The Laurels Of Sandy Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Wayland, Michigan.
- Location
- 425 E Elm St, Wayland, Michigan 49348
- CMS Provider Number
- 235313
- Inspections on file
- 29
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at The Laurels Of Sandy Creek during CMS and state inspections, most recent first.
The facility failed to maintain its roof and ceilings, leading to extensive leaks, stained and deteriorating ceiling tiles, rusted light fixtures, and moisture-damaged walls across multiple halls, nurses’ stations, medication rooms, and spa areas. One cognitively intact resident had to be moved from a preferred room after prolonged roof leaks caused a large stained area near a light fixture and disrupted use of the room, while another resident with chronic pain, depression, and moderate cognitive impairment slipped and fell on water that had leaked from the roof onto his room floor. Staff, including CNAs, an LPN, and the former DON, reported that the roof had been leaking for many months to over a year, that residents and their belongings were repeatedly exposed to water, that residents were frequently relocated due to leaks, and that water sometimes dripped on residents in shower rooms.
Two residents were subjected to abuse by nursing staff. In one case, a cognitively intact resident and his roommate reported that an RN, during a night shift interaction about oxygen use, cursed at the resident, stated "I hate you," and made an obscene gesture, which the facility’s own documentation identified as verbal abuse. In the second case, a resident with dementia, chronic pain, anxiety, and a history of pacing and anxiety-related behaviors was confronted by an LPN while she stood at a med cart. Witnesses reported that the LPN escalated the situation, grabbed the resident’s wrists, forced her arms behind her back in a painful position, slammed her into doors, took her into her room amid loud banging and the resident’s cries that she was being hurt and could not breathe, and repeatedly slammed the door on the resident as she tried to exit, while yelling at her and threatening to fight her. The resident was later observed crying, shaken, and disheveled, and reported that the LPN had choked and thrown her down. Facility leadership substantiated that verbal abuse occurred in the first case and verbal and physical abuse occurred in the second, demonstrating a failure to keep residents free from abuse by staff.
A resident with chronic pain, anxiety, and dementia became agitated and was pacing when an LPN told the resident to go to their room and stay there; after the resident refused and attempted to strike the LPN, the LPN placed the resident’s arms behind their back, physically moved the resident to the room, and closed the door, during which the resident said, “stop that hurts.” The facility’s investigation concluded the LPN’s actions constituted verbal and physical abuse and led to disciplinary action and termination, but the administrator did not submit the required report of this substantiated abuse and employment action to the state licensing authority as mandated by Michigan law, stating that although the form was completed, it was never faxed.
A resident with multiple pressure ulcers, hemiplegia, and significant skin integrity impairment had physician orders and a care plan for daily wound care to the right elbow, right plantar foot, and heel, continuous use of a soft pillow boot on the right arm, pressure-reducing boots to both feet, and regular turning and repositioning. Surveyors observed the resident in bed without the ordered pressure-reducing boots, with feet resting directly on the mattress, and later found the right elbow wound open to air with no dressing present. Staff interviews confirmed that the resident was supposed to have these pressure-relief devices in place at all times and that the resident tolerated them, while an LPN acknowledged that CNAs often failed to report when dressings were removed or dislodged, leading to missed reapplication. These findings show the facility did not consistently implement the resident’s care plan and wound care orders.
A resident with dysphagia and malnutrition, dependent on tube feeding, was repeatedly observed receiving Jevity 1.5 at 80 mL/hr while lying flat or with the head of bed below the ordered 30-degree elevation. Open Jevity containers, including one from the prior day and another undated, were left partially full on the tray table, and the feeding bag in use was not labeled or dated over multiple observations. An LPN acknowledged the resident was positioned "way too flat" and that enteral formulas should be dated and discarded appropriately, but no further assessment was performed. These actions and omissions conflicted with the resident’s orders, care plan, and the facility’s enteral feeding policy requiring semi-Fowler’s positioning and proper formula dating.
A resident with a history of elopement risk and severe psychiatric conditions exited the facility unnoticed, despite having a Wanderguard and being care planned for elopement risk. Staff failed to respond appropriately to repeated exit door alarms, did not conduct a code search when the resident was missing, and did not accurately document the resident's elopement risk, resulting in the resident being found outside the facility by an off-duty staff member.
Surveyors observed multiple failures in food service safety, including unclean utensils and pans, improper cooling and storage of food, incorrect storage of ice and ice scoops, a faulty refrigeration seal, plumbing issues in the chemical closet, and excessive sanitizer concentrations. These actions and inactions did not meet professional standards and FDA Food Code requirements.
A resident with hypertension received Lotrel outside of physician-ordered blood pressure parameters on multiple occasions. Despite a pharmacy recommendation to remind staff about proper administration, the DON did not recall the recommendation and did not provide follow-up education to nursing staff. Facility policy requiring adherence to physician orders for medication administration was not followed.
