South Haven Nursing And Rehabilitation Community
Inspection history, citations, penalties and survey trends for this long-term care facility in South Haven, Michigan.
- Location
- 850 Phillips, South Haven, Michigan 49090
- CMS Provider Number
- 235270
- Inspections on file
- 28
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 34
Citation history
Health deficiencies cited at South Haven Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
A resident with mental health diagnoses was prescribed PRN hydroxyzine for anxiety without a 14-day stop date, and no provider rationale was documented to justify use beyond this period. The DON confirmed that the required stop dates were not in place for the medication orders.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unnoticed, despite being identified as an elopement risk. Staff were aware of the resident's patterns, such as checking doors and expressing a desire to leave, but there was no individualized documentation or consistent monitoring of these behaviors prior to the incident. The resident was found walking along a busy road by a staff member and returned to the facility.
Two residents with severe cognitive impairment and a history of exit-seeking behaviors were not provided with individualized care plans. Instead, generic interventions were used, and specific behaviors such as fixation on cars and cigarettes were not addressed. One resident was able to leave the facility unsupervised, and staff interviews revealed a lack of documentation and monitoring for escalating behaviors, with care plans relying on non-individualized templates.
The facility lacks a full-time Registered Dietitian or Certified Dietary Manager to oversee nutritional services. The Dietary Supervisor, in the role for two years, is not yet certified but is taking classes. A dietitian visits only a couple of times a week, increasing the risk of food service sanitation failures and inadequate assessment of high-risk residents.
A long-term care facility was found to have multiple deficiencies in food safety and sanitation during a survey. The kitchen had issues with unlabeled and undated food items, dirty equipment, and improper storage practices. The walk-in cooler and dry storage areas contained items without proper labeling, and the kitchen equipment was not maintained in a clean condition. Additionally, the refrigeration unit in the resident area was at an unsafe temperature, posing a risk of foodborne illness.
The facility failed to maintain an effective water management plan and infection control program. The Maintenance Director was unsure of control measures beyond routine flushing and had not conducted water testing. The Infection Preventionist missed resident vaccinations, lacked a tracking process, and failed to ensure staff training on infection control. The infection control log was incomplete, and there was no clear responsibility for infection monitoring, indicating deficiencies in both programs.
A facility failed to implement an antibiotic stewardship program and monitor antibiotic use for a resident. The Infection Preventionist (IP) did not assess antibiotic use according to Mcgeer's criteria and lacked documentation on antibiotic indications, dosages, or durations. The IP also did not follow up on outcomes or provide feedback on antibiotic use, relying on nursing staff documentation. The Director of Nursing (DON) did not oversee the stewardship program, leaving all responsibilities to the IP, resulting in potential inappropriate antibiotic use and resistance.
The facility failed to maintain cleanliness and repair, affecting resident rooms and common areas. Observations revealed dust and debris in rooms, stained ceiling tiles, and disrepair in utility spaces. Residents with chronic obstructive pulmonary disease were exposed to dusty fans, and one resident had to clean her own bathroom due to dissatisfaction with housekeeping. Damaged and dirty wheelchairs were also noted, with inconsistencies in cleaning schedules and maintenance awareness.
A resident with cognitive impairment and physical limitations was repeatedly found with the call light out of reach, preventing them from calling for assistance. Despite the care plan's directive to keep the call light accessible, observations showed it was often on the floor or under the bed.
A facility failed to create a comprehensive care plan for a resident on Eliquis, an anticoagulant prescribed for deep vein thrombosis. Despite the resident's diagnoses of congestive heart failure and hypertension, no care plan was in place to address the potential side effects of the medication. The MDS Coordinator and DON both acknowledged the oversight, emphasizing the importance of care plans for high-risk medications.
A facility failed to implement care plan interventions for a resident with muscle contracture, as the resident was observed not wearing prescribed splints on multiple occasions. Despite occupational therapy recommendations and care plan documentation, staff interviews revealed a lack of awareness and adherence to the care plan, leading to the potential for worsening contractures.
