Springcreek Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Adrian, Michigan.
- Location
- 130 Sand Creek Highway, Adrian, Michigan 49221
- CMS Provider Number
- 235504
- Inspections on file
- 25
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Springcreek Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
QAPI Program Lacked Tracking, Trending, and Systematic Review: The NHA stated that the QAPI committee had identified concerns such as return to hospital, weight loss, falls, and dietary menus, and that staff, residents, the grievance project, and resident council could bring items forward. However, the NHA could not explain how concerns were monitored, tracked, or trended on a regular basis, and could not provide documentation that the odor on A hall had been reviewed as a QAPI project. The NHA said it had not been a project and then stated it should have been; only falls and dietary menus were identified as issues seen in both QAPI and the annual survey.
Resident Council members repeatedly raised concerns about food quality, cold and late meals, missing menus, and inaccurate trays, but the same issues were signed off month after month without documented resolution. The NHA approved the grievance responses, while the Dietary Mgr said she was aware of the concerns and was trying to address them, yet the only records provided were food temp audits and there was no documentation of audits for tray accuracy, menu issues, or honoring resident food preferences.
Resident Council members were not informed of their right to file grievances or where to obtain grievance forms. During a Resident Council meeting, all participants reported ongoing concerns about food, noise, late meds, and call light response times, and none knew filing a grievance was an option. Minutes from prior Resident Council meetings did not show review of resident rights or the grievance policy, and the Activity Director stated she thought she had mentioned it in earlier meetings, but no documentation was provided.
A facility failed to ensure 7 of 7 Resident Council members had their food and drink preferences honored on a daily basis. Meeting minutes showed repeated complaints that preferences were not being met, and during a State Agency meeting all 7 participants said the issue was long-standing and unresolved. Residents reported frustration that basic requests, such as orange juice at breakfast, were not honored, while the Dietary Mgr stated there were no audits for tray accuracy or preference compliance and could not explain the effectiveness of the buddy system or the root cause.
Surveyors found that multiple dependent residents did not receive consistent bathing, hair washing, shaving, or oral hygiene as required by their care plans and ADL needs. One resident with COPD, dementia, and a colostomy went at least 30 days without a documented shower or hair wash and was repeatedly observed with long chin hair despite stating she preferred it shaved. Another hospice resident’s showers and baths were provided only by hospice staff, with no evidence that facility CNAs delivered or documented any bathing during the review period, and hospice documentation was not incorporated into the facility record. A third resident with hemiplegia and major depression was observed with heavy facial hair and plaque on her teeth, reported concerns about shared razors, and had an unused personal electric shaver at bedside, while shower sheets showed no showers or bed baths in 30 days and only two documented refusals without evidence of re-approach or nurse notification.
Inaccurate code status documentation was found for a resident with acute and chronic respiratory failure and CHF. The resident was cognitively intact, stated he did not want CPR, and had an advance directive signed by the resident and physician indicating DNR, but the physician orders and MAR listed the resident as full code. An LPN stated the MAR would be the first place to verify code status during a code.
A room shared by two residents had an overpowering urine odor that could be smelled from down the hallway. One resident with a foley catheter was observed draining urine into a urinal, spilling urine onto a towel and likely the floor, while staff said he often disconnected the catheter and kept using the same towel. Staff also reported urine on the bed table, furniture, and flooring, and the roommate was unable to report the odor.
A resident with vascular dementia, severe cognitive impairment, and repeated falls experienced a decline in condition after a hip fracture and worsening ADL function. The record showed the resident had multiple falls, recent illness and weakness, and was sent to the hospital where a hip fracture and UTI were identified. The MDS was completed past the required 14-day timeframe, and the MDS LPN confirmed it was late.
A facility failed to revise care plans and related tasking for residents with changed needs. One resident’s shower schedule was not updated after a room change, another resident on hospice had no hospice certification, care plan, medication list, or visit calendar in the binder or EMR, and a third resident’s care plan did not align with her facial shaving needs and shower refusals. Staff interviews and record review showed missed or inconsistent documentation for bathing, shaving, and hospice coordination.
A resident with incomplete paraplegia, chronic pain, and a stage 3 sacral pressure ulcer lost upper-extremity mobility while in the facility. Staff did not provide ROM as expected, repositioning was not done every 2 hours as care planned, and the resident reported that care often consisted only of brief changes. The resident also reported pain during wound care and repositioning, and the scheduled opioid dose was given after morning wound treatment.
A resident with a tracheostomy, dysphagia, chronic respiratory failure, and other serious diagnoses received improper trach care when an LPN suctioned using nonsterile technique, touched sterile equipment to the bed, and changed the inner cannula and trach ties without changing gloves or washing hands. The resident’s trach ties were soiled, the oxygen collar and tubing were not dated, and the ordered weekly change of trach tubing, mask, suction canister, and ties was not documented as completed as scheduled; the DON confirmed sterile technique was required.
Expired medications were found in two medication carts, including an Allergy Relief 24 hr. tablet past expiration and Naproxen Sodium and Cetirizine HCl products with removed or wiped-off expiration dates. No outdated meds were found in the nurses' station med room, and the DON stated nurses are expected to check expiration dates and discard expired meds.
Menu Not Served as Posted: The facility did not serve the posted menu as planned and did not consistently inform residents in advance of menu changes. During tray line observation, the posted entrée was roast beef, but six residents who had ordered it were served burgers after the kitchen ran out of roast beef. The KM confirmed the shortage, and the NHA stated meals were expected to be served as posted and according to resident preference.
Delayed Meal Delivery and Unappetizing Breakfast Service: Staff left a full tray cart on the secure memory unit while residents were unattended in the dining area. A resident received breakfast about 45 minutes after the tray arrived, and another resident was not served the first bite until nearly an hour later. Staff were observed struggling to cut toast and serving oatmeal with a solid top layer, and CNAs reported the resident did not eat well that morning.