The facility did not consistently honor residents' documented food preferences and allergies, resulting in multiple residents being served unwanted or allergenic foods. Several residents expressed frustration and sadness over receiving items they disliked or were allergic to, and staff interviews revealed a lack of awareness and adherence to dietary requirements. One resident with a known allergy to pickles and cucumbers was served potato salad containing pickles, leading to an allergic reaction and the need for medication.
A resident with a history of stroke and impaired use of her dominant arm was not provided with the built up utensils specified in her care plan and physician's orders. Despite clear documentation and staff acknowledgment of the need for adaptive equipment, the resident was repeatedly served regular silverware, resulting in observable difficulty eating and handling utensils.
Surveyors observed unsanitary conditions in common and spa areas, including food debris on furniture, dried bowel movement on commodes, and improper storage of clean linens and hygiene products. Multiple exit doors had gaps and faulty weatherstripping, allowing light, air, and potential pest entry. Staff interviews confirmed these practices did not follow facility protocols for cleanliness and storage.
A resident was left alone in her room with multiple medications provided by an LPN, without a completed self-administration assessment or physician order as required by facility policy. The DON confirmed that the necessary evaluation had not been performed, and the medications were removed after the oversight was discovered.
A resident with a documented DNR order was given CPR by an LPN after becoming unresponsive, as staff were unable to quickly verify the resident's code status. Approximately 45 seconds of compressions were performed before the DNR was confirmed and CPR was stopped. The incident highlighted that code status information was not readily accessible to staff during emergencies, leading to the failure to honor the resident's advance directive.
A resident was inaccurately assessed as having schizophrenia on multiple MDS assessments, despite no supporting diagnosis, behaviors, or treatment orders in their medical record. Staff interviews confirmed the error, and the resident's actual diagnoses included depression and dementia without psychotic features.
Staff did not follow Enhanced Barrier Precautions for a resident with an abdominal feeding tube and moderate cognitive impairment. During high-contact care activities, two CNAs wore gloves but failed to wear gowns as required, despite clear signage and facility policy. One CNA admitted to forgetting the precautions and not always noticing the posted signage, and the DON confirmed the resident was on EBP requiring both gowns and gloves.
The facility did not have a full-time Registered Dietitian or Certified Dietary Manager overseeing food and nutrition services. The Dietary Manager had not completed the required certification within the allowed timeframe and believed he had more time to do so. The dietitian only visited two days per week, and staff records confirmed the absence of a full-time qualified dietary professional.
A resident with complex medical and psychological conditions experienced inappropriate interactions with staff due to inadequate training in handling severe behavioral and mental health concerns. An LPN used inappropriate language, and staff lacked specific training for managing such behaviors, leading to unmet care needs and inappropriate interactions.
A resident with a complex medical and behavioral history was involuntarily secluded after becoming agitated, leading to a physical altercation with staff. The staff did not effectively manage the situation, lacking training specific to the resident's needs. The facility's training on handling mental health crises and performing physical restraints was found to be insufficient.
The facility's infection control surveillance was found deficient due to inaccurate and incomplete data collection. The IP failed to provide a current list of residents on antibiotics, and the infection control report did not accurately reflect the status of several residents receiving treatment. The DON confirmed that daily discussions on infections and antibiotics were not properly documented in the report, leading to ongoing non-compliance.
The facility failed to follow professional standards for medication administration and documentation. An RN administered medications to two residents simultaneously without confirming their identities or the medications, and documented medications for three residents incorrectly. The RN did not follow proper procedures for verifying and documenting medications, and admitted to not knowing the facility's policy. The DON confirmed that the facility's procedures were not followed, posing a risk of medication errors.
A resident with a history of breast cancer and reconstructive surgery felt humiliated and embarrassed due to missing bras, which were essential for her self-esteem. Staffing issues in the laundry department led to delays in returning personal items, and the nursing staff failed to address the resident's concerns promptly, impacting her dignity and quality of life.
Widespread Roof Leaks, Water Damage, and Resident Fall Due to Unsafe Environment
Penalty
Summary
The facility failed to maintain the roof and interior ceilings in a safe, functional, and sanitary condition, resulting in widespread leaks and water damage throughout resident care areas. Observations on multiple halls revealed discolored, brown, and black ceiling tiles, sagging tiles, bubbling and chipping wall surfaces, rusted light fixtures, and makeshift systems such as plastic tarps funneling water into buckets at the nurses’ station. The East wing medication room and spa areas showed signs of heavy moisture damage, and numerous ceiling tiles in various halls were dried out and stained, indicating ongoing and repeated water intrusion. One cognitively intact resident had lived in a room with a large orange ceiling stain near a light fixture, measuring approximately 17 by 22 inches, with raised areas suggesting buildup or deterioration. This resident reported that the ceiling had been leaking for over a year, causing the light fixture to stop working and requiring him to move his bed and eventually be transferred to another room. Facility records confirmed that he was moved from that room due to roof leaks, and resident council minutes documented resident concerns about leaks in rooms. Another resident, with chronic pain, depression, and moderate cognitive impairment, experienced a fall in his room after slipping on water that had leaked from the roof onto the floor. An incident report and staff interviews described the resident being found on the floor near his bed with water present on the floor, and the resident himself reported that the roof had been leaking into his room for quite some time. Multiple staff members, including CNAs and the former DON, reported that the roof had been leaking for months to over a year, that residents and their belongings were getting wet, that residents were frequently moved from leaking rooms, and that leaks extended into shower rooms where residents were being dripped on during showers.
