Royalton Manor, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in St Joseph, Michigan.
- Location
- 288 Peace Blvd, St Joseph, Michigan 49085
- CMS Provider Number
- 235623
- Inspections on file
- 37
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Royalton Manor, Llc during CMS and state inspections, most recent first.
The facility failed to follow the published lunch menu and did not inform residents in advance of a menu change or notify the RD. The posted and internal menus listed BBQ chicken, macaroni and cheese, collards, corn bread, and sweet potato pie, but the meal actually served included green beans instead of collard greens. The Dietary Manager reported that collards were unavailable and she substituted green beans without RD approval, did not update the posted menu, and did not keep a log of substitutions or RD approvals, affecting all residents receiving meals from the kitchen.
Surveyors identified that desserts on resident meal trays were transported uncovered from the kitchen to a memory care unit, leaving sweet potato pie exposed to air during delivery. In addition, dietary management staff entered and moved through the kitchen without required hairnets, and one manager re-entered the kitchen, failed to perform hand hygiene, and retrieved beverages for a resident without washing hands. These practices did not comply with the facility’s nutritional services dress code or FDA Food Code requirements for covering food and using hair restraints around exposed food.
A resident with Alzheimer’s disease, type 2 DM, and anxiety, assessed as dependent for eating and ordered a regular mechanical soft diet with thin liquids, was left without a meal while seated with two other residents who had food. During the meal, another resident slid an open milk carton to him, which he drank, and he then took and ate a dessert and plate of food from the place setting of the resident next to him, despite that resident’s verbal protests. Multiple CNAs were present in the dining room and a social worker was at the nearby nurse’s station, but staff did not observe or intervene until after the resident had consumed other residents’ food, contrary to the DON’s stated expectation that residents at a table be served at the same time and in a timely manner.
A resident with dementia, severe cognitive impairment, and a known history of elopement and wandering continued to exhibit exit‑seeking behavior and repeatedly voiced intent to break and jump out of his window after a prior elopement through that window. Although maintenance installed a screw intended to limit window opening and similar screws on other windows, the maintenance director did not document follow‑up or physically test whether the windows could still be opened over the screws, relying only on visual checks. During the survey, a family member and the surveyor were able to unlock and fully open the resident’s window over the screw with little effort, and the window screen was damaged, while staff reported the resident and his daughter preferred the door closed and that the resident continued to talk about leaving and seek exits.
Two residents on regular diets reported that meals were unpalatable, with food described as cold, undercooked sausage, and french toast sticks that were “hard as a rock” and could not be cut with a fork, leading one resident to eat only one piece with her fingers and the other to be unable to eat the breakfast items at all. One resident also reported receiving two bowls of oatmeal she did not want, while another stated that lunch tasted terrible and did not match the posted menu item of collards, instead receiving green beans. Both residents repeatedly characterized the food as poor in taste and quality, and one sought fruit directly from the kitchen because she could not eat the served breakfast, despite the Dietary Manager stating that alternative “always ready” foods were available on request.
A resident with cognitive and physical impairments was kept in a geri-chair with a lap tray that acted as a physical restraint, despite regaining strength and showing signs of distress and agitation. Staff interviews and documentation confirmed the resident could not remove the tray independently and frequently expressed frustration, but the restraint was continued for convenience and fall prevention rather than medical necessity, contrary to facility policy.
The facility did not employ a Certified Dietary Manager to supervise the dietary department, relying instead on a staff member with only a ServSafe Food Handler certificate and no management training. There was also no full-time RD on site, with RD support provided remotely and in-person visits occurring infrequently due to staffing shortages.
Surveyors found that food items in the kitchen and storage areas were not consistently labeled or dated according to facility policy and FDA Food Code requirements. Items such as chicken salad, deviled eggs, milk, cheese, and sausage were observed without proper labeling, dating, or storage, creating the potential for foodborne illness among residents.
Surveyors found that several resident rooms, common areas, and equipment such as wheelchairs and dining chairs were not properly cleaned, with visible dust, debris, and stains present. Two residents had persistently dirty wheelchairs, and staff interviews revealed inconsistent cleaning routines and lack of documentation. Residents expressed dissatisfaction with the cleanliness of their environment, and observations confirmed widespread unclean conditions throughout the facility.
Two residents experienced inaccurate medication documentation, late or missed doses, and improper handling of controlled substances due to a nurse preparing and signing out medications before administration, failing to administer some medications as ordered, and using medication from another resident's supply. Medications were not always given within the required timeframe, and some were not administered at all during the observed pass.
Licensed nursing staff failed to maintain competency in medication administration, resulting in mismanagement of controlled substances and improper care for two residents. An RN was observed preparing and administering medications incorrectly, including using medications from another resident's supply and failing to document controlled substance administration as required. The facility lacked a process for ongoing competency evaluations for licensed nurses, contributing to these deficiencies.
Staff failed to maintain accurate documentation and inventory of controlled substances, resulting in multiple discrepancies between medication counts and records. A nurse administered a controlled medication late without proper documentation or physician order, and both an RN and an LPN made errors in recording and administering medications, including giving medication from one resident's supply to another. These actions led to unaccounted pills and conflicting records for several residents.
