The Orchards At Canterbury On The Lake
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterford, Michigan.
- Location
- 5601 Hatchery Road, Waterford, Michigan 48329
- CMS Provider Number
- 235555
- Inspections on file
- 35
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at The Orchards At Canterbury On The Lake during CMS and state inspections, most recent first.
A resident with right lower leg fractures, anxiety disorder, and moderately impaired cognition, who required one-person extensive assistance for bed mobility per the care plan, slid out of bed during ADL care when a CNA instructed him to roll to his side without maintaining adequate positioning safeguards. The resident reported that he told the CNA he was falling and that she did not help, and an LPN later found him partially out of bed before the resident assisted himself back onto the bed. The incident was determined by facility leadership to have resulted from improper bed mobility technique and insufficient positioning safeguards during care, and the resident was transferred to the hospital.
A resident with impaired cognition and multiple diagnoses experienced a fall resulting in severe head pain and was transferred to the hospital by EMS after the LPN notified the physician. The resident's legal decision maker was not informed of the fall or hospital transfer at the time, only learning of the incident later from the ER physician. Facility records and interviews confirmed the lack of timely notification, contrary to facility policy.
Two residents did not receive prescribed medications as ordered due to failures in timely ordering and locating medications within the facility. One resident missed an initial dose of IV antibiotics upon admission, while another experienced multiple missed doses of potassium chloride and metoprolol succinate, despite the medications being available on site. Staff did not follow established procedures for medication administration and availability.
Two residents experienced delays in care, including extended wait times for call light responses and being left wet for hours, due to insufficient CNA staffing on a shift. Staff interviews and records confirmed that only one CNA was available for several hours, leading to unmet resident needs and delayed personal care.
A resident with a PICC line and ESBL urinary tract infection did not receive required enhanced barrier precautions. Staff did not use gowns or PPE when providing care, and there was no signage or PPE available near the room. The resident's care plan and physician orders lacked instructions for transmission-based precautions, and the infection control preventionist confirmed the oversight.
Two residents experienced delays in assessment and treatment of new skin wounds, with incomplete documentation and missed wound care orders, leading to infection and prolonged healing. Another resident did not receive prescribed cardiac medications because staff failed to use available back-up medication supplies, despite the medications being in stock. The DON confirmed that immediate action was required in both wound care and medication administration, but this did not occur.
Surveyors observed multiple failures in food service safety, including improper storage of wiping cloths, accumulation of grease and debris on kitchen equipment, soiled appliances, missing plumbing components, and undated or improperly stored food items in resident refrigerators and kitchenettes. These actions did not comply with professional standards or the facility's own policies.
Surveyors found that the facility's QAPI program did not identify or address systemic issues in Infection Control and Pest Control, as evidenced by the presence of flying insects throughout resident areas and outdated pest control documentation. The QA committee was not monitoring these concerns, and there was no infection surveillance for legionella or compliance with local health department guidance.
Surveyors found that the facility did not maintain an effective pest control program, as flying insects were observed in multiple areas, uncovered food was left out attracting pests, and a resident was found with maggots in a wound. Staff were unclear about pest control responsibilities, and documentation of routine pest control services was missing or outdated.
Surveyors found expired insulin pens and vials in medication carts, as well as an expired bottle of liquid pain relief in a medication storage room. Medication carts were also observed to be unclean, with dust and sticky residues present. Nursing staff confirmed that expired medications should have been discarded and that carts should be cleaned daily, but these practices were not consistently followed.
The facility did not have an effective system to monitor antibiotic use, as several residents were prescribed antibiotics without proper documentation of clinical indications, review of appropriateness, or consultation with a physician. Infection control logs and medical records lacked evidence of symptom documentation, urinalysis, or culture results, and staff interviews confirmed that antibiotic appropriateness was not consistently reviewed.
Staff failed to consistently follow infection control protocols, including improper use of PPE during medication administration for a resident on Contact Precautions. The facility also did not implement an effective infection surveillance program or follow county health department guidance for enhanced legionella testing, missing multiple opportunities to test residents with symptoms such as cough, shortness of breath, and pneumonia. Leadership could not explain why county recommendations were not followed.
Two residents were unable to access their call lights when they needed assistance, as the devices were found out of reach—one hanging on the far side of the bed and another clipped behind an oxygen concentrator. The facility's policy did not specify that call lights must be kept within reach.
Two residents were not properly educated or given the opportunity to formulate advance directives for their healthcare wishes. One resident, despite being able to communicate his preferences, did not have documented discussions or documentation regarding advance directives, and staff provided inconsistent information about his decision-making capacity and the process for guardianship. Another resident with intact cognition also lacked documentation of being educated or offered an advance directive, with staff confirming that not all residents received this information as required by facility policy.
A resident with multiple medical conditions was left on a bedpan for four hours during the night shift, resulting in pain and skin issues. The resident was not cleaned after removal from the bedpan and had to wait until the day shift for hygiene care, with staff confirming the incident and physical evidence of neglect.
A CNA took an unauthorized photograph of a resident with moderately impaired cognition on her personal phone, showing the resident and wet bedding. The CNA stated she took the picture to defend herself, despite facility policy prohibiting staff from taking resident photos on personal devices. The administrator confirmed the CNA had received and acknowledged the relevant policies.
A resident with multiple diagnoses, including anxiety and dementia, had a PRN Ativan order that lacked a specified stop-date despite repeated pharmacist recommendations and physician indications for a limited duration. The order remained unchanged in the system, and the facility's policy did not address updating orders based on these recommendations.
A resident with multiple serious diagnoses and on hospice care was inaccurately documented in a quarterly MDS assessment as not receiving hospice services, despite previous assessments and clinical records confirming ongoing hospice care. The DON acknowledged the issue, and the facility lacked a specific policy on MDS accuracy, relying instead on the RAI Manual.
A resident with an anxiety disorder was prescribed Alprazolam as needed, but the facility did not develop or implement a comprehensive care plan addressing the resident's anxiety or include interventions to manage anxiety before medication use. The DON was unaware of the missing care plan, and no further documentation was provided.
The facility did not ensure timely review and documentation of pharmacist recommendations for two residents with complex medical and psychiatric conditions. Pharmacist recommendations regarding medication orders lacking diagnoses were not reviewed by a physician in a timely manner, and documentation was missing from the medical record. The facility also lacked an established policy for drug regimen reviews.
A resident with severe cognitive impairment and aphasia was documented in the medical record as having a court-appointed guardian, despite no supporting documents and confirmation from staff and family that no guardian existed. The progress note was e-signed by a social services staff member who denied authoring it, and the facility could not determine who made the entry, resulting in incomplete and inaccurate medical record documentation.
The facility did not ensure that two cognitively intact residents received a clear explanation of the Binding Arbitration agreement before signing, resulting in their lack of understanding about waiving their right to a court trial. The Admission Coordinator admitted to not fully explaining the agreement's terms, and documentation was incomplete or lacked proper consent details.
During a lunch meal service, a resident was left waiting for their meal significantly longer than others at their table, while two other residents at a different table also experienced delays. Flies were observed in the dining area, and one resident required staff assistance to eat. The delayed and inconsistent meal service compromised the dignity of the residents involved.
A resident was found using a facility-provided wheelchair that was missing a left armrest and had severely worn wheels. The resident's legal guardian reported the wheelchair had been in poor condition for some time without staff intervention. The maintenance director confirmed the issue had not been reported through the facility's electronic work order system, despite established procedures requiring such reporting.
The facility did not report to the State Agency two separate incidents involving two residents: one with a wound of unknown origin and another left on a bedpan for several hours without proper care. In both cases, staff and administration failed to initiate required investigations or notifications, despite facility policy and regulatory requirements.
A resident with dementia and psychotic disorder was found with a forehead injury of unknown origin. Although the CNA, nurse, physician, wound care, and family were notified and treatment was provided, no investigation or reporting was conducted because the DON and Administrator were unaware of the incident. The facility did not follow its policy to investigate unexplained injuries.
A resident with a history of cerebral infarction and diabetes, and with intact cognition, did not consistently receive scheduled bathing assistance as required by their care plan. The resident reported missing scheduled showers and having to perform a sponge bath independently, while staff documentation inaccurately indicated that showers had been provided. The DON confirmed awareness of the discrepancy between documentation and actual care provided.