Arbitration Agreement Missing Required Resident Rights Language: A resident with multiple diagnoses, including dementia, COPD, and dysphagia, had an arbitration agreement that did not state that signing was not a condition of admission or continued care, and did not state that the resident could communicate with federal, state, or local officials, including surveyors and the State Long Term Care Ombudsman. The AD confirmed the omissions after the agreement was reviewed during the survey process.
Arbitration Agreement Lacked Neutral Arbitrator Provision: A resident with multiple chronic conditions, including dementia, COPD, dysphagia, and HTN, had an arbitration agreement that did not explicitly state that a neutral arbitrator would be selected by both parties. During survey review, the resident could explain the purpose of the agreement but could not explain why it was resigned, and the AD confirmed the original agreement did not meet the required terms.
A resident with Huntington's disease, dementia, malnutrition, weakness, and repeated falls was on hospice and had moderate cognitive impairment with dependence for multiple ADLs. The hospice binder and EMR lacked the certification, care plan, med list, and visit schedule, and staff gave inconsistent accounts of where the required hospice records were kept. Facility CNAs did not provide showers or baths during the last 30 days, and all documented bathing was done by hospice CNAs, with no facility documentation explaining the missed care.
Hand hygiene and glove changes were not consistently performed during medication administration and dressing changes. An LPN was observed preparing and giving meds without hand hygiene before or after entering a resident’s room, and during wound care an RN did not change gloves between dirty and clean steps while changing a resident’s wound dressing. Another resident with serious surgical and wound-related diagnoses also had a dressing change observed, and the DON stated the expected process included hand hygiene and glove changes between removal of soiled dressings and application of clean dressings.
A resident with severe cognitive impairment, multiple comorbidities, and a history of falls had a care plan that included fall-prevention interventions such as non-skid strips at the bedside and an edge defined perimeter mattress. During observation, the resident’s wheelchair had safety features in place, but the bed was in a low position with a standard mattress, no elevated sides, and no non-skid strips at the bedside. The DON reported that the resident had a room change and that the ordered fall-prevention interventions were not transferred to the new room, despite the expectation that Unit Managers ensure all care plan interventions are in place after room changes.
A resident with multiple chronic conditions, including diabetes, rheumatoid arthritis, and osteoporosis, did not receive several ordered medications as scheduled, and the physician was not notified of the omissions. The MAR showed missed doses of weekly Alendronate, daily Arava, daily Liraglutide, and one dose of TID Cyclobenzaprine, with progress notes documenting entries such as “n/a” or “on order” and one note stating Liraglutide was “not given due to wrong order,” but without evidence of physician contact. The prescribing physician later clarified that Liraglutide should have been titrated starting at 0.6 mg daily, while the DON explained that late admissions can delay pharmacy delivery, that unavailable medications should prompt physician notification and documentation, and that Liraglutide was a pharmacy interchange for Ozempic.
Two residents with significant risk factors developed pressure ulcers due to insufficient preventive interventions and lack of timely root cause analysis. In both cases, only minimal measures were in place before the ulcers appeared, and care plans were not adequately updated to address the residents' needs. Wound care was provided after the ulcers were identified, but preventive actions were lacking.
A resident with severe cognitive impairment and dementia exhibited violent behaviors not adequately addressed in their Care Plan. Staff used various non-pharmacological interventions, such as music and activities, but these were not documented in the Care Plan, indicating a failure to update it based on the resident's needs.
A resident with nephrostomy tubes did not receive timely and appropriate care due to delayed implementation of physician orders. Observations showed improper positioning of the nephrostomy bag and a soiled dressing with discharge. The DON confirmed that care orders were not in place upon admission, leading to a deficiency in the resident's treatment.
A resident with dementia and a history of falls experienced repeated falls due to inadequate interventions. Despite being drowsy from Ativan, the resident was left to transfer independently without sufficient fall prevention measures, such as non-skid strips near the bed. Staff acknowledged the resident's reluctance to accept help, but the facility's monitoring and care plan adjustments were insufficient to prevent further incidents.
A facility failed to ensure water was accessible for a resident with Alzheimer's and Dementia, leading to potential inadequate fluid intake. Observations showed the water cup was out of reach, despite the resident's expressed preference for water. Staff interviews revealed water is often kept out of sight to prevent other residents from taking it, but it should be within reach when the resident is present. The DON acknowledged this oversight.
A facility failed to communicate a fluid restriction for a dialysis-dependent resident, leading to the resident consuming excess fluids. The resident, with moderate cognitive impairment, was observed with beverages exceeding the prescribed limit. Facility staff were unaware of the current fluid restriction status, and the dialysis center confirmed the restriction was still needed.
The facility failed to justify an increase in psychotropic medication for a resident and did not attempt non-pharmacological interventions for two residents. One resident's Trazodone dose was increased without justification after a hospital stay, while another resident was frequently given PRN Xanax for anxiety and agitation without documented attempts at non-pharmacological interventions.
The facility failed to ensure proper storage and timely removal of expired medications. Medications, including a fentanyl patch, were left unattended at the nurse's station, accessible to staff, residents, and visitors. Additionally, a medication cart contained expired Lantus insulin and Latanoprost eye drops, with staff unsure of their expiration periods.
A facility failed to coordinate hospice services for a resident with severe cognitive impairment. The resident's current hospice care plan was missing from both the hospice communication binder and the electronic medical record. The DON was unable to locate the care plan, which is essential for coordinating care and services.