A resident with dementia and a history of falls experienced a fall resulting in facial injuries due to inadequate supervision and failure to implement safety interventions. The resident, who self-ambulated in a wheelchair, fell near a chapel ramp without caution signs, despite this being part of her care plan. Observations showed the resident was often left unattended, and staff admitted to not applying necessary safety measures.
A facility failed to attempt a required Gradual Dose Reduction (GDR) for a resident's antidepressant and antipsychotic medications, potentially leading to unnecessary dosing. The resident, with a diagnosis of unspecified mood affective disorder, was prescribed Olanzapine and Sertaline. Despite the care plan indicating a need for dose reduction, there was no documentation of GDR attempts or justification for not attempting one. Interviews revealed a lack of awareness and documentation regarding GDR attempts, with reliance on a local mental health provider without evidence of collaboration or follow-up visits.
A resident with diabetes received an incorrect dose of insulin due to a new nurse's error, leading to a significant drop in blood sugar levels. The nurse, who was still in orientation, administered 32 units of short-acting insulin instead of the prescribed doses, causing the resident to experience severe symptoms and miss a dialysis appointment. The error was reported and investigated by the facility's staff.
A facility failed to administer a pneumococcal vaccine to a resident with chronic obstructive pulmonary disease, despite consent from the guardian and the resident being due for the vaccine. The Infection Preventionist acknowledged the oversight, citing staff turnover and a backlog in the vaccine program as contributing factors.
A facility failed to offer a COVID-19 vaccination to a resident with chronic obstructive pulmonary disease, as there was no record of vaccination in their Electronic Health Record. The Infection Preventionist admitted to not screening or offering the vaccine to the resident and lacked a systematic approach to ensure staff were educated and offered the vaccine, relying only on posted signs during clinics.
The facility failed to ensure timely care and services for three residents, resulting in long call light wait times, cluttered rooms, and potential feelings of diminished self-worth. One resident reported waiting up to two hours for assistance, while another's family member noted frequent delays and clutter. A third resident in extreme pain also experienced delays in receiving care.
A resident with cognitive impairments reported being punched by a CNA after using racial slurs. The facility's investigation revealed inconsistencies in staff and resident accounts, and the incident was not adequately documented. The deficiency highlights a lapse in protecting the resident from potential abuse and the need for improved adherence to abuse prevention policies.
The facility failed to ensure physician orders for scheduled pain medications were in place and did not accurately document the administration of controlled medications for a resident with terminal cancer. This resulted in inadequate pain management and potential drug diversion.
The facility failed to maintain safe infection control practices for a resident on Enhanced Barrier Precautions due to chronic wounds and a Foley catheter. Staff were observed handling the resident's catheter bag and transferring the resident without wearing the required PPE, and there was a lack of hand hygiene and PPE availability, leading to potential cross-contamination.
Failure to Limit PRN Psychotropic Medication to 14 Days Without Provider Rationale
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medications for a resident included a stop date not exceeding 14 days, as required. A male resident with diagnoses of schizoaffective disorder, bipolar disorder, and anxiety disorder was prescribed hydroxyzine, an antihistamine also used for anxiety, on a PRN basis. The medication orders were written with start and discontinue dates that exceeded the 14-day limit for PRN psychotropic medications, and there was no documentation of a provider rationale to justify extending the use beyond this period. During an interview, the Director of Nursing (DON) confirmed that PRN psychotropic medications should be limited to 14 days unless a provider documents a rationale for extension. Review of the resident's orders showed that the required 14-day stop dates were not implemented for both instances of the hydroxyzine prescription, and no provider rationale for the extended use was provided by the time of the survey exit.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure the safety and prevent the elopement of a resident who was assessed as being at risk for elopement. The resident, who had diagnoses including unspecified dementia, unspecified mood disorder, unsteadiness on feet, and required assistance with personal care, was severely cognitively impaired as indicated by a BIMS score of 3/15. Despite being identified as an elopement risk and having a care plan that included interventions such as alarms and monitoring, the resident was able to leave the facility premises unnoticed by staff. The resident was last seen by staff approximately 15 minutes before being found outside the facility, walking along a road without a sidewalk, by a staff member who happened to be driving by. Multiple staff interviews revealed that the resident had a known pattern of exit-seeking behaviors, including frequently checking doors, setting off alarms, and expressing a desire to leave the facility for cigarettes or to see white cars. Staff also reported that the resident's behaviors would escalate, but there was no documentation or consistent monitoring of these behaviors in the resident's medical record prior to the elopement event. Although the facility had a blanket behavior monitoring order for all residents, it was not individualized or specific to the resident's known behaviors. Communication about the resident's increased exit-seeking behaviors was primarily verbal and not consistently documented or shared with all staff. There was no evidence of behavior logs or specific interventions being implemented or documented in response to the resident's escalating behaviors prior to the incident, which contributed to the failure to prevent the elopement.