A resident who required assistance with bed mobility fell and injured her foot when a CNA rolled her away from herself while the bed was not properly positioned against the wall. The bed had been moved to access the call light and was not returned, leading to the resident falling between the bed and the wall. The incident was not fully communicated by the CNA, and the resident's medical history included heart disease, kidney disease, and diabetes.
A resident's family reported concerns about a nurse's rudeness and the resident being frequently found soiled, with bedding sometimes soaked. Although the concerns were documented and the DON educated the nurse, the facility failed to record corrective actions or the family's satisfaction with the outcome on the grievance form, as required by policy.
A resident with severe cognitive impairment and a history of falls experienced 15 falls over three months, including incidents resulting in a head injury and laceration. Despite requiring substantial assistance for mobility and transfers, the facility did not implement or document effective interventions such as increased supervision, and failed to address environmental hazards or thoroughly investigate each fall, leading to repeated accidents.
A resident's family member alleged that money was missing from the resident's account, citing unauthorized charges and purchases. An LPN notified the Administrator, but the allegation was not reported to the State Agency or investigated as required by facility policy. The resident was cognitively intact and managed her own affairs, and the incident was not recognized as a reportable event due to prior family disputes.
Surveyors found that medication carts were left unlocked and unattended, with a loose pill discovered in one cart and two insulin pens stored past their 28-day usage period in another. An LPN and RN confirmed these practices did not follow facility policy, which requires secure storage and timely disposal of expired medications.
A facility failed to provide regularly scheduled bathing for a resident who required assistance with ADLs. The resident, with diagnoses including heart failure and weakness, was to receive showers twice weekly per a physician's order. However, records showed missed showers on specific dates in January, and the Director of Nursing confirmed the lack of documentation for these showers. This deficiency was identified following a concern submitted to the State Agency.
A resident with dementia was physically and verbally abused by a CNA, resulting in pain and distress. The incident was witnessed by a nurse who intervened, but the police were not immediately notified. The resident was later taken to the hospital for evaluation. The facility confirmed the abuse and terminated the CNA.
A facility failed to timely report an abuse incident involving a resident who was allegedly attacked by a CNA. The incident, witnessed by an LPN, involved physical and verbal abuse over a pair of glasses. There was a delay in notifying the abuse coordinator and the State Agency, violating the facility's policy requiring immediate reporting of abuse allegations.
The facility failed to provide adequate nursing staff, resulting in residents being left in soiled briefs and not receiving necessary feeding assistance. Staffing records showed consistent understaffing, with insufficient CNAs and nurses to meet resident needs. Interviews confirmed challenges with staff call-ins and reliance on agency staff, while the facility's policy required staffing adjustments based on resident needs.
The facility failed to update its facility-wide assessment to reflect changes in resident care needs and administrative staff, resulting in insufficient resources for resident care. A resident with complex medical needs required more care than documented, highlighting the mismatch between care plans and actual needs. The Administrator was unaware of regulatory changes and did not involve direct care staff or families in the assessment process.
A resident with intact cognition was physically attacked by another resident with severe cognitive impairment, resulting in abrasions to the head and arm. The aggressive resident had previously been redirected from the victim's room but gained unsupervised access again, leading to the altercation. The victim expressed fear and feeling unsafe.
A resident with dysphagia and other medical conditions did not receive one-to-one feeding assistance as required by their care plan. The resident was left with a meal tray containing a straw, which was against their care instructions, and no staff provided the necessary assistance. An agency CNA was unaware of the resident's needs, highlighting a communication breakdown in the facility's process for informing temporary staff of care plans.
A resident with a history of pneumonia and PEG-tube placement was not provided with food and drink according to their care plan, which specified no straws and required 1:1 feeding assistance. The resident was found with a meal tray containing a straw and without a clothing protector, and they reported not receiving the usual assistance. The CNA was unaware of the resident's dietary restrictions, and the ADON acknowledged issues with kitchen staff providing inappropriate utensils.
The facility's deficiency in providing adequate dietary staffing resulted in delayed and incorrect meal services for residents. Observations and interviews revealed that residents experienced late and inaccurate meals, with dietary staff confirming daily shortages. Chef C noted that only two or three servers were available instead of the required eleven, leading to bottlenecks and delays. Resident Council meeting minutes also highlighted ongoing concerns about meal timing, quality, and accuracy.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including improper food storage without date markings, unsanitary equipment, and inadequate temperature control. The walk-in cooler and reach-in cooler had issues with cleanliness and maintenance, while the dishwashing machine was not sanitizing properly. Additionally, food storage practices were inadequate, with raw and ready-to-eat foods improperly stored, and handwashing facilities were blocked, increasing the risk of foodborne illness for residents.
The facility failed to ensure proper infection control practices, with staff frequently entering rooms of residents on transmission-based precautions without PPE or hand hygiene. For several residents, including those on Enhanced Barrier Precautions and contact precautions, there was a lack of available PPE and confusion among staff about necessary precautions. This systemic issue highlights a significant deficiency in the facility's infection control protocols.
A resident with dementia was verbally and physically abused by another resident using a walker. Despite prior incidents of aggressive behavior, the facility failed to implement interventions to prevent further abuse. A behavioral consultation recommended a management plan and medication changes, but these were not executed. The facility's administration was unaware of prior incidents, and the abuse prevention policy was not followed.
The facility failed to provide timely and accurate pressure ulcer care for two residents. One resident experienced delays in treatment due to incorrect transcription of physician orders, while another developed pressure ulcers due to inadequate assessment and documentation by the wound care nurse. The DON acknowledged the discrepancies in wound care documentation.
The facility failed to provide timely meals, with breakfast and lunch served later than scheduled due to staffing shortages. Observations and interviews revealed that residents on the 2nd floor and in the resident council were affected, with reports of cold food and incomplete meal orders. The kitchen operated with only two or three servers instead of the required eleven, leading to these deficiencies.
The facility failed to ensure the Infection Control Preventionist attended QAPI meetings at least quarterly. The Infection Control Preventionist did not sign in for meetings from January to June 2024, and there was no evidence of her participation via Zoom, as claimed by the DON. The Infection Control Preventionist initially stated she attended in person but later admitted to joining via Zoom at times.
The facility failed to implement an effective antibiotic stewardship program, as it did not consistently identify infection signs and symptoms or provide clinical justification for antibiotic use. Documentation was incomplete and inconsistent with the facility's policy, and the Infection Preventionist was unavailable for most of the survey. Discrepancies were found in the application of criteria for antibiotic use, with residents being prescribed antibiotics without meeting necessary criteria.
A resident's advance directive information was inaccurately documented, leading to conflicting records about their code status. Despite the resident's clear wish to be a DNR, facility records showed discrepancies, with some indicating Full Code status. Interviews revealed inconsistencies in the process for updating advance directives, contributing to the deficiency.
A facility failed to complete an annual OBRA Level I evaluation for a resident with severe cognitive impairment and multiple diagnoses, including psychotic disorder and dementia. The required DCH-3878 form was not sent to the local CMHSP, and the facility lacked a policy for the PASARR process. A Social Service Tech, not licensed to complete PASARR documents, confirmed the oversight during an interview.
Improper Bed Mobility Assistance Leading to Resident Fall From Bed
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper positioning and bed mobility assistance during ADL care, resulting in a resident sliding out of bed and requiring hospital transfer. The resident had been admitted with a nondisplaced trimalleolar fracture of the right ankle, a fracture of the shaft of the right fibula, and an anxiety disorder, and had a BIMS score of 10/15 indicating moderately impaired cognition. The resident’s ADL care plan specified that he required one-person extensive assistance by staff for bed mobility, including turning and repositioning while in bed. During an episode of incontinence care, the CNA instructed the resident to roll to his left side; in the process, he slid off the bed while still on top of the mattress and ended up on the floor. According to the nurse’s note and subsequent interview, the resident reported that when he began sliding off the bed and told the CNA he was falling, she did not assist him. The LPN stated that when he arrived at the room, the resident was half in and half out of the bed and that the resident then assisted himself back onto the bed. The resident later contacted an outside party and reported that he had soiled himself, could not get help, and that after he fell, the aide lowered the bed and told him he could crawl back into bed himself, which he did. The facility’s Administrator stated that their investigation concluded the incident resulted from improper bed mobility technique and insufficient positioning safeguards during care.
