The Manor Of Novi
Inspection history, citations, penalties and survey trends for this long-term care facility in Novi, Michigan.
- Location
- 24500 Meadowbrook Rd, Novi, Michigan 48375
- CMS Provider Number
- 235529
- Inspections on file
- 28
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at The Manor Of Novi during CMS and state inspections, most recent first.
A facility failed to prevent avoidable falls and provide adequate supervision for residents. A bedbound resident with dialysis dependence fell from bed after a CNA left them on their side without support and later sustained a shoulder fracture requiring hospital care. Two other residents fell when a wheelchair seatbelt was left unfastened and when a bed was left in the wrong position, and two wandering residents were not adequately redirected when one entered another resident's room.
A resident admitted with osteomyelitis, toe amputations, IV antibiotics via PICC, and AKI on hemodialysis had a sacral Stage III pressure injury that was not identified on admission. The DON acknowledged the admission LPN did not complete a thorough skin assessment, the wound care specialist was not formally consulted until the resident self-reported the wound, and later the coccyx wound was observed without a dressing in place after the resident said it had been soiled earlier and not redressed.
Insufficient Nursing Staffing and Delayed Resident Care: Residents reported long waits for call light response, delayed incontinence care, missed or late assistance with meals, and lack of fresh water, especially at night and on weekends. Multiple residents said staffing was too low, with CNAs covering too many residents and nurses covering multiple units or not present at the start of a shift. Interviews with staff and the DON confirmed call-ins, short staffing, and a shift with no nurse assigned for part of the evening.
Food Storage and Sanitation Deficiencies: An opened container of hummus and an opened package of sliced cooked turkey breast were found past the facility-marked use-by dates in the upright cooler. Two hydration carts had soiled, non-removable mesh ice scoop storage bags that were uncovered and exposed to contamination, one was frayed and torn, and additional sanitation issues were observed with a soiled ice machine bin drain line and dust buildup on kitchen ceiling tiles.
Staff failed to maintain resident dignity during care and meals. A resident was transported to the shower room facing rearward in a shower chair, staff were overheard referring to residents as “feeders,” a CNA provided 1:1 feeding while scrolling on a cell phone, two residents were seated at tables set too low for them, an LPN stood over a resident while assisting with breakfast, and an unknown staff member talked on a cell phone and discussed personal business in the hallway while transporting a resident.
An LPN prepared and administered medications for two residents at the same time, and the DON confirmed nurses should not prepare medications for different residents together. The facility also had conflicting diet orders for a resident receiving tube feeding and pleasure feeding, with food and orange juice served despite unclear NPO and PO orders. In addition, a resident had undated forearm dressings with bruising visible underneath, and the skin beneath the dressings was not assessed.
Failure to assess and treat multiple left lower leg skin openings: A resident with severe cognitive impairment and a history of kicking the left leg had a documented skin tear that was not properly assessed or tracked, and later multiple open areas were observed on the left lower leg. Staff did not document a complete wound assessment, the treatment nurse did not examine the leg, and ordered tubi grip was not observed on the resident’s legs during observations. The DON acknowledged the physician’s orders should have been followed.
A resident with intact cognition and an infected tooth had repeated reports of severe mouth/jaw pain, but ordered antibiotics were missed and the opioid pain medication was discontinued despite ongoing 10/10 pain. Dental services documented decayed teeth and recommended extraction plus antibiotics, yet the resident continued to report pain and there were no notes showing the MD was contacted about the excessive pain. The DON acknowledged the missed doses and uncertainty about why the pain medication was stopped.
Failure to Provide Fresh Water Consistently: Multiple residents reported not receiving fresh water every day, and several were observed with empty or stale water cups dated from the prior day. Residents said they had to ask repeatedly for water, including at night, and that staff sometimes refused because the CNA was assigned to the roommate. The DON stated water was passed each 12-hour shift with no required time, and resident council minutes documented repeated concerns about not receiving fresh water daily.
Resident council grievances were not promptly resolved, with multiple residents reporting ongoing problems with fresh water, staff not returning after answering call lights, CNAs using phones or earbuds during care, short staffing, wandering residents entering rooms, delayed incontinence care, and dirty rooms and bathrooms. Council minutes showed repeated complaints over several months, and residents said the issues continued despite being raised in council and to facility leadership.
Medication Not Administered Per Order: A resident with peripheral vascular disease, heart disease, and dementia did not receive ordered Pregabalin 100 mg at bedtime for several days after readmission. Medication notes showed the drug was waiting on pharmacy delivery, while the DON stated she was unaware the medication had not been given, did not run audits, and later acknowledged the back-up supply contained Pregabalin 100 mg that could have been used.
Call Light Not Kept Within Reach: A resident with intact cognition, diagnoses including DiGeorge Syndrome, severe depressive disorder, and bacterial infection, was observed on two occasions reporting pain and needing assistance while their call light was out of reach. The resident stated they could not use the call light for help, and the DON was informed that staff should ensure call lights are in reach.
A facility failed to maintain a clean, comfortable, and homelike environment for two residents. One resident, with sarcoidosis and impaired decision-making, had a wall clock that remained stuck at 8:50 during repeated observations, and the resident said it was important to know the actual time. Another resident, with COPD and impaired cognition, reported having to clean her own bathroom and make her own bed at times; the bathroom was observed with a urinal coated with dried brown substance, a trash can full of soiled briefs with visible fecal matter, and a toilet with dried brown substance on it.
A resident with diagnoses including dementia, CKD, DM, depression, and anxiety was observed in a wheelchair with a seatbelt restraint fastened during room time, a music activity, and lunch. The physician’s order required the seatbelt to be released q2h and during supervised meals and activities, but the restraint remained in place during these observations, and the DON stated the facility had no place to document restraint release.
Failure to provide ordered 1:1 feeding assistance and oral hygiene. A resident with dysphagia, sarcoidosis, and moderately impaired cognition was observed with thick oral residue and reported staff did not often help brush their teeth. The resident had an order for pureed/thin pleasure feeding with 1:1 assist, but a CNA left the meal tray in front of the resident without staying to assist, and the care plan/Kardex did not reflect the updated 1:1 feeding intervention. The resident’s care plan also directed staff to assist with oral hygiene, including brushing.
A resident with osteomyelitis, toe amputation, AKI, and hemodialysis had a PICC for IV antibiotics, but staff failed to assess the continued need for the line after antibiotics ended. The resident reported the PICC had not been used in a while, would not flush, and was uncomfortable; the site was observed with a dated dressing, rolled edges, dried blood at the insertion site, and dried blood in the lumen. Nursing leadership acknowledged the PICC should have been addressed sooner.
The facility failed to ensure that two CNAs had documented new hire and annual competency evaluations, as well as 1:1 training related to falls and transfers. One CNA left a bedbound resident alone on their side while placing a bedpan, and the resident rolled off the bed and sustained a L shoulder fracture; the other CNA’s file lacked yearly competency review documentation.
Failure to implement EBP for a resident with an unstageable coccyx pressure ulcer, osteomyelitis, a PICC line for IV antibiotics, AKI, and hemodialysis. During a dressing change, no EBP signage or PPE was posted outside the room, and an LPN used only gloves. The LPN did not think the resident needed EBP, while the Infection Control RN stated residents with pressure wounds requiring dressing changes do qualify for EBP and could not explain why the resident was not on EBP.
