Shelby Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelby Township, Michigan.
- Location
- 46100 Schoenherr Road, Shelby Township, Michigan 48315
- CMS Provider Number
- 235506
- Inspections on file
- 34
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Shelby Health And Rehabilitation Center during CMS and state inspections, most recent first.
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.
Multiple residents were unable to reliably request assistance due to a prolonged call light system outage affecting several units. Residents with physical limitations struggled to use the provided hand bells, and staff had difficulty identifying and responding to calls for help, resulting in significant delays in care. Facility documentation and staff interviews confirmed the lack of a formal plan or training to address the outage, and policies requiring timely response to resident needs were not followed.
A kitchenette cabinet under the sink was found to be water-damaged, wet, and covered with a black, mold-like substance. The Administrator and Maintenance Supervisor were previously unaware of the extent of the issue, which was attributed to seasonal humidity. The unsanitary condition was confirmed through observation and complaint review.
A resident with a history of anemia and GI hemorrhage experienced significant changes in condition, including falls, confusion, and behavioral disturbances. Staff responded by administering Haldol for new behaviors rather than promptly assessing the underlying cause or notifying the physician, despite facility policy requiring such notification. This delay resulted in pain and hospitalization for the resident.
A resident with COPD, acute respiratory failure, impaired cognition, and requiring staff assistance was left unsupervised during a nebulizer treatment. The nurse initiated the treatment and left the room without a documented self-administration assessment or care plan, returning to find the resident unresponsive. Facility policy requires supervision during nebulizer treatments unless a self-medication assessment is completed.
The facility failed to maintain proper infection control practices for three residents in isolation. A nurse entered a resident's room without full PPE, and another resident's PPE caddy was inadequately stocked. An LPN did not perform hand hygiene or use PPE when checking a resident's vitals, and equipment was not cleaned as per protocol.
The facility failed to properly store and label medications for two residents and on three medication carts. A resident had a medicine cup with a red liquid on their dresser, identified as a protein supplement, while another resident had vitamin bottles on their nightstand without being assessed for self-administration. Additionally, a partially dissolved narcotic tablet was found on a medication cart, and several insulin pens lacked labels or dates, violating the facility's medication storage policy.
The facility failed to ensure call lights were accessible to six residents, leading to a deficiency. Observations showed call lights were often out of reach or not easily locatable, confirmed by interviews with residents and family members. The residents had various medical conditions and cognitive abilities, requiring different levels of assistance. The facility's policy on call light accessibility was not followed, as confirmed by staff interviews.
A facility failed to obtain a physician's order for an advance directive upon admission for a resident with cerebral infarction and end-stage renal disease. Despite the facility's policy, no advance directive order was found in the resident's records. Interviews revealed a breakdown in the process, with the admitting nurse responsible for entering the order, but it was not completed.
A facility failed to complete an annual PASARR for a resident with vascular dementia, major depressive disorder, and other conditions. The resident's last PASARR was dated several months prior, and the social worker confirmed that an updated PASARR had not been completed, despite the requirement for annual updates. The facility did not provide a policy related to PASARRs by the end of the survey.
The facility failed to update comprehensive care plans for two residents. One resident exhibited increased refusal of care behaviors, but their care plan was not updated to address these changes. Another resident's care plan contained outdated and conflicting information regarding the use of a neck brace and hand splints. The Director of Nursing confirmed the care plans were not updated to reflect the residents' current conditions.
A resident requiring 1:1 feeding assistance due to visual impairment and recent tube feeding discontinuation was left waiting for help with meals on multiple occasions. Observations showed meal trays untouched for extended periods, and the resident expressed hunger and dissatisfaction with cold food. The facility's policy for meal assistance was not followed, as staff failed to provide timely and continuous support.
A resident with a cervical spinal cord injury was not provided with hand splints as ordered, despite multiple observations of the splints being left on a dresser. The resident reported worsening mobility due to neglect, and staff members were unaware of the need for splints. The facility's policy on medical devices was not followed, resulting in a deficiency.