Failure to Individualize Care Plans for Residents at Risk of Elopement
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans for two residents with severe cognitive impairment and a history of exit-seeking behaviors. For one male resident with dementia and a BIMS score indicating severe cognitive impairment, the care plan included generic interventions such as door alarms, quarterly elopement assessments, and offering distractions. However, the care plan did not address the resident's specific behaviors, such as his fixation on white cars and cigarettes, or his pattern of looking out windows and attempting to exit the building. Multiple staff interviews confirmed that the resident routinely checked doors, set off alarms, and expressed a desire to leave the facility for cigarettes or to return home, but these behaviors were not specifically documented or communicated in his care plan. On one occasion, this resident was able to leave the facility unsupervised and was found walking alone along a road by a staff member, who then returned him to the facility. Staff interviews revealed that while staff were aware of the resident's exit-seeking tendencies and specific interests, such as white cars and cigarettes, this information was not consistently documented or included in the care plan. The Director of Nursing and other staff acknowledged that care plans were not individualized and that there was no system in place to monitor or document escalating behaviors that could lead to elopement. A second female resident with dementia and severe cognitive impairment was also identified as an elopement risk, with a history of looking for family and attempting to leave the facility. Her care plan similarly relied on template interventions and did not include specific, individualized strategies to address her behaviors. Staff interviews indicated a lack of awareness and monitoring for elopement risk, and the care plan was not customized to reflect the resident's unique needs or patterns of behavior. The facility's practice of using pre-selected, non-individualized care plan templates contributed to the failure to adequately address and manage the elopement risks for both residents.
Lack of Full-Time Dietitian or Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to oversee kitchen and clinical nutritional services. During a kitchen tour, the Dietary Supervisor (DS) revealed that the facility only has a dietitian who visits a couple of times a week. The DS, who has been in the role for about two years, is not yet a Certified Dietary Manager but is currently taking classes to become one. She mentioned that it has been challenging to fit the classes into her schedule, and she is seeking an extension to complete them. This deficiency increases the potential for food service sanitation failures, foodborne illness, or inadequate assessment of high-risk residents among all residents.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as observed during a kitchen tour. The kitchen was found to have multiple areas of concern, including a dishwasher area with spilled powdered detergent and discoloration from dripping water. The dish area had a leaking three-compartment sink with a container to catch leaks, and a bucket of liquid detergent covered with dirt and debris. The kitchen prep area had clean utensil drawers with crumbs and debris, cracked spatulas, and equipment with excess buildup and dried food debris. The walk-in cooler contained several items without labeling or dating, such as raw onion, butter, creamed corn, and various other food items. The dry storage area also had unlabeled and undated items, including dry cereal, quick oats, and various mixes. The facility's failure to properly label and date food items, as well as maintain cleanliness and organization in storage areas, poses a risk of foodborne illness among residents. Additionally, the facility's equipment and surfaces were not maintained in a clean and sanitary condition. The can opener, microwave, and ice machine area had significant dirt and debris accumulation. The dish machine area had a cross-connection that could contaminate the potable water supply, and the refrigeration unit in the Bunny Patch resident area was found to be at an unsafe temperature. These deficiencies indicate a lack of adherence to the 2017 FDA Food Code, which outlines necessary standards for food safety and equipment maintenance.
