The Laurels Of Carson City
Inspection history, citations, penalties and survey trends for this long-term care facility in Carson City, Michigan.
- Location
- 620 North Second Street, Carson City, Michigan 48811
- CMS Provider Number
- 235636
- Inspections on file
- 26
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Laurels Of Carson City during CMS and state inspections, most recent first.
A resident with dementia, multiple comorbidities, and an ileostomy was determined by two MDs to lack capacity for medical decision-making and was left without an active POA after the designated family POA resigned in writing. Despite this, the facility had the resident sign a Medicare non-coverage notice, did not complete the care-planned home safety visit, and discharged the resident home based on the resident’s request and an assumption that the former POA would still provide support. Social services documented planned home health (PT, OT, nursing, HHA) and a PCP visit, but the listed home health agency later reported the resident was never evaluated or enrolled, and a family member found the resident at home alone in poor condition. The NHA and SSD acknowledged they did not seek emergency guardianship and could not confirm the resident’s safety or that appropriate support services and a patient representative were in place at discharge, and they did not inform a sister facility that the resident lacked a guardian or POA when asked for information.
Staff failed to use PPE as required for a resident on contact precautions for suspected MRSA, did not document interventions for repeated low chlorine levels in the facility's water management program, and did not dispose of soiled linens in a sanitary manner after providing peri-care to a resident with dementia and right-sided weakness.
Several residents dependent on staff for toileting and transfers experienced delayed call light responses, especially during evening and night shifts, leading to prolonged discomfort, incontinence, and feelings of embarrassment. Staff were observed turning off call lights without meeting residents' needs, and some were described as rough or inattentive. These actions were inconsistent with facility policies requiring timely and respectful care.
A resident with a history of sepsis, CHF, and endocarditis received hydralazine for hypertension despite a physician order to hold the medication if systolic blood pressure was below 140. The MAR showed multiple instances where the medication was administered with SBP values under the threshold, and the DON confirmed there was no documentation that the medication was held as ordered.
A resident with dementia and right-sided paralysis following a stroke was not provided with a prescribed hand splint to maintain range of motion, as outlined in her care plan. Observations showed the splint was not applied during multiple care interactions, and staff did not offer or ask about the splint, despite its availability at the bedside.
A resident with dementia, morbid obesity, and right-sided paralysis was assisted with bed mobility by only one CNA, despite a care plan requiring two staff for such assistance. The CNA instructed the resident to roll onto her sides without the required second staff member present, contrary to the documented safety intervention.
Surveyors observed that the facility did not provide a battery pack emergency light at the transfer switch in the main electrical room, failing to meet requirements for automatic emergency lighting. This was confirmed by the environmental supervisor and could impact all occupants, staff, and visitors if emergency power systems fail.
A wheelchair battery charger was found in use within a resident room in the sub-acute rehab wing, and the area lacked the required fire barrier or automatic fire extinguishing system. The environmental supervisor confirmed that wheelchair batteries are charged in resident rooms as needed, and the necessary fire protection measures, including self-closing doors, were not in place.
The facility did not provide documentation for the required semi-annual kitchen hood cleaning and monthly hood suppression inspection, as confirmed by regional staff during surveyor interviews. These deficiencies could potentially impact kitchen staff and occupants in the affected smoke compartment.
A resident with a history of heart issues experienced chest pain and took multiple doses of nitroglycerin without proper assessment or monitoring by the nursing staff. The LPN focused on removing the nitroglycerin bottle rather than evaluating the resident's condition, and vital signs were not documented. The ADON instructed the LPN to check vital signs, but this was not done, and the nurse practitioner was not informed of the chest pain. The DON confirmed that such complaints require immediate evaluation.
The facility failed to accurately assess, provide treatments as ordered, and ensure physician oversight for wounds for two residents, leading to significant deterioration of their conditions. One resident developed osteomyelitis due to delayed treatment, while another experienced worsening of a stage 3 pressure ulcer and the development of a new wound. The facility's documentation and follow-up were inconsistent, and necessary wound care supplies were not always available, exacerbating the residents' conditions.
The facility failed to promptly identify and manage outbreaks of COVID-19, Influenza, and RSV, leading to widespread transmission among residents and staff. There was inadequate implementation of transmission-based precautions, lack of prompt testing, and insufficient documentation of outbreak investigations and contact tracing.
The facility failed to provide the pneumococcal immunization to a resident who had consented to receive it. The resident was later admitted to the hospital with RSV and pneumonia. The Infection Control Preventionist admitted to missing the requirement, despite the facility's policy mandating the vaccine for residents aged [AGE] years or older or those with underlying conditions.
The facility failed to administer controlled medications following physician orders and professional standards of practice for six residents, resulting in medication errors and the withholding of medications without a physician order. Additionally, medications were not administered according to physician-ordered parameters for several residents, and there were issues with insulin administration and potential staff impairment.
The facility failed to ensure the DON did not serve as a charge nurse, leading to missed treatments and negative resident outcomes. The DON worked over 110 hours as a charge nurse, resulting in missed laboratory tests, treatments, and medications. An Immediate Jeopardy was identified due to improper pressure ulcer care and LPNs administering IV medications without proper training.