Failure to Notify Responsible Party After Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's responsible party of a significant change in condition following a fall and subsequent emergent transfer to the hospital. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), Alzheimer's Disease, and a neck fracture, was deemed unable to make her own medical decisions, with her family member documented as her legal decision maker. After the resident experienced a fall, the assigned LPN was notified by a CNA, and the resident reported severe head pain. The LPN contacted the attending physician, received an order to transfer the resident to the hospital, and arranged for EMS transport. However, there was no documentation that the resident's responsible party was informed of the fall or the hospital transfer at the time of the incident. The responsible party only became aware of the situation when contacted by the emergency room physician later that day. Facility records, including progress notes and a concern form, confirmed the lack of timely notification to the responsible party. The facility's policy required prompt communication of such events to both the attending physician and the resident's legal representative, but this was not followed in this instance. Interviews with the LPN involved revealed uncertainty about whether the notification was made and a lack of recall regarding any related education or disciplinary action.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available and administered according to physician orders for two residents. One resident, who had a peripherally inserted central catheter (PICC) for intravenous antibiotics due to a urinary tract infection with ESBL resistance and iron deficiency anemia, did not receive their prescribed IV antibiotic on the evening of admission. The medication was not available because it was not ordered in time, resulting in the first dose being missed and not administered until the following day. The resident confirmed that the antibiotic was not given as scheduled upon admission. Another resident with chronic kidney disease and dementia had multiple missed doses of prescribed medications, including potassium chloride for hypokalemia and metoprolol succinate for hypertension. Documentation in the medication administration record indicated that these medications were not administered on several days due to unavailability, with notes stating they were either awaiting delivery from the pharmacy or on order. The medications were, in fact, available in the facility, but nursing staff did not locate them in the medication cart or backup supply. Interviews with facility staff confirmed awareness of the missed doses and revealed that nursing staff did not follow proper procedures to ensure timely medication administration. The facility's policy requires medications to be administered as prescribed and for staff to be familiar with medication locations and ordering processes, but these procedures were not followed, resulting in the deficiencies observed.
Insufficient Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations, interviews, and record reviews. One resident, who required assistance with most activities of daily living and had intact cognition, reported frequent staffing shortages and significant delays in having their call light answered, resulting in unmet needs. Another resident, who was dependent on staff for care due to hemiplegia, hemiparesis, and dementia, was reportedly left wet for several hours during a day shift when only one CNA was available to care for all residents on the first floor. Staffing records confirmed that only one CNA was present for approximately 4-5 hours, and additional help did not arrive until after lunch. Staff interviews corroborated that the staffing shortage led to delayed responses to call lights, residents not receiving bathing, and some residents remaining wet longer than appropriate. The staffing coordinator acknowledged a call-off that was not covered, and CNAs reported confusion about assignments and lack of timely communication regarding the need for assistance. Facility documentation indicated that staffing should be based on resident acuity, but on the day in question, the staffing was insufficient to meet resident care needs.
Failure to Implement Enhanced Barrier Precautions for Resident with ESBL Infection
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident who was admitted with a peripherally inserted central catheter (PICC) line and an active infection, specifically an Extended Spectrum Beta Lactamase (ESBL) urinary tract infection. Upon observation, the resident reported that nursing staff did not wear gowns or other personal protective equipment (PPE) when providing care, and there was no signage or PPE available near the resident's room to indicate the need for such precautions. The resident's medical record and care plan did not include any orders or instructions for enhanced barrier or transmission-based precautions at the time of review. Further review of the resident's medical history showed they required assistance with most activities of daily living and had intact cognition. The infection control preventionist confirmed that the resident should have been on contact precautions due to the ESBL infection and the presence of a PICC line, but acknowledged that the resident was missed during the initial review for precaution requirements upon admission. The deficiency was identified through observation, interview, and record review, which revealed a lack of appropriate infection control measures for the resident in question.
Failure to Timely Assess, Treat Skin Impairments and Administer Medications
Penalty
Summary
The facility failed to assess and treat new skin impairments in a timely manner and according to physician's orders for two residents. One resident, with a history of stroke and significant physical impairment, developed a skin wound on the right forearm after receiving electrical stimulation therapy. The wound was first identified by therapy staff, but there was no timely or thorough nursing assessment or documentation of the new skin issue. Weekly skin assessments were incomplete or missing for several weeks, and the wound was not properly evaluated or treated until it became infected, requiring antibiotics. Physician orders for wound care were not promptly entered into the Medication Administration Record (MAR) or Treatment Administration Record (TAR), resulting in missed treatments. Even after the wound was considered resolved by a wound care provider, dressings continued to be applied, and there was a lack of documentation and communication regarding the wound's status. Another resident was observed with significant skin impairment on the right shin, including blistering and drainage, but there were no treatment orders in place at the time of initial observation. Treatment orders were only initiated after the wound was observed and noted by surveyors, indicating a delay in response to the resident's condition. The Director of Nursing confirmed that treatments should be implemented immediately upon identification of a wound or skin impairment, but this did not occur in these cases. Additionally, the facility failed to ensure that prescribed cardiac medications were administered to a newly admitted resident. The resident did not receive several critical medications because staff did not utilize the back-up medication supply, despite these medications being available. The MAR indicated that medications were held while waiting for pharmacy delivery, and the Director of Nursing acknowledged that the medications could have been administered from the back-up supply. The facility's medication administration policy did not address the use of back-up medication supply for such situations.
Food Service Safety and Sanitation Deficiencies Identified
Penalty
Summary
The facility failed to prepare and handle food in accordance with professional standards for food service safety, as evidenced by multiple observations during a kitchen inspection. A wet wiping rag was found lying on the counter instead of being stored in a sanitizer solution, which was confirmed by the Food Service Manager as not compliant with procedures. The vent hood grates had a buildup of grease and debris, and the vent hood was reportedly cleaned only quarterly. The interior of the microwave was soiled with dried food debris, and the ice machine filters were dusty with a thick lime scale on the top exterior. Additionally, the flooring underneath the ice machine was wet with a black, slimy film. The Atmospheric Vacuum Breaker near the dish machine room hose sprayer was missing its top cap. Further observations included undated and improperly stored food items in the 1st floor resident refrigerator, such as an Arby's roast beef sandwich, containers of soup, chicken, salad, fish, and other food items, some of which were labeled with resident names but not dated, and some dated as far back as 7/2/25. The refrigerator interior was also soiled with spills and dried food debris. In the 1st and 2nd floor kitchenette coolers, opened and undated containers of thickened liquids were found, despite manufacturer instructions to use within four days of opening. The facility's own policy requires all stored food to be covered, labeled with the resident's name and date, and discarded if not consumed within three days, which was not followed.
QAPI Program Failed to Address Infection and Pest Control Deficiencies
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify and address systemic issues related to Infection Control and Pest Control. During a recertification survey, surveyors observed ongoing concerns in these areas, including the presence of flying insects on all three resident floors and a lack of recent pest control documentation, with the last recorded service dated several months prior. Additionally, there was no evidence of infection surveillance for legionella or adherence to county health department guidance. In an interview, the Administrator confirmed that the Quality Assurance (QA) committee was not currently addressing Infection Control or Pest Control as areas of concern, and there were no active QAPI plans for these issues. Review of the facility's QAPI policy indicated that the committee is responsible for identifying and responding to quality deficiencies, developing corrective actions, and monitoring performance, but these responsibilities were not fulfilled in the areas identified by surveyors.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flying insects in multiple areas including conference rooms, hallways, resident rooms, and dining areas across all floors. Observations during the survey revealed uncovered food trays left out in dining rooms and on carts, which attracted flying insects. The main elevator was also found to have multiple dead insects inside the ceiling light cover. In one instance, a resident was identified with maggots in a wound just prior to the survey. During an interview, a resident's legal guardian confirmed the ongoing issue with flying insects in the resident's room and noted that staff had provided a vinegar gnat bait but had not followed up on its effectiveness. The legal guardian also reported that food was often left out too long before being cleared, contributing to the pest problem. Review of facility records showed a lack of routine pest control services, with the most recent documented visit occurring several months prior to the survey and no detailed findings provided. Documentation for subsequent months was either missing or outdated. Staff interviews revealed confusion regarding responsibility for pest control, with the Maintenance Director unaware of any concerns and not involved in monitoring pest issues. The facility was unable to provide documentation of staff reporting pest concerns or evidence of ongoing pest control measures, despite a policy requiring an effective pest control program and a reporting system for issues arising between scheduled pest service visits.
