Roubal Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stephenson, Michigan.
- Location
- N 306 Maple Street, Stephenson, Michigan 49887
- CMS Provider Number
- 235591
- Inspections on file
- 19
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Roubal Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with therapy recommendations for contact guard assist during ambulation fell and sustained a fractured femur when a CNA, unaware of the specific assistance level required, lost contact while attempting to position a wheelchair. The CNA was using a gait belt and walker, but did not maintain the necessary supervision as outlined in the care plan, leading to the resident's fall and injury.
Surveyors identified multiple failures in maintaining sanitary conditions in food storage and preparation areas, including debris and spills in the walk-in cooler and freezer, unclean utensils and equipment, improper sanitizer concentrations due to expired test strips, and improper air-drying of pans before storage. The Dietary Manager was often unsure about cleaning schedules and procedures, contributing to the observed deficiencies in food safety practices.
Surveyors identified failures in infection prevention and control, including improper use of Enhanced Barrier Precautions during high-contact care for two residents with indwelling devices and wounds, as well as lapses in aseptic technique during wound care. Additionally, the facility did not maintain an active water management plan to address stagnant water lines and lacked routine flushing or environmental testing to reduce the risk of waterborne pathogens.
Two residents were not provided with dignified care during personal hygiene activities, resulting in one resident being left uncovered and exposed to another resident entering through a shared bathroom. Staff failed to ensure privacy by not covering the resident or closing the bathroom door during care, and the urinary catheter drainage bag was left uncovered. The resident expressed feelings of embarrassment and helplessness due to these repeated lapses in privacy.
Two residents experienced significant discomfort due to excessive heat and persistent urine odors in their rooms. One resident, with severe cognitive impairment, was found overheated and weak, with staff and family noting the lack of temperature control and the need for a fan purchased by the family. The same resident's room had ongoing issues with urine odor and soiled linens not being promptly changed. Another resident, dependent on staff for care, reported unbearable room temperatures and was denied access to fans or air conditioning. These events reflect the facility's failure to ensure a safe, clean, and comfortable environment.
Two residents who required assistance with ADLs did not receive timely or adequate care, resulting in one being left with overgrown toenails, a full and uncovered urinary catheter drainage bag, and dried feces on his body and bedding, while another had visibly soiled, overgrown, and jagged fingernails. Staff interviews and care plan reviews confirmed gaps in addressing hygiene and grooming needs, contrary to facility policy.
A resident receiving palliative care and prescribed Fentanyl experienced multiple extended periods without a documented bowel movement, with no evidence that Miralax was administered as ordered. Facility staff, including the DON and RN, were unable to produce or explain a bowel protocol, and the facility lacked a current bowel management policy, resulting in inconsistent care for the resident.
Surveyors found that three residents with chronic heart failure who required oxygen therapy did not have their oxygen tubing changed weekly as ordered by physicians. Observations showed that the tubing had not been changed for at least ten days, and the facility's policy lacked specific guidance on tubing change frequency, despite the DON stating that weekly changes were standard practice.
Surveyors observed multiple medication administration errors, including a nurse administering a Levothyroxine tablet that had been dropped on a dirty cart, another nurse applying Voltaren gel without using the required dosing card, and improper insulin administration with a Novolog Flexpen. These actions resulted in a medication error rate of 12%, exceeding the regulatory threshold.
A group of residents and the resident council president were unaware of the procedure for accessing the most recent survey results and plan of correction. When the posted survey results were reviewed, only a draft version marked "Not Final" was available, and no plan of correction was included. The administrator confirmed the absence of the final survey and plan of correction in the publicly accessible binder.
Surveyors found that the facility did not document or post the actual hours worked by RNs, LPNs, or CNAs on the daily nurse staffing sheets, leaving required columns blank despite facility policy and federal regulations mandating this information be available and updated for each shift.
The facility did not have a current three-day emergency menu or clear procedures to ensure food and water provision for staff and patients during emergencies. The Dietary Manager was unsure how to manage food service if staff were unavailable, and the emergency plan listed a different water vendor than the one actually contracted. These deficiencies resulted in a lack of clear, updated policies for subsistence needs during emergencies.
A gate leading from the patio area was found chained shut, blocking a designated emergency exit. This obstruction was observed and confirmed by the Maintenance Director, preventing proper egress in case of emergency.
The facility did not perform or document required monthly emergency lighting tests for several months, as confirmed by record review and the Maintenance Director.