Deficiencies in Water Management and Infection Control Programs
Penalty
Summary
The facility failed to maintain an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During an interview, the Maintenance Director was unable to specify control measures beyond routine flushing of domestic fixtures and admitted to not conducting water testing due to waiting on a tester. Additionally, the water line in the family room was not being flushed. The Water Management Plan had not been reviewed with the administrator, and the facility's Water Pathogen Risk Reduction document lacked a date, indicating a lack of comprehensive implementation and documentation. The facility's infection control program was found to be ineffective, as the Infection Preventionist (IP) reported missing resident vaccinations and lacking a thorough tracking process. The IP was unable to confirm staff training on cleaning and disinfecting reusable medical equipment and environmental cleaning. The IP also failed to provide examples of infection control education for staff and could not explain how infection control audits were conducted or tracked. The facility's infection control policies and procedures were not regularly reviewed or updated, and there was no clear process for tracking employee illness or early detection of potential infectious residents. The IP's infection control log for September 2024 was incomplete, only tracking residents prescribed antibiotics, and lacked detailed information on symptoms, diagnosis, and monitoring. The IP relied on nursing staff for infection monitoring and did not ensure all staff received necessary education. The Director of Nursing (DON) reported that the IP was responsible for the infection control program, but the IP was still being assisted by the DON, indicating a lack of clear responsibility and oversight in the infection control program.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and operationalize an antibiotic stewardship program, as well as to monitor the appropriate use of antibiotics for a resident. The deficiency was identified during a review of the records and an interview with the Infection Preventionist (IP) C, who was responsible for ensuring that Mcgeer's criteria were used when prescribing antibiotics. However, IP C admitted to missing the assessment of antibiotic use for a resident who had been on antibiotics in September 2024. Furthermore, IP C was unable to provide a list of residents on antibiotics or documentation regarding the indication, dosage, or duration of antibiotic use. Additionally, IP C did not follow up on the outcomes of residents prescribed antibiotics, relying instead on nursing staff documentation. There was no established process for providing feedback on antibiotic use, resistance patterns, or prescribing practices. IP C, being new to the position, was still receiving assistance from the Director of Nursing (DON) B, who reported not overseeing or monitoring the facility's antibiotic stewardship, leaving all responsibilities to IP C. This lack of oversight and documentation resulted in the potential for inappropriate antibiotic utilization and resistance.
Facility Fails to Maintain Cleanliness and Repair
Penalty
Summary
The facility failed to maintain cleanliness and repair in several areas, affecting both resident rooms and common utility spaces. Observations revealed dust and debris accumulation in resident rooms, with specific issues such as stained ceiling tiles indicating possible roof leaks. Shared bathrooms were found with dirt accumulations, and utility rooms had cabinets in disrepair, making them difficult to clean. Additionally, a janitor's closet had a leaking hot water valve and an unlabeled spray bottle, while the central supply room was missing a light shield. Residents were directly impacted by these deficiencies. For instance, two residents with chronic obstructive pulmonary disease were exposed to dusty fans blowing directly towards them, which were not cleaned regularly as per the facility's protocol. Another resident expressed concerns about the cleanliness of her shared bathroom, which was often found with feces on the floor and toilet, despite being cleaned by housekeeping. The resident resorted to cleaning the bathroom herself due to dissatisfaction with the facility's cleaning efforts. Further issues included damaged and dirty wheelchairs, with exposed foam on arm covers and dirt on the wheels and frames. Housekeeping and maintenance staff interviews revealed inconsistencies in cleaning schedules and a lack of awareness about certain deficiencies, such as missing window screens and cracked walls. These observations highlight a systemic issue in maintaining a clean and safe environment for residents, staff, and visitors.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, resulting in the inability to call for staff assistance. The resident, who was moderately cognitively impaired with a history of cerebrovascular accident and left-sided weakness, was observed multiple times with the call light out of reach. On one occasion, the call light was on the floor, and on another, it was under the bed, both times making it inaccessible to the resident. The resident reported using the call light to request help but sometimes could not find it. A Certified Nursing Assistant confirmed that the resident used the call light to ask for assistance. Despite the care plan specifying that the call light should be within reach, observations over several days showed that this was not consistently ensured, leading to potential unmet care needs.