Staff failed to perform proper hand hygiene and did not follow Enhanced Barrier Precautions when entering and exiting a resident's room, including handling items without sanitizing hands and wearing artificial nails. Clean linens were carried against staff clothing and skin, and shared equipment such as mechanical lifts was found visibly soiled. The facility also lacked an effective water management program for Legionella prevention, with no documentation or clear protocols in place.
Two residents experienced significant weight loss due to the facility's failure to consistently monitor weights and document changes. One resident on enteral feeding had a notable decrease in weight without timely RD follow-up or physician notification, and another recently admitted resident was not weighed according to policy, with staff unaware of the weight loss. The facility did not update care plans or maintain required documentation for these cases.
Two residents were not offered or documented as having received timely influenza and pneumococcal vaccinations, with no records of vaccine history, education, or consent. The Infection Preventionist confirmed that immunizations should have been addressed at admission but were not completed or documented.
Two residents were not offered or properly documented for COVID-19 immunization upon admission. One resident had no record of vaccine education, administration, or consent, while another had no documentation of booster education or declination after admission, despite a history of prior vaccination. The Infection Preventionist confirmed that these steps were not completed or recorded as required.
A resident with Alzheimer's and dementia was accused of lying by the NHA after reporting an altercation between other residents. Despite being cognitively intact and having no history of fabrication, the resident was labeled as having a behavior problem. Multiple staff members, including CNAs and a Social Services staff member, confirmed the resident's credibility, but the NHA and Business Office Manager claimed otherwise without documentation support.
A facility failed to ensure timely physician orders and care for a resident's nephrostomy tubes, resulting in a five-day delay in monitoring and care. The resident, with a history of bladder cancer and severe sepsis, was admitted without necessary orders, and staff interviews confirmed the admitting nurse's responsibility to enter these orders. The lack of documentation on nephrostomy tube care during the initial days of admission highlighted the deficiency.
A resident with stage IV bladder cancer and nephrostomy tubes was admitted to a facility without proper orders for nephrostomy tube care. Despite the presence of the tubes being noted, there was no documentation of care or monitoring for several days. Staff reported that orders should have been in place upon admission, but there was a lack of communication and follow-up to ensure this. The Director of Nursing confirmed the admitting nurse's responsibility to enter such orders, leading to a deficiency in care.
A resident with a history of osteoporosis and Alzheimer's experienced a fall, resulting in a fracture. The facility failed to provide prompt medical care, as the initial assessment by an RN was inadequate, and the resident was moved without a thorough injury assessment. Despite severe pain and signs of a fracture, immediate hospital transport was delayed, contributing to the deficiency.
A resident with severe cognitive impairment was discharged from an LTC facility without proper authorization due to nonpayment. The facility failed to obtain the necessary approval from the Michigan Department of Licensing and Regulatory Affairs before proceeding with the discharge. Staff confusion about the approval process led to the resident being discharged on the proposed date without the required authorization.
A facility failed to provide a written notice of transfer for a resident with severe cognitive impairment, who was transferred to a hospital due to a change in condition. The facility's policy required notice before transfer, but it was found that transfer notices were not being given to residents or their representatives, leading to potential unawareness of the transfer and associated rights.
A facility failed to document a hypodermoclysis procedure for a resident with severe cognitive impairment, leading to potential inaccuracies in care assessment and communication. Despite staff training on the procedure, there was no record of it in the resident's medical records, causing confusion among staff about whether it was performed.
A resident with a history of heart and kidney issues experienced a 10-day delay in receiving antibiotic treatment for a UTI due to a communication breakdown and procedural issues. The NP waited for a paper copy of the sensitivity report before ordering treatment, despite having access to electronic results. The delay was compounded by the NP's lack of awareness that the urinalysis needed follow-up, as it was ordered by an on-call provider.
A facility failed to monitor a resident's antibiotic treatment for a UTI, lacking documentation of efficacy and adverse reactions. The resident, with multiple health conditions, was prescribed Nitrofurantoin Macrocrystal, but the care plan was delayed, and no Sepsis Screening Evaluation was completed. This oversight led to potential unrecognized side effects or ineffective treatment.
The facility failed to maintain accurate medical records for three residents, leading to incomplete care documentation. A resident's hypodermoclysis procedure was not documented, another resident's discharge process lacked comprehensive records, and a third resident's vital signs were not updated during a change in condition. Staff interviews confirmed these documentation lapses.
A resident with moderate cognitive impairment experienced a fall during a transfer due to a CNA's failure to follow the updated care plan requiring a two-person assist and the use of a gait belt. The CNA was unaware of the change and attempted the transfer alone, leading to the resident losing balance.