A facility failed to conduct an initial AIMS assessment for a resident prescribed Seroquel, an antipsychotic medication. The resident, diagnosed with Alzheimer's Disease and Brief Psychotic Disorder, required staff assistance with mobility and was unable to complete a mental status assessment. Despite the requirement for quarterly AIMS assessments for residents on antipsychotics, the facility did not perform this assessment. The DON confirmed the necessity of these assessments, and the facility did not provide a policy on antipsychotic use when requested.
A resident with impaired cognition and specific food dislikes was served a meal containing cucumbers, despite a dietary ticket indicating a dislike for them. The resident, who requires assistance with mobility and has a history of Cerebral Infarction and Dysphagia, reported that the kitchen staff often includes cucumbers despite their preference. The Dietary Manager acknowledged that staff should read and highlight tray tickets to ensure preferences are followed, as per facility policy.
A resident with Dementia and other mental health diagnoses did not receive recommended treatment following a hearing consultation. The consulting physician suggested medication to soften impacted ear wax and a follow-up visit, but these recommendations were not noted or executed. The responsible Social Worker acknowledged that the consult and recommendation were missed in the communication process.
A resident on anticoagulant medication experienced a fall with head trauma and was not promptly transferred to the hospital. Despite visible injuries and increased confusion, the facility opted for neuro checks instead of hospital transfer. The resident later had a seizure and was diagnosed with a traumatic subdural hematoma, leading to their death.
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 Ensure Timely Resident Care Due to Prolonged Call Light System Outage
Penalty
Summary
The facility failed to meet the timely care needs of six residents due to a prolonged outage of the call light system across multiple units. Residents reported that the call system had been nonfunctional for several weeks to months, and they were instead provided with small hand bells to request assistance. Several residents expressed that the hand bells were difficult to use, especially for those with physical limitations such as numbness in the hands or the need for bilateral wrist and hand splints. In some cases, residents were unable to locate their hand bells or could not bring them into the bathroom, leaving them unable to call for help when needed. Observations and interviews revealed that staff were often unable to hear or identify which resident was ringing a hand bell, leading to significant delays in response times. One resident reported waiting an hour and a half for assistance to use the restroom, while another was observed ringing their bell multiple times without staff response. Staff confirmed the difficulty in distinguishing the source of the bell sounds and noted that they had to physically check each room to determine who needed help. There was also a lack of specific training or program changes implemented to address the outage, and staff were not provided with formal guidance on how to monitor or assist residents during this period. Facility documentation showed ongoing issues with the call light system, including multiple units being affected and no clear timeline for repair. Review of policies indicated that the facility was required to provide accessible call lights and respond in a timely manner, but these standards were not met during the outage. Quality Assurance meeting agendas and education records did not reflect a formal action plan or targeted education regarding the outage, and invoices confirmed ongoing repair attempts without resolution.
Unsanitary Kitchenette Cabinet Due to Water Damage and Mold
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchenette located off the main dining room. On observation, the cabinet under the sink was found to have water-damaged doors, with the particle board swollen and warped from previous water exposure. The bottom shelf of the cabinet was wet, and a black, mold-like substance was present on the surface. The Administrator was unaware of the issue prior to the observation, and the Maintenance Supervisor indicated that the problem was seasonal, related to warmer weather and humidity. These findings were based on a complaint intake and direct observation, confirming the presence of unsanitary conditions in the kitchenette area. No information about specific residents or their medical conditions was provided in relation to this deficiency.