The facility failed to ensure call lights were within sight and reach for a resident with multiple diagnoses, including acute respiratory failure and COPD. The call light was observed out of reach on several occasions, despite the facility's policy requiring it to be within easy reach.
The facility failed to maintain safe water temperatures, with measurements showing excessively high temperatures in bathroom sinks and spa rooms, posing a scalding risk to residents. The Maintenance Director admitted that the water temperature was turned up to 140 degrees last year and some sinks were missing point-of-use mixing valves, which had not yet been installed. Water temperature logs from January to April 2024 consistently showed temperatures exceeding 120 degrees in various locations.
The facility failed to ensure appropriate catheter care for a resident with dementia and other conditions. LPNs performed unnecessary catheter flushes without proper protective equipment, and the origin of the order was unclear. The resident's urologist confirmed that the flushes were not recommended, posing a significant infection risk.
The facility failed to follow best practice standards for two residents receiving supplemental oxygen. One resident had undated oxygen tubing and lacked proper documentation, while another had no documented oxygen delivery rate or regular observations, and her care plan lacked necessary interventions for COPD.
A facility failed to ensure IV medications were administered by trained and licensed nurses, leading to an LPN administering IV antibiotics to a resident without the required specialized training. The DON confirmed the lack of documentation for such training.
The facility failed to maintain clean ventilation filters, resulting in reduced air quality and circulation in several resident rooms. A resident reported that maintenance had not changed the filter since before winter, and the air seemed to come out slower. The Maintenance Director stated that filters are supposed to be checked monthly and changed as needed, but the facility's preventative maintenance program requires filters to be replaced or thoroughly cleaned every three months. The maintenance log showed the task was last completed on 3/31/2024.
The facility failed to properly assess and manage pain for a cognitively impaired resident with a history of stroke and contracture. Despite displaying signs of pain, the resident was not consistently assessed using the PAINAD scale, and there was inadequate documentation of pain characteristics. This led to an increased perception of pain and unmet pain needs, highlighting a significant deficiency in the facility's pain management practices.
A resident was administered an antibiotic daily for 12 days without a proper order from the urologist. The facility staff failed to verify the medication order and demonstrated a lack of knowledge regarding criteria for antibiotic use in residents with indwelling catheters.
A resident with chronic kidney disease was inappropriately prescribed Augmentin for a suspected UTI without waiting for urinalysis and culture results. The resident exhibited no UTI symptoms and did not meet the McGeer Criteria, leading to inappropriate antibiotic use.
Failure to Ensure Safe Discharge and Representative Support for Incapacitated Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate caregiver/support availability and a safe discharge plan for an incapacitated resident who lacked an active guardian or POA. The resident had dementia and multiple medical conditions, including vertebral compression fractures, CKD, ulcerative colitis, COPD, OSA, DM2, and an ileostomy, and required assistance with self-care and mobility. Although an earlier MDS showed intact cognition, subsequent documentation included a Statement of Capacity signed by two MDs in late January certifying the resident was incapable of making informed medical decisions, and the facility’s SSD acknowledged awareness of this determination. The resident’s POA succession documents showed that a family member (FM H) had become the active POA after the prior POA was revoked, and two physicians had already determined the resident was unable to participate in treatment decisions months before admission. On 1/29, FM H submitted a written memo resigning as the resident’s medical POA, leaving the resident without an active POA or guardian. Despite this, the facility had the resident sign a Notice of Medicare Non-Coverage on the same date, even though the resident had been deemed not capable of making medical or treatment decisions as of 1/23. The form was witnessed by the BOM. The care plan, initiated earlier in the stay, identified a functional ability deficit and required assistance with self-care/mobility, with an intervention for a home safety visit prior to discharge. However, the PTA later confirmed that no home safety visit was completed before the resident’s discharge. A Social Services note documented that the resident requested discharge home, that the former POA had expressed concerns about the resident’s safety at home alone, and that home health services (PT, OT, nursing, HHA) and a PCP appointment were planned, with the brother to transport the resident. The SSD reported that in cases where a resident lacked capacity and no POA was identified, the facility’s practice was to seek emergency guardianship, but this was not done because they believed the former POA was still supporting the resident despite the written resignation. The NHA and SSD stated they could not confirm the resident was safe to discharge home alone without confirmation of appropriate support services and a patient representative. A family member later reported finding the resident at home in poor condition, with no evidence of home health services having been initiated, and a representative from the listed home health agency confirmed the resident was never seen or enrolled for services. The SSD also acknowledged that when a sister facility later requested information, they did not disclose that the resident lacked a guardian or POA because they were not specifically asked.