Unapproved Menu Substitution and Failure to Inform Residents of Meal Changes
Penalty
Summary
The facility failed to ensure that the published lunch menu was followed, that residents were informed of menu changes in advance, and that the Registered Dietitian (RD) was notified of these changes. The posted and facility menu for lunch on 3/18/2026 listed BBQ chicken, macaroni and cheese, collards, corn bread, and sweet potato pie. However, during a kitchen observation, the test lunch tray contained green beans instead of the planned collard greens. In an interview, the Dietary Manager stated that collard greens were not available, so she substituted green beans without obtaining prior approval from the RD, did not update the posted menu outside the dining room, and did not maintain a log of substitution changes or RD approvals. These actions and omissions resulted in the potential for all residents consuming food from the kitchen to be dissatisfied with their meal service and for meals to not be nutritionally adequate, as the menu was not served as planned, residents were not informed of the change, and the RD was not consulted regarding the substitution.
Uncovered Desserts and Lack of Hair Restraints in Dietary Services
Penalty
Summary
The deficiency involves failure to follow food safety and dress code standards in the dietary department, specifically related to uncovered food during transport and lack of required hair restraints in the kitchen. Surveyors observed a dietary aide transporting two carts of resident meal trays to the memory care unit, with multiple trays containing uncovered sweet potato pie desserts that were exposed to air. The facility’s own policies, as well as the 2022 FDA Food Code, require food to be stored and transported in covered containers or wrappings to protect it from cross-contamination. Surveyors also observed dietary management staff in the kitchen area without required hairnets and without performing hand hygiene upon entering the kitchen. One Dietary Manager walked across the kitchen without a hairnet to assist a staff member, then re-entered the kitchen, did not wash her hands, and retrieved orange juice and milk. In an interview, this manager acknowledged having a hairnet but stated she forgot to put it on and did not wash her hands, explaining that she was in and out of the kitchen frequently and did not touch food. On another occasion, a different Dietary Manager entered the kitchen, approached the steam table, accepted a plate of food from a dietary cook, and placed it on a tray while not wearing a hairnet. These actions were inconsistent with the facility’s Nutritional Services Department Dress Code, which requires hair restraints to prevent hair from contacting exposed food and related items.
Failure to Maintain Dignity and Supervision During Dining
Penalty
Summary
Failure to ensure dignity with dining occurred when a male resident with Alzheimer’s disease, type 2 diabetes, and anxiety, who was assessed as dependent for eating and required CNA assistance with meals, was left without appropriate meal service and supervision in the dining room. His care plan and orders specified a regular, mechanical soft (Level 3 Advanced) diet with thin liquids and enriched foods three times daily, and the Kardex indicated CNAs were to assist him with meals as needed. On one occasion, he was the last resident served and did not receive his meal tray until 14 minutes after he was observed sitting alone at a table. On a subsequent occasion, he was seated with two other male residents who had plates of food, while he had no food in front of him. During this later meal observation, an unknown resident pushed an open milk carton across the table to him, which he then drank. He subsequently reached into the place setting of the resident next to him, took that resident’s dessert bowl and spoon, and began eating it, then took the same resident’s plate and continued eating the remaining food. The resident whose food was taken verbally protested with single words such as “Hey!” and “Mine!”, while the first resident moved his arm to keep the plate out of reach. Throughout these events, multiple CNAs were present in the dining room and the social worker was seated at the nearby nurse’s station, but no staff observed or intervened until after the resident had consumed other residents’ food. The DON later stated his expectation was that each resident at a table be served at the same time and that meal trays be served timely.
Failure to Ensure Effective Post‑Elopement Window Safety Measures for an Exit‑Seeking Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and ensure the effectiveness of post‑elopement interventions for a resident assessed as an elopement risk. The resident was admitted with dementia with psychotic disturbance and anxiety, had a BIMS score of 4/15 indicating severe cognitive impairment, and was documented as ambulatory with a history of elopement attempts and wandering that placed him at significant risk of reaching dangerous areas. An FRI documented that the resident broke his room window and eloped from the memory care unit, after which one‑to‑one supervision was ordered until the window was amended. The resident’s elopement risk assessments and MDS continued to show a high elopement risk and wandering behaviors occurring on multiple days. Following the elopement, the care plan identified the resident as having a history of elopement out of the window and at risk for elopement related to dementia, with interventions including 1:1 care until the window was repaired. Progress notes over the subsequent months documented repeated statements by the resident about breaking and jumping out of the window, wanting to leave, and exit‑seeking behaviors such as wandering halls, going from door to door, pushing on exit doors, and packing belongings to leave. Staff notes indicated the resident was placed on 15‑minute checks at times due to wandering and exit seeking, and multiple entries described the resident expressing intent to break the window, jump out, or leave so that he might be harmed. Despite the resident’s ongoing exit‑seeking and window‑focused statements, the facility’s physical intervention on the window was not effectively monitored or verified. The maintenance director reported that after the elopement he installed screws on the resident’s window and other windows but did not document follow‑up, did not physically test the windows to see if they could be opened over the screws, and only visually confirmed the presence of screws. During surveyor observation, the resident’s family member and the surveyor were each able to unlock and open the resident’s window fully over the screw with little effort, and the window screen was observed to be busted at the bottom. Staff interviews confirmed that the resident and his daughter liked the door closed, and that the resident continued to talk about leaving and was exit seeking for a while after the elopement, while leadership acknowledged there was no documentation of window checks and that they believed the windows had been repaired.