Failure to Implement Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed an anticoagulant medication, Eliquis, for a history of deep vein thrombosis. The resident, a female with diagnoses of congestive heart failure and hypertension, did not have a care plan that addressed her anticoagulant therapy, which is crucial due to the potential side effects such as heavy bruising. The MDS Coordinator, responsible for creating care plans for high-risk medications, acknowledged the absence of a care plan for the resident's anticoagulant therapy during an interview and record review. The Director of Nursing also confirmed that care plans should be in place for high-risk medications to ensure staff are aware of and monitor potential side effects.
Failure to Implement Care Plan for Contracture Prevention
Penalty
Summary
The facility failed to implement care plan interventions to prevent the worsening of contractures for a resident with a diagnosis of muscle contracture. The resident was admitted with pertinent diagnoses, including contracture of muscles, and had been discharged from occupational therapy with specific recommendations for wearing a right hand T bar splint and a left upper extremity hand roll or gauze during the day as tolerated. These recommendations were documented in the resident's care plan, which specified the use of these assistive devices during morning care and their removal at lunch or as tolerated. Observations on multiple occasions revealed that the resident was not wearing the prescribed splints on the right hand, left hand, or elbow while sitting in a wheelchair in the dining room or lying in bed. Interviews with facility staff, including a Physical Therapy Assistant and a Certified Nursing Assistant, confirmed that the expectation was for the CNAs to place the splints on the resident during morning care. However, the CNA reported being unaware of the requirement for the resident to wear the splints during the day, indicating a lapse in communication or adherence to the care plan, leading to the potential for worsening of the resident's contractures.
Failure to Implement Safety Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and implement necessary safety interventions for a resident, identified as R15, who was at high risk for falls due to cognitive impairment and a history of falls. R15, who had dementia and was able to self-ambulate in a wheelchair, experienced a fall resulting in facial bruising and a laceration that required sutures. The fall occurred when R15 was self-ambulating near the chapel, an area with a ramp that posed a hazard, and there were no yellow caution signs or strips in place to warn of the descent, despite this being an intervention listed in the resident's care plan. The resident's care plan, which identified her as at risk for falls due to dementia, altered mental status, and limited mobility, included interventions such as keeping her in high traffic areas and applying yellow caution strips at the start of the ramp to the chapel. However, these interventions were not consistently implemented. Observations revealed that R15 was often left unattended in her wheelchair, both in the dining room and near the nursing station, where she attempted to self-ambulate, leading to her legs becoming tangled in the wheelchair's foot pedals. Interviews with staff and family members highlighted concerns about the lack of supervision and the failure to implement safety measures. Family members questioned why R15 was left unsupervised, and staff acknowledged that the resident was known to self-ambulate throughout the facility. The Director of Nursing admitted that the yellow caution strips were never applied, despite being part of the care plan, and the resident continued to be at risk for falls due to inadequate supervision and environmental hazards.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a required Gradual Dose Reduction (GDR) of antidepressant and antipsychotic medications for a resident, resulting in the potential that the resident was receiving the medication at an unnecessary dose or for an unnecessary length of time. The resident was admitted with diagnoses including unspecified mood affective disorder and was prescribed Olanzapine and Sertaline. The care plan indicated a need for dose reduction, but there was no documentation of any attempts for GDRs or justification for not attempting a GDR since October 2023. Interviews with the Director of Nursing (DON) and the Social Worker (SW) revealed a lack of awareness and documentation regarding the resident's GDR attempts. The DON could not report the last GDR attempt or any clinical indication for not attempting a GDR. The SW indicated reliance on a local mental health provider for managing the resident's psychotropic medications, but there was no evidence of collaboration or follow-up visits for nearly a year. The facility was unable to provide documentation justifying the absence of GDR attempts prior to the survey exit.