Failure to Protect Residents From Verbal and Physical Abuse by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and physical abuse by nursing staff. One cognitively intact resident with a BIMS score of 13 reported that a night-shift RN told him he did not need oxygen, said “f*** you, I hate you,” and gave him the middle finger during a late-night interaction. The resident stated this was the first time the RN had used that specific profanity toward him, but that the RN had previously told him he did not like him. The resident’s roommate, who also had a BIMS score of 13, corroborated hearing the RN and the resident arguing and hearing the RN use a curse word and say “I hate you.” Facility documentation, including the facility-reported incident and complaint forms, identified this as an allegation of verbal abuse by the RN, and the facility concluded that verbal abuse had occurred based on the resident’s report and the roommate’s confirmation. A second deficiency involved physical and verbal abuse of another resident by an LPN. This resident had chronic pain, anxiety, dementia, and a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for impaired communication and potential verbal aggression related to dementia, depression, and poor impulse control. On the evening in question, the resident was pacing the hallway as was her usual pattern. According to the LPN involved, she approached the resident at another nurse’s medication cart, asked the resident to give the other nurse space, and then, after the resident turned and began swinging at her, she got behind the resident and guided her to her room with her hands around the resident’s arms. The LPN stated the resident went into her room, continued pacing, and voiced intent to leave, and that she did not yell but had a loud voice. Multiple staff witnesses provided a different account of the same event, describing escalating verbal and physical actions by the LPN toward the resident. A former CNA reported that the LPN had been rude to the resident earlier, then told the resident she was bothering the other nurse and needed to go to her room. When the resident refused, the LPN escalated, grabbed both of the resident’s wrists, forced her arms together behind her back, and held them up in a way that appeared painful while walking her down the hall. The CNA stated the resident repeatedly yelled “ouch, that hurts” and “get off of me,” and that the LPN “bashed” the resident into a utility closet door and then into the entrance area of the resident’s room before entering the room and slamming the door. The CNA reported hearing further “bashing” noises and the resident screaming “Stop, I can’t breathe,” and later observed the resident visibly shaken, crying, with disheveled hair, and reporting that the LPN had choked her and thrown her to the ground. Another LPN witness stated that the resident had been calmly standing and chatting at her med cart, which helped the resident’s anxiety, and that the resident was not being disruptive when the involved LPN approached and told the resident the nurse did not want her bothering her. According to this witness, the resident laughed, which appeared to escalate the LPN, who then loudly insisted the resident go to her room. When the resident refused and attempted to strike the LPN, the LPN grabbed the resident’s arms, “whipped” them behind her back, and walked her toward her room while the resident yelled that she was being hurt and tried to break free. This witness also described the LPN picking up the resident and slamming her into the utility closet door, then taking her toward her room, after which loud bashing noises and the resident’s yelling were heard from the room. Both this LPN and the CNA reported seeing the LPN slam the resident’s door on her twice as the resident tried to exit, while yelling at her to stay in her room, and hearing the LPN say she would “fight” the resident. Additional corroboration came from the receptionist, who encountered the resident shortly after the incident. The receptionist described the resident speed walking, crying, and saying she had just gotten into a fight. When the receptionist attempted to escort the resident back toward her room, the resident became more distressed and said she did not want to go down that hallway because she did not want another fight. The receptionist observed the resident’s hair was messed up and that she appeared very shaken, and reported that the resident said the LPN had grabbed her by the shirt and thrown her down. The administrator later confirmed that, based on witness interviews, she substantiated that the LPN had verbally and physically abused the resident. Together, these events demonstrate that the facility failed to ensure residents were free from verbal and physical abuse by staff, as required by its abuse policy and resident rights. The facility’s own investigation documents characterized the LPN’s conduct as verbal and physical abuse and noted that the LPN did not use de-escalation skills and that her frustration intensified the situation. The resident involved had known behavioral and communication needs, including dementia and a history of pacing and anxiety, and the care plan called for specific communication and de-escalation strategies such as not rushing, using simple cues, and providing verbal and physical cues to alleviate anxiety. Despite these identified needs and interventions, the LPN’s actions, as described by multiple witnesses and the resident, involved forceful physical handling, painful arm positioning, slamming into doors, door slamming to confine the resident, and threatening statements, all of which constituted abuse and a failure to follow the resident’s care plan and the facility’s abuse policy. In both cases, the residents and witnesses were considered by the administrator and social worker to be reliable historians without a known history of making false allegations. The facility’s own documentation and interviews with leadership acknowledged that verbal abuse occurred in the first case and that verbal and physical abuse occurred in the second case. These findings establish that the facility did not protect residents from all types of abuse by staff, including verbal and physical abuse, as required by regulation and by the facility’s own abuse policy, resulting in residents being subjected to abusive language and physically abusive handling by nursing staff.