Failure to Promptly Assess and Notify Physician for Acute Change in Condition
Penalty
Summary
The facility failed to promptly identify, assess, and notify a physician regarding an acute change in condition for a resident, resulting in pain and hospitalization. The resident, who was admitted with acute posthemorrhagic anemia and gastrointestinal hemorrhage and had an intact cognitive status on admission, experienced several significant changes in condition, including a fall, confusion, dizziness, low oxygen saturation, and behavioral changes such as combativeness and self-injurious actions. Despite these changes, the facility's response included administering Haldol for new behaviors rather than immediately evaluating the underlying cause or notifying the physician in a timely manner. Documentation revealed that the resident had a foley catheter bag full of blood, experienced multiple falls, and displayed a marked change from their baseline mental status. Staff interviews indicated that these behaviors were not typical for the resident, and there was uncertainty about whether the physician or DON had been notified about the significant findings, such as the blood in the foley bag and the resident's confusion after falls. The facility's policy required notification of the physician and designated representative for significant changes in status, but this was not consistently followed, leading to a delay in appropriate medical evaluation and intervention.
Failure to Supervise Resident During Nebulizer Treatment
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, impaired cognition, and requiring staff assistance for bed mobility and transfers, was left unsupervised during a nebulizer treatment. The resident had complained of shortness of breath, and a nurse initiated a nebulizer treatment but left the room, returning ten minutes later to find the resident unresponsive with the face mask off. There was no documentation of a self-administration of medication assessment or care plan in the resident's medical record. Facility policy requires staff to remain with a resident during nebulizer treatments unless a self-medication assessment has determined the resident can safely self-administer. The Director of Nursing confirmed that staff are expected to stay with residents during such treatments or ensure someone else is present if they must leave. The lack of a completed self-administration assessment and the absence of supervision during the nebulizer treatment led to the deficiency.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices for three residents in isolation and precautions. For one resident, a nurse entered the room without donning the required personal protective equipment (PPE) despite clear signage indicating the need for gloves, mask, and gown. The nurse only wore gloves while disconnecting the resident's IV machine, which was against the facility's infection control expectations. This resident had impaired cognition and required assistance with mobility and transfers. Another resident's PPE caddy was consistently found to be inadequately stocked, lacking essential items such as gloves, gowns, and face masks. This resident required assistance for all activities of daily living, including catheter care. Additionally, a Licensed Practical Nurse (LPN) failed to perform hand hygiene and did not use PPE when entering a resident's room to check blood pressure and glucose levels. The LPN also did not clean the equipment after use, contrary to the stated cleaning protocol. The facility's equipment cleaning policy was requested but not provided by the end of the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for two residents and on three medication carts. For one resident, a medicine cup filled with a red liquid was found on their dresser, which the resident believed to be cough medicine. However, the Unit Nurse Manager identified it as a protein supplement and discarded it. The resident's medical record indicated they were moderately cognitively impaired and required maximum assistance for most activities of daily living. Another resident was found with bottles of Vitamin C and Vitamin B-12 on their nightstand, which they claimed to self-administer daily. The Director of Nursing confirmed that this resident had not been assessed for self-administration of medications, indicating a lapse in protocol. Additionally, during a review of medication carts, a partially dissolved narcotic tablet was found in a medicine cup, which had been spat out by a resident. The LPN explained they were waiting for a second nurse to dispose of it properly. Furthermore, several KwikPen Humalog insulin pens were found without labels or dates on two different medication carts. The facility's policy requires accurate labeling and dating of medications, which was not adhered to in these instances. The Director of Nursing confirmed that wasted narcotics should be disposed of immediately with the presence of two licensed nurses, a procedure that was not followed in this case.
Deficiency in Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were accessible to six residents, leading to a deficiency in call light accessibility. Observations revealed that residents' call lights were often out of reach or not easily locatable. For instance, one resident's call light was found on their wheelchair, out of reach, while another resident's call light was located in a shut dresser drawer, making it inaccessible. Additionally, a resident's call light was observed hanging underneath their bed, out of sight and reach. Interviews with residents and family members confirmed these observations, indicating that the issue was recurrent. The residents involved had various medical conditions, including cellulitis, heart failure, sepsis, paroxysmal atrial fibrillation, epilepsy, asthma, Alzheimer's disease, and anxiety. Their cognitive abilities ranged from moderately impaired to intact, with some residents requiring maximum assistance for activities of daily living. The facility's policy on call light accessibility, which mandates that call lights be within reach of residents, was not adhered to, as confirmed by interviews with staff, including a Licensed Practical Nurse and the Nursing Home Administrator.