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. A resident, who was cognitively intact and had a diagnosis of diabetes, reported receiving an incorrect dose of insulin. The error occurred when a new nurse, who was still in her orientation period, administered 32 units of short-acting insulin instead of the prescribed 2 units of short-acting and 30 units of long-acting insulin. This mistake was attributed to the nurse being nervous and in a rush, leading her to not verify the correct type of insulin before administration. As a result of the medication error, the resident experienced a significant drop in blood sugar levels, leading to symptoms such as fatigue, inability to keep her eyes open, and verbal non-responsiveness. The resident's blood sugar dropped to 54, prompting immediate intervention with carbohydrates and milk to stabilize her condition. The error also caused the resident to miss a dialysis appointment. The incident was reported by the physical therapist and investigated by the Director of Nursing, who confirmed the error and provided education to the nurse involved.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility to receive pneumococcal vaccinations, specifically for one resident among those reviewed. Resident #22, who was admitted with chronic obstructive pulmonary disease, had a consent form signed by their guardian indicating a willingness to receive the pneumococcal vaccine, provided it had been more than three years since the last dose. The Michigan Care Improvement Registry showed that Resident #22 was due for a pneumococcal vaccine on 9/7/22, but this was not administered. During an interview, the Infection Preventionist (IP C) confirmed responsibility for screening and administering vaccines and acknowledged that Resident #22 was due for an updated pneumococcal vaccine. However, IP C could not explain why the vaccine had not been administered, attributing the oversight to the facility's vaccine program being behind schedule due to staff turnover and her recent assumption of the IP position in March 2024. This lapse resulted in the potential risk of acquiring or transmitting pneumococcal pneumonia.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered to a resident, leading to a deficiency in their vaccination protocol. Resident #51, who was admitted with chronic obstructive pulmonary disease, did not have any record of receiving a COVID-19 vaccination in their Electronic Health Record. Although a Vaccine Consent Form indicated that the resident had previously received a COVID-19 vaccination, it did not specify if additional doses were desired. During an interview, the Infection Preventionist (IP) admitted to not having offered the COVID-19 vaccine to Resident #51 and acknowledged a lapse in tracking and offering vaccinations to both residents and staff. The IP also reported that there was no systematic approach to ensure staff were screened, educated, and offered the vaccine annually, relying instead on posting signs during clinics without further follow-up.
Failure to Ensure Timely Care and Services
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity for three residents, resulting in long call light wait times, cluttered rooms, and potential feelings of diminished self-worth, sadness, and frustration. Resident #200, who was cognitively intact, reported waiting up to two hours for assistance with repositioning and an hour for help with changing and getting ready for bed. The Director of Nursing and Unit Manager were unaware of any staffing issues that could explain the delays, and the facility lacked a specific policy or timeframe for responding to call lights. Resident #201's family member reported that the resident often had to wait up to an hour for call lights to be answered and was frequently found lying in bed with food on him and in a soiled brief. The room was observed to be cluttered with various items. Resident #202, who was in extreme pain from terminal cancer, also experienced delays in receiving pain medication and toileting assistance, with staff appearing bothered when asked for help. Observations of the nurses' station revealed outdated and incomplete information on a dry erase board, further indicating a lack of attention to detail and resident care needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. Resident #201, who was moderately cognitively impaired and had a history of stroke, weakness, depression, anxiety, and dementia, reported being punched by a CNA. The incident was initially reported by a hospice worker who observed a bruise on the resident's right upper arm. The facility's Director of Nursing (DON) confirmed the presence of the bruise but did not document it with measurements or photographs. The resident admitted to using racial slurs towards the CNA, which led to the alleged physical altercation. Multiple staff members, including the CNA involved, reported that the resident had been combative during care, but other staff and family members noted that the resident was typically pleasant and non-combative. The facility's investigation included interviews with the resident, staff, and family members, but there were inconsistencies in the accounts of the resident's behavior and the events leading to the bruise. The facility's abuse prevention policy explicitly states that striking a combative resident is not an appropriate response, yet the investigation did not conclusively determine whether the CNA's actions constituted abuse. The care plan for the resident was