The Orchards At Lapeer
Inspection history, citations, penalties and survey trends for this long-term care facility in Lapeer, Michigan.
- Location
- 239 South Main Street, Lapeer, Michigan 48446
- CMS Provider Number
- 235654
- Inspections on file
- 26
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at The Orchards At Lapeer during CMS and state inspections, most recent first.
A resident with diabetes, neuropathy, osteomyelitis of the left ankle/foot, and a prior right BKA developed a swollen left ankle that was lanced by a practitioner, creating an open wound with drainage and an order for daily wound care. Imaging showed joint deformity, soft tissue edema, and air in the tissues, and subsequent wound assessments documented an in‑house–acquired lateral ankle wound with granulation tissue, undermining, mild subcutaneous emphysema, and apparent tendon exposure. However, nursing documentation showed no wound treatment orders for the ankle until a week after it was first lanced and only one documented dressing change thereafter, with no recorded monitoring of wound worsening. The DON acknowledged concerns about the lack of assessment, monitoring, and timely treatment, despite facility policies requiring consistent skin inspection and necessary wound care. The resident was later sent from an ortho appointment to the hospital, where extensive soft tissue gas, joint destruction, and necrotizing soft tissue infection were identified, resulting in emergent surgery and subsequent amputations.
The facility failed to submit required payroll-based journal (PBJ) direct care staffing data to CMS for an entire fiscal quarter. A review of the PBJ Staffing Data Report showed a triggered concern for failure to submit any data for the quarter, which should have included the type, number, and hours worked for clinical staff providing resident care. In an interview, the Administrator reported that the corporate office was responsible for sending the staffing documents and acknowledged that the information was not submitted, despite being aware of the quarterly CMS reporting requirement.
Improper food labeling, storage, and hot holding were observed in the kitchen and a resident refrigerator. Surveyors found multiple unlabeled or undated food items, including salad, fruit cocktail, cut lemons, lettuce, bologna, and hot dogs, with the DM stating the hot dogs should have been discarded. During lunch, pureed turkey and meat patties were initially hot but later dropped below the required hot-holding temperature, and the DM stated food on the steam table should be 145 F or higher.
Surveyors found that the facility failed to provide adequate nursing staff and RN coverage, leading to resident reports of long call light response times, delayed ADL and toileting assistance, and cold meals. A group of residents described waiting up to an hour for call lights to be answered, staff turning off call lights without returning, and meal carts sitting in hallways for extended periods before trays were passed or feeding assistance provided. Individual residents with significant medical conditions and full cognitive abilities reported waiting 45 minutes in the bathroom for help, frequent hour-long waits for call light response, and inconsistent assistance on both day and night shifts. Review of posted Daily Staffing Reports showed they were not updated daily, did not consistently distinguish RNs from LPNs, and documented multiple days with very low nurse and CNA numbers, including nights with only one nurse for more than 60 residents and days with no RN listed. The DON and Administrator acknowledged nurse turnover, the DON’s frequent work on the floor for extended hours, and a missed PBJ staffing submission for an entire quarter, while staffing records for numerous days were missing or incomplete.
A resident with cognitive impairment was observed receiving lunch with all food items mixed together and fed in that form, despite the care plan indicating eating assistance only as needed and another CNA later serving the meal with items separated. Another resident reported a CNA made negative comments about the resident’s surgeon before surgery, which upset the resident and made her feel nervous. In addition, a group of residents reported ongoing concerns with staff using phones during care, rude behavior, lack of privacy, delayed call light response, and hallways blocked with equipment, with repeated complaints documented in Resident Council minutes.
Residents reported strong urine and bowel odors in the halls, clogged or nonworking toilets, and trash left with soiled briefs. Survey observations confirmed urine odors in rooms and hallways, trash on the floor near a resident's bed, stained privacy curtains around a resident's bed, a ceiling vent falling out of the ceiling, and bathrooms with strong sewer gas odors and out-of-order signs. The administrator attributed the odor to outside air, but the outside area smelled normal while the odor remained inside the facility.
