and the public.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of three residents, as well as address several unmet needs reported during Resident Council Meetings. Resident #10, a male with a history of stroke and left-sided weakness, was observed to have remained in bed for extended periods without being assisted out of bed by staff, despite care plan interventions that included encouraging participation in facility life and assisting with activities. Observations over several days showed that Resident #10 was not engaged in any meaningful activities, and staff interviews confirmed that he had not been assisted out of bed due to time constraints. Resident #4, a cognitively intact female, expressed concerns about call light wait times, reporting that it could take up to an hour for her call light to be answered. She also reported that staff did not inform her of extended wait times and often had excuses for not promptly assisting her. On one occasion, she was not assisted to get up or cleaned before breakfast, which was against her usual preference. Resident #18, another cognitively intact female, reported similar issues with call light wait times, particularly during the evening shift, and described the CNAs as having bad attitudes and being unresponsive to residents' needs. The Resident Council Meetings consistently highlighted issues with slow call light response times, particularly during the second and third shifts, and problems with the distribution of evening snacks and water. These concerns were documented over several months, indicating a pattern of unmet needs and preferences among residents. The facility's policy on call light response times, which states that staff should respond within a reasonable period of no longer than 10 minutes, was not adhered to, contributing to the deficiencies observed.
Fall Hazards and High Water Temperatures Identified
Penalty
Summary
The facility failed to maintain an environment free of fall hazards and high hot water temperatures. During an observation, the clean utility/pantry room was found unlocked and accessible to self-mobile residents, containing an unsecured aerosol spray can of disinfectant cleaner. Additionally, two thick black rubber mats were observed folded and placed in the walkway, creating a tripping hazard. These mats were left in the resident hallway, causing staff and residents to navigate around them, with some staff stepping over the mats instead of removing them. This situation persisted for a significant period, with multiple staff members observed passing by without addressing the hazard. Furthermore, during a facility tour, it was discovered that the hot water temperature at the central spa hand sink reached 123.9°F, exceeding safe levels. The Maintenance Director confirmed that the water heater supplying this area was set too high and attempted to adjust the mixing valve to lower the temperature. Similarly, the hot water in the dining room sink was found to reach 126.8°F, with a point of use mixing valve that required adjustment. These findings indicate a failure to adequately monitor and control water temperatures, posing a risk to residents.
Failure to Follow Tube Feeding Protocols
Penalty
Summary
The facility failed to adhere to standards of practice for two residents receiving nutrition and hydration through feeding tubes. Resident #10, a male with a history of stroke and blindness, was observed with a syringe and plastic basin used for tube feeding that were not properly dated and stored. Additionally, the tube feeding setup lacked proper labeling, including the resident's name, date, time, and the ordered rate, as required by the facility's policy. Resident #25, a female with a history of cerebral infarction, was observed multiple times with her head of bed elevated below the recommended 30 degrees while receiving tube feeding. The feeding setup also lacked proper labeling, missing the resident's name and the time the feeding was started. These observations indicate a failure to follow the facility's policy and standard nursing practices for tube feeding management.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications in one of two medication carts and one of two medication storage rooms. During an observation, an LPN was found with a medication cart containing several open bottles of artificial tears, some without dates indicating when they were opened, and other medications such as Moisture Eye drops, Fluconazole nasal spray, Azelastine nasal spray, and Dorzolamide eye drops, all lacking proper labeling or opened dates. Additionally, a large spray bottle with an unidentified clear liquid was found in the cart, which the LPN assumed was hand sanitizer. The LPN acknowledged that the medications should have been dated and not used if opened without a date. In another instance, the medication storage room near the front nursing station had a refrigerator storing insulins and other medications at an incorrect temperature of 32 degrees, with the temperature log last completed several days prior. Expired medications, including a liquid multivitamin and Cherry flavored liquid acetaminophen, were also found in the storage room. An LPN admitted to not knowing the correct refrigerator temperature and acknowledged the expired medications. Furthermore, a resident was found with unused/unopened dropperettes of cyclosporine 0.05% (Restasis) on her nightstand, which she reported were left by facility nurses, and she did not administer them herself.