The facility did not ensure that the kitchen hood was inspected and cleaned at least semi-annually as required by NFPA 96, with records showing only one cleaning report and the hood's cleaning sticker indicating the next cleaning was overdue. This was confirmed by the Maintenance Director.
The facility did not maintain or test its fire alarm system in accordance with NFPA standards, as most smoke detectors were found out of sensitivity or unserviceable and had not been replaced. There was also confusion and lack of documentation regarding the replacement of the fire alarm control panel, with discrepancies between reported and observed equipment. Additionally, the fire alarm control panel breaker lacked a required lock to prevent unauthorized disconnection.
A review of inspection records and staff interview revealed that the facility did not repair the outside bell on the automatic sprinkler system after it was found inoperable during the most recent annual inspection. The maintenance director confirmed the issue remained unresolved.
The facility did not transmit the fire alarm signal during required fire drills on the third shift or the following day for multiple instances, as confirmed by the Maintenance Director. This action did not meet regulatory requirements for conducting fire drills, which must include the transmission of a fire alarm signal and simulation of emergency fire conditions.
The facility did not ensure portable fire extinguishers were properly inspected and maintained according to NFPA 10, with one extinguisher lacking inspection records and another found overpressurized. These issues were confirmed by the Maintenance Director and could impact 15 occupants.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week. After one RN resigned and another went on leave, the facility was left without adequate RN staffing despite attempts to recruit more RNs.
The facility failed to implement a comprehensive infection prevention and control program, leading to deficiencies in managing RSV and Norovirus outbreaks. The Infection Preventionist did not adequately track or document employee and resident illnesses, and no formal investigation was conducted for the outbreaks. This lack of adherence to established policies contributed to the facility's inability to control the spread of infections effectively.
The facility failed to ensure a qualified Infection Preventionist was working at least part-time and provided sufficient time to manage the Infection Prevention and Control Program. The designated IP was responsible for three facilities and primarily worked remotely, leading to deficiencies in outbreak surveillance, antibiotic stewardship, and immunizations. Specific residents did not receive necessary immunizations, and there was a lack of ongoing surveillance and outbreak investigations.
The facility failed to make grievance forms accessible to residents and family members and did not follow up on a resident's concerns about being woken up at night, which exacerbated his anxiety. The resident's care plan did not reflect his preferences for care timing, leading to ongoing dissatisfaction.
The facility failed to report and investigate an injury of unknown origin for a resident with multiple diagnoses, including alcohol-induced dementia and high blood pressure. Despite the resident experiencing increased right leg pain and an x-ray revealing a possible fracture, the facility did not report the injury to the State Agency, hold a Trigger Call, or conduct an internal investigation, violating their policies and procedures.
The facility failed to follow professional standards for medication administration for two residents, resulting in medications being given outside of physician-ordered parameters. One resident received metoprolol despite low blood pressure and heart rate, while another received amlodipine despite low blood pressure readings.
The facility failed to implement their policy for post-fall assessments for two residents reviewed for accidents and hazards. One resident with dementia and a history of falling experienced an unwitnessed fall resulting in a scalp laceration and hematoma, with no neurological assessment or new safety interventions. Another resident with dementia and orthostatic hypotension experienced multiple unwitnessed falls, with no neurological exams or new interventions added to the care plan to prevent future falls.
The facility failed to implement its antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. Antibiotics were administered based on urine dip tests without waiting for culture results, and documentation did not meet McGeer Criteria for initiating antibiotics.
The facility failed to provide pneumococcal immunizations per CDC recommendations for two residents. One resident had not received the vaccine since 2016 despite consent and an order, while another had no documentation of receiving the last influenza or pneumococcal vaccines. The Infection Preventionist confirmed the immunizations were not up to date.
Failure to Provide Adequate Supervision and Proper Use of Assistive Devices Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and proper use of assistive devices for a resident who was at risk for falls. The resident, who had therapy recommendations for ambulation with a front-wheeled walker, contact guard assist, and a wheelchair to follow, was being assisted by a CNA during ambulation. The CNA reported using a gait belt and gripper socks, with one hand on the gait belt and the other pulling the wheelchair behind. When the resident expressed fatigue and a desire to sit, the CNA attempted to position the wheelchair but lost contact with the resident, resulting in the resident losing balance and falling sideways into a wall. The resident sustained a right femur fracture and required surgical intervention. Documentation and interviews revealed that the CNA was not fully aware of the specific contact guard assist requirement and believed the resident was an assist of one during ambulation. The incident report and progress notes confirmed that the plan of care, which required close supervision and specific assistive techniques, was not fully adhered to at the time of the fall. The lack of consistent application of the recommended supervision and assistive device use directly contributed to the resident's fall and subsequent injury.