A resident with diabetes, ESRD, hemodialysis, limited mobility, and Hoyer lift use sustained skin tears after an argument with a CNA over getting up and dressed. Staff documented open areas and later described neck, arm, and other skin tears, but the investigation relied on assumptions that the Hoyer sling caused the injuries and did not thoroughly address the circumstances, contributing factors, or a formal review with the involved staff and resident.
A resident admitted for hospice respite care with dementia, chronic respiratory failure, and a history of falls had no documented shoulder issues on admission or during an early skin check, but at discharge staff identified a purplish/yellow discoloration on the upper shoulder. Hospice CNAs later reported that bruising was not initially present but was observed on a subsequent visit, and imaging after discharge showed a healed or healing nondisplaced femoral neck fracture. Facility staff, including the DON and Administrator, were unable to determine the cause of the shoulder bruise, completed an IA report, and acknowledged that the injury was of unknown origin, yet they did not report this injury to the State Agency as required by the facility’s abuse/neglect reporting policy.
A resident who had previously reported a conflict with a CNA and requested not to be assigned to that caregiver was nonetheless assigned to the same CNA on multiple occasions. Facility staff confirmed the resident's complaint and acknowledged that the CNA should not have been assigned to the resident, but staffing records and care documentation showed otherwise, resulting in resident dissatisfaction and a complaint to the State Agency.
A resident reported a conflict with a CNA and requested not to have that CNA assigned to their care. Despite this request and facility policy requiring staff to assist with grievance documentation, the CNA was reassigned to the resident and no grievance form was completed or filed.
The facility failed to maintain sanitary conditions in the kitchen and on the C hall medication cart. Observations revealed pooled milk and blood in the walk-in cooler, improper storage of raw meats, and uncovered utensils. Additionally, a water pitcher on the medication cart was not changed as per facility policy, with staff admitting to a lack of standard procedure for changing pitchers.
The facility did not protect the personal health information of nine residents, as their names and dialysis schedules were visible on a bulletin board at the nursing station. The Director of Nursing confirmed that the schedules were posted without a privacy cover, violating the facility's HIPAA policy on confidentiality.
The facility failed to ensure appropriate use of restraints for two residents. One resident was unable to exit a Merry Walker independently, indicating it functioned as a restraint, while another had a seatbelt that was not released as required by their care plan. The facility's restraint management policy was not followed, and there was no documentation of restraint release or consent.
A resident with multiple infections and a midline IV did not have a comprehensive care plan addressing their use of antibiotics and current diagnoses. Despite being on IV antibiotics for a UTI and pneumonia, the care plans were not updated, and the only existing plan was for being at risk for a UTI. Interviews with the Infection Preventionist and DON revealed a lack of responsibility and adherence to the facility's care planning policy.
A nurse in an LTC facility failed to provide care according to professional standards by inaccurately informing a resident about the contents of their medication cup. The nurse did not include Tylenol in the cup but told the resident that a different pill was Tylenol. This was confirmed by the DON, who stated that the nurse should not have misinformed the resident.
The facility failed to provide routine showers and hygiene care for two residents as per their scheduled care plans. One resident, with moderate cognitive impairment, reported not receiving a scheduled shower, and the EMR confirmed infrequent showers with no documented refusals. Another resident was observed with poor hygiene despite documentation indicating care was provided. The DON confirmed the lack of documentation and was informed of the residents' conditions.
A resident with diabetic ulcers did not receive daily wound care as ordered, with dressings observed unchanged for two days. The treatment was incorrectly signed off as completed, despite the resident's confirmation of missed care. The DON acknowledged the requirement for adherence to physician's orders.
The facility failed to prevent accidents for two residents, resulting in a fall and potential injuries. One resident was found on the floor due to an improperly secured seatbelt, while another was unsafely transported in a shower chair facing rearward. The Director of Nursing confirmed these actions were against facility policy.
The facility exceeded the acceptable medication error rate with two errors involving two residents. One resident received an incorrect calcium supplement, while another received Dorzolamide eye drops in both eyes instead of just the left. The errors were attributed to not following physician orders and medication administration protocols.
A facility failed to obtain physician-ordered x-rays for a resident with pain in the right shoulder and hips. The resident, who had type 2 diabetes, insomnia, and end-stage renal disease, had an x-ray order dated 12/28/24, but no documentation showed the x-rays were completed. The DON stated that STAT orders are usually completed within 4 to 6 hours, and general orders are set for three days to avoid being missed, yet the x-ray was not done.
Two residents were at risk due to a sharp metal strip on their doorway frame, which was not identified by the facility's maintenance or reporting systems. The Unit Manager and Maintenance Director were unaware of the issue until it was highlighted during a survey, despite regular environmental rounds and audits.
A resident reported that a package containing pharmacy items was opened and partially missing when delivered to their room, violating their right to receive unopened mail. The facility's Administrator confirmed the package was mistakenly opened by staff, contrary to the facility's policy that mail should be delivered unopened unless otherwise indicated by the resident.
A facility failed to notify the wound care practitioner and update interventions for a resident with a stage IV pressure wound. Despite a treatment plan by the DON, no further interventions were implemented, and the wound worsened, leading to hospitalization. Staff interviews revealed a lack of awareness and communication regarding the resident's wound care needs.
A resident with severe cognitive impairment frequently wandered into other residents' rooms, leading to an incident where another resident, feeling threatened, hit them on the head. Despite interventions like stop signs and a wander-guard, staff were unable to consistently redirect the wandering resident, resulting in a failure to protect residents from abuse.
A resident with no prescribed narcotics was found unresponsive and required Narcan, raising concerns about a possible medication error. Another resident with severe cognitive impairment and a history of wandering exited the facility through a fire exit door, highlighting inadequate supervision and intervention. Staff were aware of the behaviors but were not always present to redirect the resident.
A resident was found unresponsive and given Narcan by EMS, suggesting opioid presence. Despite a physician's order for a urine drug test, the facility failed to collect the sample. The ADON stated the nurse couldn't obtain it, and the order was marked completed automatically. The resident had diagnoses including COPD, depression, and dementia, and showed symptoms indicating possible opioid use, but no test was conducted to confirm.
Falls and Supervision Lapses
Penalty
Summary
The facility failed to prevent avoidable falls for three residents and failed to provide adequate supervision for two wandering residents. One resident, who was cognitively intact, bedbound, non-ambulatory, and admitted with acute kidney failure, morbid obesity, and dialysis dependence, reported that after a CNA turned them onto their side to use a bedpan and left the room, they slipped off the bed while waiting for help and landed on the floor. The resident stated they had no assist bars in place at the time and that their call light became tangled underneath them. They were later transferred to the hospital and diagnosed with a comminuted minimally displaced humeral head fracture and pain in the left shoulder and arm. Facility records and interviews confirmed the resident was at risk for fall-related injury and required total assistance for transfers and bed mobility. The incident report documented that the resident was found on the floor with left shoulder pain and was sent to the hospital. The CNA involved stated they left the room for about 15 minutes after placing the resident on their side, and an RN later stated the CNA should never have left the resident alone because the resident was bedbound, obese, and had nothing to hold on to while on their side. The record also showed no documentation that the CNA had received initial training or 1:1 training related to the incident, despite staff stating education had been provided. The facility also failed to ensure supervision for two residents. One resident was observed sliding from a wheelchair because the seatbelt was not fastened, and the DON confirmed the CNA did not ensure the belt was secured. Another resident was found on the floor beside the bed after the head of bed had been elevated when it should have been flat due to the resident's seizure-related jerking movements, and the DON confirmed the bed position contributed to the fall. In a separate observation, one resident entered another resident's room while a CNA called out from the hall but did not go to redirect the resident, and the resident in the room called for help because of the unwanted person; the DON later stated the CNA should have gone to redirect the resident away from the room.