Failure to Report Substantiated Staff Abuse to State Licensing Authority
Penalty
Summary
The deficiency involves the facility’s failure to follow policies and state law requiring timely reporting of staff-to-resident abuse to the appropriate state licensing authority. Resident #104, who had chronic pain, anxiety, and dementia, was involved in an incident where an LPN (LPN CC) engaged in conduct that the facility later substantiated as verbal and physical abuse. According to the facility-reported incident investigation, the resident was agitated and pacing when LPN CC instructed the resident to go to her room and stay there. The resident refused, approached the LPN, and attempted to strike her. LPN CC then placed the resident’s arms behind her back, physically assisted the resident to her room, and closed the door, during which the resident stated, “stop that hurts.” The facility’s in-depth analysis documented that the LPN did not use de-escalation skills and that her frustration intensified the situation, resulting in verbal and physical abuse. The investigation summary did not document that the facility reported LPN CC to the State Bureau of Professional Licensing, despite the substantiated abuse and the disciplinary action taken against the nurse. During interviews, the Nursing Home Administrator confirmed that she had substantiated the verbal and physical abuse and that the LPN’s employment had been terminated. When asked whether the termination and abuse had been reported to the State Bureau of Professional Licensing, the administrator initially could not recall and later confirmed that no report had been made. She stated that she had completed the reporting form but forgot to fax it, and the report was missed. This failure to report occurred despite state law (Michigan Public Health Code MCL 333.20175) requiring health facilities to report specified disciplinary actions and employment changes related to licensed health professionals within 30 days.
Failure to Implement Ordered Pressure-Relief and Wound Care Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions and physician-ordered wound care for a resident with significant skin integrity issues. The resident had chronic pain, a history of cerebral infarction with expressive aphasia, left hemiplegia, obesity, bowel incontinence, diarrhea, and moderate protein-calorie malnutrition, and was identified as having actual impairment to skin integrity. The care plan and orders included daily wound care to the right elbow, right plantar foot, and heel, as well as continuous use of a soft pillow boot on the right elbow and pressure-reducing boots to both lower extremities, along with turning and repositioning every two hours and as needed. Despite these orders and care plan interventions, surveyor observations on the same day showed the resident lying on her back in bed without the ordered pressure-reducing boots, which were instead found in a chair, and her feet resting directly on the bed without any offloading devices. Further observation during wound care revealed that when the RN removed the soft pillow from the resident’s right arm, the right elbow wound was open to air with no dressing in place, and no dislodged dressing could be found in the bed or on the floor. Interviews with staff confirmed that the resident was supposed to wear the pressure-reducing devices on the right arm and both feet at all times and that the resident tolerated these devices well. The wound care NP stated that the resident was at high risk for worsening skin breakdown and that adherence to pressure-reducing interventions was crucial. An LPN reported that CNAs were not consistently communicating when dressings became soiled or dislodged and were removed, resulting in nurses not being notified to reapply dressings. These observations and interviews demonstrate that the facility did not consistently implement the resident’s care plan interventions and wound care orders as written.
Failure to Maintain Safe Positioning and Handling of Enteral Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate care and monitoring for a resident receiving enteral nutrition. The resident had a history of dysphagia following a cerebral infarction and moderate protein-calorie malnutrition, and was dependent on tube feeding and water flushes. Physician orders and the care plan required Jevity 1.5 at 80 mL/hr at bedtime and elevation of the head of bed to at least 30 degrees during feeding. On multiple observations, the resident was found lying flat or with the head of bed not elevated to 30 degrees while the tube feeding was running. During one observation, the assigned LPN acknowledged that the resident was “way too flat” and raised the head of bed to 45 degrees but did not further assess the resident. The facility also failed to ensure proper handling and labeling of enteral feeding formula. Surveyors observed two opened bottles of Jevity on the resident’s tray table, one dated from the previous day and one not dated, both partially full. The running formula bag was not labeled or dated to indicate when the formula was opened or when the feeding was started, and this lack of labeling persisted across several observations on consecutive days. The LPN caring for the resident stated that the open Jevity containers should have been discarded and that nurses were supposed to date enteral feeding formulas with the date and time when opened to ensure the formula was safe and not spoiled. These practices were inconsistent with the facility’s enteral feeding policy, which required residents to be in semi-Fowler’s position (30–45 degrees) during administration and for 30 minutes to one hour after to prevent aspiration.