Expired and Improperly Stored Medications Found in Medication Carts and Storage Room
Penalty
Summary
Surveyors observed multiple deficiencies in the storage and labeling of medications and biologicals within the facility. On several occasions, expired insulin pens and vials were found in medication carts on the second floor, with nursing staff confirming that these expired medications should have been discarded. Additionally, a medication cart on the third floor was found to be unclean, containing dust and sticky residues on supplement bottles and cart handles. Nursing staff acknowledged that the carts should be cleaned daily, indicating a lapse in routine cleaning procedures. Further inspection of the medication storage room on the third floor revealed an opened bottle of liquid pain relief with an expiration date that had already passed. Facility policy requires that outdated, contaminated, or deteriorated medications be immediately removed from stock and disposed of according to established procedures. The observations made by surveyors demonstrated that these policies were not consistently followed, resulting in expired and improperly stored medications remaining accessible in medication storage areas.
Failure to Monitor and Review Antibiotic Use
Penalty
Summary
The facility failed to ensure an effective system to monitor antibiotic use for four residents, as evidenced by interviews and record reviews. Infection control logs and medical records showed that multiple residents were prescribed antibiotics without adequate documentation of clinical indications or review of appropriateness. For example, one resident was started on Macrobid for confusion, but the medical record did not document urinary symptoms or urinalysis and culture results. Another resident was prescribed antibiotics for reported urinary symptoms, but the medical record lacked documentation of those symptoms and culture results. Additionally, a newly admitted resident was prescribed metronidazole without documentation of a review for appropriateness, and another was prescribed Macrobid for an asymptomatic urinary tract infection without documentation of signs or symptoms. Further review revealed that the infection control logs and medical records did not contain evidence of review for the appropriateness of antibiotics prescribed to these residents. During interviews, the Infection Preventionist (IP) stated that they input data into a computerized checklist and reviewed labs and referrals but did not consult with the physician regarding the appropriateness of antibiotic use. The Director of Nursing (DON) and IP were unable to provide documentation or further explanation regarding the review of antibiotic appropriateness for the affected residents by the end of the survey.
Failure to Follow Infection Control Protocols and County Guidance for Legionella Surveillance
Penalty
Summary
The facility failed to consistently follow infection control standards, practices, and protocols, as well as to implement an effective infection control surveillance program. During a medication administration for a resident on Contact Precautions, an LPN was observed wearing an isolation gown and mask into the resident's room, then exiting the room and preparing medications at the medication cart while still wearing the same gown and mask. The LPN only removed the PPE after leaving the area for the second time, contrary to facility policy and infection prevention protocols, which require all PPE to be removed before exiting a Contact Precaution room. The Infection Preventionist confirmed that PPE should not be worn outside the resident's room. Additionally, the facility failed to follow guidance from the county health department regarding enhanced monitoring and testing for legionella. The county epidemiologist had provided specific criteria for enhanced legionella testing, including monitoring for clinical symptoms such as acute onset of lower respiratory illness with fever and/or cough. Despite this guidance, the facility did not identify or conduct enhanced legionella testing for multiple residents who met the criteria, as documented in the facility's infection surveillance logs and resident medical records. Several residents exhibited symptoms such as cough, shortness of breath, congestion, and pneumonia, but enhanced testing was not performed. Interviews with the Infection Preventionist, DON, and Administrator revealed a lack of communication with the health department and a failure to implement the recommended clinical criteria for legionella testing. The facility had instead adopted its own criteria, testing only residents with a fever of 102 degrees or above, which did not align with the county's recommendations. No explanation or additional documentation was provided by the facility for not following the health department's guidance.
Call Lights Not Kept Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, resulting in the potential for delayed response to their care needs. In one instance, a resident was observed in their wheelchair with their foot wedged between the wheelchair pedal and the bed rail, and when asked to activate their call light for assistance, reported not having access to it. The call light was found hanging on the side of the bed against the wall, out of the resident's reach. In another case, a resident requested assistance to use the restroom but was unable to reach the call light, which was clipped to the bed linens behind an oxygen concentrator, approximately five feet away. The facility's call light policy was reviewed and found not to address the requirement for call lights to be kept within resident reach.
Failure to Educate and Offer Advance Directives to Residents
Penalty
Summary
The facility failed to ensure that two of three residents reviewed for advance directives were properly educated and given the opportunity to formulate an advance directive for their healthcare wishes. In the case of one resident with a history of cerebral ischemia and aphasia, documentation showed that although the resident was able to communicate and expressed a preference for a specific family member to make decisions on his behalf, there was no evidence that the facility had a meaningful conversation with him about advance directives or code status. The clinical record lacked documentation of an advance directive, and the process for determining decision-making capacity and pursuing guardianship was inconsistently documented and communicated among staff, the resident, and his family. Staff interviews revealed confusion about the resident's capacity and the steps taken to establish a legal guardian, with conflicting statements about whether the resident was able to make his own decisions and whether his son had been designated as DPOA. For another resident with diagnoses including hemiplegia, hemiparesis, and anxiety disorder, and who was noted to have intact cognition, there was no documentation in the medical record that the resident had been educated about or offered the opportunity to formulate an advance directive. Staff interviews confirmed that the process for educating and offering advance directives was inconsistently applied, with the Director of Social Work stating that not all residents received this conversation, particularly those with short stays. The Director of Nursing also indicated that while nurses asked about existing advance directives on admission, they did not provide education on the topic. Facility policy required that all competent adult residents be provided information on advance directives at admission or shortly thereafter, and that this be documented in the social services progress notes. However, the records for both residents lacked this required documentation, and staff interviews confirmed that the policy was not consistently followed. There was also a lack of clear communication and documentation regarding the roles and responsibilities of staff in the advance directive process, as well as the steps taken when a resident was deemed unable to make medical decisions.
Resident Left on Bedpan for Extended Period Without Hygiene Care
Penalty
Summary
A resident with a history of traumatic subdural hemorrhage, repeated falls, and Parkinson's Disease was left on a bedpan for four hours during the night shift. The resident reported significant discomfort, including pain in the bottom, legs, and heels, and was not cleaned after being removed from the bedpan. The resident had to wait until the day shift for proper hygiene care, at which time dried feces and a ring from the bedpan were observed on the skin. The resident communicated the incident to the Social Worker the following day. Interviews with staff confirmed the resident's account, with the day shift CNA noting the resident's distress and the physical evidence of prolonged bedpan use. The DON stated that residents should be checked within five minutes of being placed on a bedpan and always cleaned afterward. Facility records and staff interviews indicated that the expected standard of care was not met, resulting in neglect as defined by facility policy.
Unauthorized Photograph of Resident by CNA
Penalty
Summary
A certified nursing assistant (CNA) was found to have taken a photograph of a resident on her personal phone without authorization. The resident, who had moderately impaired cognition and required staff assistance for toileting, was observed sitting in a wheelchair in his room. The CNA explained that she took the picture to defend herself, and the image depicted the resident sitting on a bed with visible wet bedding. The resident's face was not visible, but the image was identifiable as the resident. The facility's policies, as outlined in the Employee Handbook and Abuse Policy, prohibit employees from taking pictures of residents on personal devices. The CNA's employee file confirmed she had received and acknowledged these policies. The incident was discovered during an interview with the CNA, who produced the photograph from her phone and stated she had taken numerous pictures of residents. The administrator confirmed that such actions were not permitted by facility policy.
Failure to Specify Stop-Date for PRN Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that a stop-date was included for a PRN (as needed) anti-anxiety medication order for one resident. The resident, who had multiple diagnoses including heart disease, malnutrition, adjustment disorder, anxiety disorder, falls, delirium, depression, and dementia with behaviors, had a physician order for Ativan 0.5 mg to be given every four hours as needed. This order, originating in December, was re-ordered in March and June with the same instructions and no defined duration for use. Monthly medication regimen reviews by the facility's pharmacist in January, February, and March each recommended that a duration of use be specified for the PRN Ativan order. The attending physician signed these reviews and indicated a specific duration (either 14 or 30 days) on the forms, but the original order in the system was never updated to reflect these durations. During the survey, it was discovered that the monthly medication regimen reviews for April and May could not be located by the facility's Director of Nursing. When questioned, the Director of Nursing stated that if the physician signed the form and specified a duration, it was the physician's responsibility to update the order in the computer system. Additionally, a review of the facility's Drug Regimen Review policy revealed that it did not address the process for changing orders based on the pharmacist's recommendations and the physician's responses. As a result, the resident's PRN Ativan order remained active without a specified stop-date, contrary to recommendations and documentation.