Inadequate Food Options and Meal Variety
Penalty
Summary
The facility failed to provide adequate food options that accommodate resident preferences and dietary needs, as evidenced by the experiences of two residents. Interviews and record reviews revealed that the facility's dietary system was not effectively offering alternative or optional food choices. The Dietary Supervisor indicated that residents could choose between a main entree and an alternate menu, but the process relied on residents communicating their preferences to nursing staff, who would then inform the kitchen. However, the system was not consistently implemented, as some items on the alternative menu were not regularly available, and residents were not always able to receive their preferred meals. Resident #4, a cognitively intact female, expressed dissatisfaction with the quality and variety of the meals, describing them as "lousy and cold." Similarly, Resident #18, also cognitively intact, reported a lack of variety and repetitive meal options, such as being served pork for several consecutive days and receiving hot dogs as the only alternative meal. This resident also faced challenges in obtaining suitable meals for those with chewing or swallowing difficulties. The resident expressed frustration with the requirement to request alternative meals before a specific time and felt that the facility's approach did not adequately cater to individual needs.
Inaccurate DPOA Documentation Leads to Miscommunication
Penalty
Summary
The facility failed to accurately record the activated medical and financial Durable Power of Attorney (DPOA) in the medical record for a resident, leading to the potential for inappropriate delegation of resident rights. The resident, an elderly female, was admitted to the facility with family members designated as her DPOA for medical and financial decisions. However, discrepancies were found in the documentation: one family member was incorrectly listed as the primary contact for both medical and financial decisions, despite not being the legal DPOA. This resulted in the wrong individual being notified of changes in the resident's health status and medication. Interviews and record reviews revealed that the facility's process for documenting DPOA information was not followed correctly. The social worker confirmed that the contact information for each DPOA should be documented in the electronic health record and on the admission record, specifying if there are separate DPOAs for financial and medical decisions. The facility's policy on advance directives requires that a copy of the advance directive be placed in the resident's medical record upon admission, but this was not accurately done in this case, leading to the deficiency.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to provide necessary notifications to residents regarding their Medicare coverage and potential liability for services not covered. Specifically, the facility did not issue Advance Beneficiary Notices (ABN) and Notices of Medicare Non-Coverage (NOMNC) to three residents who were discharged from a Medicare-covered Part A stay with benefit days remaining. During an entrance conference, a request was made for a list of such residents discharged in the past six months. Subsequently, the Nursing Home Administrator and Social Worker confirmed that they did not have the required ABN or NOMNC for the selected residents. The facility's policy mandates the issuance of these notices to inform beneficiaries of their rights and potential liabilities, but this was not adhered to in these cases.
Inappropriate Antibiotic Utilization Due to Lack of Culture and Sensitivity Reports
Penalty
Summary
The facility failed to ensure appropriate antibiotic prescriptions for three residents, leading to inappropriate antibiotic utilization. Resident #142 was prescribed ciprofloxacin without a culture and sensitivity report to confirm its effectiveness against the bacteria. Resident #143 was initially prescribed cephalexin, which was ineffective against the urinary tract infection as indicated by the laboratory report. The resident was later switched to ciprofloxacin after a delay in treatment. Resident #144 was also prescribed ciprofloxacin without any culture and sensitivity documentation to verify its appropriateness. The Director of Nursing (DON) confirmed during interviews that there were lapses in reviewing culture and sensitivity reports upon admission and that the facility's antibiotic stewardship program required closer monitoring. The facility's policy on antibiotic stewardship outlines the roles of the Infection Preventionist and DON in coordinating and supporting antibiotic stewardship activities, including monitoring antibiotic use and ensuring prescriptions are appropriate. However, these protocols were not adequately followed, resulting in the deficiencies noted in the report.
Inadequate Infection Preventionist Role and Time Allocation
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was working at least part-time and was provided sufficient time to perform the Infection Prevention and Control Program (IPCP) duties. The Director of Nursing (DON) was listed as the Infection Control Preventionist in the Facility Assessment, but the actual IP, who was certified in infection prevention and control, was also working full-time as a floor nurse. This dual role limited the IP's ability to focus on infection control duties, as the IP did not have designated time to maintain or monitor the IPCP effectively. Interviews revealed that the IP, who took over the role after the previous IP left, did not have set hours or days for assessing, developing, implementing, monitoring, and managing the IPCP. The DON, who had not completed specialized training in infection prevention and control, was covering the IPCP duties when the IP was unavailable. This lack of dedicated time and specialized training led to inadequate surveillance and tracking of infections, as evidenced by the failure to complete an outbreak investigation for a COVID-19 outbreak and the omission of residents on antibiotics from the Resident Infection Control Log. The facility's policy required the IP to be employed at least part-time, with the amount of time determined by the facility assessment. However, the assessment did not specify the time needed for the IP to complete IPCP duties. The report highlighted deficiencies in antibiotic stewardship, as antibiotics were administered without confirming their effectiveness against identified bacteria. The DON confirmed the need for improved antibiotic stewardship and acknowledged the inadequacies in the IPCP, including the lack of an outbreak investigation and an incomplete Resident Infection Control Log.
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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