Failure to Maintain Sanitary Food Service Conditions and Proper Sanitization
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions and professional standards for food service safety in the facility's kitchen and food storage areas. During a tour of the walk-in cooler, there was an accumulation of debris on the wire rack shelving, a dried yellow spill, and paper trash under racks and along the floor perimeter. The walk-in freezer also contained paper trash debris from date marking stickers. In the clean utensil drawer, crumbs were found along the back wall, and the Dietary Manager was unsure how often this area was cleaned. The stand-up mixer, covered with a plastic bag to keep it clean, had dried food debris on its underarm. Both the manual and electric can openers had significant accumulations of rust, pitting, and dark debris, and the pantry microwave had visible food debris on its interior top surface. Further deficiencies were noted in the facility's sanitation practices. Staff obtained sanitizer from the janitor's sink and filled spray bottles, but the test strips available for checking sanitizer concentration were expired. Testing revealed that one sanitizer spray bottle had a concentration of 0 to 50 ppm, while a bucket prepared by the Dietary Manager exceeded 500 ppm, indicating inconsistent and improper sanitizer levels. The Dietary Manager was unsure about the cause of this inconsistency. Additionally, in the clean pots and pans storage area, several pans were found stacked while still wet, without proper air drying, contrary to required procedures. These observations were corroborated by interviews with the Dietary Manager, who acknowledged uncertainty regarding cleaning schedules and procedures for several areas and equipment. The report references specific sections of the 2022 FDA Food Code, highlighting the requirements for cleanliness of food-contact and non-food-contact surfaces, proper use and testing of sanitizing solutions, and the necessity for air-drying equipment and utensils before storage. The documented failures in cleaning, sanitizing, and storage practices represent a deficiency in maintaining food safety standards as required by federal regulations.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures according to current guidelines and professional standards for two residents. For one resident with an indwelling urinary catheter and requiring maximal assistance, staff did not consistently use Enhanced Barrier Precautions (EBP) during high-contact care activities such as emptying the urinary catheter drainage bag and transferring the resident. Observations showed that staff either did not wear protective gowns as required or were unclear about when EBP should be used, despite CDC signage indicating the need for gowns and gloves during specific care activities. Additionally, the resident's care plan did not include interventions related to EBP, and the facility's infection control policy lacked procedures for EBP use. Another resident with end-stage renal disease, dementia, and a deep tissue injury was observed receiving wound care without staff donning gowns for EBP, as indicated by posted CDC guidance. During the wound care procedure, the nurse failed to maintain aseptic technique, including contaminating sterile supplies with gloved hands that had touched environmental surfaces, and retrieving gloves from a scrub pocket considered unclean. The nurse acknowledged these lapses in infection control practices during an interview. The facility also lacked an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in the water system. Observations revealed stagnant water lines, unused fixtures, and discolored water from infrequently used faucets. Staff interviews confirmed the absence of a routine flushing schedule for water fixtures and no environmental water testing as part of the water management program. The facility's water management policy referenced control measures and corrective actions but did not specify their implementation or documentation.
Failure to Maintain Resident Dignity and Privacy During Personal Care
Penalty
Summary
The facility failed to provide dignified care and ensure privacy for two residents during personal care activities. One resident, who was admitted with diagnoses including obstructive uropathy, peripheral vascular disease, morbid obesity, and depression, was completely dependent on staff for all transfers, mobility, and personal care due to an indwelling urinary catheter and bowel incontinence. The resident was cognitively intact and expressed feelings of embarrassment and helplessness related to his dependence on staff and lack of privacy during care. During morning care, two CNAs were observed providing incontinence care to the resident, who was left uncovered and exposed while stool was being cleansed from his body. The shared bathroom door between the resident's room and an adjoining room was left open, allowing another resident to enter and view the exposed resident during care. The CNAs did not offer or assist with covering the resident at any time during the observation. Additionally, the urinary catheter drainage bag was not covered, and the resident's body was partially exposed during a transfer from bed to a recliner, with the bathroom door again left ajar. The Director of Nursing confirmed that the resident did not use the bathroom due to incontinence and catheter use, but staff used the bathroom during care provision. The DON acknowledged the importance of keeping the door closed to ensure privacy and dignity for both residents sharing the bathroom. The observations and interviews revealed repeated failures to maintain the resident's privacy and dignity during care, as required by resident rights regulations.