The facility did not ensure that 11 out of 12 residents were informed of their rights, the location of the resident rights posting, and the contact information for the Ombudsman and State Agency. Residents were unaware of their right to file complaints, and the poster for complaints had incorrect information. The Activities Director did not educate residents about their rights during meetings, and the Administrator was informed of these deficiencies.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
QAPI Program Lacked Tracking, Trending, and Systematic Review
Penalty
Summary
The facility failed to develop and maintain a QAPI program that identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to remedy those deficiencies. During interview, the NHA stated that over the last year the QAPI committee had identified concerns related to return to hospital, weight loss, falls, and dietary menus, and that items could be brought forward by staff, residents, the grievance project, and resident council. However, when asked how areas of concern were determined to need a QAPI project, the NHA stated the QAPI council would make that determination and could not explain how systems or items were monitored, tracked, or trended on a regular basis to ensure quality of care. The NHA was also unable to provide documentation showing that the odor on A hall had been monitored, tracked, or trended as a QAPI project. When asked whether the issue had been identified as a QAPI project, the NHA stated that it had not been a project and then stated that it should have been. The NHA could only identify falls and dietary menus as issues that had been identified during QAPI and also during the annual recertification survey. Review of the facility policy showed that the QAA coordinator reviews information for QAA meetings, that facility trends and additional data are to be reviewed, and that leadership oversight is used to identify systems, understand causes of variation, select improvement strategies, and monitor outcomes.
Resident Council Food Grievances Not Adequately Resolved
Penalty
Summary
The facility failed to adequately address and make a good faith effort to resolve repeated Resident Council grievances for 7 of 7 council members regarding food quality and meal service. Resident Council meeting minutes documented ongoing complaints that residents were not receiving requested menu items, food was cold, meals were served late, menus were not being provided, and meal trays were inaccurate. In response to these concerns, the Nursing Home Administrator signed off on forms directing residents to speak with the Dietary Manager, noting that the Dietary Manager would check with residents randomly, audit requested items, and remind staff about menus, but the same concerns continued to be raised month after month. During the Resident Council meeting on 3/25/26, all 7 participants reported that they had complained repeatedly about food quality, temperatures, not being provided menus, not receiving requested items, and receiving items they disliked, and stated the same complaints kept falling on deaf ears without resolution. On 3/26/26, the Dietary Manager stated she was aware of the concerns and was trying to address them, but the audits provided were limited to food temperatures and included several undated pages; there were no audits related to meal tray accuracy, honoring food preferences, or menu concerns. The Dietary Manager also stated a buddy system was used to ensure menus were provided and tray accuracy was maintained, but there was no documentation that this was done. The NHA confirmed she signed off on each concern form but stated she did not attend Resident Council and offered no response when asked about the repeated unresolved complaints.
Resident Council Not Informed of Grievance Filing Rights
Penalty
Summary
The facility failed to ensure that 7 of 7 Resident Council members were informed of their right to file a grievance with the facility. During the 3/25/26 Resident Council meeting, all 7 participants reported ongoing complaints about food palatability, menu items, food preferences not being honored, and noise levels. When asked whether they had voiced concerns or filed a grievance or concern form, individual participants raised additional concerns such as late medications and call light response times, and none of the seven knew that filing a grievance was an option or how or where the forms were located. One participant stated they believed they had to attend Resident Council in order to get a grievance or concern documented. Review of Resident Council minutes from September 2025 through February 2026 did not show that resident rights were reviewed in relation to the facility grievance policy, and on 03/27/2026 the Activity Director stated she conducted monthly Resident Council meetings and thought she had mentioned it in prior meetings. No documentation was provided by the exit of the survey showing that grievances, the facility policy, or resident rights related to filing grievances had been reviewed since the last certification survey.
Food Preferences Not Honored for Resident Council Members
Penalty
Summary
The facility failed to ensure that 7 of 7 resident council members had their food preferences met on a daily basis. Resident Council meeting minutes dated 9/30/25, 10/27/25, 12/30/25, 1/30/26, and 2/27/26 documented repeated concerns that residents said their food preferences were not being honored. During a Resident Council meeting with the State Agency on 3/25/26, all 7 participants stated this had been a long-standing issue that was not being addressed, and they reported frustration and anger that basic food and drink preferences were not honored, including a request for orange juice every day at breakfast but receiving apple juice instead. On 3/26/26 at 11:28 AM, the Dietary Manager stated there were no audits related to meal tray accuracy, honoring food preferences, or menu concerns, and said the facility used a buddy system to ensure tray accuracy and resident preferences were met, but did not respond when asked about the effectiveness of that system or the root cause of the ongoing issue.
Failure to Provide and Document Basic ADL Care for Multiple Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document basic activities of daily living (ADL) care, including bathing, hair washing, shaving, and oral hygiene, for multiple dependent residents. One resident with COPD, dementia, colon cancer with colostomy, anxiety, and depression required substantial to maximal assistance with showering, personal care, toileting, dressing, and transfers per the MDS and care plan. This resident reported that staff only sometimes shaved her facial hair and confirmed she preferred to have her chin shaved, yet surveyors repeatedly observed long chin hairs over several days. Review of the care plan showed she needed physical assistance with personal hygiene and that staff often needed to shave whiskers on her chin. Task sheets and shower documentation revealed no recorded bath or hair wash in the last 30 days, and two shower sheets within that period documented that she was not shaved on either shower day, with no explanation for missed showers or refusals. Further interviews and record reviews showed systemic documentation and scheduling issues contributing to the lack of care. A CNA stated the resident was scheduled for showers twice weekly and that refusals were to be documented on shower sheets and escalated to the nurse, but the facility could not produce adequate shower documentation for the prior 30 days. The DON later explained that CNAs did not know how to enter PRN showers and that when the resident was moved from one bed to another months earlier, her shower task days were not updated, leading CNAs to mark “NA” and follow an outdated schedule. The DON acknowledged that the resident had been moved in June of the prior year and that staff had continued to rely on the old schedule, and also acknowledged that no one had noticed the resident was not receiving showers as ordered. Another resident on hospice services, who was dependent on staff for all ADLs, also did not receive showers or baths from facility CNAs during the review period. Hospice coordination notes showed that a hospice CNA provided showers or baths on several specific dates, but there was no documentation that facility CNAs provided any showers or baths or documented refusals during the last 30 days. The DON stated that hospice admission information and visit notes were sent to the business office and ward clerk and were expected to be scanned into the electronic record or placed in a hospice binder, but record review revealed no hospice documentation in the electronic medical record or paper chart. The hospice binder was instead sitting in someone’s email account, and the DON stated she expected facility CNAs to provide care regardless of hospice involvement. A third resident with hemiplegia, muscle disorder, cervical disc disorder, fistula, difficulty walking, and major depression was dependent for all ADLs and was observed with visible plaque buildup on her teeth and heavy facial hair on her chin and upper lip. She reported that she had asked staff to shave her facial hair but was told the same razor was used on multiple residents, leading her to refuse that method and have her husband bring in an electric razor, which remained unused on her overbed table for at least a day. A CNA confirmed that the resident had not had her facial hair shaved until that point and that she was scheduled for a bed bath that day. The care plan directed staff to shave her face as needed and to encourage her to allow shaving, and there was no care plan entry stating she did not want her facial hair shaved. Shower sheets listed her for showers/bed baths twice weekly, but documentation showed no showers or bed baths in the last 30 days, with only two dates marked as refusals and no evidence of re-approach or nurse notification. The DON stated the expectation was twice-weekly showers or bed baths and acknowledged that refusals were only documented on two dates, with no corresponding progress notes showing re-approach or nurse follow-up, aside from a single progress note where the resident refused shaving with no documented follow-up.
Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to ensure accurate advance directive information was in place for one resident, R100, who was admitted with acute and chronic respiratory failure and congestive heart failure. The resident’s MDS dated 3/25/26 showed a Brief Interview for Mental Status score of 13 out of 15, and nursing progress notes dated 3/19/26 documented that R100 was alert and oriented x4, able to make needs known, and stated he did not want to be resuscitated if his heart stopped. The clinical record also showed that R100 and the facility physician signed an advance directive on 3/19/2026 reflecting the resident’s wish to be DNR. However, physician orders on 3/25/2026 listed R100 as full code, and during an interview on 03/25/2026 at 7:46 AM, an LPN stated that the MAR would be the first place to verify code status in the event of a code. The MAR reviewed with the LPN reflected R100 as full code.
Overpowering Urine Odor in Shared Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment because two residents shared a room with an overpowering smell of urine. One resident had paraplegia, acute kidney failure, a urinary device, abnormal gait and mobility, and required maximal assistance with toileting, showering, dressing, sit-to-stand, and transfers. The other resident had Huntington’s disease, dementia, protein-caloric malnutrition, weakness, repeated falls, was on hospice, and required dependent assistance with toileting, showering, lower body dressing, sit-to-stand, and transfers with a mechanical device. During screening and later observations, staff and surveyors noted an overpowering urine odor coming from the room and detectable from several rooms down the hallway. The resident with the urinary device was observed draining his foley catheter urine into a urinal and placing it on the bedside table, with a hand towel on his lap because urine spilled during the transfer. The same soiled towel was later still on his lap, and staff stated he preferred to disconnect the foley from the collection bag during the day and drain it himself, which caused urine spills on the floor and lingering odor. Staff interviews confirmed the room had ongoing urine contamination. A CNA stated the resident spilled urine when draining the catheter and continued using the same towel, and that the roommate could not report the odor. A housekeeper stated she cleaned the room daily, sometimes twice daily, changed mop heads because the room was so bad, and found urine on the bed table legs and base, with urine soaking into the flooring. The Maintenance Director and DON acknowledged the strong odor, repeated mattress replacement, discussion of replacing furniture, use of charcoal bags, and uncertainty about what to do next, while the roommate remained unable to speak for himself about the odor in the room.
Untimely Significant Change MDS Completion After Resident Decline and Hip Fracture
Penalty
Summary
The facility failed to complete a significant change MDS timely for one resident with multiple falls and a decline in ADL function. The resident had diagnoses including unsteadiness on feet, lack of coordination, vascular dementia, and a displaced subtrochanteric fracture of the right femur. The record showed the resident had severe cognitive impairment on the BIMS and experienced repeated falls, including being found face down with his shoulder pinned under a roommate’s bed, being found on the floor in front of his bed, and later being observed on the floor next to a roommate’s bed with a laceration above the right eyebrow. After the fall on 1/20/26, the resident was sent to the hospital and was reported to have a right hip fracture and a UTI. The incident report noted the resident was alert but disoriented and confused, with recent illness and weakness. A nurse stated the resident had been ill and had stayed in bed mostly for days before the fall. The DON stated the resident had been weak after a procedure earlier in the day during one fall, and that the resident had another fall in his room later in the year. The record also reflected that the resident’s falls were repeatedly addressed with interventions such as nonskid strips, a fall mat, and a bed in the lowest position. The significant change MDS for the resident was completed on 2/23/26, and the MDS LPN confirmed that significant change MDS assessments are to be completed within 14 days after the change occurs. The MDS LPN also confirmed that the resident required a significant change MDS because of the hip fracture and decline in ADL function, but that it was completed past the 14-day timeframe.
Care Plans Not Updated for Room Change, Personal Care Needs, and Hospice Services
Penalty
Summary
The facility failed to revise care plans for residents to reflect changes in room assignment, personal care needs, and hospice services. Review of records and interviews showed that Resident #1 had been moved from bed 1 to bed 2 in June 2025, but the shower schedule/task sheet was not updated to match the new assignment. Staff continued using the old schedule, and the DON stated the CNA did not know how to enter a PRN shower and that nobody changed the days under the task. During observations, Resident #1 had long facial hair on the chin and stated she liked having her chin shaved, while the care plan already noted staff should assist with shaving whiskers and oral care. Resident #7 was admitted to hospice on 02/12/2026, but the hospice binder and chart lacked certification paperwork, care plans, medication list, and a completed calendar of projected visits. Staff interviews showed confusion about where hospice documentation should be kept and what information should be available. The record also showed no hospice documentation scanned into the EMR as required, and facility staff stated hospice CNAs were providing showers and baths while facility CNAs were not doing them. The facility CNAs did not provide showers or baths in the last 30 days, and there was no documentation from facility staff explaining why those services were not provided. Resident #22 had diagnoses including hemiplegia and hemiparesis following stroke, lack of coordination, cervical disc disorder, fistula of the stomach and duodenum, difficulty walking, and major depression. During observation, she had heavy facial hair on her chin and mustache, and plaque buildup on her teeth. She stated she had asked staff to shave her facial hair but was told they used the same razor on residents, so her husband brought in an electric razor. The care plan stated staff were encouraged to shave her face as needed, but the record showed she did not receive showers or bed baths in the last 30 days, with refusals documented on two shower sheets and no further documentation showing re-approach or reporting to the nurse. Staff interviews also showed uncertainty about whether facial shaving refusal was care planned and whether follow-up occurred after refusal.