Missed Sacral Pressure Ulcer Assessment and Delayed Wound Care
Penalty
Summary
The facility failed to identify and provide treatment and services for a Stage Three sacral pressure ulcer for one resident who was admitted with osteomyelitis of the left foot requiring toe amputation, IV antibiotics through a PICC line, and AKI requiring hemodialysis. The resident was alert, oriented, and able to make needs known. On initial discussion, the resident reported that the dressing on their bottom had been missed over the weekend, stated the wound was present before admission, and described pain in the sacral area that became more intense when sitting. Hospital discharge paperwork documented a midline sacral Stage Three pressure injury with orders for cleansing, an enzymatic debriding agent, gauze, and a silicone dressing. Facility documentation later identified the wound as a facility-acquired unstageable pressure ulcer, and the DON acknowledged the admission LPN did not perform a thorough skin assessment and missed the sacral wound. The DON also stated that new resident skin assessments should include looking at every inch of skin and placing a wound consult with a treatment plan until consultation is completed. The admission LPN documented only amputated toes and a dialysis port on the comprehensive evaluation, and later said they had seen a small area on the coccyx but forgot to document it. The wound care specialist stated they were not formally consulted and only assessed the resident after the resident self-reported the wound while the specialist was on the unit for another resident. During a later dressing observation, the resident’s coccyx wound was found open with no dressing in place, and the resident stated no one had put the dressing back on after they had soiled it earlier that morning.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. During observation, interview, and record review, multiple residents reported delayed assistance with incontinence care, call light response, meals, and water, and several residents stated that staffing was especially poor at night and on weekends. Residents identified as needing help with toileting, transfers, feeding, and supervision described long waits for care, with some stating they were left wet in bed, did not receive timely assistance to eat, or did not receive fresh water for extended periods. On 4/6/26, R58 reported that call lights often took about an hour to be answered, especially at night and on weekends. R101 was observed crying and stated that the last time her incontinence brief had been changed was around 11:00 PM the previous night; she reported she had not yet been changed and said staff sometimes did not have enough help to take her to the toilet, causing her to wet her pants. R101 and her roommate were observed with Styrofoam cups dated 4/5/26, and both indicated water had been passed only that morning and not since. R55 reported being left wet in bed and said there had only been one person working on the hall the previous evening. R79 was observed with an empty water cup dated 4/5/26 and stated nobody had passed fresh water since Sunday morning. R17 stated that only CNAs changed him or got water because nurses were too busy, and that he needed help to eat but by the time staff assisted him, the food was cold and he did not want to eat it. Resident interviews on 4/7/26 with 11 anonymous residents further described staffing shortages. Four residents said there was not enough staff, one reported CNAs had been changed to 12-hour shifts and then quit from burnout, and another said a nurse did not come in on Easter Sunday so another nurse covered the whole C unit. Residents also reported wandering residents entering rooms and taking belongings, call lights not being answered, and incontinence care not being provided in a timely manner. Nine of 11 residents said they did not receive fresh water every day. Staff interviews and schedule review confirmed call-ins and short staffing on the 7 PM to 7 AM shift, with two CNAs covering the C and D halls and no nurse assigned to the D hall, and no nurse starting on the C hall until about 8:15 PM. The Administrator and DON confirmed several call-ins and that no nurse showed up for the evening shift.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain best practices in food service and hydration areas during an initial kitchen tour and related observations. In the upright cooler, an opened container of hummus with facility-marked use-by dates of 3/27-4/4 and an opened package of sliced cooked turkey breast with facility-marked use dates of 3/31-4/5 were observed; dietary staff member LL discarded both items when they were identified. The report cited 2022 FDA Food Code section 3-501.18 regarding ready-to-eat, time/temperature control for safety food that exceeds the specified time and temperature combination. During observation of two nursing hydration carts being prepared for use on the units, each cart had an attached mesh bag used to store the ice scoop. The storage bags were observed to be soiled and discolored on the bottom interior, not removable for routine cleaning, and uncovered so the ice scoop was exposed to potential contamination in the unit hallways; one bag was also frayed and torn. Later observations in the dining room found the ice machine bin drain line soiled with a black substance, and in the kitchen several ceiling tiles adjacent to the ceiling vent were soiled with dust buildup. The report cited FDA Food Code sections 4-202.16, 4-903.11, 6-501.18, and 6-501.12 related to nonfood-contact surfaces, storage of cleaned equipment, cleaning of plumbing fixtures, and cleaning of physical facilities.
Failure to Maintain Resident Dignity During Care and Meals
Penalty
Summary
The facility failed to ensure treatment in a dignified manner for seven residents during observations of care and meals. One CNA transported a resident to the shower room in a shower chair by pulling the chair forward while the resident faced rearward. During lunch in the dining room, staff were overheard talking across the room about residents’ physical abilities to feed themselves and repeatedly referring to some residents as “feeders,” and another CNA was overheard asking if a resident was a feeder. The Administrator later acknowledged that it was not appropriate to refer to residents as feeders. Additional observations showed a CNA providing one-to-one feeding assistance to a resident while scrolling through a cell phone between bites. Two residents were seated at an adjustable table that was in its lowest position and only reached their knees, and another resident was observed hunched over while self-feeding from a table at knee level. An LPN was observed standing over a resident while assisting with breakfast and continued to do so after stating there were no chairs in the room. In another hallway observation, an unknown staff member was talking on a cellular phone and then discussing personal business in the hallway while transporting a resident in a wheelchair.
Medication Administration, Diet Order Clarification, and Skin Assessment Failures
Penalty
Summary
The facility failed to provide medications according to professional standards of practice for two residents. On 4/6/26 at 9:42 AM, an LPN entered the room of two residents with both residents’ medications, gave one resident her medications first, and then gave the other resident’s medications. When interviewed later that day, the LPN stated that medications for different residents were not supposed to be prepared at the same time, but she was trying to get them done. The DON later confirmed that nurses should not prepare medications for different residents at the same time. One resident had diagnoses including hereditary spastic paraplegia and dementia with moderately impaired cognition, and the other had diagnoses including a history of stroke and diabetes with intact cognition. The facility also failed to ensure diet orders were clarified and accurate for a resident receiving tube feeding and pleasure feeding. The resident was observed receiving nutrition through a feeding tube, with orange juice present on the over-bed table, while the clinical record contained active orders for both NPO status for tube feeding and a regular pureed diet with thin liquids and 1:1 assistance for pleasure feeding. A meal tray labeled as a pleasure tray with 1:1 feed was later delivered, and orange juice was again observed in front of the resident. The NP note stated the resident had been NPO since returning from hospitalization and that the current feeding regimen would continue until SLP evaluation and further recommendations, while the SLP screen documented that the resident was cleared to return to the previous pleasure tray diet. The unit manager stated there should not be two conflicting orders and that they should have been clarified before food was served by mouth, and the DON stated the nurse should have contacted the dietician for clarification prior to serving food. The facility failed to assess skin under an undated dressing for a resident with bilateral forearm dressings. The resident was observed with an undated dressing on the right forearm and another on the left forearm, with bruising visible underneath the left dressing. The resident had diagnoses including peripheral vascular disease, heart disease, and dementia, and had moderately impaired cognition. No physician order for dressings was found in the record. When the DON later removed both dressings, she stated they appeared to be from a blood draw and explained that the last blood draw at the facility had been months earlier, while the resident had been readmitted from the hospital shortly before the observation. The DON stated her expectation was for the nurse to remove the dressing to see what was under it and assess the skin.