Failure to Maintain Safe, Comfortable, and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by two residents experiencing significant discomfort due to excessive heat and persistent urine odors in their living areas. One resident, with multiple diagnoses including dementia and end-stage renal disease, was found to be overheated and weak after wearing multiple layers of clothing on a hot day. Staff and the resident's power of attorney reported that the room was extremely hot, and the facility did not provide a fan, requiring the family to purchase one. The environmental services director confirmed there was no monitoring of room temperatures, and the facility had no documentation to ensure temperatures remained within regulatory limits. Additionally, the same resident's room was repeatedly noted to have a strong urine odor, with wet bed sheets and soiled pads left unaddressed after the resident was moved from bed. Staff acknowledged the presence of urine odor and wet linens, and the director of nursing confirmed that such linens should have been changed immediately. The resident's representative reported ongoing issues with urine odors and soiled pads, indicating a pattern of inadequate housekeeping and maintenance services. Another resident, who was dependent on staff for mobility and hygiene, reported that the temperature in his room was unbearable on several days, and requests for a fan or air conditioning were denied. The resident stated that he preferred to keep his door closed for privacy, which exacerbated the heat, and he was uncertain if a window air conditioner he ordered would be permitted. These findings demonstrate the facility's failure to provide adequate temperature control and maintain odor-free, comfortable living conditions for its residents.
Failure to Provide Timely ADL Care and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide timely and adequate activities of daily living (ADL) care for two dependent residents. One resident, who was cognitively intact and had multiple diagnoses including diabetes and bowel incontinence, was observed with overgrown toenails, a full and uncovered urinary catheter drainage bag containing dark yellow urine, and dried feces on his bedding and body. The resident had not been checked or changed since the previous evening, as staff reported honoring his request not to be disturbed overnight, but did not check on him at the beginning of the morning shift. The resident's care plan did not address bowel incontinence or nail care related to his diabetes diagnosis, and staff confirmed that nail care was the responsibility of licensed nurses, with no podiatrist available. Another resident, who required substantial assistance with bathing and personal hygiene and had mild cognitive impairment, was observed with visibly soiled, overgrown, and jagged fingernails. The resident's nails had dark coloring under the nail beds and were unkempt, with one thumbnail appearing sharp and jagged. The resident expressed resignation about the state of his nails when asked if he would prefer to have them cleaned and trimmed. His care plan noted a self-care performance deficit and the need for assistance with personal hygiene and oral care. Review of the facility's ADL policy indicated that residents unable to carry out ADLs should receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, observations and interviews revealed that these services were not consistently provided, resulting in residents being left with unmet hygiene and grooming needs.
Failure to Implement Bowel Protocol for Resident on Constipating Medication
Penalty
Summary
The facility failed to consistently implement a bowel protocol program for one resident who was admitted with chronic systolic congestive heart failure, protein-calorie malnutrition, and was receiving palliative and hospice care. The resident was prescribed Fentanyl, a medication known to cause constipation, and had a physician's order for Miralax to be administered as needed for constipation. However, medical record review showed multiple extended periods—ranging from four to over five days—without a documented bowel movement, and no documentation that Miralax was administered during these times. The Medication Administration Record for the month showed no evidence that the medication was given, despite the absence of bowel movements. Interviews with facility staff, including the DON, NHA, and a registered nurse, revealed that there was confusion and lack of clarity regarding the bowel protocol. The DON and NHA could not produce a current bowel protocol or explain the existing one, and the RN was unable to locate the protocol or specify the order of interventions. The Medical Director confirmed that the expectation was for staff to notify her after three days without a bowel movement and to administer Miralax as ordered, but this was not done. The facility did not have a current bowel policy in place at the time of the survey, and staff were unable to demonstrate consistent implementation of bowel management for the resident.