Infection Control Failures in PPE Use, Water Management, and Linen Handling
Penalty
Summary
The facility failed to properly implement its infection prevention and control program in several areas. For one resident with dementia and muscle weakness, who was under contact precautions due to a suspected MRSA infection in a heel wound, staff did not follow required protocols. Despite clear signage on the resident's door instructing staff to don gloves and a gown before entry, a certified nursing assistant entered the room without the appropriate personal protective equipment. The infection preventionist confirmed that the resident's status had recently changed to contact precautions and that gloves and gowns were required prior to room entry. Additionally, the facility did not follow its water management policy and procedures. Chlorine level testing records showed multiple instances where chlorine levels were below the acceptable range, but there was no documentation of interventions or use of the Water Management Team Meeting Minutes form as required by policy. Furthermore, during peri-care for another resident with dementia and right-sided weakness following a stroke, a certified nurse aide placed soiled washcloths on the resident's over-bed table and did not clean or sanitize the table before leaving the room, failing to dispose of soiled linens in a sanitary manner.
Plan Of Correction
F tag 880 Infection Prevention and ControlSS=F 1. Staff member involved was immediately educated on the use of PPE for all residents in isolation. Soiled washcloths were immediately bagged and placed in the soiled utility room for laundering and the bedside stand disinfected. The water management meeting was held on 5/6/25. The following departments attended the meeting: Environmental Service Director, Maintenance, Infection Control (IC), Nursing, and NHA. 2. Residents residing in the house are at risk related to the deficient practice. Residents in the house were reviewed by the nursing team to ensure there was no spread of infection for failure to follow proper IC protocols when entering a room without proper PPE, no s/sx of legionella, and lack of proper handling of linen. The city's water department was contacted regarding the chlorine levels that were noted to be outside of parameters. A visit is scheduled for the week of 5/12 to test the facility's chlorine levels, using their device. If it is determined that the results are not within parameters, we will work with the water dept to regulate chlorine levels to appropriate parameters. 3. The QAPI Committee reviewed the policies and procedures related to Multi Route Transmission Based Precautions, Infection Control, and the Water Management Program and deemed it appropriate. Facility staff were re-educated by the DON/Designee on Multi Route Transmission Based Precautions and Infection Control. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. The Maintenance Director and ICP were re-educated on the water management program and the requirement of monthly meetings. The Maintenance Director was educated that if levels are not within parameters, an action plan needs to be developed and implemented to include rechecks on the levels. 4. The Infection Control Preventionist/Designee will observe 5 residents on isolation weekly times four weeks to ensure that staff are adhering to all IC protocols including Donning and Doffing PPE, handling of linen, water management program, then monthly for 3 months. The results of these audits will be forwarded to the QAPI Committee for further direction and guidance. The IC Preventionist is responsible for ongoing compliance. The NHA will review the monthly Water Management meetings to ensure that chlorine levels are within parameters. The NHA is responsible for ongoing compliance of the Water Management Program.
Failure to Ensure Timely Call Light Response and Dignified Care
Penalty
Summary
The facility failed to ensure dignified care for four residents who were dependent on staff for assistance with toileting and transfers. Multiple residents reported delayed responses to call lights, particularly during evening and night shifts, resulting in prolonged periods of discomfort and incontinence. One resident described staff turning off the call light and promising to return, but then failing to do so, leaving the resident wet and uncomfortable for extended periods. Another resident reported that staff were sometimes rough during transfers and that delays in call light response led to episodes of incontinence and soreness from sitting for long periods. Residents also reported that staff behavior varied, with some being attentive while others were described as crabby or rough. One resident noted that call lights were answered more promptly when family members were present, but otherwise, waits could exceed 30 minutes, sometimes resulting in accidents. Staff interviews confirmed that some staff members turned off call lights without meeting residents' needs, which is against facility policy. Observations included a resident waiting over 30 minutes for assistance after activating a call light, with staff walking past the room without responding. Facility policies require call lights to be answered in a timely manner and not to be turned off until the resident's needs are met. The failure to respond promptly to call lights and provide timely assistance with toileting and transfers compromised residents' dignity and comfort, as evidenced by their reports of embarrassment, discomfort, and feeling unwanted.
Plan Of Correction
F tag 550 Resident Rights/Exercise of Rights SS=E 1. Residents R50, and R4 have no LTC affects from not having their call lights answered in a timely manner. Resident R11 and R75 no longer reside at the facility. 2. Residents who reside in the facility are at risk of being affected by this deficient practice. Residents in-house were interviewed by the IDT team through Quality Rounds to ensure their needs are addressed timely. Any concerns were addressed through the guest assistance concern process. 3. The QAPI Committee reviewed the Call light Policy and Resident Rights Policy and deemed them appropriate. Facility staff were re-educated by the NHA/Designee on the policies and procedures related to Call lights, and Resident Rights. Staff who have not been educated by Date of Compliance will be re-educated prior to returning to work. 4. The IDT Team will interview 10 residents weekly to ensure that their needs are being met timely through the Quality Rounds Program. These audits will continue weekly times four than monthly x 3 months. The results of these audits will be forwarded to the QAPI Committee for further direction. The NHA is responsible for continued compliance.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency was identified when the facility failed to administer blood pressure medication in accordance with a physician's order for one resident. The resident, who had diagnoses including sepsis, congestive heart failure, and endocarditis, had an active order for hydralazine 25 mg by mouth twice daily, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 140. Despite this order, the Medication Administration Record (MAR) showed that hydralazine was administered multiple times when the resident's SBP was below 140, with recorded SBP values ranging from 106 to 138 at the time of administration. Interviews with the Director of Nursing (DON) confirmed that the medication was given contrary to the physician's order on several occasions, and a review of the electronic medical record did not reveal any documentation that the medication had been appropriately held on those dates. The facility's policy requires medications to be administered according to written physician orders, but this was not followed in the case of this resident.