Failure to Timely Resolve Repeated Resident Grievances: A group of residents repeatedly voiced concerns about blocked hallways, staff using phones or earbuds during care, rude behavior, delayed call light response, staff leaving to smoke, and inconsistent water delivery. Resident Council minutes showed the same issues recurring over multiple months, and the residents reported that complaints were brought up again and again without resolution. Concern forms were often incomplete, and interviews with the NHA and DON confirmed that the concerns were discussed but not consistently resolved.
A resident on oxygen and a confidential group of residents were affected when portable oxygen tanks were unavailable, and the crash cart tank was found empty. A resident with COPD also had nebulizer equipment stored uncovered on a towel bar with condensation still present, and the MAR showed no nebulizer treatment signed out that month.
A facility failed to consistently provide fresh bedside water to residents. During a group meeting, residents reported that water passes were missed, old cups were left in rooms for days, and some had to go elsewhere to get water. Resident council minutes showed the same concern over several months. Interviews and observations found dated cups still in use, no fresh cup or straw available for one resident, and staff acknowledging problems with timely water passes and cup shortages.
The facility failed to follow CDC guidance for respiratory illness management for three residents, including not testing symptomatic residents for influenza and COVID-19, and one resident with respiratory failure, COPD, and pneumonia signs later required transfer after worsening oxygenation. Residents reported hallway ice buckets and scoopers were accessible to other residents, the laundry room layout forced staff to work around a frequently used hopper, and wound care for a resident with a large MDR-organism sacral wound did not fully follow EBP/PPE practices. The facility also lacked an active legionella/water management process, with multiple plumbing fixtures showing disuse, discoloration, leaks, and unclear flushing oversight.
The facility did not maintain an up-to-date daily nurse staffing report. Surveyors found that the staffing list posted at the main entry was several days old, leaving residents, visitors, and staff without accurate, current information about which staff were on duty.
Survey Results and Plan of Correction Not Readily Accessible: The facility failed to keep the most recent State survey results and POC readily available for residents, representatives, visitors, and staff. During a resident group meeting, several residents said they did not know where the survey binder was, and others reported it had previously been kept near the front office but was no longer available. The DON stated the binder was usually stored in a wall-mounted wire rack by the front office, but it was not there, and the rack was too high for a resident in a wheelchair to easily reach. The NHA also observed the binder was missing from the rack.
Failure to provide life enrichment activities and care plan interventions for two residents. One resident with aphasia, mood disorder, and stroke was repeatedly observed in bed without activity support, despite documented preferences for TV and in-room activities and no life enrichment care plan. Another resident with head injury, dementia, and psychotic disturbance had documented interests in sports, golf, TV, movies, news, and pet visits, but activity notes showed no activities provided since admission.
Failure to prevent a left heel pressure injury: A resident with hemiplegia, DM2, and limited mobility developed a heel blister that later opened again. The resident said staff did not provide heel boots or heel elevation before the area developed, while wound care and the DON described the area as a dark purple spot that became a fluid-filled blister. Records showed the resident was at mild risk for pressure injuries and needed frequent turning and repositioning, but the heel protection intervention was not consistently in place.
A resident with DM and venous insufficiency had very long, curled, broken toenails and lower-leg scabbed/open areas, yet the facility did not properly identify the need for timely podiatry care. Although the care plan included podiatry referral and nail care, the Kardex did not mention nail care, the resident reported not knowing when the nails were last trimmed, and staff found broken toenail pieces on the bed while the DON noted the resident could have been seen sooner than the routine 60-day interval.
Failure to Supervise Wandering Resident Led to Resident-to-Resident Altercation: A resident with dementia, psychosis, and a history of wandering into other residents’ rooms was not consistently supervised and entered another resident’s room, where she was struck in the face. Surveyors observed the resident continuing to wander independently through the facility, including into the dining room, kitchen, and other residents’ rooms, while staff were not present in key areas and the resident had previously required one-to-one watching during the night.
Incomplete Foley Care and Documentation: A resident with a Foley catheter and colostomy was observed with the catheter hanging improperly and later lying flat on the floor, with sediment noted in the tubing. Orders required catheter care, catheter checks, and output documentation every shift, but the TAR showed multiple missing entries for care, checks, and output. The DON confirmed the care and documentation should have been completed.