Failure to Maintain Sanitary Oxygen Tubing per Physician Orders
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of respiratory care, specifically regarding the maintenance of sanitary oxygen tubing for three residents who required oxygen therapy. Each resident had physician orders specifying that oxygen tubing should be changed weekly, with the tubing dated and initialed at each change. However, observations revealed that the oxygen tubing for all three residents had not been changed for at least ten days, as the tubing was last dated as changed on 6/16/25, despite observations occurring on 6/24/25 and 6/26/25. The residents involved had diagnoses including chronic diastolic and systolic congestive heart failure and were documented as requiring oxygen therapy per their care plans and physician orders. Interviews with the Director of Nursing confirmed that the facility's practice was to change oxygen tubing weekly, but the facility's written policy on oxygen administration did not specify the frequency for changing tubing. The lack of adherence to physician orders and the absence of clear policy guidance contributed to the failure to maintain sanitary oxygen tubing for the affected residents.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 12% based on 3 errors out of 25 observed opportunities. One incident involved a registered nurse preparing Levothyroxine for a resident, during which the tablet was dropped onto the top of a medication cart that was acknowledged as dirty and not disinfected. The nurse picked up the tablet with gloved hands, without performing hand hygiene, and administered it to the resident instead of discarding it and using a new tablet, as required. Another incident involved a nurse preparing Diclofenac Sodium (Voltaren) gel for a resident's knees without using the required dosing card to measure the correct 4-gram dose. The nurse was unaware of the dosing card's existence and could not confirm the correct amount was administered. A third incident involved the administration of fast-acting insulin using a Novolog Flexpen, where the nurse changed the needle after priming and did not follow the manufacturer's instructions to keep the needle in the skin for six seconds after the dose counter reached zero, potentially resulting in an incomplete dose. These actions were observed and confirmed through interviews and record reviews.
Failure to Provide Accessible Survey Results and Plan of Correction
Penalty
Summary
The facility failed to honor residents' rights to examine the results of the most recent survey conducted by Federal or State surveyors, as well as the associated plan of correction. During a confidential group meeting with six residents, it was revealed that none of the residents were aware of the procedure for accessing the survey results or knew where these results were posted. The resident council president also confirmed a lack of knowledge regarding the location of the last survey results. Upon inspection with a resident, a binder containing survey results was found hanging on the wall. However, the most recent survey displayed was marked "Not Final" on each page, and there was no plan of correction included. The Nursing Home Administrator confirmed that the binder did not contain a final copy of the last annual survey or the required plan of correction, indicating that the facility did not make these documents readily accessible as required.
Failure to Post Actual Nurse Staffing Hours
Penalty
Summary
The facility failed to comply with federal requirements for posting daily nurse staffing information. On multiple occasions, surveyors observed that the Nurse Staffing Sheets posted in a prominent location did not include the actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Certified Nurse Aides (CNAs) for any shift. The columns designated for recording these actual hours were left blank for the reviewed dates. This omission was confirmed during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), who acknowledged that the actual hours worked were not documented as required. A review of the facility's own policy indicated that the Nurse Staffing Sheet should be updated daily to reflect actual hours worked, including adjustments for staff absences or call-outs, and should include all nursing staff paid by the facility, including contract staff. Despite this policy, the posted sheets did not contain the required information, resulting in noncompliance with federal regulations regarding nurse staffing data transparency.
Failure to Establish and Maintain Emergency Subsistence Policies and Procedures
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during emergencies, as required by federal regulations. During an interview, the Dietary Manager was unable to confirm the existence of a three-day emergency menu and stated that food provisions would be based on the regular menu cycle. The Dietary Manager also expressed uncertainty about how the facility would manage food service if dietary staff were unable to work due to weather conditions. It was noted that a three-day emergency menu had previously existed but was not re-established after a change in food vendors. Additionally, a review of the facility's emergency preparedness plan revealed inconsistencies regarding water supply arrangements. The written policy indicated reliance on one vendor for emergency water provision, while the Administrator reported having a contract with a different vendor not reflected in the plan. These deficiencies indicate a lack of clear, updated, and actionable procedures to ensure the availability of food, water, and other essential resources for staff and patients in the event of an emergency.
Obstructed Emergency Exit Due to Chained Patio Gate
Penalty
Summary
A deficiency was identified when, during an observation, a gate providing exit from the patio area was found to have a chain wrapped around it and the adjoining fence, which prevented the gate from being used as an emergency exit. This obstruction to the means of egress was discovered at approximately 11:37 AM and was confirmed by the Maintenance Director at the time of the observation. The report does not mention any specific residents or staff being directly affected at the time of the deficiency, nor does it provide details about their medical history or condition.