Inaccurate MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident who was receiving hospice care. The resident, who had diagnoses including atherosclerotic heart disease, moderate protein-calorie malnutrition, paroxysmal atrial fibrillation, and was under palliative care, was observed in bed with a hospice nurse present. Review of the clinical record confirmed the resident had been on hospice services since a specified date and remained on hospice at the time of the survey. However, while previous MDS assessments correctly identified the resident as receiving hospice care, a subsequent quarterly MDS assessment inaccurately documented that the resident was not on hospice care. During interviews, the DON identified the staff responsible for MDS assessments and acknowledged the concern regarding the inaccurate documentation. The facility did not have a specific policy addressing MDS accuracy and instead referred to the RAI Manual for guidance. The deficiency was identified through record review and staff interviews, which confirmed the inconsistency in the MDS documentation for a resident on hospice services.
Failure to Develop and Implement Care Plan for Anxiety Disorder
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan for a resident diagnosed with an anxiety disorder. Observation and interview revealed the resident was receiving Alprazolam 0.5 mg orally every 8 hours as needed for anxiety or panic related to their diagnosis. Review of the resident's medical record and care plans showed there was no documentation of a care plan addressing the anxiety disorder or any non-pharmacological interventions to manage anxiety prior to administering medication. When interviewed, the DON stated that care planning was a team responsibility but was unaware that a care plan for the resident's anxiety disorder had not been implemented. No additional explanation or documentation was provided by the facility.
Failure to Review and Document Pharmacist Recommendations for Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that pharmacist recommendations from monthly drug regimen reviews were reviewed and acted upon in a timely manner, and that documentation of these recommendations and physician responses was maintained in the medical record. For one resident with hemiplegia, hemiparesis, dysphagia, and anxiety disorder, the pharmacist made repeated recommendations over several months regarding multiple medication orders lacking associated medical diagnoses, particularly for psychotropic medications. There was no documentation that the physician reviewed or was informed of these recommendations until two months after the initial recommendation. For another resident with dementia, bipolar disorder, anxiety disorder, and adjustment disorder, the pharmacist's reports for two separate months referenced irregularities, but the facility was unable to provide documentation of these reports or any follow-up. Additionally, the facility did not have an established policy for drug regimen reviews and was relying on the pharmacy consultant to provide one. The lack of timely review, documentation, and policy implementation contributed to the deficiency.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of stroke, aphasia, and heart disease, who was admitted with severely impaired cognition. A progress note in the resident's clinical record, dated 7/19/25 and attributed to a social services staff member, stated that the resident had been deemed incompetent by a court and had a public legal guardian. However, upon review, there were no guardianship documents in the record, and both the social services staff member and the administrator confirmed that the resident did not have a guardian. The family member was in the process of obtaining Power of Attorney, as advised by a lawyer, due to the resident's aphasia and cognitive impairment. Further investigation revealed that the social services staff member whose name was on the progress note denied writing it and stated she did not share her computer with anyone else. The administrator was unable to determine who authored the note, despite it being electronically signed by the staff member. The facility's policy requires that medical records be complete, accurately documented, and systematically organized, but this incident demonstrated a failure to ensure the accuracy and integrity of the resident's medical record.
Failure to Clearly Explain Binding Arbitration Agreements to Residents
Penalty
Summary
The facility failed to ensure that staff had a clear understanding of the Binding Arbitration agreement and did not provide residents with a clear explanation of the agreement prior to signing. During interviews, the Admission Coordinator stated that she was responsible for reviewing the admission contract, which included the Binding Arbitration agreement, but admitted she did not inform residents that they could only rescind the agreement within the first 30 days or that signing the agreement would waive their right to a trial in court. The review of the facility's arbitration agreement document confirmed that it included language about waiving the right to a trial and the process for rescinding the agreement, but this information was not consistently communicated to residents. Two residents who were cognitively intact, as confirmed by their Minimum Data Set (MDS) assessments, were found to have signed or verbally consented to the arbitration agreement without understanding its implications. One resident's record showed only a verbal consent with no date or representative identified, and the resident later stated he did not know what the agreement was. The other resident signed the agreement but reported not knowing what it entailed and stated she would not have signed if she had known it meant waiving her right to go to court. Both residents had significant medical histories, including heart disease, kidney disease, and other conditions, at the time of admission.
Delayed Meal Service and Lack of Dignity During Dining
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident during a lunch meal service in the second floor dining room. Sixteen residents were observed waiting to be served, with the first tray not being served until 30 minutes after the initial observation. Flies were present in the dining area. While most tables received their meals, two residents at one table and another resident at a different table were left without meals after others at their tables had been served. One of these residents required staff assistance to eat. The last resident was not served until nearly an hour after the initial observation, by which time others at the same table had almost finished or completed their meals. These actions resulted in a lack of dignity and timely service for the affected residents.
Failure to Maintain Resident Equipment in Good Repair
Penalty
Summary
A deficiency was identified when a resident's wheelchair was observed to be in poor condition, specifically missing a left armrest and having wheels with no treads and very worn. The resident's legal guardian confirmed that the wheelchair was provided by the facility and had been in disrepair for an extended period, with no staff having previously inquired about its condition. The legal guardian stated that the issue had not been addressed or reported by facility staff. Further investigation revealed that the facility's process for reporting equipment in need of repair or replacement involved either verbal communication or leaving a note outside the maintenance office, despite the existence of an electronic work order system (TELs). The Maintenance Director confirmed the poor condition of the wheelchair and stated they were not previously aware of the issue. Review of the electronic maintenance records showed no documentation of the wheelchair's condition, indicating a failure to follow the facility's established procedures for reporting and addressing equipment repairs.
Failure to Report Alleged Neglect and Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of neglect and an injury of unknown origin to the State Agency for two residents. For one resident with dementia and a history of behavioral disturbances, a new skin issue was observed on the forehead, described as a wound or burn of unknown origin. Documentation showed that the CNA and nurse noted the injury, notified the physician and family, and initiated wound care, but no investigation or report was submitted to the State Agency as required. The Director of Nursing and Administrator both stated they were unaware of the injury and confirmed that no investigation or reporting occurred due to this lack of awareness. Another resident, admitted with traumatic subdural hemorrhage, repeated falls, and Parkinson’s Disease, reported being left on a bedpan for several hours overnight without being cleaned up until the next shift. The resident, who was cognitively intact, relayed the incident to the Social Worker the following day. Facility documentation confirmed the concern, and interviews with the DON and Administrator revealed that the incident was not reported to the State Agency. The DON acknowledged that leaving a resident on a bedpan for an extended period without cleaning could be considered neglect. The facility’s own policy required immediate reporting of all alleged violations and substantiated incidents to the State Agency. In both cases, the required reporting and investigation procedures were not followed, resulting in a failure to comply with state regulations regarding the timely reporting of suspected abuse, neglect, or injuries of unknown origin.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to complete and document a thorough investigation into an injury of unknown origin for one resident. The resident, who had diagnoses including dementia and brief psychotic disorder and required supervision for most activities of daily living, was observed with a new skin issue—specifically, discoloration and a possible laceration or burn on the forehead. Progress notes indicated that the injury was first noticed by a CNA, and the nurse, physician, wound care, and family were notified. Treatment was ordered, but there was no documentation of a fall or clear cause for the injury. The physician's note referenced an infection or burn and stated that staff reported no fall occurred. Despite these findings, there was no evidence in the Michigan reporting system of an investigation being initiated for this injury of unknown origin. Interviews with the DON and Administrator revealed that neither was aware of the injury at the time it occurred, and as a result, no investigation or reporting to the State Agency was conducted. The facility's own policy requires that all incidents of possible abuse or unexplained harm be investigated, including interviews with involved parties and a root cause analysis. However, these steps were not taken in this case, and the origin of the resident's injury remained unknown and uninvestigated.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
A deficiency was identified when a resident, who was admitted with diagnoses including cerebral infarction and type 2 diabetes mellitus and had intact cognition, did not consistently receive bathing assistance as required. The resident reported that showers were scheduled twice weekly, on Tuesdays and Fridays, but stated that only one shower per week was being provided. On one occasion, the resident did not receive the scheduled shower and had to perform a sponge bath independently. Documentation in the medical record indicated that staff had recorded providing physical help with bathing on the scheduled days, but the resident denied receiving this assistance. The care plan specified that the resident should receive showers twice weekly and be provided with a sponge bath if a full bath or shower could not be tolerated. The DON confirmed the facility's policy of twice-weekly showers and acknowledged awareness that showers were not being provided as assigned, despite documentation to the contrary.