Failure to Assess and Treat Multiple Left Lower Leg Skin Openings
Penalty
Summary
The facility failed to identify, assess, implement treatment for, and follow physician’s orders related to a resident’s left lower leg skin tear and additional open areas. The resident had severe cognitive impairment, was dependent on staff for all activities of daily living, and had diagnoses including Alzheimer’s disease, protein-calorie malnutrition, unspecified convulsions, and anoxic brain damage. The resident also had a care plan noting risk for skin integrity related to vigorously kicking the left leg at times, with tubi grip ordered for both legs. On 3/30/26, staff documented a skin tear on the resident’s left shin, and hospice staff cleaned and covered the area with treatment orders placed. On 4/1/26, the resident was again noted to have a skin tear to the left shin and the area was cleansed and dressed. However, there was no documented assessment form for the skin tear or any other open areas, and no documentation of additional open areas despite later findings. The physician’s order included cleaning the left shin with normal saline, covering with border gauze, applying tubi grip to both legs, and removing tubi grip and checking skin integrity every shift. During observation on 4/6/26 and 4/7/26, the resident was seen repeatedly kicking the left leg up and down while seated in a geri-chair. Five pink open areas were first observed on the top of the left lower leg without a dressing, and later multiple open areas were found on the top and back of the left lower leg after a dressing was removed. Staff reported the wound was thought to be only a skin tear, one LPN stated she was not wound care certified, and the treatment nurse reported she had not looked at the resident’s left lower leg. The DON acknowledged the wound should have been assessed and that the physician’s orders should have been followed, while the facility record showed no documented wound assessment and no elastic bandages observed on the resident’s bilateral legs during the observations.
Failure to Provide Ordered Pain Relief and Antibiotics for Dental Infection
Penalty
Summary
The facility failed to ensure a resident with intact cognition and diagnoses including DiGeorge Syndrome, severe depressive disorder, and bacterial infection received needed pain management and antibiotic treatment for an infected tooth. The resident reported right lower tooth pain beginning on 3/3/26, and a provider note documented a suspected tooth abscess with an order for Augmentin. The medication administration record showed the antibiotic was not given as ordered on 3/3/26 and again on 3/10/26, resulting in the resident receiving only six days of the prescribed seven-day course. Dental services later evaluated the resident on 3/20/26 and documented dental pain in the lower right, decayed teeth, and a recommendation for extraction and a 10-day course of amoxicillin. The MAR showed the amoxicillin ordered on 3/20/26 was not administered on 3/20/26 or 3/21/26, with the medication noted as not available and on order. A progress note on 3/25/26 documented continued toothache and an order for Hydrocodone-Acetaminophen 5-325 mg every 6 hours as needed for 14 days. The resident continued to report severe pain, including 10/10 tooth pain on 4/6/26 and 4/7/26, and received ibuprofen. The record contained no notes showing the physician was contacted about the excessive pain. On 4/8/26, the resident again reported being in pain and stated the call light was out of reach; the resident also said staffing purposely did not place the light within reach. The DON acknowledged awareness of the tooth infection, missing antibiotic doses, and uncertainty about why the opioid order had been discontinued, but could not explain why the physician was not contacted regarding the resident’s high pain levels.
Failure to Provide Fresh Water Consistently
Penalty
Summary
The facility failed to ensure fresh water was passed and available to residents consistently and upon request for four residents reviewed for hydration: R4, R22, R79, and R101. On 4/6/26 at 9:30 AM, R101 and R22, who were roommates, were observed with Styrofoam cups dated 4/5/26 from 7:00 AM to 7:00 PM, and both stated that water had last been passed on the morning of 4/5/26 and had not been passed again by the time of the observation. On 4/6/26 at 10:04 AM, R79 was observed with a Styrofoam water cup dated 4/5/26 from 7:00 AM to 7:00 PM; when asked about fresh water, R79 shook the cup, which was empty, and said nobody had passed fresh water since Sunday morning 4/5/26. During an interview on 4/7/26 at 10:00 AM with 11 residents who wished to remain anonymous, 9 of 11 reported they did not receive fresh water every day. Residents described the problem as chronic, said they had gone a whole day without water, and reported that when they asked a CNA for water, the CNA assigned to their roommate would say they were not their CNA and would not get them water. One resident also reported not being given fresh water at night and said that when they asked, staff said they would bring it but never returned. Resident council minutes from October 2025 through March 2026 documented repeated concerns about not receiving fresh water every day. The DON stated that water was passed each 12-hour shift with no specific required time and that staff should provide water upon request or if cups were empty; the DON was not aware that water had not been passed on 4/5/26 after the first shift on A Hall. R101 had a history of stroke and diabetes and was cognitively intact; R79 had COPD and moderately impaired cognition. R4 was admitted with osteomyelitis of the left foot requiring toe amputation, IV antibiotics via PICC line, and AKI requiring hemodialysis, and was alert, oriented, and able to make needs known. R4 reported requesting a glass of water four to five times on Easter Sunday and not receiving anything to drink until the next day, despite knowing they needed to drink more because of urination concerns.
Resident Council Grievances Were Not Promptly Addressed
Penalty
Summary
The facility failed to promptly act on grievances raised through the resident council, and concerns documented in council minutes from October 2025 through March 2026 remained unresolved for multiple residents. The minutes reflected repeated complaints about not receiving fresh water every day, as well as concerns that CNAs were splitting rooms, using phones during care, and telling residents they would return but not coming back. During a confidential interview with 11 residents who attended resident council meetings, 9 reported ongoing concerns that had not been resolved, including lack of fresh water, staff not returning after answering call lights, and staff talking on phones or wearing earbuds while providing care. Residents described repeated problems with access to water and assistance. Several said they did not receive fresh water daily, including at night, and one resident reported going a whole day without water. Residents also reported difficulty obtaining water because of the split-room CNA assignment system, where a CNA would say the roommate was not their resident and would not provide water. One resident stated that when staff passed medications, there was sometimes no water available except a small cup brought by the nurse. Another resident reported that staff would say they would bring water or return after being asked, but often did not come back. Residents also reported other unresolved concerns affecting daily care and the environment. Four residents said there was not enough staff, with reports of CNAs and nurses covering multiple units, burnout from 12-hour shifts, and missed coverage on the evening of Easter Sunday. Three residents reported wandering residents entering rooms and taking belongings, and one resident reported delayed incontinence care, stating a brief changed at 11:30 PM on 4/5/26 was not changed again until a shower at 3:00 PM on 4/6/26. Multiple residents also reported dirty rooms and bathrooms, and one resident said housekeeping concerns brought to a department head were met with anger and were not resolved.