Failure to Maintain ROM and Provide Planned Repositioning
Penalty
Summary
The facility failed to maintain range of motion for a resident with chronic obstructive pulmonary disease, chronic respiratory failure, dysphagia, a stage 3 sacral pressure ulcer, incomplete paraplegia, chronic pain, and muscle wasting and atrophy. The resident was cognitively intact, dependent for multiple activities of daily living, and reported that staff did not perform range of motion on her left side because her bed was against the wall. She stated she had more mobility when she arrived at the facility, including movement of her arms, wrists, hands, and fingers, but later lost that mobility while at the facility. The resident was care planned for turning and repositioning every two hours and as needed, but task sheets showed she was rolled from left to right only two to three times per day over the last 30 days, not every two hours as planned. She also reported that staff generally only changed her brief and did not provide range of motion during care. The record showed she was dependent on staff for repositioning and transfers, and the facility stated there was no restorative program, with ROM expected to be done by CNAs during morning and night care. The resident also had pain management issues during wound care for her coccyx pressure ulcer. She received scheduled oxycodone every 8 hours, but wound care was ordered for 7:00 AM and the scheduled dose was at 8:00 AM, after the treatment. The resident reported pain during wound care and repositioning, stated her pain was not maintained at a tolerable level, and said rolled washcloths placed in her palms by OT were not included on the care plan. At discharge, she was observed with no movement or mobility in her arms, wrists, hands, or fingers and stated she had lost the mobility she had on admission.
Improper Tracheostomy Care and Missed Scheduled Equipment Changes
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with a tracheostomy, dysphagia, chronic respiratory failure, and multiple other diagnoses including stroke, paralysis, and protein-calorie malnutrition. During observation, the resident was lying in bed and did not respond to verbal stimuli. The tracheostomy ties were observed to be soiled with dried mucus, and the oxygen collar and oxygen circuit tubing connected to the tracheostomy were not dated. The oxygen tubing was also not dated. Review of the treatment record showed the ordered weekly change of trach tubing, mask, suction canister, and trach ties was not documented as completed on the scheduled day, and the last charted change had been several days earlier. During direct observation of tracheostomy care, an LPN suctioned the resident using improper technique. The nurse opened a suction kit, put on sterile gloves, connected the suction catheter, then placed the sterile-gloved hand holding the catheter on the bed and allowed the catheter to touch the bed before suctioning the resident. After suctioning, the nurse removed the gloves, put on non-sterile gloves, removed the inner tracheostomy cannula, performed outer tracheostomy care with sterile q tips and sterile saline, then handled and inserted a sterile inner cannula without changing gloves or washing hands. The nurse also changed the tracheostomy ties without changing gloves or washing hands. The DON confirmed that tracheostomy suctioning and inner cannula replacement were to be completed using sterile technique and that the resident's trach tubing, mask, suction canister, and ties were not documented as changed as ordered.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to remove expired medications from two of four medication administration carts used to administer medications to residents. During observation and interview on 03/25/2026 at 8:16 AM, an expired Allergy Relief 24 hr. 180 mg tablet with an expiration date of 01/26 was found in the Hall A medication cart, along with Naproxen Sodium 220 mg tablets whose expiration date had been removed and the bottle was plain white with no date. During observation and interview on 03/25/2026 at 8:36 AM, Cetirizine HCl 10 mg tablets were found in the Hall B medication cart with the expiration date wiped off and no visible date. During observation and interview on 03/25/2026 at 10:45 AM, no outdated medications were found in the medication room at the nurses' station, and refrigerator and freezer temperatures were within normal range. During interview on 03/26/2026 at 10:29 AM, the DON stated the expectation was that all nurses check expiration dates on bottles and dispose of medications once they are identified as expired.
Menu Not Served as Posted
Penalty
Summary
The facility failed to ensure the published menu was served as planned and failed to consistently inform residents in advance of menu changes affecting all residents receiving food from the kitchen. During a kitchen tour and interview, the Kitchen Manager reported that residents had menu options, including an alternate entrée and always available items. However, during tray line observation, the posted menu was verified as roast beef, potatoes, butter carrots, roll, and beverages, and several meal tickets were observed with requests for grilled cheese and veggie burgers that were honored. During the same tray line service, six resident meal tickets that had requested the main menu item were still pending when the Hall A service was reached, and those residents were served burgers after the facility ran out of the posted roast beef. The Kitchen Manager confirmed that roast beef had run out for the six residents who had ordered it and that burgers were placed in the oven to serve them. In a later interview, the Nursing Home Administrator stated meals would be expected to be served as posted and according to resident preference, including main menu items.
Delayed Meal Delivery and Unappetizing Breakfast Service
Penalty
Summary
The facility failed to ensure palatable and appetizing food was served to two residents. During observation on 3/25/2026 at 7:21 AM, a full uninsulated tray cart was seen on Hall C, the secure memory unit, with no staff delivering trays at that time, while two nurses were at the medication cart and several residents were wandering the hall and six residents were seated at the dining room table with no staff present in the dark. At 8:08 AM, CNA LL entered Resident #2's room with a breakfast tray about 45 minutes after the tray arrived. At 8:15 AM, Resident #49 was served the first bite of breakfast with staff assistance, almost one hour after the tray was delivered. In the secure memory dining room, staff were observed assisting residents at the table, attempting to cut toast that could not be cut, and breaking up oatmeal that had a solid top layer before stirring it for a resident on her right side. During interview, CNA LL and CNA MM reported that the resident on her right side did not eat well that morning and confirmed the toast could not be cut. The NHA stated that meal trays would be expected to be delivered to residents immediately after arrival.