Failure to Conduct Monthly Emergency Lighting Tests
Penalty
Summary
The facility failed to conduct monthly emergency lighting tests for the months of June 2024 through October 2024, as required by regulations. This was identified during a record review on June 25, 2025, when no documentation of the required testing was available. The Maintenance Director confirmed that the records for these months were not provided at the time of the survey exit. This deficiency could affect all occupants in the event of a power failure, as automatic emergency lighting is required to be tested regularly to ensure proper function.
Failure to Perform Required Semi-Annual Kitchen Hood Cleaning
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Specifically, the kitchen hood was not inspected or cleaned at least semi-annually as required. Record review showed only one hood cleaning report dated October 2024, and the cleaning sticker on the hood indicated that the next cleaning was due in April 2025. This deficiency was confirmed during an interview with the Maintenance Director at the time of discovery. No information was provided regarding specific patients or their medical conditions in relation to this deficiency.
Deficient Fire Alarm System Testing, Maintenance, and Documentation
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained according to NFPA 70 and NFPA 72 standards. During record review, it was found that the most recent annual fire alarm inspection and sensitivity reports indicated that most smoke detectors were out of sensitivity or unserviceable and needed replacement. When questioned, the Maintenance Director (MD) confirmed that these issues had not been corrected. Documentation provided showed that some components such as duct detectors, key switches, and panel parts were replaced, but there was confusion regarding whether the fire alarm control panel (FACP) itself had been replaced. Further review revealed a discrepancy between the inspection report, which listed an Edwards EST Panel, and the observed installed panel, which was a Kidde FX Series. No evidence was provided to clarify if the deficiencies noted in the inspection and sensitivity reports had been addressed or to explain the discrepancies regarding the FACP. Additionally, it was observed that the breaker for the Fire Alarm Control Panel did not have a device to prevent unauthorized disconnection, such as a circuit breaker lock, as required by NFPA 72. This finding was confirmed by the MD at the time of discovery. No further information was provided to indicate that this issue had been resolved.
Failure to Repair Sprinkler System Alarm After Inspection
Penalty
Summary
The facility failed to provide required maintenance and testing for its automatic sprinkler system in accordance with NFPA 25. During a record review on June 25, 2025, it was found that the most recent annual sprinkler inspection, dated March 25, 2025, documented that the outside bell failed to operate. An interview with the maintenance director confirmed that this issue had not been fixed. This deficiency was identified through both documentation and staff confirmation.
Failure to Transmit Fire Alarm Signal During Fire Drills
Penalty
Summary
The facility failed to conduct fire drills in accordance with regulatory requirements, specifically by not transmitting the fire alarm signal during fire drills on the third shift or immediately the next day for several documented dates. This deficiency was identified through record review and confirmed by the Maintenance Director. The report notes that fire drills are required to include the transmission of a fire alarm signal and simulation of emergency fire conditions, but on multiple occasions, this procedure was not followed as required.
Failure to Maintain and Inspect Portable Fire Extinguishers per NFPA 10
Penalty
Summary
The facility failed to ensure that portable fire extinguishers were selected, installed, inspected, and maintained in accordance with NFPA 10 standards. During an observation on June 25, 2025, a fire extinguisher located in the patio area was found to have no record of inspection. Additionally, another fire extinguisher located behind the 200 wing nurses station was observed to be overpressurized. These deficiencies were confirmed by the Maintenance Director at the time of discovery. The deficient practices could affect 15 occupants in the event of a fire, as noted in the findings.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) reported that the facility had 2 RNs employed in addition to the DON until one RN resigned on 3/08/2024. Despite attempts to recruit more RNs, no new hires were made. The facility assessment indicated that staffing should include two full-time RNs working 10-hour shifts, 4 days a week, with coverage 7 days a week. However, the March 2024 master schedule showed that after the resignation, the facility was left without an RN for the required hours starting on 3/16/2024. The April 2024 schedule further reflected that the remaining RN began a leave of absence on 4/24/2024, exacerbating the staffing deficiency.