Plan Of Correction
F tag 658 Services Provided Meet Professional Standards SS=D 1. Resident R69 no longer resides at the facility. On 4/24, the DON notified the Nurse Practitioner of the findings. Patients' charts and vitals were reviewed. The patient was assessed and showed no signs of distress. Education was initiated. Resident discharged home with her spouse on 5/4/2025. 2. Residents residing in the facility receiving blood pressure medications are at risk of being affected by this deficient practice. Residents receiving BP meds with parameters were reviewed by the DON to ensure that medications were held if the BP was not within parameters. Any concerns were addressed. 3. The QAPI Committee reviewed the Medication Administration Policy and deemed it appropriate. Nursing staff were re-educated by the DON/Designee on the policies and procedures related to Medication Administration specific to medications with parameters. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review 5 residents weekly times four to ensure that physician orders are followed regarding medication parameters then monthly x 3 months. The results of these audits will be forwarded to the QA Committee for further guidance and direction. The NHA is responsible for continued compliance.
Failure to Implement Hand Splint Intervention for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with dementia and right-sided weakness and paralysis following a stroke was not provided with appropriate interventions to maintain or improve range of motion (ROM) as outlined in her care plan. The care plan specified that the resident should wear a right hand resting splint from morning to bedtime. However, multiple observations over several days revealed that the resident consistently did not have the splint on her right hand, despite the splint being present on the bedside table. Staff were observed providing care without offering or applying the splint, and the resident reported that staff had not asked her if she wanted the splint on during those times. The lack of adherence to the care plan was confirmed through both staff actions and resident interviews. The resident was observed in bed and in a wheelchair, participating in activities such as bingo, without the splint in place. At no point during the observed care interactions did staff attempt to apply the splint or inquire about its use, despite the resident's care plan directive. This failure to implement the prescribed intervention resulted in the facility not providing appropriate care to maintain or improve the resident's ROM.
Plan Of Correction
F tag 688 Increase/Prevent/Decrease in ROM/Mobility SS=D 1. Resident #25 was evaluated to determine if the resident had any new discomfort or worsening of contracture due to the staff's failure to offer and utilize her right-hand splint. The care plan was reviewed and updated as needed. 2. Residents residing in the facility with splints or other contractual devices have the potential to be affected by the deficient practice. The nursing team reviewed patients with contractual devices to ensure devices were being offered and utilized by physician order. Any refusals were documented, and care plans were updated to reflect preferences. 3. The QAPI Committee reviewed the Brace and Splint Program and deemed it appropriate. Nursing staff were re-educated by the DON/Designee on the Brace and Splint Program. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review 5 residents weekly for four weeks to ensure that their devices are being utilized by physician order, then monthly for 3 months. The results of these audits will be forwarded to the QAPI Committee for further guidance and direction. The NHA is responsible for continued compliance.
Failure to Follow Two-Person Assist for Bed Mobility
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) provided peri-care to a female resident with dementia, morbid obesity, and right-sided weakness and paralysis following a stroke, without following the resident's care plan intervention. The care plan specified that the resident was dependent on two staff members for bed mobility. However, during the observed care, only one staff member was present to assist the resident with bed mobility, and the CNA instructed the resident to roll onto her sides without additional assistance. This action was not in accordance with the documented safety intervention for the resident.
Plan Of Correction
F tag 689 Accidents SS=BAccidents 1. Resident #25 was evaluated to determine if any injuries were sustained due to staff's failure to follow the care plan/Kardex during repositioning the resident. No injuries noted due to deficient practice. The CNA involved received 1:1 education. 2. Residents who reside in-house are at risk due to the deficient practice. Residents in-house who sustained an accident in the last 10 days were reviewed by the nursing team to ensure that the care plan was followed and that the accident didn't occur based on failure to follow the care plan. Any concerns will be addressed. 3. The QAPI Committee reviewed the Standards of CNA/STNA Practice and deemed it appropriate. CNA's were re-educated by the DON/Designee on the Standards of CNA/STNA Practice. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review residents with accidents weekly times four to ensure that their care plans are being followed, then monthly x 3 months. The results of these audits will be forwarded to the QAPI Committee for ongoing direction and further guidance. The NHA is responsible for continued compliance.
Failure to Provide Emergency Lighting at Main Electrical Room Transfer Switch
Penalty
Summary
During an observation on April 24, 2025, at approximately 10:29 am, it was found that the facility did not provide a battery pack emergency light at the transfer switch located in the main electrical room. This was identified as a failure to ensure automatic emergency lighting in accordance with section 7.9. The deficiency was confirmed through an interview with the facility's environmental supervisor at the time of the observation. This deficiency could affect all occupants, staff, and visitors in the event that the emergency power systems fail to operate as designed during an electrical utility power outage.