updated after the incident to address his behavioral symptoms, including negative racial statements and combativeness during care. However, the facility's failure to adequately document and investigate the incident, as well as the conflicting reports from staff and the resident, indicate a deficiency in protecting the resident from potential abuse. The facility's policy on abuse prevention emphasizes the importance of professional behavior and the safety and well-being of residents, but the handling of this incident suggests a lapse in adherence to these standards. The deficiency highlights the need for more thorough documentation and consistent application of abuse prevention protocols to ensure resident safety. The facility's response to the incident, including the lack of immediate documentation and the delayed care plan update, underscores the importance of timely and accurate reporting in abuse investigations. The conflicting accounts from staff and the resident further complicate the investigation, making it difficult to determine the exact nature of the incident and whether the resident's rights were adequately protected. The facility's failure to protect the resident from potential abuse and the inconsistencies in the investigation process indicate a need for improved training and adherence to abuse prevention policies. The incident underscores the importance of maintaining a safe and respectful environment for all residents, particularly those with cognitive impairments and behavioral challenges. The facility must take steps to ensure that all staff are trained in appropriate responses to combative behavior and that incidents of potential abuse are thoroughly documented and investigated. The deficiency in this case highlights the need for ongoing monitoring and quality improvement efforts to protect residents from harm and uphold their rights to a safe and dignified living environment.
Failure to Implement Physician Orders and Document Controlled Medications
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not ensuring physician orders were in place for scheduled pain medications and not accurately documenting the administration of controlled medications for a resident with terminal cancer. The resident, who was in extreme pain, had a physician's order to change his narcotic pain medication from PRN (as needed) to a scheduled dose. However, this change was not implemented until days later, resulting in the resident receiving inadequate pain management during his stay at the facility. The resident's family member reported that the call light for pain medication often went unanswered, and the resident was eventually transferred to a hospital where he passed away shortly after. The Director of Nursing (DON) confirmed that new orders should go into effect immediately and acknowledged past issues with the physician responsible for the resident's care. Additionally, the controlled substance sign-out sheets revealed that the resident received multiple doses of pain medication that were not recorded in the Medication Administration Record (MAR), indicating a failure in proper documentation and potential drug diversion. Interviews with the facility staff, including the DON, Unit Manager (UM), and Assistant Director of Nursing (ADON), revealed confusion and lack of documentation regarding the resident's pain medication orders. The ADON could not recall why the medication order was changed days after the physician's visit, and the DON confirmed that the doses of pain medication administered were not recorded in the MAR. This lack of accurate documentation and timely implementation of physician orders led to the resident experiencing unmanaged pain and highlighted significant deficiencies in the facility's medication management and documentation practices.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to maintain safe infection control practices for Resident #200, who was on Enhanced Barrier Precautions (EBP) due to chronic macerated wounds and a Foley catheter. During an observation, a CNA and an LPN were seen handling the resident's catheter bag and transferring the resident without wearing the required PPE, such as gowns and goggles. Additionally, the CNA did not perform hand hygiene after removing gloves, and there was no PPE cart in sight. The resident had multiple superficial open wounds on his thighs that were not adequately covered by dressings, and the staff continued to handle the resident and his equipment without changing gloves or donning additional PPE, even when the resident had a bowel movement and required assistance with a bedpan. Interviews with staff revealed a lack of awareness and adherence to the EBP requirements. One CNA was unaware of the reason for the EBP and noted that gowns were not available in the resident's room. The Director of Nursing confirmed that staff should wear gowns, gloves, and goggles when providing direct care to Resident #200, especially when managing his catheter bag. The failure to follow proper infection control protocols resulted in the potential for cross-contamination and the spread of multi-drug resistant bacteria.
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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