Medication Not Administered Per Order
Penalty
Summary
The facility failed to ensure medications were acquired and administered according to physician orders for one resident. The resident was admitted and later readmitted with diagnoses including peripheral vascular disease, heart disease, and dementia, and the MDS assessment indicated moderately impaired cognition. A physician order dated 4/2/26 directed Pregabalin 100 mg by mouth at bedtime for neuropathy, but the April MAR showed the resident did not receive the medication on 4/2/26, 4/3/26, 4/4/26, or 4/5/26. Medication Administration Notes documented that Pregabalin 100 mg was on order and waiting for the pharmacy to deliver on multiple days. During interview, the DON stated she had not known the resident had not received the medication, did not run medication audits, and relied on Unit Managers’ reports in morning meetings; she also stated there had not been a morning meeting since 4/2/26. The DON said nurses should have contacted the pharmacy and physician when the medication was not available. A review of the facility’s back-up medication supply showed six capsules of Pregabalin 100 mg were available, and the DON later stated the nurses should have used the back-up supply until the pharmacy delivered the medication.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure that one resident's call light was within reach. On 4/6/26, the resident was observed sitting in a wheelchair with food on their shirt, reported being in pain, and stated they wanted to see a nurse, but the call light was out of reach and the nurse was informed of the resident's pain. On 4/8/26, the resident was again observed sitting in a wheelchair, reported pain in the lower left jaw area, and stated they needed assistance, but the call light was on the other side of the bed and the resident could not push it for help. The resident stated they believed staffing purposely did not put the light within reach. The resident's record showed diagnoses including DiGeorge Syndrome, severe depressive disorder, and bacterial infection, and the most recent MDS showed a BIMS score of 14/15. The DON was later informed of the call light being out of reach and stated staff should ensure call lights are in reach.
Unclean Resident Bathroom and Nonworking Clock
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents. One resident, who had sarcoidosis and moderately impaired decision-making ability, was observed in bed with a wall clock at the foot of the bed that remained stuck at 8:50 during multiple observations. The resident indicated that she could read the clock and that it was important to know the actual time, but the clock was not working. Another resident, who had COPD and moderately impaired cognition, reported that it took a long time for her room and bathroom to be cleaned and that she often had to make her own bed and clean the bathroom. She stated that the adjoining resident sometimes left soiled briefs with feces, urine, and menstrual blood on the floor, the toilet was often dirty, and the trash was not emptied regularly. Observation of her bathroom showed a urinal with dried brown substance caked on the bottom, a trash can filled to the top with soiled briefs with visible fecal matter, and a toilet with dried brown substance on the outside front part; the bathroom remained in the same condition on a later observation.
Failure to Release and Document Seatbelt Restraint Use
Penalty
Summary
The facility failed to release a seatbelt restraint during supervised activities and supervised dining, and failed to document removal of the restraint every two hours per the physician’s order for one resident, R60. R60 was observed in a wheelchair with a seatbelt fastened across the waist while in the resident’s room on 4/6/26, in the activity room during a scheduled music activity on 4/7/26, and in the dining room while eating lunch on 4/8/26. During the observations, staff were present in the activity room and dining room providing assistance to other residents, and the seatbelt remained fastened across R60’s waist. R60’s record showed diagnoses including diabetes, chronic kidney disease, dementia, depression, and anxiety disorder. The physician’s order dated 8/24/24 directed that the seatbelt restraint be released every 2 hours and with supervised activities, and the care plan directed release and repositioning every 2 hours, with supervised meals, supervised activities, and toileting. When the DON was interviewed on 4/7/26 about documentation for restraint release, the DON stated the facility did not have a place to document the release of restraints. The facility policy stated restraints should be periodically removed and should always be removed during supervised mealtimes and activities unless clinical contraindications are documented.
Failure to Provide Ordered 1:1 Feeding Assistance and Oral Hygiene
Penalty
Summary
The facility failed to assist one resident with activities of daily living, specifically oral hygiene and feeding assistance. On 4/6/26, the resident was observed lying in bed receiving nutrition through a feeding tube, with a cup of orange juice on the over-bed table and a copious amount of thick, stringy, white substance extending from the top to the bottom of the resident’s mouth. When asked, the resident stated staff did not often assist with brushing their teeth and said they wanted their mouth cleaned and teeth brushed. The resident’s record showed active orders for a regular diet with pureed texture, thin consistency, and 1:1 assistance at all meals for pleasure feeding, with a start date of 3/11/26. On 4/7/26, a CNA delivered a breakfast tray, placed the food in front of the resident, and left the room; the meal ticket noted pleasure tray 1:1 feed. The SLP documented that the resident had been cleared to return to the previous diet with 1:1 assist as needed for all meals, but the care plan was not updated to include this intervention and the Kardex did not include instructions for 1:1 feeding assistance. The resident’s care plan also identified oral/dental health problems and directed staff to provide, assist, and encourage oral hygiene, including set up and assistance with brushing. The DON stated the CNA should have stayed with the resident to provide feeding assistance and that oral care was performed in the morning, at night, or when visibly needed. The resident had diagnoses including sarcoidosis and dysphagia, and the MDS indicated moderately impaired cognition and dependence on staff for oral hygiene.
Failure to Assess and Discontinue Unneeded PICC Line
Penalty
Summary
The facility failed to assess and monitor the continued need for a PICC line used for IV antibiotic administration for a resident admitted with osteomyelitis of the left foot requiring toe amputation, acute kidney injury, and hemodialysis. The resident was alert, oriented, and able to make needs known. During an initial interaction, the resident reported concern about the PICC in the right upper arm, stating it had been placed for antibiotics, had not been used in a while, and the last attempt to flush it would not work. The resident also said the line was uncomfortable and becoming annoying. Observation of the PICC site showed the dressing dated 3/18, with rolled adhesive edges not fully adhered to the skin, a large amount of dark brown dried blood at the insertion site under the transparent dressing, and dried blood inside the catheter lumen. The resident also reported that the clear dressing would sometimes bubble and they had to press the air out. Record review showed orders to flush and monitor the PICC until 3/23 and to change the transparent dressing weekly, while the last antibiotic infusion was documented on 3/17. Nursing leadership acknowledged the PICC should have been assessed for discontinuation sooner than 4/6, and an LPN stated the order to discontinue the PICC was placed only after noticing the resident still had the line and realizing antibiotics had already ended.