Failure to Provide Palatable, Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that food was palatable, appetizing, and properly prepared for two residents on regular diets with regular texture and thin liquid consistency orders. One resident with bipolar disorder, anxiety, and depression reported that the food was “yucky” and sometimes cold, and that staff did not reheat it when requested. On one morning, she anticipated receiving french toast sticks and stated she would eat them but expected they would probably be cold. Later that morning, her breakfast tray was observed at her bedside with the lid on the plate; she reported the food temperature was acceptable but stated the sausage was undercooked and the french toast sticks were “hard as a rock.” She demonstrated that she could not cut the french toast sticks with a fork, that only one of four was soft enough to bite, and that she had to eat the one she did consume with her fingers after covering it in syrup. Three french toast sticks and two sausage links remained on the plate, and the hardness of the french toast sticks was both seen and heard during the observation. Another resident with unspecified dementia, weakness, and a history of falls reported that breakfast “sucked,” describing the food as cold, the sausage as needing more cooking, and the french toast sticks as “rock hard,” which she stated she could not eat at all. Her tray contained two bowls of oatmeal and two cups of fruit; she reported she did not know why she received two bowls of oatmeal and that she would not eat even one, though she stated the fruit was acceptable. She later reported that lunch was “terrible,” did not taste good, and that she did not receive the collards listed on the menu but instead was served green beans, which she stated were not the same. On another morning, she reported she could not eat whatever was served for breakfast and was observed going to the kitchen to obtain fruit, stating that whatever she had been served “needed some help.” The posted menu for that day listed sausage links, cereal of choice, french toast sticks, and juice for breakfast, and chicken BBQ, macaroni & cheese, collards, cornbread, and sweet potato pie for lunch. The Dietary Manager stated that residents could request alternative choices from a list of “always ready” foods if they did not like something.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, anxiety disorder, major depressive disorder, and edema was subjected to the use of a geri-chair with a lap tray, which functioned as a physical restraint. The resident had previously been hospitalized and returned to the facility with decreased trunk control, leading to the initial use of the geri-chair for support. However, subsequent assessments and staff interviews indicated that the resident had regained strength and could sit unsupported, yet the use of the geri-chair and lap tray continued. Observations and interviews revealed that the lap tray and positioning of the geri-chair restricted the resident's mobility, preventing her from standing or moving independently. Multiple staff members, including CNAs and the DON, acknowledged that the resident was unable to remove the tray herself and frequently expressed distress, agitation, and frustration while restrained. Documentation in nursing progress notes and behavior logs showed repeated episodes of the resident banging on the tray, yelling, and attempting to get out of the chair, indicating ongoing emotional and physical discomfort. Despite the resident's improved physical condition and clear behavioral signs of distress, the facility continued to use the geri-chair and lap tray, primarily to reduce falls and for staff convenience, rather than for a current medical necessity. The facility's own restraint policy prohibits the use of physical restraints for convenience and requires reassessment with any significant change in condition. The required reassessment and communication with the hospice care coordinator regarding the resident's improved status and negative response to the restraint did not occur, resulting in the continued inappropriate use of a physical restraint.
Lack of Qualified Dietary Management and Inadequate RD Coverage
Penalty
Summary
The facility failed to employ a staff member with the appropriate credentials to supervise and manage the dietary department. During a kitchen tour, the Dietary Manager (DM) stated he was not a Certified Dietary Manager (CDM), was not enrolled in certification classes, and only held a ServSafe Food Handler certificate, which did not include management training. The DM also reported that the facility did not have a full-time Registered Dietitian (RD), and that RD support was limited to phone consultations and infrequent in-person visits, with the RD only visiting the facility a few times over two years. Corporate RD confirmed the DM's lack of CDM credentials and acknowledged that RD coverage was limited due to staffing shortages, with remote RDs assisting with documentation but being primarily assigned to other facilities.
Improper Labeling and Dating of Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple instances of improper labeling and dating of food items in the facility's kitchen and food storage areas. During an initial tour, a small plastic container of chicken salad and a container of deviled eggs were found open with only the date of opening and no use by date. Additionally, a gallon of 2% milk was found open without any label or date. On a subsequent tour, cheddar cheese slices were found in a plastic bag with a use by date that had already passed, and sausage was stored in a metal pan that was only partially covered with aluminum foil. Review of the facility's Food Purchasing and Storage Policy confirmed that all food items in refrigerators are required to be properly dated, labeled, and stored in sealed containers or bags. The observations made by surveyors indicated that these procedures were not consistently followed, resulting in the potential for foodborne illness among residents consuming food from the kitchen. No specific residents were identified as being directly affected at the time of the survey.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
Surveyors observed multiple instances of uncleanliness and lack of maintenance in resident rooms and common areas. Dust, dirt, food, and paper debris were found along the wall and floor perimeters in several resident rooms, as well as in hallways and alcoves. Additional observations included a plastic drink lid with a red liquid and a dried red substance on the wall, as well as accumulations of personal items and debris under beds. These findings were corroborated by interviews with housekeeping staff, who described daily cleaning routines but did not provide evidence of consistent or thorough cleaning practices. Two residents were specifically noted to have unclean wheelchairs. One resident, who was cognitively intact, reported that her wheelchair was dirty and likely had not been cleaned. Observations over several days confirmed the presence of crumbs and dried food on and under the wheelchair cushion. Interviews with CNAs and LPNs revealed that while there was an expectation for night shift CNAs to clean wheelchairs, there was no specific schedule or documentation to ensure this was done. The DON acknowledged that cleaning wheelchairs was a challenge and that the process was supposed to be coordinated with resident shower days, but this was not consistently implemented. In the memory care unit, a resident reported that dining chairs needed more frequent cleaning and pointed out dust and debris on the chair frame. Observations confirmed that most dining chairs and table bases were soiled with dried liquids, crumbs, and dust. Multiple brown and yellow stains were noted on the carpets in entryways and common areas, and a heavily soiled emergency exit door was also observed. These conditions contributed to decreased satisfaction with the living environment among residents.