Resident Fall Due to Improper Bed Mobility and Bed Positioning
Penalty
Summary
A deficiency occurred when a resident, who required partial to moderate assistance with bed mobility, was rolled in bed by a CNA without ensuring the bed was properly positioned against the wall. The bed had been moved away from the wall to access the call light, and neither the resident nor the CNA realized it had not been returned to its original position. During care, the CNA rolled the resident away from herself, resulting in the resident falling between the bed and the wall, injuring her foot. This incident was the second time x-rays were taken of the resident's foot due to ongoing pain. The resident reported the incident, and it was confirmed through interviews and record review that the bed's position and the method of rolling contributed to the fall. The resident had a history of heart disease, kidney disease, and diabetes, and was cognitively intact according to her most recent MDS assessment. Staff interviews revealed that the CNA did not communicate the details of the fall to the nursing staff, and the incident was only fully understood after the resident described what happened. Facility policy indicated that any fall, regardless of injury, should be reported and managed. The DON confirmed that residents should always be rolled toward the staff member, not away, especially when only one staff member is present.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to properly address and document the resolution of grievances raised by a resident's family member. The family member reported concerns during a phone call with the social worker, including allegations that a nurse was rude and that the resident was frequently found soiled, sometimes to the extent that her bedding was soaked. These concerns were documented in a typed note and a Concern Form initiated by the social worker and completed by the facility's administrator. However, the sections of the form designated for corrective actions and for indicating whether the filer was satisfied with the outcome were left blank. During an interview, the administrator acknowledged awareness of the grievances and confirmed that the nurse in question had been educated and that an offer to place an indwelling catheter was made but declined by the family. Despite this, there was no documentation on the Concern Form regarding the actions taken or the satisfaction level of the family. The facility's own grievance policy requires prompt efforts to resolve grievances and documentation of outcomes, but these steps were not completed in this case.
Failure to Investigate and Prevent Repeated Falls in Cognitively Impaired Resident
Penalty
Summary
The facility failed to thoroughly investigate and address repeated falls for a resident with severe cognitive impairment, resulting in 15 falls over a three-month period, including incidents that led to a head injury and forehead laceration. The resident, who had diagnoses of dementia, psychotic disorder with delusions, and insomnia, required substantial to maximal assistance for bed mobility and transfers, and had a history of falls prior to and during admission. Despite these risk factors, the facility did not implement or document effective interventions, such as increased supervision, to prevent further falls. Multiple incident reports and progress notes detailed the resident's repeated attempts to self-transfer, get out of bed, or move without assistance, often resulting in falls. In several cases, the root cause was identified as self-transfer without staff assistance, but interventions were limited to offering the resident a chair, repositioning, or encouraging use of the call light. There was a lack of documentation regarding increased supervision, and in some instances, environmental hazards such as the call light or water cup being out of reach were not addressed. The care plan was revised multiple times, but increased supervision was not consistently included as an intervention. Interviews with facility leadership, including the DON, confirmed that despite multiple interventions, the resident continued to fall and the facility was unable to identify an effective solution. The resident was eventually moved to a dementia unit after numerous falls, but continued to experience incidents. The facility's failure to conduct thorough investigations into each fall, address environmental hazards, and implement adequate supervision contributed to the ongoing risk and occurrence of accidents for this resident.
Failure to Report Allegation of Misappropriation of Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property involving one resident, as required by policy and regulation. The incident began when the resident's daughter reported to staff that someone at the facility had been taking money from the resident, citing unauthorized charges on the resident's accounts, including a large cell phone bill, purchases at local stores, and the depletion of the resident's funds. The daughter expressed these concerns during a visit to the facility, during which she was visibly upset and confrontational with staff. A Licensed Practical Nurse (LPN) was informed by the daughter of the alleged theft and subsequently notified the Administrator. The Administrator, who also served as the facility's Abuse Coordinator, instructed the LPN to call the police due to the daughter's behavior but did not recognize or act upon the allegation of misappropriation as a reportable event. The Administrator later stated that the history of disputes between the resident, her daughter, and an online acquaintance may have influenced the perception of the allegation, but acknowledged that the report should have been made to the State Agency as per facility policy. The facility's policy clearly requires that all allegations of abuse, neglect, or misappropriation of property be reported immediately to the Administrator and to the State Agency within specified timeframes. In this case, the allegation was not reported as required, and no investigation was initiated at the time of the complaint. The resident involved was noted to have intact cognition and was her own decision maker, with a history of not wanting family involvement in her care or finances.
Improper Medication Storage and Expired Insulin Pens Found on Medication Carts
Penalty
Summary
Surveyors observed that medications and biologicals were not stored in accordance with accepted professional principles on two medication carts. On one unit, a medication cart was found unlocked and unattended, and a loose, unidentified pill was discovered in a plastic cup inside the cart. An LPN confirmed that the cart should have been locked when not attended and that medications should remain in their original packaging until administration. The LPN identified the loose pill as benzonatate, reportedly left from the midnight shift, and acknowledged that this was not proper practice. On another unit, two insulin pens were found in the medication cart that had been opened and dated beyond the 28-day usage period, as confirmed by an RN. The facility's policy requires that medications be stored securely, in their original containers, and that outdated medications be immediately removed and disposed of according to procedures. The DON confirmed that medication carts should be locked when unattended, medications should not be pre-prepared or stored loose, and insulin pens should be discarded after 28 days from opening.
Failure to Provide Regularly Scheduled Bathing for a Resident
Penalty
Summary
The facility failed to ensure regularly scheduled bathing was provided for a resident, identified as R902, who required assistance with activities of daily living (ADLs). R902 was admitted with diagnoses including heart failure and weakness, necessitating assistance from facility staff for bathing. A physician's order dated November 18, 2024, specified that R902 was to receive showers twice weekly on the night shift every Monday and Thursday, with any missed showers to be documented in a nursing note. However, a review of R902's treatment administration record (TAR) for January 2025 revealed that the resident did not receive a shower on January 2, 2025, and from January 14, 2025, through the date of discharge on January 22, 2025. The lack of documentation for showers after January 13, 2025, was confirmed during an interview with the Director of Nursing (DON), who acknowledged the absence of records indicating that R902 was provided with the required showers. The DON also noted that no issues with showers had been reported since R902's discharge. The deficiency was identified during a survey following a concern submitted to the State Agency, which alleged that R902 was not receiving regular bathing. The facility's failure to adhere to the prescribed bathing schedule and document any deviations led to the citation of this deficiency.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with dementia and other mental health diagnoses, who was physically assaulted by the CNA. The assault included being punched, kicked, and verbally abused with derogatory language. The resident was left in pain and distress following the incident. The abuse was witnessed by a nurse who intervened to separate the CNA from the resident. Despite being instructed to leave the facility, the CNA initially refused to comply. The nurse reported the incident to the facility's Administrator and Director of Nursing (DON), but the police were not immediately notified. The resident was later assessed by emergency medical services and taken to the hospital for further evaluation at the request of her daughter. The facility's investigation confirmed the abuse, and the CNA was subsequently terminated. The resident expressed feelings of unsafety following the incident, although she was reassured by the removal of the CNA from the facility. The facility's policy on abuse and elder justice was reviewed, highlighting the resident's right to be free from abuse by anyone, including facility staff.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to develop and implement policies and procedures for timely reporting of a reasonable suspicion of a crime, as required by section 1150B of the Act. This resulted in a delay in notifying the abuse coordinator and the State Agency about an incident involving a resident, identified as R901, who was allegedly physically and verbally abused by a CNA. The incident occurred on the morning of October 12, 2024, when the CNA reportedly attacked the resident over a pair of glasses, as witnessed by Nurse D. The report details that the CNA was aggressive towards the resident, grabbing her by the neck, kicking her, and verbally abusing her. Nurse D intervened and attempted to remove the CNA from the facility. However, the CNA initially refused to leave, causing further disruption. The Administrator was informed of the situation by phone but was not immediately made aware of the abuse allegations. It was only after the Director of Nursing (DON) was informed by Nurse D that the full extent of the incident was communicated to the Administrator, leading to the police being notified. The facility's investigation revealed that there was a significant delay in reporting the incident to the appropriate authorities. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but not later than two hours after the allegation is made. In this case, the delay in reporting the abuse to the State Agency and the police was a clear violation of this policy, highlighting a deficiency in the facility's handling of the situation.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple observations and interviews. Residents reported being left in wet or soiled briefs for extended periods and not receiving feeding assistance as per their care plans. For instance, one resident, who required one-on-one feeding assistance, often found their meal trays left unattended, resulting in cold meals. Another resident, who was involved in a physical altercation, was supposed to have a one-on-one sitter but staffing shortages affected the availability of such care. The facility's staffing records revealed consistent understaffing issues, particularly on the second floor. On several occasions, the number of Certified Nursing Assistants (CNAs) and nurses scheduled was insufficient to meet the needs of the residents, especially those requiring more intensive care. For example, on a day when the census was 50, only four CNAs were available to care for 49 residents, as one CNA was assigned to a one-on-one duty. This pattern of inadequate staffing was observed across multiple shifts and days, with some shifts having only two nurses available. Interviews with staff, including the facility's staffing scheduler and a nurse, confirmed the challenges posed by staff call-ins and the reliance on agency staff. The facility's policy stated that staffing should be adjusted based on residents' needs, but the actual staffing levels did not reflect this requirement. The administrator acknowledged the concerns but did not provide an explanation for the failure to adjust staffing ratios according to the acuity needs of the residents.