Failure to Prevent Elopement and Inadequate Response to Exit Door Alarm
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for elopement due to a history of attempts to leave the facility unattended, impaired safety awareness, severe depression with psychotic symptoms, and anxiety, was able to exit the facility without staff knowledge. The resident had a Wanderguard device in place and was care planned for elopement risk, including interventions such as placement and function checks of the Wanderguard, redirection, and 1:1 observation as of the date of the incident. Despite these interventions, the resident was able to leave the facility in a wheelchair and was found approximately 50 yards away on a sidewalk near a road by an off-duty staff member. Staff interviews and record reviews revealed that on the morning of the incident, multiple staff members heard the exit door alarm sounding several times but did not respond appropriately. One CNA deactivated the alarm without fully investigating the cause or ensuring all residents were accounted for, and did not call a code search when the resident's whereabouts were unknown. The DON also deactivated the alarm and returned to her office without first checking outside the building for a missing resident. The alarm system was observed to function properly, sounding when a Wanderguard was near the door, regardless of whether the door code was entered. However, staff failed to follow protocol for responding to exit alarms and did not ensure the safety of residents at risk for elopement. Documentation also showed that the resident's elopement risk assessments were not accurately completed prior to the incident, as they did not reflect the resident's ongoing verbalizations and behaviors indicating a desire to leave. Staff interviews confirmed that the resident had been expressing anger and a desire to leave the facility, but these were not properly documented in the risk assessments. The combination of inaccurate assessments, failure to respond appropriately to exit alarms, and lack of immediate action to locate the resident resulted in the resident eloping from the facility without staff knowledge.
Removal Plan
- DON and nurse assessed Resident #101 in the parking lot and returned him to the facility.
- Resident #101's responsible party was notified.
- Resident #101 was placed in dining room under supervision for breakfast and then on 15-minute checks, escalating to 1:1 supervision after further elopement attempt, until transfer to psychiatric facility.
- Resident #101's elopement risk assessment was updated, and his care plan and orders were reviewed.
- Resident #101's Wanderguard was tested for function and placement upon return to building.
- Elopement books were updated and placed at the front desk and each nurse's station.
- Housekeeping Supervisor and Maintenance Director inspected all emergency exits and completed a Wanderguard test on doors.
- Secure Care was notified to validate door function; maintenance reviewed main door for proper alarm function.
- Secure Care validated and cleared system functions.
- All residents were assessed for risk of elopement; residents determined at risk had care plans reviewed for completeness.
- Maintenance Director or Housekeeping Supervisor/designee checks and logs all exit doors for proper function; Administrator reviews logs.
- DON/designee provided education to staff regarding Elopement policy, including immediate response to door alarms, exiting building for full view, use of light source, and calling code search if no one is observed.
- Staff were educated; remainder received 1:1 education or were educated upon arrival to work before assignment.
- Ongoing staff education on Elopement Policy and procedure, including residents at risk for exit seeking and Wanderguard use.
- Missing Guest Book/Residents with Wanderguards is updated minimally weekly and with any changes by the Interdisciplinary team.
- DON/Designee reviewed all residents at risk for exit seeking and Wanderguards for elopement risk; ongoing assessment upon admission, quarterly, and with change of condition.
- Administrator reviewed the investigation performed by DON and interviewed all staff from relevant shifts.
- Administrator and QAPI committee reviewed the missing guest policy and deemed it appropriate.
- Administrator audited the elopement books for accuracy and currency.
- New employee orientation includes Elopement policy and procedure education.
- Maintenance Director/Designee checks alarmed doors as part of Preventative Maintenance; findings submitted to QAPI committee; Administrator reviews logs.
- Code search drills were held on all shifts; ongoing process of code search drills.
- Medical Director was made aware of the elopement.
- Incident reviewed in ad hoc and monthly QAPI meetings; root cause analysis performed; decision to add light source to reception desk for search.
- Continued education on elopement policy and response to alarms, complete visualization, and calling code search; drills to ensure proper response and reduce alarm fatigue.
- All staff completed education prior to next shift worked.
Deficient Food Service Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain professional standards for food service safety, as evidenced by multiple observations of unclean kitchen equipment and improper food handling. During a kitchen tour, clean utensil bins were found to contain utensils with dried food debris, and clean pots and pans had stuck-on food and faded date stickers that should have been removed during washing. Large sheet pans stored under a preparation table were observed with encrusted grease, and the Dietary Manager acknowledged that staff often rely solely on the dish machine rather than scrubbing by hand. Additionally, the seal gasket on a refrigeration unit was not properly attached, compromising its ability to maintain a good seal. Improper storage and handling of ice and ice scoops were also noted. An ice chest used for water pass was found full of ice with no drainage for melted water, and ice scoops in two pantries were stored right side up in their holders, contrary to best practices for air drying and contamination prevention. The facility did not regularly log cooling for food saved from service, and sausage patties from breakfast were left in a tightly covered container on a preparation table before being moved to a cooler, where their temperature was found to be 88°F, indicating improper cooling procedures. Further deficiencies included a kitchen chemical closet with a four-way splitter on the faucet, causing constant back pressure on the internal vacuum breaker, and two spray bottles of quaternary ammonium sanitizer in the dish machine area with concentrations around 500 ppm. These findings demonstrate a lack of adherence to FDA Food Code requirements for equipment cleanliness, food cooling, utensil storage, plumbing maintenance, and chemical sanitizer use.