Failure to Follow Professional Standards During Medication Administration
Penalty
Summary
The facility failed to follow professional standards of practice during medication administration for two residents, resulting in inaccurate documentation, late or missed medications, and the potential for worsening medical conditions. For one resident with a history of blood infection requiring IV antibiotics, the nurse was unsure if the IV medication had been administered as scheduled. During observation, the nurse prepared both IV and oral medications, but several medications were signed out as administered before they were actually given. Some medications were not observed being administered at all, and others were documented as not given without explanation. The IV medication was left attached to the resident for longer than ordered, and the nurse was unable to explain the proper administration process. Additionally, the nurse reported administering a controlled pain medication after the scheduled time but could not verify or properly document this, and it was later discovered that the medication may have been taken from another resident's supply. For the second resident, the nurse was observed retrieving unlabeled medications from the medication cart that had been pulled earlier and stored together, rather than preparing them immediately prior to administration as required by policy. The nurse administered a group of oral medications and insulin more than an hour after the scheduled time, and some ordered medications were not observed being given at all. The nurse also made a verbal error regarding the injection site for insulin. Review of physician orders and the medication administration record confirmed that several medications were not administered within the required timeframe, and some were not administered at all during the observed medication pass. Facility policy requires medications to be prepared immediately prior to administration, prohibits administering medications from one resident's supply to another, and mandates that medications be administered within 60 minutes of the scheduled time. Documentation is to occur immediately after administration, not before. The observed practices deviated from these standards, resulting in inaccurate records, late or missed doses, and improper handling of controlled substances.
Failure to Ensure Nursing Staff Competency Leads to Medication Mismanagement
Penalty
Summary
The facility failed to ensure that all licensed nursing staff maintained the necessary competencies and skills to provide appropriate care to residents, resulting in mismanagement of controlled substances and improper medication administration. During medication administration, a registered nurse (RN) was observed handling medications that were not labeled with resident names and preparing them in advance, contrary to facility policy. The RN also demonstrated a lack of knowledge regarding insulin injection sites and the operation of IV medication administration, as evidenced by her inability to explain the process or duration for a resident's IV antibiotic therapy. Further review revealed that the RN administered a controlled substance, Tramadol, to a resident without proper documentation or verification of orders, and took the medication from another resident's supply. The RN failed to document the administration of controlled substances on the required inventory sheets, instead recording them on a piece of paper with the intention to update records later. Discrepancies were found between the number of doses signed out and those actually administered, and the RN could not provide clear explanations for these actions during interviews. The investigation also uncovered that the facility did not have a process in place for ongoing competency evaluations of licensed nursing staff after orientation. The staff development educator confirmed that only certified nursing assistants received competency evaluations, and there was no system to ensure that licensed nurses remained competent in their roles. This lack of oversight contributed to the observed deficiencies in medication management and resident care.
Failure to Accurately Document and Account for Controlled Substances
Penalty
Summary
The facility failed to maintain accurate and clear documentation of controlled substance counts and administration, impacting nine residents across two medication carts. Registered Nurse (RN) JJ did not administer a resident's prescribed Tramadol as scheduled because it was not available in the medication cart, and subsequently administered the medication later without proper documentation or a physician's order for the late dose. RN JJ also failed to document the administration of controlled substances on the appropriate inventory sheets, instead recording them on a separate piece of paper with the intention to update the records later. This led to discrepancies between the actual medication counts and the documented inventory for multiple residents. Observations and interviews revealed that controlled substance counts for several residents did not match the inventory sheets, with pills unaccounted for in multiple cases. For example, one resident's Tramadol card had fewer pills than indicated on the inventory sheet, and similar discrepancies were found for other controlled medications such as Clonazepam, Oxycodone, Morphine, Hydrocodone/Acetaminophen, and Hydromorphone. Additionally, an LPN reported signing out a medication that was later refused by a resident, but the MAR indicated the medication was administered and effective, showing conflicting documentation. Another instance involved a nurse possibly administering medication to the wrong resident with a similar order. Further review determined that RN JJ had taken Tramadol from one resident's supply and administered it to another without proper documentation, and attempted to return medication to the original card from the backup supply. The Director of Nursing confirmed multiple errors in documentation and administration, including actual medication errors and failure to follow professional standards and facility policy. The facility's records and staff interviews consistently showed a lack of adherence to required procedures for controlled substance management and documentation.