Plan Of Correction
K291 Emergency Lighting SS=F 1. A battery pack emergency light was installed at the transfer switch located in the main electrical room on 5/15/25. 2. Residents residing within the facility have the potential to be affected. 3. Facility administrator has re-educated the maintenance director on the regulatory requirement for an emergency backup light at the transfer switch. The facility preventative maintenance system (TELS) has been updated to ensure that back up lighting is testing per regulatory standards. 4. Facility Administrator and/or designee will verify regulatory compliance with emergency backup lighting monthly x4. Findings will be reported to the QAPI committee for further review and/or recommendations. The Administrator is responsible for sustained compliance.
Failure to Provide Required Fire Protection for Hazardous Area
Penalty
Summary
A deficiency was identified when a wheelchair battery charger was observed in use within a resident room located in the sub-acute rehab wing. The facility failed to ensure that hazardous areas, such as those where battery charging occurs, were protected by a fire barrier with a 1-hour fire resistance rating and 3/4 hour fire rated doors, or by an automatic fire extinguishing system as required by code. The doors to these areas were also not self-closing or automatic-closing as specified by the regulations. During the survey, the environmental supervisor confirmed that residents' wheelchair batteries are charged within their rooms as needed. This practice was directly observed and verified through staff interviews. The deficiency was cited due to the lack of appropriate fire protection measures in areas where hazardous activities, such as battery charging, take place.
Plan Of Correction
K321 Hazardous Areas SS=E 1. The power chair in room 121 was unplugged immediately and relocated for charging. The resident residing in room 121 was educated that the facility will need to charge the chair in a safe area (Therapy Room). 2. Residents residing within the facility have the potential to be affected. Residents utilizing power chairs have been educated that chairs need to be charged in the Therapy Dept and not within their rooms. 3. Staff have been educated that wheelchairs cannot be charged in resident rooms but only in the Therapy Room. 4. The Maintenance Director and/or designee will audit weekly x4, monthly x3 to ensure that wheelchairs are being charged in the designated area. Findings will be reported to the QAPI Committee for further review and recommendations. The Administrator is responsible for sustained compliance.
Failure to Maintain Required Kitchen Hood Cleaning and Inspection Documentation
Penalty
Summary
The facility failed to provide documentation of the required semi-annual hood cleaning service report for the kitchen hood system, as required by NFPA 96. Although an invoice for the hood service was provided by regional staff, the actual cleaning report was not available for review. Additionally, the facility did not provide documentation of the required owner's monthly hood suppression inspection, as mandated by NFPA 17A. Both deficiencies were confirmed through interviews with regional staff at the time of observation. These lapses could potentially affect kitchen staff and 23 occupants within the nearest smoke compartment in the event of a fire within the kitchen hood system.
Plan Of Correction
K324 Cooking Facilities SS=E1. The required semiannual hood cleaning was completed on 4/9/25. The monthly hood suppression inspection was completed May 1, 2025, and signed off through TELS and signed off on the tag that is located in the dietary dept. The NHA validated that the TELS system has a monthly task to complete the monthly hood suppression inspection and that it was signed off in a timely manner by the Maintenance Director. The NHA educated the Maintenance Director on obtaining and uploading service inspections into the TELS system and completing the monthly hood suppression inspection. The NHA will validate that the monthly hood suppression inspections are completed and checked off monthly for 3 months and that service reports are uploaded into the TELS system from the Date of Compliance. The results of these audits will be forwarded to the QA Committee to ensure continued compliance. The NHA is responsible for ongoing compliance.