Arbitration Agreement Missing Required Resident Rights Language
Penalty
Summary
The facility failed to ensure its Arbitration Agreement explicitly stated that neither the resident nor the resident’s representative was required to sign a binding arbitration agreement as a condition of admission or as a requirement to continue receiving care, and it also failed to state that the agreement allowed communication with federal, state, or local officials, including surveyors and the Office of the State Long Term Care Ombudsman. This deficiency was identified for one resident reviewed for arbitration agreements, Resident #73, whose record showed admission on 02/01/2023 with diagnoses including atherosclerotic heart disease, polyneuropathy, insomnia, contracture of the left elbow, lack of coordination, muscle weakness, dementia, abnormal posture, COPD, dysphagia, hypertension, cognitive communication deficit, alcohol abuse, gastro-esophageal reflux, and chronic hepatitis. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact at the time of the assessment. During interview, the resident explained the purpose of the facility arbitration agreement but was not willing to review the signed agreements from 02/03/2023 or 03/25/2026 and could not explain why the agreement was resigned. Review of the 02/03/2023 agreement showed it did not contain the required statement that signing was not a condition of admission or continued care, and it did not state that the resident or anyone else could communicate with federal, state, or local officials, including surveyors, health department employees, or the State Long Term Care Ombudsman. The Admission Director confirmed these omissions and stated the resident’s agreement did not meet requirements when it was requested during the survey process.
Arbitration Agreement Lacked Neutral Arbitrator Provision
Penalty
Summary
The facility Arbitration Agreement failed to explicitly state that the agreement provided for the selection of a neutral arbitrator agreed upon by both parties for one resident reviewed for arbitration agreements. Resident #73 was admitted with multiple diagnoses including atherosclerotic heart disease, polyneuropathy, insomnia, contracture of the left elbow, lack of coordination, muscle weakness, dementia, abnormal posture, COPD, dysphagia, hypertension, cognitive communication deficit, alcohol abuse, gastro-esophageal reflux, and chronic hepatitis. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact at the time of the assessment. During the survey, the resident explained the purpose of the facility arbitration agreement but was not willing to review the signed agreement from admission or the later agreement signed again by the resident. The resident could not explain why the arbitration agreement was resigned. Review of the original agreement signed on admission showed that it did not provide for the selection of a neutral arbitrator agreed upon by both parties. The AD confirmed that the agreement did not meet the requirements and stated that the resident was asked to sign a new arbitration agreement after this issue was identified during the survey process.
Failure to Coordinate Hospice Services and Maintain Hospice Documentation
Penalty
Summary
The facility failed to provide coordination of care for hospice services for one resident who was admitted to the facility and later signed onto hospice. The resident had diagnoses including Huntington's disease, dementia, muscle disorders, emotional deficit related to cerebrovascular disease, protein-caloric malnutrition, weakness, and repeated falls. The most recent MDS showed moderate cognitive impairment with a BIMS of 10 and dependence on toileting, showering, lower body care, sit-to-stand, and transfers with a mechanical device. Record review and staff interviews showed the hospice documentation was not available in the resident's binder or electronic record as required. The binder contained no certification paperwork, care plans, medication list, or completed calendar of projected visits. Staff members, including an LPN, hospice RN, CNA, unit managers, and the DON, gave inconsistent information about where the hospice records should be kept and who was responsible for them. The hospice RN stated the CNA and nurse visited on certain days and that the office would send the required information, but the documents were not present in the binder or scanned into the EMR. The record also showed that facility CNAs did not provide showers or baths for the resident during the last 30 days, and all showers were given by hospice CNAs. Staff stated that hospice CNAs did the personal care when they came in, while other staff said facility CNAs should still provide care regardless of hospice involvement. The only hospice coordination notes obtained showed hospice CNA shower visits on several dates, but there was no facility documentation supporting why facility CNAs did not provide showers or baths during that period.
Hand Hygiene and Dressing Change Technique Not Followed
Penalty
Summary
The facility failed to ensure appropriate hand hygiene and glove changes during medication administration and dressing changes. During an observation on 03/25/2026 at 8:04 AM, an LPN was preparing medications for a resident and was not observed performing hand hygiene before entering the medication cart area, before going into the resident’s room, after administering the medication, or before returning to the medication cart. During interviews, the Infection Preventionist and the DON stated they expected nurses to use hand hygiene between residents and after medication administration. During a dressing change observation on 03/25/2026 at 2:25 PM, an RN was training another RN while changing a resident’s right hip wound dressing. The wound was described as about baseball-sized with rolled, curled, scarred edges. The RN removed the soiled dressing, cleaned the wound with normal saline, and packed it with fingers only using Dakin-soaked gauze, then covered it with aquacell and an ABD pad. The RN did not change gloves between the soiled and clean portions of the dressing change and did not follow the treatment orders. The supervising RN stated she would have expected gloves to be changed between dirty and clean steps and acknowledged she walked away to get supplies without correcting the other RN. A separate resident had diagnoses including Fournier gangrene, retroperitoneal abscess, muscle wasting, anemia, type 2 diabetes, hypertension, hepatic encephalopathy, abnormal posture, and alcoholic cirrhosis, and had a BIMS score of 15. During a dressing change observation, an LPN sanitized hands, donned gown and gloves, removed blood-soaked packing from the scrotal surgical site, cleansed the site, packed it, applied skin prep and calcium alginate, and covered it with a dressing. The LPN later assisted the resident with a brief and then removed gloves and washed hands. The DON stated that hand hygiene and glove changes were expected between removal of a soiled dressing and application of the new dressing, and the facility policy for non-sterile dressing changes required handwashing and glove changes at specific steps during the procedure.