A resident with multiple chronic conditions and full cognitive abilities reported that pain medication was not available on arrival and that she waited over 24 hours for relief, with Tylenol ineffective and repeated requests for pain treatment. Records showed the first pain medication was not administered until about 28 hours after admission, despite prior facility records showing she had been receiving Tramadol before transfer, and the pain care plan only addressed observing and reporting pain rather than including pain treatment interventions.
A facility failed to follow the posted lunch menu by not offering bread to residents in the dining room and by not consistently serving all listed dessert items. During a resident group meeting, residents voiced concerns that menu substitutions were made without notice, menus were not being provided, and items on the menu were not what was served. Staff confirmed the facility had bread, and a server stated it was forgotten even though it was their responsibility to provide it.
A facility failed to explain arbitration agreements in a way residents could understand during admission paperwork. Four residents who signed the agreements later reported confusion, lack of recall, or regret about signing, while the SW said he asks if they understand arbitration and explains it as a mediator-based way to resolve issues and that signing is not required for admission.
A resident with multiple serious conditions and documented Full Code status experienced a cardiac arrest and was found unresponsive and not breathing. Nursing staff initiated CPR, but confusion arose over whether the resident was Full Code or DNR after a nurse misinterpreted the code status form, leading to chaotic communication and multiple calls to 911 in which EMS was requested, cancelled, and later re-requested. When EMS arrived, staff were performing CPR, but the CPR backboard was improperly positioned, the crash cart drawers were unopened, and the AED on the cart had not been used. Review of records showed the resident’s EMR, physician orders, and care plan all indicated Full Code, while several nurses present lacked current AHA BLS for Healthcare Provider certification, and the facility had no specific CPR policy, resulting in a failure to provide basic life support consistent with the resident’s documented code status.
Two residents did not receive adequate and consistently monitored nutrition and hydration. One resident with severe cognitive impairment, multiple chronic conditions, and a respiratory infection had highly inconsistent and contradictory meal-intake documentation over several days, with missing meals, entries recorded before typical meal times, and no reliable record of whether three daily meals were provided, despite a care plan requiring staff to monitor and record intake. Another resident with DM and ESRD on hemodialysis left for early-morning dialysis without breakfast or a sack meal, sometimes did not receive an HS snack, and had dialysis communication forms repeatedly indicating no meal or snack sent, while care plans and task documentation lacked clear interventions or consistent records for HS snacks or pre-/post-dialysis nutrition.
The facility failed to maintain proper infection control practices, leading to cross-contamination. Staff were observed not performing hand hygiene or wearing PPE during resident care. Medical equipment, including glucose monitors and blood draw supplies, was improperly cleaned and stored, increasing infection risk. The DON confirmed that cleaning protocols were not followed.
The facility failed to treat residents with dignity, as staff used personal phones and ear buds during care, causing confusion and embarrassment. Residents reported feeling ignored and disrespected, particularly during off shifts and weekends. The DON acknowledged the issue, which violated the facility's policy against phone use in care areas.
A facility failed to accurately code a pressure ulcer on the MDS for a resident with multiple diagnoses, including congestive heart failure and major depressive disorder. The resident developed an unstageable pressure ulcer on the right heel, which was not documented in the MDS assessment. Interviews revealed that the ulcer began as a hematoma and was not coded due to an oversight by the MDS Nurse, despite the facility's policy requiring accurate assessments.
The facility failed to timely revise care plans for two residents, leading to inaccuracies. One resident's care plan did not reflect their DNR status, while another resident's pressure ulcer care plan was delayed. The Social Service Director and DON acknowledged the oversights, which were contrary to the facility's policy requiring timely updates.
A facility failed to maintain accurate orders and proper care for a resident's unused feeding tube. The resident, with full cognitive abilities, experienced redness and pain at the insertion site, and the tube was not routinely flushed. Documentation inconsistencies were noted, with outdated care plans still indicating tube feeding dependence. The Director of Nursing acknowledged the issues, highlighting a need for process improvements.
A facility failed to follow standards of practice for PICC line care for a resident, resulting in inadequate documentation and monitoring. The resident's PICC line dressing was not changed within 24 hours of admission, and subsequent changes were inconsistently documented. The facility lacked a specific policy for PICC line care, and the required measurements of the catheter were not recorded, leading to a deficiency in the administration of IV fluids.