Infection Control Failures in Hand Hygiene, Linen Handling, Equipment Cleaning, and Water Management
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in several key areas. Staff did not perform adequate hand hygiene when entering and exiting a resident's room under Enhanced Barrier Precautions (EBP), nor did they demonstrate understanding of the EBP signage or requirements. Both an Activities Aide and a Certified Nursing Assistant entered the room without performing hand hygiene, handled items within the room, and wore artificial nails that extended beyond the fingertips, contrary to infection control recommendations. The resident involved was cognitively intact and had a stage 2 pressure wound, increasing the importance of proper infection control. Additionally, clean linens were observed being transported improperly, with a CNA carrying towels and washcloths under her arm, allowing them to come into contact with her clothing and exposed skin. This practice was acknowledged by the Infection Preventionist as inappropriate due to infection control concerns. Shared resident equipment, such as mechanical lifts, was found to be visibly soiled with dirt, dust, and dried substances, and staff interviews confirmed that such equipment should be cleaned after each use to prevent cross-contamination. The facility also failed to maintain an effective water management program to prevent Legionella. The Maintenance Director was unaware of the facility's protocols for Legionella prevention, including water sampling and documentation of flushing procedures for off-line rooms. There were no logs or evidence of compliance with the facility's policy, which requires regular cleaning, disinfection, and documentation to minimize the risk of Legionella and other water-borne pathogens.
Failure to Monitor and Document Weight Loss in Residents
Penalty
Summary
The facility failed to ensure timely and consistent weight monitoring and complete and accurate documentation for two residents, resulting in undetected weight changes and the potential for nutritional status decline. One resident, who was admitted with diagnoses including weakness and dysphagia and was receiving enteral feeding via PEG tube, experienced a significant weight loss of 6.48% over a short period. Despite this, there was no documentation from the Registered Dietitian (RD) or Dietary Manager (DM) regarding the weight loss after it was initially identified, nor was there evidence that the physician was notified. The resident's care plan was not updated to reflect the weight loss, and there was no follow-up assessment or intervention documented by the RD after the admission nutrition evaluation. Another resident, recently admitted following two surgeries, also experienced significant weight loss. The weight records showed inconsistent monitoring, with a three-week lapse between weighings and a substantial drop in weight. Staff interviews revealed confusion about who was responsible for monitoring and addressing weight loss, and the Dietary Manager admitted to not being aware of the resident's weight loss or having spoken to the resident about it. The facility's policy required weekly weights for new admissions and for residents with significant weight changes, but this was not followed for this resident. The facility's own Weight Management Policy stipulated that residents at risk or with significant weight changes should be weighed weekly, and that the RD should assess and make recommendations to prevent or treat unintended weight loss. However, these procedures were not followed for either resident, as evidenced by the lack of timely weight monitoring, absence of documentation, and failure to update care plans or notify the physician as required.
Failure to Offer and Document Timely Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that eligible residents were offered influenza and pneumococcal vaccinations in a timely manner, as required. For two residents reviewed, there was no documentation of influenza or pneumococcal vaccination history, education, or consent being offered. Specifically, one resident had no record of either vaccine or related education and consent upon admission, and the Infection Preventionist confirmed that the immunization process had not been completed for this resident. Another resident had historical documentation of receiving two pneumococcal vaccines but lacked any record of influenza vaccination, education, or consent. The Infection Preventionist acknowledged that immunizations should have been addressed at admission for both residents, but this was not done or documented.
Failure to Offer and Document COVID-19 Immunization for Residents
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered and properly documented for two of five residents reviewed. For one resident, there was no record of COVID-19 vaccine administration, education, or consent on file, and the Infection Preventionist confirmed that immunizations had not been discussed upon admission. For another resident, although there was documentation of four prior COVID-19 vaccine doses before admission, there was no documentation of further booster education, declinations, or consents after admission. The Infection Preventionist acknowledged that these discussions and documentation should have occurred at the time of admission, but there was no record of them.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to protect a resident's right to dignity and respect, as evidenced by an incident involving a cognitively intact resident with Alzheimer's disease, dementia, depression, and anxiety. The resident reported witnessing an altercation between two other residents and informed the Nursing Home Administrator (NHA). The NHA allegedly responded by calling the resident a liar, which led to the resident feeling upset and crying. This interaction was witnessed by a Licensed Practical Nurse (LPN), who confirmed the resident's account of being called a liar by the NHA. The incident was also discussed in a morning meeting attended by various department heads, where it was noted that the resident had reported the altercation to another resident's family member. Despite the resident's cognitive intactness and lack of history of fabricating stories, a care plan was created labeling the resident as having a behavior problem related to making false accusations. Interviews with multiple Certified Nursing Assistants (CNAs) and a Social Services staff member indicated that the resident was not known to fabricate stories. The NHA, however, maintained that the resident had a history of making things up, although no documentation in the resident's chart supported this claim. The Business Office Manager also described the resident as someone who gossips and lies, but this was not corroborated by other staff or documentation.