Failure to Monitor Resident with Chest Pain
Penalty
Summary
The facility failed to adequately assess and monitor a resident, identified as Resident #101, who was experiencing chest pain and using nitroglycerin. Resident #101, who was cognitively intact and had a history of congestive heart failure and hypertensive heart, reported chest pain to a family member over the phone. Despite the resident's complaints and the family member's insistence, the nurse on duty focused on removing the nitroglycerin bottle from the resident's room rather than assessing the resident's condition or taking vital signs. The nurse did not return to the resident's room for an extended period, during which the resident took multiple doses of nitroglycerin without proper monitoring. The nurse, identified as LPN B, documented the presence of the nitroglycerin bottle and the resident's refusal to relinquish it but failed to document any vital signs or assessments related to the resident's chest pain. The nurse contacted the Assistant Director of Nursing (ADON) and the on-call physician but did not communicate the resident's chest pain or nitroglycerin use. The ADON instructed the nurse to check vital signs every hour, but no such documentation was found in the resident's electronic medical record. The nurse practitioner was also not informed of the resident's chest pain or nitroglycerin use. Interviews with other staff members, including a CNA and RN, revealed that the resident's complaints of chest pain were not properly addressed, and the necessary evaluations were not conducted. The Director of Nursing (DON) confirmed that residents with chest pain should be promptly evaluated, including taking vital signs after each dose of nitroglycerin. The failure to assess and monitor the resident's condition resulted in incomplete information being communicated to medical practitioners and the potential for unnoticed cardiovascular compromise.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to accurately assess, provide treatments as ordered, and ensure physician oversight for wounds for two residents, resulting in significant deficiencies. Resident #276, a male with a history of chronic osteomyelitis and other conditions, was not provided care in accordance with professional standards. His left heel wound was not accurately assessed or treated promptly, leading to the development of osteomyelitis. Despite the wound being identified on 12/21/23, appropriate treatment was delayed, and the wound deteriorated significantly, showing signs of infection and requiring hospitalization for severe bone infection and surgical intervention. The facility's documentation and follow-up were inconsistent, and the wound team did not adequately monitor or update the treatment plan, resulting in further complications for the resident. Additionally, the facility failed to ensure the availability of necessary wound care supplies, further delaying treatment and exacerbating the resident's condition. Resident #64 experienced a similar lack of proper wound care. The resident's right heel wound, initially identified as a stage 3 pressure ulcer, was not treated consistently as per the orders. The dressing changes were not performed as scheduled, and the wound showed signs of maceration and significant deterioration. A new wound on the left heel was also identified but not promptly addressed. The facility's documentation of wound measurements was inconsistent, and there was a lack of manual measurements and depth recording, leading to inadequate monitoring and treatment of the wounds. The care plan for this resident did not focus on healing or preventing the worsening of the wound, and the facility failed to ensure timely and appropriate wound care interventions. The deficient practices in the facility placed all residents at risk for pressure injuries and delayed wound healing. The facility's failure to accurately assess, document, and treat wounds as ordered, along with inadequate physician oversight and lack of timely interventions, resulted in significant harm to the residents. The facility's policies and procedures for wound care were not followed, leading to the deterioration of existing wounds and the development of new pressure injuries. The lack of proper wound care management and oversight highlights serious deficiencies in the facility's ability to provide adequate care for residents with skin integrity issues.
Failure to Manage Respiratory Illness Outbreaks
Penalty
Summary
The facility failed to promptly identify and manage an outbreak of acute respiratory illness, including COVID-19, Influenza, and Respiratory Syncytial Virus (RSV). The facility did not implement transmission-based precautions for residents showing symptoms, nor did it ensure prompt testing and documentation of surveillance for respiratory infections. This led to widespread transmission among residents and staff. Specific instances included a CNA testing positive for COVID-19 without subsequent contact tracing or testing of potentially exposed individuals, and multiple residents and staff members testing positive for COVID-19 over several months without adequate outbreak investigation or containment measures being documented or implemented. The facility also failed to manage an influenza outbreak effectively. Staff members and residents who exhibited symptoms or tested positive for influenza were not promptly isolated or treated with antiviral medications. For example, a resident who tested positive for Influenza A was not placed in droplet isolation while symptomatic, and there was no documentation of contact tracing or offering of antiviral medications to exposed individuals. This lack of action contributed to the spread of influenza within the facility. Additionally, the facility did not properly handle an RSV outbreak. Residents and staff who tested positive for RSV were not placed in appropriate isolation, and there was no outbreak investigation or contact tracing conducted. The facility's infection control practices were inadequate, as evidenced by the lack of training and proper implementation of transmission-based precautions. This resulted in multiple residents testing positive for RSV over several months without adequate measures to prevent further transmission.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide the pneumococcal immunization to a resident as per consent and CDC recommendations. The resident, a [AGE] year-old female, was admitted to the facility on 1/23/24 and had consented to receive the pneumonia vaccine on the same day. However, the resident did not receive the vaccine before being discharged. The resident was later admitted to the hospital with RSV and right lobe pneumonia, which was confirmed by a chest x-ray. The Infection Control Preventionist acknowledged that the resident did not receive the vaccine and admitted to missing this requirement. The facility's policy on pneumococcal vaccination, last revised on 3/27/23, states that all residents aged [AGE] years or older, or younger residents with underlying conditions, should receive the pneumococcal vaccine. Despite this policy, the resident did not receive the vaccine, leading to a failure in adhering to the established guidelines. This oversight was identified during an interview with the Infection Control Preventionist, who confirmed the lapse in administering the vaccine to the resident.
Medication Administration Deficiencies and Staff Conduct Issues
Penalty
Summary
The facility failed to administer controlled medications following physician orders and professional standards of practice for six residents, resulting in medication errors and the withholding of medications without a physician order. For example, Resident #13 did not receive a scheduled dose of gabapentin, and the documentation was inconsistent between the Controlled Substances Proof of Use form and the Medication Administration Record. Similarly, Resident #25 did not receive multiple doses of tramadol, despite documentation indicating otherwise. Resident #58 also missed a dose of tramadol, with discrepancies noted in the records. The Director of Nursing confirmed these medication errors and reported immediate education on narcotic administration would begin. Additionally, the facility failed to administer medications according to physician-ordered parameters for several residents. Resident #11 received metoprolol despite having a heart rate below the prescribed threshold on multiple occasions. Resident #275 was administered glipizide even when blood sugar levels were below the specified limit. Resident #43 received midodrine despite having a systolic blood pressure above the ordered parameter. These actions indicate a lack of adherence to physician orders and professional standards of practice. Furthermore, there were issues with the administration of insulin and potential staff impairment. Resident #2's insulin was administered without priming the pen or holding it to the skin for the required time, contrary to manufacturer guidelines. Resident #225 reported that an LPN who administered her nighttime medications appeared to be under the influence of alcohol. These incidents highlight significant lapses in medication administration and staff conduct, contributing to the overall deficiencies noted in the facility.