Facility Assessment Deficiency Due to Inadequate Updates
Penalty
Summary
The facility failed to ensure that the facility-wide assessment was reviewed and revised in accordance with current regulatory requirements, resulting in insufficient resources to provide for resident care and emergency/disaster needs for all 97 residents. The assessment, last reviewed on 6/28/24, did not reflect changes in resident care needs, such as those of a resident admitted with cerebral aneurysm, mood disorder, and systemic lupus erythematosus, who required significant assistance with activities of daily living. The facility assessment also did not account for administrative changes, including the turnover of key staff positions like the Administrator, Infection Preventionist, and Social Services Manager. The report highlights a specific complaint regarding a resident who was supposed to receive 45 minutes of one-on-one care but was only provided with 20 minutes. Documentation revealed that the resident's care often required multiple staff members and extended periods, sometimes up to two hours, indicating a mismatch between the care plan and actual care needs. Despite these documented needs, the facility assessment was not updated to reflect the increased acuity and staffing requirements for this resident. Interviews with the Administrator confirmed that the facility assessment had not been updated to reflect the specific staffing needs based on changes to the resident population, including the needs of the resident in question. The Administrator was unaware of the regulatory changes and had not involved direct care staff, residents, or families in the assessment process. This lack of awareness and involvement contributed to the deficiency in adequately assessing and planning for the facility's resource needs.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. On August 4, 2024, a resident with intact cognition reported being physically attacked by another resident with severe cognitive impairment. The incident occurred when the cognitively impaired resident entered the other resident's room and became aggressive, causing abrasions to the head and right upper arm of the victim. The victim expressed feelings of fear and being unsafe following the incident. The aggressive resident had previously been redirected from the victim's room earlier that day but was able to gain unsupervised access again, leading to the altercation. The facility's investigation confirmed the aggressive behavior and the resulting injuries. The facility's policy on abuse was referenced, which includes examples of physical abuse such as hitting and slapping, actions that were consistent with the reported incident.
Failure to Provide One-to-One Feeding Assistance
Penalty
Summary
The facility failed to provide one-to-one feeding assistance for a resident, identified as R806, who was unable to perform activities of daily living independently. During an observation, R806 was found in their room in a reclined position with a meal tray placed in front of them, containing a Styrofoam container and a cup with a straw, despite their care plan indicating they should not have straws and required one-to-one feeding assistance. R806 expressed distress as they were not brought to the dining room for meals as usual, reportedly due to a COVID outbreak, and no clothing protector was offered. The resident's meal ticket clearly stated the need for one-to-one assistance and no straws, yet these instructions were not followed. The Certified Nursing Assistant (CNA) who entered the room to remove the meal tray was unaware of the resident's specific needs, as they were agency staff and had not been informed of the care plan requirements. The Assistant Director of Nursing (ADON) acknowledged that agency staff should be informed of residents' care plans through shift-to-shift reports or by the nurse on duty. The facility's policy on Activities of Daily Living, dated 2019, mandates that residents unable to perform ADLs independently should receive necessary services, including checking the care plan for specific instructions. However, this policy was not adhered to, resulting in the deficiency.
Failure to Follow Dietary Restrictions and Provide Feeding Assistance
Penalty
Summary
The facility failed to provide food and drink according to the individualized care plan for a resident, identified as R806, who was observed in a reclined position in a gerichair with a meal tray that included a Styrofoam cup with a straw, despite the care plan indicating no straws should be used. The resident was not provided with a clothing protector and had food spilled on their clothing. The resident expressed dissatisfaction as they were not brought to the dining room for meals due to a COVID outbreak and reported not being offered assistance with feeding, which was part of their care plan. Further investigation revealed that the Certified Nursing Assistant (CNA) responsible for the resident's care was unaware of the specific dietary restrictions and feeding assistance required for R806. The Speech Therapist confirmed that the resident should not use straws due to a high risk of aspiration, given their medical history of pneumonia and recent PEG-tube placement. The Assistant Director of Nursing acknowledged issues with the kitchen staff providing cups with straws and confirmed that CNAs were responsible for ensuring compliance with dietary orders. The facility's policy mandates that residents receive meals modified according to their special dietary needs, which was not adhered to in this case.