Failure to Adhere to Medication Administration Parameters for Antihypertensive
Penalty
Summary
Nursing staff failed to administer medication in accordance with physician orders for a resident with hypertension. The resident had a physician order for Lotrel, an antihypertensive medication, to be held if the systolic blood pressure (SBP) was less than 110 or heart rate was less than 60. Despite this, review of the Medication Administration Record showed that Lotrel was administered on multiple occasions when the resident's SBP was below the ordered threshold. Documentation indicated that an LPN was responsible for administering the medication on most of these occasions. A pharmacy consultation report identified the issue and recommended that staff be reminded of the importance of adhering to medication administration parameters. However, the DON, who signed the pharmacy recommendation, reported not recalling the recommendation and confirmed that no follow-up education or action was taken to ensure staff compliance with the ordered parameters. The facility's own policy requires medications to be administered according to physician orders, but this was not followed in this case.
Failure to Honor Resident Food Preferences and Allergies
Penalty
Summary
The facility failed to consistently honor residents' food and drink preferences, allergies, and intolerances as documented on their meal tickets and care plans. Multiple residents were observed being served food items they had specifically indicated as dislikes, such as sausage, eggs, black pepper, carrots, zucchini, and lima beans, despite these preferences being clearly listed. Residents expressed frustration, sadness, and anger over receiving unwanted food and drink items, and some reported that this was a common occurrence. In several cases, residents left the unwanted food uneaten, and one resident noted that she did not receive the correct number of coffee creamers as requested. In addition to disregarding preferences, the facility also failed to prevent exposure to known food allergens. One resident with documented allergies to cucumbers and pickles was served potato salad containing pickles, which resulted in him experiencing mouth itching and requiring antihistamine and anti-nausea medication. The resident expressed ongoing fear and vigilance regarding his meals due to this incident. Review of his records showed that his allergies were documented in multiple places, including his meal ticket and medical record, but this information was not effectively communicated to or recognized by all staff involved in meal delivery. Interviews with dietary staff and CNAs revealed a lack of awareness and adherence to residents' documented food preferences and allergies. The dietary manager confirmed that food items were available to meet residents' preferences but were not provided as required. Staff also failed to cross-reference ingredient lists with residents' allergies, leading to the serving of allergenic foods. The facility's own policy required that food preferences be identified and honored on tray tickets, but this was not consistently implemented.
Failure to Provide Adaptive Dining Equipment for Resident with Stroke History
Penalty
Summary
A resident with a history of stroke and impaired use of her dominant right arm was repeatedly not provided with the adaptive dining equipment specified in her care plan and physician's orders. Despite clear documentation on her meal tickets and in her care plan indicating the need for built up utensils, she was served regular silverware at multiple meals. Observations showed the resident struggling to handle standard utensils, resulting in awkward and insecure grips, slow eating, and multiple attempts to pick up food. The resident herself reported difficulty using regular utensils and stated that built up utensils would make eating easier. Interviews with staff, including the Dietary Manager, confirmed that the resident was supposed to receive built up utensils with all meals as ordered. The facility's policy also required culinary staff to provide adaptive equipment for residents who would benefit from their use. Despite these requirements, the resident was not provided with the necessary adaptive utensils during the observed meals, leading to ongoing difficulty with eating.
Failure to Maintain Sanitary and Safe Environment in Common and Spa Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During multiple tours of common areas, including the East Day room, East Hall Spa, and various shower rooms, surveyors observed accumulations of food crumbs, paper trash, and debris under and around seat cushions, as well as on furniture. In spa and shower areas, dried bowel movement was found on commodes, and there was an accumulation of dirt and debris behind toilets. Clean linens such as wash cloths and towels were improperly stored on shower chairs and paper towel holders, rather than in designated cabinets, and personal hygiene products were stored alongside cleaning disinfectants. Staff interviews confirmed that these practices were not in accordance with facility protocols, as these areas and items should be cleaned and stored properly to maintain sanitation. Additionally, during a facility-wide inspection, several exit doors were found to have gaps and spaces between the doors, frames, and weatherstripping, allowing visible light, air, and potential pest entry. These deficiencies were observed at multiple exit points, including hall doors and the dining room exit. The combination of unsanitary conditions, improper storage of linens and hygiene products, and compromised building integrity contributed to an environment that was not safe, sanitary, or comfortable for residents, staff, or visitors.
Failure to Assess and Authorize Resident for Medication Self-Administration
Penalty
Summary
A resident was observed alone in her room with eight pills in a disposable medication cup placed next to her meal tray. The medications had been provided by an LPN prior to breakfast, but the resident had not yet taken them, and no staff were present in the room or nearby. The LPN later confirmed she had given the medications to the resident and was unaware they had been left unattended. Upon discovering the situation, the LPN removed the medication cup containing buspirone, duloxetine, ferrous gluconate, furosemide, lisinopril, metformin, metoprolol, and Tylenol from the resident's room. Review of the resident's record revealed that no medication self-administration assessment had been completed, and there was no physician order authorizing self-administration. The facility's policy requires a self-administration evaluation and physician authorization before a resident is permitted to self-administer medications. The resident was cognitively intact according to a recent mental status score, but the required assessment and documentation were not in place, resulting in the resident being left alone with medications contrary to facility policy.