Failure to Implement Fall-Prevention Care Plan After Room Change
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive care plan for a resident at risk for falls. The resident had multiple diagnoses, including a left femur neck fracture, seizures, difficulty walking, diabetes, dementia, and an impulse disorder. A Quarterly MDS with an ARD of 12/11/25 documented severe cognitive impairment, with a BIMS score of 6/15, and two or more falls since admission or the prior assessment. On observation, the resident was seen in a wheelchair equipped with anti-rollback brakes, rear anti-tip bars, and a drop seat, and the resident’s bed was in a low position with a standard mattress and the left side of the bed against the wall. Non-skid strips were not observed on the floor at the bedside. The resident’s care plan identified them as being at risk for falls and included specific interventions such as non-skid strips at the bedside, initiated on 2/2/25, and an edge defined perimeter mattress, initiated on 7/25/24. However, these interventions were not in place at the time of the surveyor’s observation. In an interview, the DON stated that care plans were reviewed quarterly by the MDS nurse and that falls care plans were reviewed by the IDT after a fall. The DON explained that the resident had a room change in October 2025 and acknowledged that the resident’s interventions, including the non-skid strips and edge defined perimeter mattress, were not moved to the new room, despite Unit Managers being responsible for ensuring all interventions were in place after a room change.
Failure to Ensure Accurate Medication Orders and Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate medication orders and administration according to physician orders for one cognitively intact resident with multiple chronic conditions, including rheumatoid arthritis, pain, diabetes, atrial fibrillation, fibromyalgia, and osteoporosis. The resident’s Medication Administration Record (MAR) for December showed that Alendronate Sodium 70 mg, ordered once weekly on Sunday at 6:00 AM for osteoporosis, was not documented as administered on the scheduled date, and there was no progress note explaining the omission or indicating that the physician was notified. Arava (Leflunomide) 20 mg, ordered once daily in the morning for inflammation, was not documented as administered on a scheduled morning dose, with a correlating progress note simply stating “n/a for Arava” and no documentation of physician notification. The MAR also reflected an order for Liraglutide 1.2 mg SC daily at 8:00 AM for diabetes that was not documented as administered on two separate days. Progress notes for those dates recorded “n/a for Liraglutide” and “Not given due to wrong order,” but did not document that the physician had been notified of the missed doses or the concern about the order. In a subsequent interview, the prescribing physician clarified that the intended Liraglutide dosing should have started at 0.6 mg daily for one week, then increased to 1.2 mg daily, and possibly to 1.8 mg daily, indicating the order in the record did not reflect the intended titration. Additionally, Cyclobenzaprine 10 mg, ordered three times daily for muscle spasm relief, was not documented as administered for one scheduled evening dose, with a progress note stating the medication was “on order” and again no documentation that the physician had been notified. The DON reported that medications arriving after late admissions might not be available until the next day and that if medications were unavailable, the physician should be notified and the notification documented, and also noted that Liraglutide was a pharmacy interchange for Ozempic.
Failure to Prevent Development of Pressure Ulcers in At-Risk Residents
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in two residents who were at risk due to their medical conditions. One resident, admitted with multiple diagnoses including Alzheimer's disease, diabetes, obesity, and peripheral vascular disease, did not have adequate interventions in place prior to developing a pressure ulcer on the right trochanter. The only documented preventive measure was the use of a pressure-reducing mattress and wheelchair cushion. The wound was first identified by nursing staff and later assessed by the wound nurse, who could not specify what interventions were in place before the ulcer developed. No root cause analysis was documented in the medical record, and the Director of Nursing acknowledged that the ulcer was avoidable and that additional interventions, such as an air mattress, should have been implemented earlier. Another resident, admitted with a history of fractures, cerebral palsy, developmental disorder, and severe cognitive impairment, developed a deep tissue injury to the right heel. Prior to the injury, the only intervention listed was to elevate the heels off the bed surface while at rest. The wound was documented and treated after it was discovered, but there was no evidence of a root cause analysis being performed. The Director of Nursing stated that the injury was avoidable and that more interventions should have been in place given the resident's risk factors and medical history. In both cases, the facility did not implement comprehensive preventive measures or conduct timely root cause analyses after the pressure ulcers developed. The lack of documented interventions and failure to update care plans contributed to the development of avoidable pressure ulcers in residents with significant risk factors. Observations confirmed that wound care was provided after the ulcers were identified, but preventive actions were insufficient prior to their occurrence.
Failure to Revise Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to revise the Care Plan for a resident with severe cognitive impairment and a history of dementia with violent behaviors. The resident, who was admitted and readmitted to the facility with diagnoses including unspecified dementia, Alzheimer's Disease, major depressive disorder, and anxiety disorder, was observed on multiple occasions displaying behaviors that were not adequately addressed in their Care Plan. Staff interviews revealed that the resident could be aggressive, with interventions such as talking, sitting with the resident, and providing snacks sometimes being effective. However, the Care Plan did not reflect these behavioral triggers or interventions, including the resident's enjoyment of music and playing the harmonica. Staff members, including CNAs and a social worker, reported various non-pharmacological interventions that were used to manage the resident's behaviors, such as engaging the resident in activities or using music. Despite these efforts, the Care Plan lacked documentation of these strategies and did not include specific behavioral triggers or interventions that were identified by the staff. The absence of these details in the Care Plan indicates a failure to update and revise it based on the resident's current needs and behaviors, as observed and reported by the staff.