CNA competency and training records were incomplete
Penalty
Summary
The facility failed to ensure that two CNAs had the appropriate competencies to care for residents, including new hire evaluations, yearly competency evaluations, and 1:1 training related to falls and transfers. One CNA was hired on or about 1/20/26, but the personnel file contained no documentation of initial training upon hire or 1:1 training related to R5's fall. Another CNA had been hired on 1/7/2025, and the last competency evaluation in the file was completed upon hire, with no yearly training or evaluation provided. The deficiency was identified during review of an incident involving R5, who was observed lying in bed with a sling on the left arm after reporting that a CNA turned them onto their side, placed a bedpan on the bed, and left the room while the resident was on their side. R5 rolled off the bed and was sent to the hospital, where they were diagnosed with a left shoulder fracture. RN MM reported hearing yelling, finding R5 on the floor, and stated that the CNA should never have left the resident alone because the resident was bedbound, obese, and had nothing to hold on to while on their side. The report also states that RN MM provided 1:1 training with the CNA after the incident, but the personnel file did not contain documentation of initial training or 1:1 training.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow its Enhanced Barrier Precautions (EBP) policy for one resident who was admitted with osteomyelitis of the left foot requiring toe amputation, IV antibiotics through a PICC line, acute kidney injury, and hemodialysis. The resident was alert, oriented, and able to make needs known. During a pressure ulcer dressing observation, there was no EBP signage or PPE outside the resident’s room, and an LPN donned only gloves while cleansing and treating an unstageable coccyx pressure ulcer with an open horizontal wound and yellow slough. When interviewed, the LPN stated they had been educated on EBP when hired but did not think the resident needed EBP because the resident did not have a Foley catheter and was not on antibiotics, though they said they could figure it out. The Infection Control RN stated that residents with pressure wounds requiring dressing changes do qualify for EBP and that the facility discusses EBP status in daily meetings, but did not know why this resident was not on EBP and acknowledged they should have been.
Incomplete Investigation of Alleged Mistreatment and Injury of Unknown Origin
Penalty
Summary
The facility failed to complete a thorough investigation of an alleged mistreatment and injury of unknown origin involving a resident who had diabetes managed with insulin, ESRD requiring hemodialysis, limited mobility, and use of a Hoyer lift. The resident’s spouse reported that the resident was verbally challenged by a CNA when the resident did not want to get up and get dressed, and that an improper Hoyer transfer caused skin tears to the neck and head. The resident’s MDS documented a BIMS score of 13/15, indicating no cognitive impairment. The clinical record showed that on the morning of the incident, a nurse overheard the resident yelling in the room and learned from the aide that the resident had said no to getting up and did not want to get out of bed until later, but the aide still proceeded with getting the resident dressed and placing the Hoyer pad underneath him. The nurse documented open areas on the left side of the body and that the resident requested the aide be removed from future care. Later interviews with nursing staff described arguing between the CNA and the resident, with the resident stating the CNA was not listening and did not want to get up. One nurse observed skin tears on the neck, arm, and another area, and believed they may have resulted from the Hoyer sling being pulled up from under the resident, but no staff member witnessed the injury. The investigation documentation did not address predisposing environmental, physiological, or situational factors. The DON’s late entry note stated the interdisciplinary team met to discuss skin tears and attributed the injury to the resident’s fragile skin and the Hoyer process, but the DON could not explain why only the neck was identified in one note when other injuries were documented elsewhere, could not describe the treatment provided, and acknowledged there was no formal discussion with the involved staff or resident as part of the investigation. The record also reflected that the incident was assumed to be caused by the Hoyer without a thorough determination of how the injuries occurred.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency (SA) for a hospice respite resident. The resident was admitted for a five-day hospice respite stay with diagnoses including unspecified dementia, chronic respiratory failure, and a history of falling. On admission, documentation showed pain 0/10 and skin findings limited to right ankle discoloration and slight redness to the front peri area. A subsequent skin check documented no skin issues. At discharge, however, staff identified discoloration to the upper left shoulder described as purplish/yellow. The DON assessed the area and noted it appeared to be from pre-trauma prior to admission, and an Incident/Accident (IA) report was completed. The IA report documented that the charge nurse discovered the discoloration during a pre-discharge skin assessment, that the DON observed purple and yellow coloration suggesting healing, and that the facility could not identify a fall or other cause for the bruise based on staff interviews. Further information from hospice staff indicated that hospice CNAs did not observe bruising on one visit but noted bruising to the left shoulder area on a later visit when providing a shower, and the facility was unable to determine the cause of the bruise. Imaging performed after discharge showed a healed or healing nondisplaced femoral neck fracture of the left hip, consistent with a non-acute fracture. The Administrator/Abuse Coordinator acknowledged in interview that the cause of the bruise could not be determined and stated they should have reported the injury of unknown origin to the SA. The facility’s Abuse Prohibition Policy required that allegations of abuse or neglect and incidents resulting in injury be thoroughly investigated, documented, and reported to appropriate state agencies, with notification to state or federal agencies within two hours if there was an abuse allegation or serious injury. Despite this policy and the unknown cause of the shoulder injury, the facility did not report the injury of unknown origin to the SA.
Resident's Right to Caregiver Choice Not Honored
Penalty
Summary
A resident reported having a conflict with a newly assigned Certified Nurse Aide (CNA), describing the CNA as having a bad attitude and being rude. The resident communicated their concerns to the Unit Manager and was assured that the CNA would no longer be assigned to their care. Despite this, staffing records and CNA charting documentation confirmed that the same CNA was assigned to the resident's care on at least two subsequent occasions, including after the initial complaint was made. The resident was unable to identify the CNA by name but recognized them by their behavior and reported the issue to the State Agency when the CNA was again assigned to their care. Interviews with facility staff, including the Unit Manager and Administrator, confirmed awareness of the resident's complaint and the expectation that the CNA should not have been assigned to the resident following the complaint. However, review of staffing sheets and care documentation showed that the CNA continued to be assigned to the resident's unit and provided care. The facility's own policy states that residents have the right to a dignified existence, self-determination, and freedom of choice regarding their care, which was not upheld in this instance.
Failure to Implement Grievance Process After Resident Complaint
Penalty
Summary
A resident reported having a conflict with a newly assigned Certified Nurse Aide (CNA), describing the CNA as having a bad attitude and being rude. The resident communicated their concerns to the Unit Manager and requested that the CNA no longer be assigned to their care. The Unit Manager confirmed receiving the complaint and assured the resident that the CNA would not be assigned to them again. However, the CNA was subsequently assigned to the resident's care on a later night shift. The resident was not assisted in filling out a grievance form, and no documentation of the complaint was found in the facility's records. Interviews with facility staff, including the Unit Manager and Administrator, confirmed that the grievance process was not followed as required by facility policy. The policy states that staff should encourage and assist residents in filing written grievances and that all concerns, whether oral or written, should be actively resolved. Despite this, the resident's complaint was neither documented nor formally addressed through the established grievance process.
Sanitation Deficiencies in Kitchen and Medication Cart
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. In the walk-in cooler, there was pooled milk underneath milk crates, and a tray of raw chicken with blood pooled at the bottom and spilled on the floor. Raw ground beef and pork were stored directly next to the raw chicken, which is against the 2017 FDA Food Code that requires separation to prevent cross-contamination. Additionally, there were uncovered and unlabeled containers of white and tan powders next to the toaster, which should have been covered and labeled according to the FDA Food Code. Clean utensils were stored uncovered on a lower shelf, exposing them to potential contamination, contrary to the FDA guidelines that require such items to be stored in a clean, dry location and covered or inverted. The facility also failed to maintain the C hall medication cart water pitcher in a sanitary manner. A clear plastic pitcher filled with water and ice was observed on top of the cart with a sticker dated two days prior. Nurse 'E' admitted to forgetting to change the pitcher and stated there was no standard for when pitchers should be changed. Unit Manager 'F' indicated that water pitchers should be changed at the end of each night shift, with water and ice changed every shift, which was not followed. The facility's policy requires nursing staff to send water pitchers to the dietary department for daily cleaning and sanitizing, which was not adhered to in this instance.