DNR Order Not Honored Due to Delayed Code Status Verification
Penalty
Summary
A deficiency occurred when a resident with a documented Do Not Resuscitate (DNR) order received cardiopulmonary resuscitation (CPR) from facility staff. The resident had a clearly documented DNR order, signed by both the resident and the attending physician, indicating that no resuscitation should be attempted in the event of cardiac or respiratory arrest. On the day of the incident, the resident became unresponsive and staff could not detect a pulse after a transfer using a hoyer lift. A Licensed Practical Nurse (LPN) responded to calls for help and, unable to immediately confirm the resident's code status, initiated CPR. The LPN reported that she began compressions because staff were unable to quickly provide the resident's code status, and she acted as she would in a situation where code status was unknown. Approximately 45 seconds of compressions were performed before other staff confirmed the DNR status, at which point CPR was stopped. The resident subsequently regained a pulse and began breathing again. Interviews with staff revealed that the process for verifying code status was not efficient, as the information was only available in the computer and not readily accessible during emergencies. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that CPR was performed on a resident with a DNR order and that no incident report or immediate follow-up education was completed after the event. The facility's policy required staff to validate code status before initiating CPR, but this was not followed due to delays in accessing the information.
Inaccurate MDS Assessment Due to Erroneous Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure that a resident received an accurate clinical assessment reflective of their actual status at the time of assessment. Specifically, the Minimum Data Set (MDS) assessments for the resident on two separate occasions documented an active medical diagnosis of schizophrenia. However, a review of the resident's electronic health record showed no diagnosis of schizophrenia, no documented behaviors, and no treatment orders related to schizophrenia. The resident's PASARR evaluation also indicated no mental illness, and behavioral care notes described diagnoses of major depressive disorder and dementia without behavioral or psychotic disturbances. Interviews with facility staff confirmed that the resident did not have any orders for psychotropic medications and did not exhibit behaviors indicative of schizophrenia. The MDS-Registered Nurse acknowledged that the schizophrenia diagnosis was entered in error on multiple MDS assessments. This inaccurate documentation resulted in the resident's clinical status being misrepresented in official records.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an abdominal feeding tube and moderate cognitive impairment. During high-contact care activities, including transferring the resident from a wheelchair to bed, assisting with positioning, and checking the resident's incontinence brief, two Certified Nursing Assistants (CNAs) wore gloves but did not wear gowns as required by the facility's EBP policy. Signage on the resident's door clearly indicated that both gloves and gowns were required for high-contact care activities such as transferring and changing briefs. The CNAs involved acknowledged that they had received training on EBP but one CNA admitted to forgetting the resident was on these precautions and sometimes not noticing the posted signage. The Director of Nursing/Infection Preventionist confirmed that the resident was on EBP and that staff were required to wear both gowns and gloves during high-contact care. Review of the facility's policy and physician orders confirmed the requirement for EBP, including the use of gowns and gloves for specified care activities.
Lack of Qualified Dietary Oversight
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian or a Certified Dietary Manager to oversee kitchen and clinical nutritional services. During a kitchen tour, it was observed that the current Dietary Manager had not yet completed the Certified Dietary Manager certification, despite being in the position for over a year. The Dietary Manager believed he was allowed the full duration of the certification course, which is 18 months, rather than the one year permitted upon hire. Additionally, the dietitian only visits the facility two days a week, and a review of staff records confirmed there was no full-time Certified Dietary Manager or full-time Dietitian on staff.
Inadequate Staff Training for Behavioral Health Needs
Penalty
Summary
The facility failed to ensure that staff members possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly in the case of a resident with complex medical and psychological conditions. This resident, a female with diagnoses including spina bifida, chiari syndrome, anxiety, depression, and mood disorders, experienced inappropriate interactions with staff. An incident was reported where an LPN used inappropriate language towards the resident, telling her to "get your ass in your room," which was witnessed by other staff members. The resident expressed dislike for the LPN and another CNA, indicating a strained relationship. Further investigation revealed that the staff lacked training specific to handling residents with severe behavioral and mental health concerns. Interviews with various staff members, including CNAs and LPNs, highlighted a gap in training for dealing with residents who have mental health issues beyond dementia and Alzheimer's. The staff reported feeling unequipped to manage the resident's behaviors, and there was a lack of documented interventions in the resident's care plan to address such situations. The facility's social worker, who was temporarily filling in, also noted that staff did not have a deep understanding of the residents' triggers and effective interventions. The Director of Nursing acknowledged that the staff did not implement person-centered behavioral interventions as outlined in the care plan. The care plan suggested moving the resident to a quiet place to calm down, but the staff's actions of forcing the resident into her room were not part of the care plan. The facility's administrator recognized the challenges faced by the staff in dealing with a younger population with mental health concerns and noted that previous incidents might have influenced staff responses. Despite some training efforts, the facility's staff were not adequately prepared to handle the specific behavioral health needs of the resident, leading to unmet care needs and inappropriate staff-resident interactions.