Failure to Ensure Proper Oversight and Care by Director of Nursing
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse in a facility with a daily average census of more than 60 residents. This resulted in a lack of consistent clinical services oversight and negative resident outcomes. The DON worked as a charge nurse for over 110 hours since January 2024, which prevented her from fulfilling her full-time responsibilities as the DON. This led to missed laboratory testing, treatments, and medications, as reported by a Licensed Practical Nurse (LPN). The DON admitted to working as a charge nurse and acknowledged the difficulty in keeping track of her hours for the Payroll Based Journal (PBJ) report. The deficiency was further highlighted by the identification of an Immediate Jeopardy (IJ) at F-686, Pressure Ulcer Prevention and Care. This began when facility licensed nurses failed to accurately assess, provide treatments as ordered, and ensure physician oversight for a resident's newly identified pressure injury. Another resident experienced the worsening of a wound on his right heel and developed an additional wound on his left heel due to missed treatments and delayed care. Additionally, it was found that LPNs were administering IV medications through Peripherally Inserted Central Catheters (PICC) lines without evidence of specialized training or oversight, which is outside the scope of practice for LPNs.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure call lights were within sight and reach for a resident reviewed for call light placement. The resident, a [AGE] year old female with diagnoses including acute respiratory failure with hypoxia, COPD, chronic pain, retention of urine, and severe protein-calorie malnutrition, was observed multiple times with the call light out of reach. On several occasions, the call light was draped over the footboard or curled up at the head of the bed, making it inaccessible to the resident. This was confirmed through interviews and observations over several days, despite the facility's policy requiring call lights to be within easy reach when a resident is in bed or confined to a chair.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain safe water temperatures, resulting in the potential for scalding residents. On 4/22/24, the hot water temperatures in the bathroom sinks of two rooms and the 200 hall spa room were measured and found to be excessively high, ranging from 123 to 130 degrees Fahrenheit. Resident #52 confirmed that the water gets very hot. During an interview, the Maintenance Director admitted that the water temperature was turned up to 140 degrees last year and some sinks were missing point-of-use mixing valves, which had not yet been installed. The facility's water temperature logs from January to April 2024 consistently showed temperatures exceeding 120 degrees in various locations, including the Beauty Shop Hair Sink and multiple showers in the 300 Spa area.
Failure to Ensure Appropriate Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatments and orders were in place to prevent catheter-associated urinary tract infections for a resident with a primary diagnosis of unspecified dementia, pressure ulcer, MSSA, and obstructive and reflux uropathy. During an observation, two LPNs were seen performing a catheter flush on the resident using normal saline, despite not knowing the reason for the procedure. They did not use gowns or face shields, increasing the risk of infection. The order for the catheter flush had been in place since the resident's admission, but neither the LPNs nor the Director of Nursing (DON) could identify its origin or necessity. The DON speculated that the order might have come from a hospitalization but could not confirm this. Upon contacting the resident's urologist, it was confirmed that the urologist did not order the catheter flushes and would not recommend them due to the significant risk of infection from opening the closed drainage system twice a day. This lack of clarity and improper procedure led to the potential for complications from cross-contamination and infections.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to ensure best practice standards for residents receiving supplemental oxygen. Resident #67, a female with chronic obstructive pulmonary disease and obstructive sleep apnea, was observed receiving oxygen at 2.5 liters per minute via nasal cannula on multiple occasions without a date on the oxygen tubing indicating when it had last been changed. This lack of documentation and monitoring could lead to potential health risks for the resident. Resident #70, a female with acute respiratory failure with hypoxia and chronic obstructive pulmonary disease, also experienced deficiencies in her respiratory care. Her electronic medication and treatment administration record did not contain an order for the rate of oxygen delivery, nor did it document regular observations by nursing staff to ensure the oxygen was set correctly. Additionally, her care plan lacked interventions for supplemental oxygen use and concerns for COPD. Observations revealed undated oxygen tubing and humidifier bottles, and reports indicated that the oxygen concentrator was sometimes set incorrectly. The Director of Nursing was unable to explain the discrepancies in the dating of the oxygen tubing.