Failure to Implement Effective Infection Control Program
Penalty
Summary
The facility failed to implement a comprehensive infection prevention and control program, leading to deficiencies in preventing, identifying, reporting, investigating, and controlling infections and communicable diseases among residents, staff, volunteers, and visitors. Specifically, the facility did not adequately investigate and document outbreaks of RSV and Norovirus that occurred between December 2023 and March 2024. The Infection Preventionist, DRC C, acknowledged that employee and resident illnesses were not tracked on a specific surveillance tool but were instead scattered across various communication platforms and records, making it difficult to manage and control the outbreaks effectively. During interviews, it was revealed that the Director of Regulatory Compliance (DRC) C, who was responsible for infection surveillance, found it challenging to determine the validity of employee call-ins and to gather additional information from employees. The Previous Director of Nursing (PDON) D confirmed that no formal investigation into the RSV and Norovirus outbreaks was completed, and no documentation was available to confirm that an outbreak investigation had been conducted. This lack of documentation and follow-up indicates a significant gap in the facility's infection control practices. The review of the Employee Line Listings from January to May 2024 showed multiple instances where employees called off work due to illness without any follow-up or tracking documentation to determine if residents had been exposed to an illness. Additionally, the facility's policies on infection outbreak response and investigation, infection prevention and control program, and employee work restrictions were not adhered to, as evidenced by the lack of outbreak investigation and inadequate tracking of employee illnesses. This failure to follow established policies contributed to the facility's inability to control the spread of infections effectively.
Inadequate Infection Preventionist Presence and Oversight
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, provided sufficient time to perform the IP role, and was present to properly manage the Infection Prevention and Control Program (IPCP). The Director of Regulatory Compliance (DRC) was designated as the IP for the facility but was responsible for overseeing three facilities and primarily performed her duties remotely. The DRC was only physically present at the facility one to two days a week, which was insufficient to meet the requirements of the IPCP. This lack of adequate presence and oversight led to deficiencies in outbreak surveillance, antibiotic stewardship, and immunizations. The facility's Antibiotic Stewardship Program was not properly implemented, as evidenced by the treatment of three residents with antibiotics without appropriate indications for use. Additionally, the IP did not ensure that eligible residents received the pneumococcal vaccine, and there was a failure to keep all resident immunization statuses up to date. Specific residents were identified as not having received the necessary immunizations, highlighting the gaps in the facility's infection control practices. Furthermore, the facility's Infection Control Program lacked ongoing surveillance for employee illnesses and did not conduct outbreak investigations for significant events, such as an RSV outbreak and a Norovirus outbreak. The facility's policy outlined the responsibilities of the IP, including surveillance, reporting, and managing infections, but these were not adequately fulfilled due to the insufficient presence and involvement of the designated IP. This failure to adhere to the established policies and guidelines resulted in significant lapses in infection prevention and control within the facility.
Failure to Provide Accessible Grievance Forms and Follow Up on Resident Concerns
Penalty
Summary
The facility failed to make grievance forms readily available to all residents and family members, and did not follow up with one resident's grievances. Observations on multiple dates revealed that the plastic tray labeled for grievance forms near the nurses' station was consistently empty and situated at a height inaccessible to residents in wheelchairs. Additionally, there were no instructions on the posting regarding who would follow up on the grievances and the expected time frame for follow-up. An LPN was unable to locate any grievance forms when asked, indicating a systemic issue in the availability of these forms. A resident, who was cognitively intact, reported dissatisfaction with the follow-through on his concerns about being woken up at night, which exacerbated his anxiety. The resident had submitted grievances about being woken up early to clean his fecal collection container and requested that this care be performed between 7 AM and 3 PM. However, the care plan did not reflect these preferences, and there was no indication that the resident was content with the plan of care. The resident's care plan was updated to include a note about his changing preferences, but the specific request to sleep in until he naturally wakes up was not addressed, leading to ongoing dissatisfaction and anxiety for the resident.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to implement policies and procedures for reporting an injury of unknown origin for a resident (R16). R16 was admitted with multiple diagnoses, including non-traumatic subarachnoid hemorrhage, rhabdomyolysis, alcohol-induced dementia, high blood pressure, weakness, and hearing loss. On 1/25/24, a progress note indicated that R16 was very weak, unsteady, and experiencing increased right leg pain. The resident was sent to the hospital for an x-ray, which revealed a deformity of the right pubic bone that could relate to an acute or chronic fracture. A follow-up evaluation confirmed a fracture of multiple pubic rami with routine healing. Despite these findings, the facility did not report the injury of unknown origin to the State Agency, did not hold a Trigger Call, and did not conduct an internal investigation into the injury. During interviews, the Director of Nursing and the Nurse Consultant confirmed that there was no investigation into the fracture identified in R16's x-ray. The facility's policies, including the Trigger Event policy and the Abuse and Neglect Policy, require reporting all injuries of unknown origin to the department of public health and conducting internal investigations. However, these procedures were not followed in this case, leading to the deficiency. The failure to report and investigate the injury of unknown origin was a clear violation of the facility's policies and procedures designed to protect residents' health and welfare.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for two residents, resulting in medications being administered outside of the physician-ordered parameters. Resident #6, a [AGE] year-old female with hypertension, had multiple instances where her blood pressure and heart rate were below the prescribed thresholds, yet metoprolol was still administered. Specifically, on 5/1/24, her blood pressure was 98/60; on 5/2/24, her heart rate was 64; and on 5/5/24, her blood pressure was 104/54 with a heart rate of 58, but the medication was given each time regardless of these readings. Resident #36, a [AGE] year-old male with hypertension, also experienced similar issues. His April Medication Administration Record revealed that amlodipine was administered despite his blood pressure being below the ordered parameters on multiple occasions. For instance, on 4/9/24, his blood pressure was 108/70; on 4/10/24, it was 110/70; and on 4/19/24, it was 102/80. Additionally, on 4/25/24, his blood pressure readings were 108/58 and 98/54, yet the medication was still administered. The Director of Nursing acknowledged that the nursing staff did not follow the physician's orders and stated that the staff would receive education to ensure compliance with medication administration protocols.