Failure to Prevent Involuntary Seclusion of Resident with Complex Needs
Penalty
Summary
The facility failed to prevent involuntary seclusion of a resident, identified as Resident #102, who has a complex medical history including spina bifida, chiari syndrome, anxiety, depression, and other conditions. The resident's care plan highlighted past trauma and specific triggers, such as being alone with males and loud noises, which could lead to increased anxiety and agitation. Despite these known triggers, the staff did not effectively manage the resident's behavior, leading to an incident where the resident became agitated and was involved in a physical altercation with staff. On the day of the incident, Resident #102 became frustrated with another resident and a visitor, leading to a situation where staff attempted to escort her to her room. The resident resisted, resulting in a physical struggle where she scratched and attempted to bite staff members. The staff involved did not attempt to redirect the resident or implement other interventions from her care plan, and instead focused on physically moving her to her room, which escalated the situation. Interviews with staff revealed a lack of training specific to handling residents with severe behavioral and mental health issues, contributing to the inadequate response. The facility's training on abuse and neglect was found to be insufficient, with a significant number of staff not having completed the required education. Additionally, staff reported not receiving training on handling mental health crises or performing physical restraints, which are not used by the facility. The lack of appropriate training and intervention strategies for dealing with residents with complex behavioral needs was a significant factor in the failure to prevent the involuntary seclusion of Resident #102.
Inaccurate Infection Control Surveillance in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control surveillance plan, as evidenced by the lack of accurate and timely data collection and interpretation for residents with infections. The Infection Preventionist (IP) reported using a computer-based program for infection control surveillance but was unable to provide a current list of residents on antibiotics or confirm their inclusion in the program. The IP acknowledged that there were eight residents with infections but had not yet collected all necessary information. The infection control report was found to be inaccurate, as it did not reflect the current status of several residents, including those who were still receiving antibiotic treatment. Specific deficiencies were noted in the cases of four residents. One resident's antibiotic treatment was inaccurately reported as completed, while another resident's ongoing treatment was not included in the report. Additionally, two residents with infections were omitted from the surveillance report entirely. The Director of Nursing (DON) confirmed that infections and antibiotics are discussed daily in morning meetings and should have been accurately reflected in the infection control report. The Nursing Home Administrator was informed of the ongoing non-compliance, which precluded acceptance of past compliance efforts.
Failure to Follow Medication Administration and Documentation Standards
Penalty
Summary
The facility failed to follow professional standards of practice for medication administration and documentation for six residents. During an observation, a Registered Nurse (RN) was seen administering medications to two residents simultaneously without confirming their identities or the medications. The medication cups were not labeled, and the RN did not follow the proper procedure for documenting medication administration. Additionally, the RN documented medications for three residents that were either refused, already administered, or given by another nurse, which is against the facility's policy. Further observations revealed that the RN did not compare medications with physician orders or check off medications as they were pulled from the cart. The RN admitted to not knowing the facility's policy on medication documentation and did not see an issue with administering medications to two residents at the same time. The Director of Nursing (DON) confirmed that the facility's procedure requires nurses to verify medications with orders, identify residents before administration, and document immediately after administration. The DON also stated that preparing medications for multiple residents simultaneously is not allowed and poses a risk of medication errors.
Failure to Promote Resident Dignity Due to Laundry Issues
Penalty
Summary
The facility failed to provide an environment that promoted resident dignity for a resident with a history of breast cancer and reconstructive surgery. The resident reported feeling self-conscious about the difference in the size of her breasts and expressed a preference for wearing a bra to make them appear more equal. However, the resident's bras had been going missing, and although the facility replaced them, the process took time, leaving the resident without a bra on multiple occasions. This situation caused the resident to feel humiliated and embarrassed, impacting her sense of dignity and self-worth. Interviews with staff revealed that the facility's laundry department had been experiencing staffing issues, leading to delays and problems in returning residents' personal items, including the resident's bras. The Certified Nursing Assistant (CNA) and Housekeeping Manager (HKM) both acknowledged the challenges in managing the laundry due to recent staff turnover and the need to label new residents' clothing promptly. Observations of the laundry area confirmed that there were significant amounts of personal laundry in various stages of processing, further indicating the backlog and inefficiencies in the system. The Director of Nursing (DON) confirmed that the laundry department had been understaffed due to retirements and resignations, which contributed to the delays in returning personal items to residents. The DON also noted that the nursing staff had not addressed the resident's concern on the day it occurred, and she was unaware of the situation until it was reported to her. This lack of timely response and communication further exacerbated the resident's distress and feelings of indignity.
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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