Failure to Protect Residents' Personal Health Information
Penalty
Summary
The facility failed to protect the personal health information of nine residents, as observed during a survey. On two separate occasions, a bulletin board at the nursing station on the A unit displayed the names and dialysis treatment times of these residents, visible to anyone passing by. This was confirmed during an interview with the Director of Nursing, who acknowledged that the Unit Manager posted the schedules without ensuring they were covered to maintain privacy. The facility's HIPAA policy, dated September 30, 2021, emphasizes the residents' right to privacy and confidentiality of their personal and medical records, which was not upheld in this instance.
Inappropriate Use of Restraints for Two Residents
Penalty
Summary
The facility failed to ensure the appropriate use of restraints for two residents, R59 and R67, as observed during a survey. R59 was found in a Merry Walker, a device that should not be considered a restraint if the resident can exit it independently. However, R59, who has severe cognitive impairment due to dementia, was unable to demonstrate the ability to exit the device, indicating it functioned as a restraint. The Director of Nursing (DON) confirmed that R59 required staff assistance to get in and out of the Merry Walker, contradicting the facility's policy that it was not a restraint. R67 was observed with a seatbelt buckled across their lap while in a wheelchair, unable to unbuckle it themselves. Despite having a care plan that required the seatbelt to be released every two hours and during supervised activities, there was no evidence that this was being done. The DON acknowledged that the seatbelt should have been unbuckled during meals and activities, but there was no documentation to support that the restraint was being released as required. R67's care plan and physician's orders were not followed, as the seatbelt remained buckled during meals and while the resident was asleep, missing opportunities for supervised activities. The facility's policy on restraint management, revised in September 2022, states that restraints should only be used when medically necessary and must be removed periodically for repositioning and during meals and activities. The policy also requires a signed consent for the use of restraints, which was not documented for either resident. The facility's failure to adhere to its own policy and the lack of documentation for restraint release and consent contributed to the deficiency identified by the surveyors.
Failure to Develop Comprehensive Care Plan for Resident with Infections
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R111, who was observed with a midline intravenous (IV) line, antibiotics, and multiple infections. R111 was admitted with diagnoses including acute gastritis with bleeding, pneumonia, urinary tract infection (UTI), and cellulitis. Despite these conditions, the care plans did not address the resident's midline IV or the use of antibiotics for the current UTI and pneumonia diagnoses. The only care plan in place was for being at risk for a UTI, which had not been revised since the resident's admission. Interviews with the Infection Preventionist (IP 'A') and the Director of Nursing (DON) revealed a lack of clarity and responsibility regarding the initiation and revision of care plans. IP 'A' acknowledged the recent start of IV antibiotics for the resident's UTI and pneumonia but could not explain why the care plans were not updated. The DON indicated that IP 'A' should have initiated the care plans and acknowledged that any nurse could have done so. The facility's policy requires care plans to be specific, resident-centered, and updated with significant changes, which was not adhered to in this case.
Medication Administration Error Due to Inaccurate Communication
Penalty
Summary
The facility failed to ensure that care was provided according to professional nursing standards during a medication administration observation for one resident. Nurse 'J' was observed preparing medications for a resident at the medication cart but did not include Tylenol in the medication cup. When the resident questioned whether one of the pills was Tylenol, Nurse 'J' incorrectly informed the resident that a different pill was Tylenol, despite it not being present. This discrepancy was later confirmed by the Director of Nursing, who acknowledged that Nurse 'J' should not have misinformed the resident about the medication content. The facility's Charge Nurse Job description emphasizes the importance of providing safe and accurate medication-related interventions, including administering and documenting medications according to each resident's medication schedule using current standards of medication pass technique. The incident highlights a failure to adhere to these standards, as Nurse 'J' did not accurately communicate the contents of the medication cup to the resident.
Failure to Provide Scheduled Showers and Hygiene Care
Penalty
Summary
The facility failed to provide routine showers and hygiene care for two residents, R91 and R52, as per their scheduled care plans. R91, who has moderate cognitive impairment and is dependent on staff for bathing, reported not receiving a scheduled shower and confirmed it had been a while since their last one. The Electronic Medical Record (EMR) showed that R91 only received four showers in the past 30 days, with no documented refusals or alerts indicating refusal. The Director of Nursing (DON) confirmed the lack of documented showers and stated that any refusals should have been recorded in the TASK section, which did not occur. R52 was observed with poor hygiene, including greasy hair and face, discolored teeth, and debris in their nostrils, despite documentation indicating hygiene care was provided. R52, who has moderately impaired cognition and requires assistance for hygiene and bathing, reported receiving a bed bath two days prior. However, their appearance suggested inadequate care. The DON was informed of R52's condition but had not yet addressed the issue at the time of the report.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care treatments according to physician's orders for a resident with diabetic ulcers on both feet. On January 30, 2025, the resident was observed with dressings dated January 28, 2025, despite the requirement for daily changes. The resident confirmed that the wound care was not being performed daily as prescribed. A review of the treatment administration record showed that the treatment for January 29, 2025, was signed off as completed, even though the dressings had not been changed. The resident, who was admitted with chronic kidney disease, deep vein thrombosis, diabetes, and high blood pressure, had a wound care consultation on January 24, 2025, which specified daily treatment with Medi-honey and bulky dressings. The Director of Nursing acknowledged that treatments should be performed per physician's orders and only signed off if completed. The facility's policy on skin management, revised in August 2024, emphasizes the importance of providing appropriate treatment to promote prevention and healing for residents with wounds.
Failure to Prevent Accidents and Ensure Safe Transport
Penalty
Summary
The facility failed to implement necessary interventions and provide adequate care to prevent accidents for two residents, resulting in a fall and potential injuries. One resident, who had a history of falls, femur fracture, cataracts, anxiety, and dementia, was observed in a wheelchair without anti-tipping devices and without Dycem to stabilize the cushion. The resident's clinical record indicated the use of a seatbelt restraint, but an incident report revealed that the resident was found on the floor with the seatbelt improperly secured around their chest. The Director of Nursing confirmed that the seatbelt was not tightened correctly, allowing the resident to slide out of the wheelchair. Another resident was transported by a CNA in a shower chair facing rearward, with the CNA pulling the chair in a forward motion. This method of transport was identified as a safety concern by the Director of Nursing, as it was contrary to the facility's policy, which requires wheelchairs to be rolled in a forward direction. The CNA did not provide a satisfactory explanation for this method of transport, and the chair did not require maintenance or repair.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.69% during a medication pass observation. Two medication errors were identified involving two residents. In the first instance, Nurse 'K' administered a 600 mg calcium supplement to a resident who did not have an order for it, instead having an active order for a Calcium Carbonate-Vitamin D 500 mg-200 mg combination supplement. This error was discovered upon reviewing the resident's medication orders. In the second instance, Nurse 'I' administered Dorzolamide eye drops to a resident, placing one drop in both the right and left eyes, contrary to the physician's order which specified administration in the left eye only. Nurse 'I' initially followed the instructions on the pharmacy label, which led to the error. The Director of Nursing acknowledged the errors and emphasized the importance of adhering to the Five Rights of medication administration. The facility's medication administration policy, revised in October 2023, requires verification of the medication label against the medication administration record for accuracy.