Failure to Implement Post-Fall Assessments and Safety Interventions
Penalty
Summary
The facility failed to implement their policy for post-fall assessments for two residents reviewed for accidents and hazards. Resident #6, a female with dementia and a history of falling, experienced an unwitnessed fall resulting in a scalp laceration and hematoma. Despite the severity of the injury, no neurological assessment or post-fall assessment was conducted, and no new safety interventions were implemented. Additionally, there were no orders for nursing to monitor and assess the resident's scalp laceration, contrary to the facility's policy for head injuries. Resident #14, who had diagnoses including dementia and orthostatic hypotension, experienced multiple unwitnessed falls. After a fall in the bathroom and another in his room, no neurological exams were conducted, and no new interventions were added to the care plan to prevent future falls. The care plan did not address the causative factors of the falls, and subsequent progress notes lacked details surrounding the incidents. The facility's failure to follow their own policies for post-fall assessments and care planning contributed to the deficiencies noted by the surveyors.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program effectively, resulting in inappropriate antibiotic use for three residents. Resident #14 was administered Cipro for a suspected urinary tract infection (UTI) based on a urine dip test, without waiting for culture results. The culture later indicated contamination, and the antibiotic was discontinued after three doses. Documentation did not provide adequate symptoms to meet McGeer Criteria for initiating antibiotics prior to culture results. Resident #18 exhibited confusion and unusual behavior, leading to a urine dip test that was positive for leukocytes, nitrates, and blood. Despite not meeting McGeer Criteria, the resident was started on nitrofurantoin before culture results were available. The culture later showed resistance to the prescribed antibiotic, necessitating a change to Amoxicillin. Documentation did not justify the initial antibiotic use based on McGeer Criteria. Resident #6 showed increased confusion and hallucinations, prompting a urine dip test that was positive for leukocytes and nitrites. An antibiotic was started before culture results, which later indicated contamination. The facility's documentation did not provide sufficient symptoms to meet McGeer Criteria for initiating antibiotics. The Director of Regulatory Compliance confirmed that the facility's antibiotic stewardship program was not followed as required, leading to inappropriate antibiotic use.
Failure to Provide Pneumococcal Immunizations Per CDC Recommendations
Penalty
Summary
The facility failed to provide the pneumococcal immunization per consent and CDC recommendations for two residents. Resident #37, a female admitted on [DATE], had not received a pneumococcal vaccine since 9/9/2016, despite having a signed consent dated 4/1/24 and an order to administer the vaccine every 5 years. Resident #191, a female admitted on [DATE], had no documentation of receiving the last influenza or pneumococcal vaccines, even though a signed consent was provided on 5/1/24 and an order to administer the influenza vaccine annually was in place. The Director of Nursing reported that the Director of Regulatory Compliance, who is also the Infection Preventionist, was responsible for the immunization program but was unable to locate the immunization tracking information. The Infection Preventionist confirmed that the pneumococcal immunizations were not up to date and was in the process of updating the residents' immunization status. The facility's policies on infection prevention and control, as well as pneumococcal vaccination, were not followed, leading to the deficiency in providing the required immunizations.
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A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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