Failure to Obtain Advance Directive Order Upon Admission
Penalty
Summary
The facility failed to obtain a physician's order for an advance directive upon admission for a resident with cerebral infarction and end-stage renal disease. The resident, identified as having impaired cognition with a Brief Interview for Mental Status score of 8/15, required staff assistance with bed mobility and transfers. Despite the facility's policy requiring the entry of a physician's order for code status upon admission, no such order was found in the resident's medical records. Interviews with facility staff revealed a breakdown in the process of entering advance directive orders. The social worker indicated that the admitting nurse is responsible for entering the code status order, which is then reviewed at the care conference. However, the Director of Nursing was unaware of why the order was not completed for this resident. The facility's policy specifies that a physician's order for Full Code status should be entered into the electronic health record system, but this was not done for the resident in question.
Failure to Complete Annual PASARR for Resident
Penalty
Summary
The facility failed to complete an annual Preadmission Screen and Resident Review (PASARR) for a resident reviewed for PASARR screening. The resident, identified as R121, was observed on March 3, 2025, and had been admitted with diagnoses including vascular dementia, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction, and dysphagia. The resident's medical record showed a Minimum Data Set (MDS) assessment with a Brief Interview for Mental Status (BIMS) score of 12, indicating mild cognitive impairment, and a Patient Health Questionnaire score of 9, indicating severe depression. The last PASARR was dated October 8, 2023, and during an interview on March 5, 2025, the social worker confirmed that an updated PASARR had not been completed, acknowledging that it should be updated annually. The facility did not provide a policy related to PASARRs by the end of the survey.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and updated for two residents, R51 and R89. For R51, the medical record indicated increased behaviors of refusal of care and assistance, such as refusing bathing and assistance weekly during February 2025. Despite these changes, the behavioral care plan initiated in July 2024 was not reviewed or updated to address these increased behaviors. Social Worker C confirmed that no updates were made to the care plan to address the recent behaviors. For R89, the care plan contained outdated and conflicting information. R89, who receives nutrition via tube feeding and is supposed to have hand splints applied, had a care plan that still included a neck brace, which was discontinued after a post-operative appointment in early February. The Therapy Director confirmed the neck brace should have been removed from the care plan, and there was confusion regarding the application of hand splints due to conflicting information. The Director of Nursing confirmed that R89's care plan was not updated to reflect the current condition, and a facility policy addressing care plans was not provided by the completion of the survey.
Failure to Provide Adequate Feeding Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance to a resident, identified as R142, who required 1:1 feeding assistance due to visual impairment and recent discontinuation of tube feeding. On multiple occasions, R142's meal trays were observed untouched for extended periods, indicating a lack of timely assistance. On March 3, 2025, R142's lunch tray remained untouched for over an hour, and the resident expressed hunger and the need for assistance. Physical Therapy staff noted the resident had not eaten, and R142 later reported that the food was cold by the time assistance was provided, resulting in minimal consumption. Further observations on March 5, 2025, revealed similar issues with breakfast, where R142 waited for assistance to finish their meal. Despite being identified as needing 1:1 feeding assistance, the resident was left waiting, and staff were not immediately responsive to their needs. The Director of Nursing acknowledged that staff should not leave trays unattended and should provide continuous assistance until the resident finishes eating. The facility's policy mandates that residents receive meal assistance according to their individual needs and care plans, which was not adhered to in this case.