Failure to Ensure Timely Nephrostomy Tube Care
Penalty
Summary
The facility failed to adhere to professional standards by not ensuring that physician orders were in place for the monitoring and care of nephrostomy tubes for a resident. The resident, who had a history of malignant neoplasm of the bladder, severe sepsis, and infection due to nephrostomy catheters, was admitted to the facility without the necessary orders for nephrostomy tube care. Despite the presence of discharge papers that should have served as admission orders, the admitting nurse did not enter the required orders, nor did they contact the on-call provider to obtain them. This oversight resulted in a delay of five days before the orders for monitoring and care of the nephrostomy tubes were put in place. Interviews with facility staff, including LPNs, an RN, the wound nurse, and the DON, confirmed that the responsibility for entering admission orders, including those for special devices like nephrostomy tubes, lay with the admitting nurse. The staff acknowledged that the resident should not have gone without orders over the weekend following admission. The lack of documentation regarding the monitoring and care of the nephrostomy tubes during the initial days of the resident's stay further highlighted the deficiency in adhering to professional standards of care.
Failure to Provide Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide proper care for a resident with nephrostomy catheters, which are tubes placed through the skin into the kidneys to drain urine. The resident, who had a history of stage IV bladder cancer and severe sepsis, was admitted to the facility with bilateral nephrostomy tubes. Upon admission, the resident's nephrostomy sites were covered with appropriate dressings, but there was no documentation of care or monitoring of the nephrostomy tubes for several days following admission. The facility's staff, including LPNs and RNs, reported that orders for nephrostomy tube care should have been in place upon the resident's admission. However, there was a lack of communication and follow-up to ensure these orders were obtained and documented. The Wound Nurse confirmed that no orders were entered for the care or monitoring of the nephrostomy tubes until five days after the resident's admission, despite the presence of the tubes being noted in the admission paperwork. The Director of Nursing acknowledged that the admitting nurse was responsible for entering orders for special devices like nephrostomy tubes. The facility's failure to have orders in place for the care and monitoring of the resident's nephrostomy tubes resulted in a lack of documented dressing changes and monitoring for several days, which could potentially lead to complications such as infection or catheter dislodgement.
Failure to Provide Prompt Medical Care After Resident Fall
Penalty
Summary
The facility failed to provide prompt medical care after a fall for a resident, resulting in significant pain and a delay in emergent care. The resident, who had a history of osteoporosis, Alzheimer's disease, and previous falls, experienced a fall that was witnessed by staff. Despite the fall being observed, the initial assessment by the responding RN was inadequate, as the resident was moved without a thorough assessment for injuries. The RN did not immediately recognize the signs of a potential fracture, such as the outward rotation and shortening of the resident's right leg, and did not pursue immediate transport to the hospital. The resident's pain was later assessed as severe, with a pain level of 8 out of 10, and an x-ray confirmed an acute fracture. Interviews with staff revealed that the resident was in significant distress, unable to bear weight on the affected leg, and exhibited signs of pain and injury. The LPN who later assessed the resident noted the need for immediate hospital evaluation, which was not initially pursued by the RN. The delay in recognizing the severity of the injury and the failure to transport the resident promptly to the hospital contributed to the deficiency. Interviews with the facility's staff, including the DON and other nursing staff, highlighted the expectation that a full assessment should be conducted immediately after a fall, prior to moving the resident. The staff acknowledged that the resident should have been sent to the emergency room immediately upon identifying the signs of a serious injury. The family member and DPOA for the resident also expressed that the resident should have been transported to the hospital for evaluation immediately after the fall, indicating a lapse in following the appropriate protocol for post-fall care.
Improper Facility-Initiated Discharge Due to Nonpayment
Penalty
Summary
The facility failed to follow proper procedures for a facility-initiated discharge of a resident, resulting in an untimely and unapproved discharge. The resident, who had severe cognitive impairment due to Alzheimer's disease, dementia with mood disturbances, and generalized anxiety disorder, was given a notice of involuntary transfer or discharge due to nonpayment. The notice was dated over a month before the proposed discharge date, and the facility was required to have a discharge plan approved by the Michigan Department of Licensing and Regulatory Affairs before proceeding. Despite this requirement, the facility discharged the resident on the proposed date without having received the necessary approval. Interviews with facility staff revealed confusion about the approval process, with the social worker and accounts receivable coordinator both mistakenly believing they had received approval. The approval letter was only provided to the surveyor two weeks after the discharge, indicating that the discharge occurred without the proper authorization, as confirmed by electronic communications from the regulatory body.
Failure to Provide Transfer Notice
Penalty
Summary
The facility failed to provide written notice of transfer for a resident who was reviewed for hospital transfers. This deficiency was identified during an interview and record review, where it was found that the resident and/or the resident's representative were not informed of the transfer, the reasons for the transfer, or the resident's rights. The resident in question had diagnoses including repeated falls, altered mental status, and adult failure to thrive, and was assessed to be severely cognitively impaired with a BIMS score of 3/15. The facility's policy required that notice be made as soon as practicable before transfer or discharge, especially in cases of emergency transfer to an acute care facility. However, it was revealed that the transfer notices were kept in a folder at each nurse's station and were not being given to residents or their representatives prior to any transfer or discharge. This oversight resulted in the potential for the resident and/or their representative to be unaware of the transfer and the associated rights.