Untrained LPN Administers IV Medication
Penalty
Summary
The facility failed to ensure that intravenous (IV) medications were administered by licensed nurses who had demonstrated proficiency with IV medication administration through training and monitoring in accordance with State professional standards of practice. This deficiency was observed when a Licensed Practical Nurse (LPN) administered IV antibiotics to a resident without having the required specialized training. The facility's Charge Nurse Job Description and Medication Administration policy both emphasize the need for safe and accurate medication administration by qualified personnel, but these standards were not met in this instance. The Director of Nursing (DON) confirmed that the LPN did not have specialized training at the facility and could not provide proof of such training from any other facility. The incident involved a resident who was admitted with diagnoses including discitis of the lumbosacral region, cellulitis of the back, streptococcus infection, and a pressure ulcer of the sacral region. The resident had an order for Penicillin G Potassium to be administered intravenously for sepsis and wound care. During an observation, the LPN was seen performing tasks such as flushing the PICC line and administering the IV antibiotics, which are outside the scope of practice for an LPN in the State of Michigan. The DON later confirmed that there was no documentation of specialized training for any LPN to administer IV medications through PICC lines at the facility.
Failure to Maintain Clean Ventilation Filters
Penalty
Summary
The facility failed to maintain clean ventilation filters, resulting in reduced air quality and circulation in resident rooms 204, 214, 326, and 327. On multiple occasions, PTAC units in these rooms were observed to be caked with dust. A resident reported that maintenance had not changed the filter since before winter, and the air seemed to come out slower. The Maintenance Director stated that filters are supposed to be checked monthly and changed as needed, but the facility's preventative maintenance program requires filters to be replaced or thoroughly cleaned every three months. The maintenance log showed the task was last completed on 3/31/2024.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to operationalize policies and procedures to appropriately evaluate and assess pain for a resident, resulting in the absence of pain assessments and unmet pain needs. Resident #27, a [AGE] year-old female with severe cognitive impairment and a history of stroke with right-sided hemiplegia and contracture, was not consistently assessed for pain using the appropriate Pain Assessment in Advanced Dementia (PAINAD) scale. Despite having a history of pain and being prescribed pain medication, the resident's pain was not adequately monitored or documented, leading to an increased perception of pain and unmet pain needs. Observations and interviews revealed that the resident displayed signs of pain, such as facial grimacing and verbalizing pain, but staff did not consistently use the PAINAD scale to assess her pain. The resident's pain assessments were sporadic, with significant gaps between assessments, and there was a lack of documentation regarding the type, severity, onset, duration, location, or quality of pain. This inconsistency in pain assessment and documentation indicates a failure to follow the facility's pain management policy, which requires regular monitoring and evaluation of pain, especially for residents with cognitive impairments. The facility's policy on pain management emphasizes the importance of evaluating and identifying pain, developing a care plan, and monitoring residents for pain regularly. However, the facility did not adhere to these guidelines, as evidenced by the lack of consistent pain assessments and inadequate documentation of the resident's pain. This failure to properly assess and manage pain for Resident #27 highlights a significant deficiency in the facility's pain management practices, resulting in the resident's increased perception of pain and unmet pain needs.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that Resident #64 received medications as ordered. Resident #64 was admitted with a primary diagnosis of unspecified dementia, pressure ulcer of the right heel, stage 3, Methicillin Susceptible Staphylococcus Aureus (MSSA), and obstructive and reflux uropathy. The resident was seen by a urologist for urinary retention and bilateral hydronephrosis, and the urologist prescribed a single-day antibiotic prophylaxis. However, the facility administered the antibiotic Bactrim DS daily from 4/16/2024 to 4/28/2024 without an order from the urologist to do so. During interviews, the Medical Assistant for the urologist confirmed that the antibiotic was intended for one day only. The Director of Nursing was unable to explain why the antibiotic was started without a proper order, and the Infection Control Nurse admitted to not having a copy of the urologist's order and failing to verify the transcription. The Infection Control Nurse also demonstrated a lack of knowledge regarding McGeer's criteria for starting an antibiotic in a resident with an indwelling catheter.
Inappropriate Antibiotic Utilization
Penalty
Summary
The facility failed to ensure that a resident who required an antibiotic was prescribed the appropriate antibiotic. A resident, a [AGE] year-old female with chronic kidney disease, was admitted to the facility and later reported not voiding for 12 hours. A straight catheterization was performed, and a urine dipstick test indicated a urinary tract infection (UTI). Consequently, the resident was prescribed Augmentin 500 mg three times a day for 10 days without waiting for the results of a urinalysis and culture and sensitivity test. The resident received the antibiotic from the morning of 4/14/24 through the evening of 4/23/24, despite the absence of a positive urinalysis and culture and sensitivity results. The Infection Control Preventionist (ICP) confirmed that the resident exhibited no signs or symptoms of a UTI, did not meet the McGeer Criteria for diagnosing a UTI, and had no history of UTIs. The facility's policy on antibiotic stewardship emphasizes the importance of prescribing antibiotics only when appropriate and discourages the use of broad-spectrum antibiotics while a culture is pending. The ICP reported that a culture and sensitivity should be reviewed prior to initiating antibiotic treatment to ensure the appropriate antibiotic is prescribed. The facility's failure to adhere to these guidelines resulted in inappropriate antibiotic utilization for the resident.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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