Failure to Obtain Physician-Ordered X-Rays for a Resident
Penalty
Summary
The facility failed to obtain physician-ordered x-rays for a resident, identified as R69, who was reviewed for radiology/diagnostic services. R69 had a physician order dated 12/28/24 for an x-ray of the right shoulder and hips due to pain. However, the record did not show any documentation that the x-rays had been obtained. R69 was admitted to the facility with diagnoses including type 2 diabetes, insomnia, and end-stage renal disease. An interview with the Director of Nursing (DON) revealed that for a STAT order, x-rays are usually completed within 4 to 6 hours, while general orders are set for three days to ensure they are not missed. Despite this protocol, the DON was unable to provide evidence that the x-ray ordered on 12/28/24 had been completed for R69.
Unsafe Doorway Frame Poses Risk to Residents
Penalty
Summary
The facility failed to maintain a safe environment for two residents, as observed in the room they occupied. The doorway frame had a sharp metal strip at ankle height that was pulled away, exposing sharp metal edges. This condition was observed on multiple occasions over three days, indicating a potential risk for injury to residents entering the room. The Unit Manager, who had been in their role for a short period, confirmed the hazardous condition upon being informed but was not previously aware of it. The facility's electronic reporting system, TELS, did not document this issue over the past three months. The Maintenance Director was also unaware of the problem until it was pointed out during the survey. Despite conducting environmental rounds, the maintenance staff had not identified the sharp metal doorframe as a concern. The facility's environmental audits for the past month did not specify which areas were observed, and no issues with the doorframe were documented. The facility's policy on environmental rounds emphasizes the importance of identifying and addressing issues to meet regulatory standards, yet this deficiency was not detected until the surveyor's intervention.
Failure to Ensure Resident's Right to Private Mail Delivery
Penalty
Summary
The facility failed to ensure a resident's right to receive unopened and private mail delivery, as evidenced by an incident involving a resident identified as R701. The resident, who was alert and had intact cognition with a BIMS score of 13/15, reported that a package containing pharmacy items was delivered to the facility but was opened and partially missing when it was finally brought to their room. The package, which included mouth wash and bed pads, was delayed by approximately a week, and upon receipt, the resident noted that three bottles of mouth wash and a pack of bed pads were missing. The facility's Administrator acknowledged that the package was mistakenly opened by staff and some items were missing by the time it was located. The facility's policy on resident mail clearly states that mail should be delivered unopened unless otherwise indicated by the resident or their representative, and staff should not open mail without permission. Despite this policy, the incident occurred, leading to a violation of the resident's rights to privacy and proper mail handling.
Failure to Notify Wound Care Practitioner and Update Interventions
Penalty
Summary
The facility failed to notify the appropriate wound care practitioner and update interventions for a resident with a pressure injury. The resident, identified as R704, was admitted with a stage IV pressure wound on the sacrum, initially identified as a skin injury upon admission from a hospital stay. Despite a treatment plan being put in place by the Director of Nursing (DON), there was no evidence of further interventions or notification to the wound care practitioner. The wound worsened over time, leading to the resident being sent to the hospital due to a change in condition. Interviews with staff revealed a lack of awareness and communication regarding the resident's wound care needs. The Unit Manager was unaware of the wound's history, and the Wound Care Coordinator noted that the wound had worsened after the resident's stroke. The DON acknowledged the lack of follow-up and was unaware that the care plan had not been updated since 2023. The facility was noted to be working on improving the consistency of their wound care program.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in one resident hitting another on the head. The incident occurred when a resident with severe cognitive impairment, who frequently wandered into other residents' rooms, entered the room of a cognitively intact resident. The latter resident, feeling threatened by the intrusion, responded by hitting the wandering resident on the head, causing redness. This incident was reported to the State Agency, and the facility conducted an investigation but could not substantiate abuse, although it was confirmed that the hitting occurred. The wandering resident, who has a history of adjustment disorder, insomnia, and dementia, was noted to have a BIMS score of 0/15, indicating severe cognitive impairment. This resident frequently wandered into other residents' rooms, which had been documented in their clinical record. Despite interventions such as placing stop signs in Russian and using a wander-guard, the resident continued to enter other rooms, leading to multiple incidents where other residents expressed discomfort or reacted aggressively. Staff interviews revealed that while they were aware of the wandering behavior and attempted to redirect the resident, they were not always successful in preventing the resident from entering other rooms. The facility's policy on abuse prohibition emphasizes the responsibility of staff to provide a safe environment, yet the interventions in place were insufficient to prevent the incident of physical abuse. The facility's failure to consistently monitor and redirect the wandering resident contributed to the deficiency in protecting residents from abuse.
Failure to Prevent Accidental Opioid Ingestion and Elopement
Penalty
Summary
The facility failed to protect a resident from a likely accidental opioid ingestion. A resident, who did not have any narcotic medications prescribed, was found unresponsive and required Narcan administration by EMS to become responsive. The resident's guardian expressed concern about the incident and lack of answers from the facility. The resident had severely impaired cognition and was independent for most activities of daily living. The facility's investigation revealed that the nurse assigned to the resident was also responsible for administering narcotic medications to another resident on a different unit, raising concerns about a possible medication error. The facility also failed to ensure timely interventions to prevent a resident with a known history of elopement and wandering from exiting the facility. The resident, who had severe cognitive impairment and a history of wandering and elopement attempts, managed to exit through a fire exit door. Although staff responded and redirected the resident back into the building, the incident highlighted the lack of adequate supervision and timely intervention. The resident's care plan included interventions such as stop signs in Russian and 30-minute checks, but there were no logins for time checks in the electronic task section. Interviews with staff and the administrator revealed awareness of the resident's wandering and elopement behaviors, but staff were not always present to redirect the resident. The social worker noted that while interventions were in place, staff were not always around to implement them effectively. Attempts to transfer the resident to a secured facility were not followed through by the resident's family, and there was no current guardian for the resident.
Failure to Conduct Ordered Urine Drug Test
Penalty
Summary
The facility failed to ensure a urine drug test was collected per physician orders for a resident who was reviewed for narcotic medications. A complaint was filed alleging that the resident, who does not take any narcotic medications, was found unresponsive and was administered Narcan by EMS, after which the resident became responsive. Despite the physician's order for a urine drug screen, the test was never conducted. The Assistant Director of Nursing (ADON) explained that the nurse was unable to collect the sample, and the order was automatically marked as completed when it reached the end date, even though the test was not performed. The resident, who was admitted with diagnoses including COPD, depression, and dementia, was found lethargic with slurred speech and pinpoint pupils, leading to the administration of Narcan. The attending physician indicated that these symptoms suggested the presence of an opioid, but confirmation would require a drug screen. The facility's policy requires that orders given by a physician or state-permitted healthcare professional must be accepted by a licensed nurse, yet the urine drug test was not collected, resulting in a failure to meet the resident's needs for timely and quality laboratory services.
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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