Insufficient Dietary Staffing Leads to Meal Service Issues
Penalty
Summary
The facility failed to provide sufficient support personnel to effectively carry out the functions of the food and nutrition service, resulting in delayed and incorrect meal services for residents. Observations and interviews revealed that residents, including R5, R28, and R64, experienced issues with meal delivery. R5's family member reported that meals were often late and incorrect, with a specific incident on 7/13/24 where lunch was served at 1:30 PM and required correction. Dietary staff confirmed that they were short-staffed daily, leading to bottlenecks and delays in meal service. R64 reported not receiving dinner the previous day and expressed concerns about consistently late meals. During a group interview, multiple residents echoed these concerns, indicating a lack of sufficient kitchen staff. Chef C confirmed the shortage of dietary staff, stating that only two or three servers were available instead of the required eleven. R28 also experienced issues with meal accuracy, receiving scrambled eggs and non-diet root beer instead of their ordered sunny side up egg and diet cola. The December 2023 Resident Council meeting minutes further highlighted ongoing concerns about meal timing, quality, and accuracy.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as evidenced by multiple observations of improper food storage and handling. During an inspection, various food items such as cooked eggs, tomato sauce, cheese, sliced ham, shrimp, deli meat, and chicken salad were found in the walk-in cooler without date markings, violating the 2017 FDA Food Code requirements for date marking of ready-to-eat foods. Additionally, the walk-in cooler's floor was soiled with dried spills and food debris, and the condenser line was improperly installed, causing water to leak onto the floor, which could lead to further contamination. The inspection also revealed significant issues with equipment maintenance and cleanliness. The reach-in cooler had water accumulation, and the cloth inside was saturated, indicating a lack of proper drainage. The cookline hood ventilation filters were layered with grease, and the floor drain grates were caked with grease, posing a risk of contamination. Utensil bins and a mechanical scoop were found with food debris, and bulk containers of flour and sugar had debris on the lids. Furthermore, the dishwashing machine was not functioning correctly, as it failed to show sanitizer availability, and staff were unaware of this issue, continuing to use the machine improperly. Food storage practices were also found to be inadequate, with raw ground beef stored directly on a box of pork chops, and a tub of ice cream stored on the floor. The egg/milk cooler was not maintaining the required temperature, and several food items in the cold well were above the safe temperature threshold. Additionally, the hand sink in the 1st floor kitchenette was blocked, making it inaccessible for handwashing, and plastic utensils and other items were improperly stored under a sink. These deficiencies collectively increased the risk of foodborne illness for all residents in the facility.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices and protocols were followed, particularly concerning transmission-based precautions and Enhanced Barrier Precautions (EBP) for several residents. For Resident R7, an EBP sign was posted, but no personal protective equipment (PPE) was available near the room, and staff members were observed entering and exiting without PPE or performing hand hygiene. LPN L was unsure about which resident required EBP and had to verify the information at the nurse's desk. CNA U also entered R7's room without PPE or hand hygiene, indicating a lack of awareness about the precautions needed. Resident R18 was on contact precautions, but there was no PPE available near the room, and staff were observed entering without donning the necessary protective gear. CNA I and Nurse H were unaware of the specific precautions required for R18, and there was confusion about where to obtain PPE. Staff M, a laundry aide, also entered R18's room without PPE or hand hygiene, and subsequently entered another room without taking necessary precautions, demonstrating a systemic issue with infection control practices. For Resident R63, who was on contact precautions for C. difficile, Nurse N was observed exiting the room without using hand sanitizer or washing hands, citing a lack of available hand sanitizer. Similarly, Resident R298 was initially not identified as needing EBP, and staff entered the room without appropriate precautions. Resident R49 had an EBP sign, but no PPE was available, and staff were unaware of the need for precautions. These observations highlight a widespread failure in the facility's infection control practices, with staff frequently unaware of or not adhering to necessary precautions for residents on transmission-based precautions.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from verbal and physical abuse by another resident, resulting in continued abuse. The incident involved a resident with dementia who was verbally and physically attacked by another resident using a walker. The facility reported the incident to the State Agency with an incorrect date, and the medical records confirmed the event occurred earlier than reported. The resident who was attacked required staff assistance for all activities of daily living due to dementia. Prior to the incident, there were documented threats and aggressive behavior from the resident who committed the abuse. Despite these warnings, the facility did not implement additional interventions to prevent further abuse. The facility's records showed that the aggressive resident had a history of threatening behavior, and staff had previously intervened to de-escalate situations. However, the facility's administration was unaware of these prior incidents and did not take steps to protect the victimized resident. A behavioral consultation was conducted for the aggressive resident, recommending a management plan and medication adjustments. However, the facility failed to implement or document these recommendations. The Director of Nursing and the Administrator were unable to explain why the behavioral management plan was not executed. The facility's policy on abuse prevention was not followed, as measures to prevent recurrence and protect residents were not adequately taken.
Deficiencies in Pressure Ulcer Care and Assessment
Penalty
Summary
The facility failed to implement physician treatment orders in a timely manner for a resident with pressure ulcers. The resident, who had a history of ulcers and required assistance with daily activities, was observed in pain and reported that wound dressings were not consistently changed. A review of the medical records revealed discrepancies in the transcription of physician orders, leading to delays in the administration of the correct treatment. Specifically, a change in treatment ordered on June 10 was not implemented until June 20, and the incorrect frequency of treatment was transcribed, resulting in inadequate care. Another deficiency was identified in the facility's failure to assess and prevent the development of pressure ulcers for a different resident. This resident, who had intact cognition and was admitted with acute respiratory failure and heart failure, was found to have two open areas on the buttocks and general redness in the peri area. Despite having an order for an air loss mattress, the wound care nurse documented that there were no open areas and no need for the mattress, based on an assessment from the previous week. The nurse admitted to not updating the progress note to reflect the current condition of the resident's skin. The Director of Nursing confirmed that the wound care documentation did not accurately reflect the resident's current skin condition and acknowledged the issue. The facility's failure to provide timely and accurate wound care assessments and treatments contributed to the development and worsening of pressure ulcers in the residents reviewed.
Meal Service Delays Due to Staffing Issues
Penalty
Summary
The facility failed to provide meals in a timely manner, which did not align with the residents' needs and preferences. Observations on 7/16/24 revealed that breakfast was still being served at 9:30 AM, and the last lunch tray was delivered at 1:30 PM, despite the scheduled meal times being earlier. Dietary staff confirmed that meals were often served late due to staffing issues. Residents on the 2nd floor and those in the resident council were affected by these delays. Interviews with residents and staff highlighted that the kitchen was understaffed, with only two or three servers available instead of the required eleven. This staffing shortage led to late meal times, cold food, and incomplete meal orders. The December 2023 Resident Council meeting minutes also documented ongoing concerns about meal quality and timing, with residents expressing a preference for earlier meal times and reporting issues such as food being too salty or spicy, and not receiving all ordered items.
Infection Control Preventionist's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Infection Control Preventionist attended the Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly, as required. During a review of the facility's QAPI program, it was discovered that the Infection Control Preventionist did not sign in for the QAPI meetings held from January through June 2024. The Nursing Home Administrator confirmed the absence of the Infection Control Preventionist's signature on the sign-in sheets. The Director of Nursing stated that the Infection Control Preventionist joined the meetings via Zoom, but there was no evidence to support this claim. When questioned, the Infection Control Preventionist initially stated she attended the meetings in person but later admitted to joining via Zoom at times.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of consistent identification of infection signs and symptoms and the absence of clinical justification for antibiotic use. The surveyors requested infection control logs and the McGeer Criteria documentation, but the facility was unable to provide these in a timely manner. The Infection Preventionist (IP) Nurse A was unavailable for most of the survey, delaying the provision of necessary documentation. When the documentation was finally reviewed, it was found to be incomplete and inconsistent with the facility's policy, which required the use of McGeer Criteria for assessing antibiotic use. The review of the provided documentation revealed discrepancies in the application of criteria for antibiotic use. For instance, a resident was prescribed antibiotics for a fungal skin infection without meeting the necessary criteria, as only one of the required conditions was documented. Similarly, another resident was treated for Clostridium Difficile Infection without fulfilling all the required criteria. The facility's records indicated the use of McGeer Criteria, but the documentation provided was based on different definitions, leading to inconsistencies in antibiotic stewardship practices. Additionally, there was no documentation of symptoms or testing for a resident who was prescribed Amoxicillin, further highlighting the deficiency in the facility's antibiotic stewardship program.
Failure to Ensure Accurate Advance Directive Information
Penalty
Summary
The facility failed to ensure accurate advance directive information for a resident, resulting in conflicting documentation regarding the resident's code status. The resident, who had intact cognition and no communication concerns, expressed a desire to be a Do-Not-Resuscitate (DNR) and had completed the necessary paperwork. However, the facility's records showed discrepancies, with an advance directive form signed by the resident and a physician indicating a DNR status, while the current advance directive order listed the resident as Full Code. Social service assessments also contained conflicting entries, with some indicating the resident was Full Code despite the resident's expressed wishes and completed DNR paperwork. Interviews with facility staff revealed a lack of clarity and consistency in the process for completing and updating advance directives. The Social Services Coordinator acknowledged the discrepancies and noted that the social worker responsible for some of the conflicting documentation was new. The facility's policy on advance directives outlined a process for ensuring DNR orders are properly documented and entered into the Electronic Health Record (EHR), but this process was not followed, leading to the deficiency. The failure to accurately document and update the resident's advance directive information highlights a breakdown in communication and procedure within the facility.
Failure to Complete Annual OBRA Level I Evaluation
Penalty
Summary
The facility failed to complete an annual OBRA Level I evaluation for a resident to determine if a Level II Evaluation was needed or if an exemption was applicable. The resident, who was admitted with diagnoses including psychotic disorder, Lewy Body Dementia, and Parkinsonism, had a severely impaired cognitive status as indicated by a BIMS score of 4/15. The PASRR Level 1 document in the resident's clinical record showed that the resident had mental illness and dementia diagnoses and was on antipsychotic medications. However, there was no documentation that the required DCH-3878 form had been sent to the local Community Mental Health Service Program (CMHSP) as mandated. During an interview, a Social Service Tech (SST) reported that they were not a licensed social worker and were unfamiliar with completing PASARR documents. Although a licensed social worker had been recently hired, they were not present and likely unfamiliar with the resident's case. The SST attempted to contact CMHSP for further information and confirmed that the facility had not submitted the necessary document. Additionally, when requested, the facility failed to provide a policy regarding the PASARR process by the end of the survey.
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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