Failure in Nephrostomy Tube Care for a Resident
Penalty
Summary
The facility failed to ensure proper nephrostomy tube care for a resident with significant medical conditions, including tubulointerstitial nephritis, hydronephrosis with renal and ureteral calculus obstruction, and obstructive and reflux uropathy. The resident was admitted with bilateral nephrostomy tubes, but the necessary care orders were not implemented until several days after admission. Observations revealed that the nephrostomy bag was improperly positioned on the bed, and the dressing was not secured, leading to a soiled and undated dressing with greenish discharge. Interviews and record reviews confirmed that the physician's order for cleaning the nephrostomy tube site was delayed and not completed as required. The Director of Nursing acknowledged that the orders should have been in place upon admission. The resident's condition was further compromised by redness and discharge at the nephrostomy site, indicating a lack of timely and appropriate care. The facility's failure to follow proper procedures for nephrostomy tube care resulted in a deficiency in the resident's treatment and care.
Inadequate Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement effective interventions to prevent repeated falls for a resident with a history of falls and significant medical conditions. The resident, who has dementia, aphasia, and a history of strokes, was observed with a bruised eye after reportedly falling twice in one day. The resident had been administered Ativan following a seizure, which was noted to cause drowsiness and contribute to the falls. Despite the resident's tendency to transfer independently and refusal of assistance, the facility did not have adequate fall prevention measures in place, such as non-skid strips near the bed where the falls occurred. Interviews with staff revealed that the resident's care plan and fall risk interventions were reviewed regularly, but adjustments were not sufficient to prevent further incidents. The resident's preference for certain caregivers and reluctance to accept help were acknowledged, yet the facility's measures, such as frequent monitoring and keeping the door open for visual checks, were inadequate. The absence of non-skid strips near the bed, a known site of previous falls, highlighted a gap in the facility's fall prevention strategy.
Failure to Provide Accessible Water for Resident
Penalty
Summary
The facility failed to ensure that water was readily available and within reach for a resident, identified as R24, which resulted in the potential for inadequate fluid intake. During observations, it was noted that R24's water cup was placed on a bedside table positioned to the left side of the bed and up against the wall, making it out of sight and reach. Despite R24 expressing a liking for water, the water cup remained in the same inaccessible position during subsequent observations. R24, who has Alzheimer's Disease and Dementia, was observed with a dry mouth, indicating possible dehydration. Interviews with staff revealed that water cups are typically kept out of sight to prevent other confused residents from taking them. However, when a resident is in their room, water should be placed within easy reach, which was not the case for R24. The Director of Nursing acknowledged that water should be within reach for residents. The report highlights the importance of maintaining adequate hydration for older adults, especially those with chronic conditions, as stated in an article by the National Library of Medicine.
Failure to Communicate Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center regarding a fluid restriction for a resident dependent on renal dialysis. The resident, who had moderate cognitive impairment, was observed consuming beverages that exceeded the previously prescribed fluid restriction. The medical record indicated a fluid restriction was in place prior to a hospitalization, but it was not reordered upon the resident's readmission. Interviews with facility staff revealed uncertainty about the resident's current fluid restriction status, and the dialysis center had not communicated any changes. Despite the resident's history of fluid overload and pulmonary edema, the facility did not verify the continuation of the fluid restriction with the dialysis center. The Director of Nursing and Licensed Practical Nurses were unaware of the resident's current fluid restriction needs, and the dialysis Registered Dietitian confirmed the resident was still on a fluid restriction. The lack of communication and verification led to the resident not adhering to the necessary fluid intake limits, potentially impacting their health condition.
Failure to Justify Psychotropic Medication Increase and Lack of Non-Pharmacological Interventions
Penalty
Summary
The facility failed to ensure justification for an increase in psychotropic medications and did not attempt non-pharmacological interventions for two residents. Resident #9, who has severe cognitive impairment and was diagnosed with vascular dementia, bipolar disorder, and depression, was readmitted to the facility with an increased dose of Trazodone from 100 mg to 150 mg after a hospital stay. The hospital discharge summary did not provide justification for this increase, and the Director of Nursing confirmed that no justification could be located for the dose change. Resident #33, also with severe cognitive impairment and diagnosed with unspecified dementia, Alzheimer's Disease, major depressive disorder, and anxiety disorder, was administered PRN Xanax multiple times for anxiety and agitation without documentation of non-pharmacological interventions being attempted first. The facility's records did not reflect any attempts at non-pharmacological interventions prior to administering the medication, and the Social Worker reported relying on staff documentation for behavioral observations, which lacked details on interventions or responses.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure the appropriate storage of medications, including narcotics, and to keep medication carts free of expired medications. On December 18, several medications, including a fentanyl transdermal patch and various oral tablets, were observed unattended and accessible at the nurse's station. These medications were accessible to staff, ambulatory residents, and visitors, which was identified by the Nursing Home Administrator, who acknowledged that the medications should have been locked up. Additionally, on December 20, during an observation of a medication cart, a bottle of Lantus insulin belonging to a resident was found to have been opened on October 12, exceeding its 28-day usability period. Similarly, a bottle of Latanoprost eye drops, opened on October 18, was also found on the cart, with the LPN unsure of its expiration period. The Director of Nursing later confirmed that Lantus is good for 28 days after opening, while Latanoprost is good for 42 days, indicating that both medications were expired.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to coordinate hospice services for a resident with severe cognitive impairment. The resident was admitted with a diagnosis of senile degeneration of the brain and was utilizing hospice services. However, during a review of the hospice communication binder and the electronic medical record, it was found that the resident's current hospice care plan was missing. The Director of Nursing was unable to locate the current care plan in either the hospice binder or the electronic medical record, despite acknowledging that the care plan is essential for coordinating care and services.
Failure to Inform Residents of Their Rights and Contact Information
Penalty
Summary
The facility failed to ensure that 11 out of 12 residents in a group were aware of their resident rights, the location of the posting of these rights, and the contact information for the Ombudsman and State Agency. During a group meeting, these residents expressed that they did not know who the Ombudsman was, where the contact information was posted, or that they had the right to file a complaint with the State agency. An observation confirmed that the contact information was located in a common area leading to the dining/activity room, but the poster for filing a complaint had incorrect department information. The Activities Director, who attended resident council meetings, admitted to not informing or educating residents about their rights during these meetings. The Administrator was made aware of these issues during an interview.
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A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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