Failure to Document Hypodermoclysis Procedure
Penalty
Summary
The facility failed to maintain professional nursing standards of documentation for a resident, resulting in potential inaccuracies in assessment and communication of care needs. The resident had diagnoses including repeated falls, altered mental status, and adult failure to thrive, and was severely cognitively impaired. There was a discrepancy regarding whether the resident received hypodermoclysis, a procedure requiring a physician's order and proper documentation. Interviews with various staff members, including the Director of Nursing, Registered Nurse, Nurse Practitioner, and Licensed Practical Nurses, revealed conflicting accounts about whether the procedure was performed on the resident. Despite education and training provided on hypodermoclysis, including the importance of documentation, there was no record of the procedure in the resident's medical records, medication administration record, or progress notes. The lack of documentation led to uncertainty among staff about whether the procedure was actually performed, highlighting a failure in maintaining accurate and complete medical records for the resident's care.
Delayed Treatment for UTI Due to Communication Breakdown
Penalty
Summary
The facility failed to provide timely treatment for a urinary tract infection (UTI) for a resident, resulting in a delay of 10 days before antibiotic treatment was initiated. The resident, who had a history of paroxysmal atrial fibrillation, heart failure, and chronic kidney disease stage 3, had a positive urine culture result on 6/29/24. Despite the positive result, the antibiotic treatment was not ordered until 7/10/24. The delay was due to a communication breakdown and procedural issues within the facility. The nurse practitioner (NP) acknowledged the positive result on 6/29/24 but waited for a paper copy of the sensitivity report before ordering treatment, as per facility instructions. However, the infection preventionist noted that the NP had access to the results in the electronic medical record and did not need to wait for the paper copy. Additionally, the regional clinical coordinator discovered that the NP was not aware of the need to follow up on the urinalysis because it was ordered by an on-call provider, not by the NP herself. This miscommunication and procedural delay led to the resident not receiving timely treatment for the UTI.
Failure to Monitor Antibiotic Efficacy and Adverse Reactions
Penalty
Summary
The facility failed to consistently and timely monitor the antibiotic medication efficacy and adverse reactions for a resident diagnosed with Paroxysmal Atrial Fibrillation, Heart Failure, and Chronic Kidney Disease Stage 3. The resident had a positive urine culture indicating a UTI and was prescribed Nitrofurantoin Macrocrystal. Despite the prescription, there was a lack of documentation regarding the monitoring of the antibiotic's adverse reactions or efficacy during the treatment period. The care plan addressing the UTI and antibiotic treatment was developed and implemented five days after the treatment began, with no prior care plan focus on the UTI and antibiotic treatment. An interview with the Infection Preventionist revealed that residents on antibiotics should be monitored daily for improvement and side effects, with documentation in the form of a Sepsis Screening Evaluation. However, a review of the resident's electronic medical record showed no such evaluation had been completed since April 2022. This lack of monitoring and documentation resulted in the potential for unrecognized side effects or ineffective treatment for the resident.
Deficiencies in Medical Record Documentation for Three Residents
Penalty
Summary
The facility failed to maintain clear, concise, and accurate medical records for three residents, leading to incomplete records of care needs and the potential for diminished medical outcomes. For Resident #101, there was a lack of documentation regarding the initiation and administration of hypodermoclysis, despite verbal orders and educational training being conducted. The Medication Administration Record and Progress Notes did not reflect the procedure, which was confirmed by interviews with staff who witnessed the procedure. Resident #106's discharge process was inadequately documented. Although the social worker communicated with the resident's guardian about discharge plans, the medical record lacked comprehensive documentation of the discharge process. Interviews with staff revealed discrepancies in the discharge documentation, with some staff unaware of the resident's transfer to the hospital, and others failing to document the discharge in the resident's records. For Resident #104, there was a significant gap in the documentation of vital signs between specific dates, despite the resident experiencing a change in condition. The Change in Condition form used outdated vital signs, and staff interviews indicated that the form should have been updated with current measurements. The facility's policy emphasized the importance of obtaining vital signs during a change in status, which was not adhered to in this case.
Unsafe Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a fall and potential injury. The resident, who had a moderate cognitive impairment and was diagnosed with pulmonary embolism and anxiety, was being assisted by a CNA during a transfer from bed to wheelchair. The CNA, who was unaware of the recent change in the resident's care plan from a one-person to a two-person assist, attempted the transfer alone without using a gait belt, leading to the resident losing balance and being eased to the floor. Interviews and record reviews revealed that the CNA had been educated on proper transfer techniques, including the use of gait belts, but did not adhere to the updated care plan. The CNA was unclear about the resident's transfer requirements, and the facility's policy mandates the use of gait belts for safety during transfers. The incident highlighted a lapse in communication and adherence to the care plan, resulting in an unsafe transfer situation.
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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