Failure to Apply Hand Splints as Ordered
Penalty
Summary
The facility failed to apply hand splints as ordered for a resident, identified as R89, who was observed multiple times lying in bed with their arms folded and hands on their chest, while the prescribed hand splints remained on the dresser across the room. R89, who has an unspecified injury at the cervical spinal cord level and intact cognition, reported that they were supposed to wear the hand splints but that no one ever applied them. The resident expressed that their condition had worsened due to neglect, as they were initially able to move their arms and hands more than they can now. The physician's orders and care plan indicated that the hand splints were to be worn at night and removed in the morning, yet staff members, including an LPN and a CNA, were unaware of the resident's need for hand splints. The Therapy Director confirmed that the splints should be applied at night by nursing staff, as restorative aides are not present during that time. The Director of Nursing acknowledged that applying hand splints is a collaborative effort between nursing and therapy, but the facility's policy on accommodating residents with medical devices was not followed, leading to the deficiency.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to conduct an initial Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was prescribed an antipsychotic medication, Seroquel, once daily. The resident, who was admitted with diagnoses of Alzheimer's Disease and Brief Psychotic Disorder, was unable to complete a mental status assessment and required staff assistance with mobility. Despite the requirement for quarterly AIMS assessments for residents on antipsychotics, the facility did not perform this assessment for the resident. During an interview, the Director of Nursing acknowledged that nursing staff should complete AIMS assessments quarterly for residents on antipsychotics, regardless of psychiatric follow-up. Additionally, the facility failed to provide a policy related to antipsychotic use upon request by the surveyors.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as R142, who was reviewed for food preferences. On March 3, 2025, R142's lunch tray was observed with cucumbers in the side salad, despite a dietary ticket indicating a dislike for cucumbers, highlighted in pink. R142 expressed that they do not like cucumbers and that the kitchen staff often includes them despite their preference. R142 was admitted to the facility with diagnoses of Cerebral Infarction and Dysphagia and had an impaired cognition with a Brief Interview for Mental Status score of 10/15. The resident also required staff assistance with bed mobility and transfers. The Dietary Manager, DM Q, stated that dietary staff should read and highlight tray tickets to ensure preferences are seen, and floor staff should check trays before serving them to residents. The facility's policy on Food Preferences and Select Menus states that meals should accommodate resident allergies, intolerances, and food preferences.
Failure to Implement Consultant's Recommendations for a Resident
Penalty
Summary
The facility failed to ensure that a resident received the recommended treatment following an outside consultation. The resident, who was admitted with diagnoses including Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety, was evaluated by a consulting hearing service. The consulting physician was unable to remove impacted ear wax and recommended a medication to soften the wax, with a follow-up visit in 1-3 months. However, this order was not noted or carried out. An interview with the responsible Social Worker revealed that the process for communication involves the Social Worker receiving the completed consult/report, reviewing the documentation, and requesting appropriate orders from the physician or setting up a follow-up appointment. The Social Worker admitted that the consult and the recommendation were missed.
Failure to Ensure Timely Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to ensure a comprehensive nursing assessment and timely acute care emergent hospital transfer for a resident who sustained a fall with head trauma and bleeding while on anticoagulant medication. The resident, who had quadriplegia and atrial fibrillation, was found on the floor with a bruise on the right eyelid, a superficial scrape on the right forearm, and a skin tear. Despite these injuries and the resident's confusion, the decision was made to conduct neuro checks instead of transferring the resident to the hospital. The resident's medical record indicated that they were on Eliquis, a blood thinner, and had a history of moderate cognitive impairment. After the fall, the resident exhibited increased confusion, which was attributed to a urinary tract infection. The facility's staff, including a nurse practitioner, assessed the resident and decided against hospital transfer, despite the resident's unwitnessed fall and visible head injury. The facility's policy did not specifically address unwitnessed falls for residents on anticoagulant medication. Later, the resident experienced a seizure and was transferred to the hospital, where they were diagnosed with a traumatic subdural hematoma. The resident's condition deteriorated, leading to their death four days later. The facility's failure to promptly transfer the resident to a higher level of care after the fall and head injury, especially given the resident's anticoagulant use, was a significant deficiency in their care.
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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