Two residents in the facility experienced significant health issues due to failures in medication administration. One resident with epilepsy did not receive seizure medications, leading to increased seizures and hospitalization. Another resident with multiple health conditions missed doses of several medications due to unavailability. The facility's procedures for managing medication shortages were not followed, resulting in repeated instances of medications being on order or awaiting delivery without timely resolution.
The facility failed to provide meals and snacks according to the menu for several residents, resulting in incomplete meals and missing snacks. A resident did not receive rice, vegetables, or cake with their meal, while another's breakfast was missing several items. Two residents did not receive dinner rolls, and a group of residents reported not consistently receiving evening snacks. The Dietary Manager and DON were unaware of these issues, indicating a breakdown in meal and snack distribution processes.
A facility failed to provide fresh water to residents, as observed with a resident who had a Styrofoam cup dated from the previous day containing warm water without ice. Staff refilled cups throughout the day, but residents were found without fresh water at scheduled refill times. Residents expressed dissatisfaction with the use of Styrofoam cups and reported attempts by others to access water from the hallway cart, risking contamination.
The facility failed to label, date, and dispose of expired foods in both the walk-in and resident refrigerators/freezers, risking foodborne illness. Items like frozen zucchini, french onion dip, and hot dogs lacked expiration dates, while resident food items were found without identifiers or proper labeling. The dietary manager confirmed that dietary aides are responsible for these tasks, but the facility's policy for safe food storage was not followed.
A resident with multiple medical conditions experienced a change in condition, including shortness of breath and low oxygen saturation. Although a physician evaluated the resident and intended to order a chest x-ray and expectorant, these orders were not entered or carried out, and the resident did not receive the prescribed cough syrup. There was also no care plan addressing the resident's respiratory symptoms, and communication lapses between the physician and nursing staff contributed to the failure to provide appropriate care.
A resident with a history of multiple falls and significant medical conditions experienced repeated falls due to inadequate interventions and supervision. Despite being at high risk, the care plans were not consistently updated, and the falls were unwitnessed, leading to a femur fracture. The facility's policies on accidents and maintaining a safe environment were not effectively implemented.
The facility failed to develop and implement comprehensive care plans for three residents, resulting in potential unmet care needs. One resident lacked a care plan for oxygen use, another had no care plans for ADLs, Wanderguard, or hospice care, and a third resident's care plan did not include required PASARR evaluations.
The facility failed to ensure sufficient nursing staff, resulting in inadequate care and supervision. Residents reported long call light response times and insufficient assistance with daily activities. Staff interviews confirmed frequent understaffing, particularly during night shifts, leading to increased workloads and compromised resident safety. Specific incidents included a resident falling and subsequently dying due to insufficient staff on duty.
The facility failed to ensure proper labeling and secure storage of medical supplies and medications. Treatment carts were left unattended and unlocked, containing supplies for wound dressings and prescription treatments. Opened containers of wound packing strips, Eucerin cream, peroxide, eye drops, and urinalysis test strips were found without proper dating. Three controlled substances were discovered on the side of a medication cart, not properly disposed of as per facility policy.
The facility failed to ensure that residents, responsible parties, and staff had a clear understanding of the facility's binding arbitration agreement prior to signing it. Interviews revealed that residents did not fully understand the agreements, and some were not aware they had signed them. The Administrator admitted that several staff members presented the agreements without necessarily having received proper education on the subject.
The facility failed to follow Infection Prevention and Control standards for Transmission-Based Precautions, leading to expired hand sanitizer, improper PPE use, and staff confusion about resident precautions. A resident with multiple diagnoses had incorrect signage for precautions, and staff did not follow proper PPE protocols.
The facility failed to ensure a safe environment by not maintaining accessible call lights for residents and improperly storing an oxygen tank. Multiple residents with impaired cognition were found with call lights out of reach, and an oxygen tank was improperly stored in a cloth basket. These deficiencies led to residents' frustration and the potential for unmet care needs.
The facility failed to complete an annual Level II Evaluation for a resident with multiple mental health diagnoses, resulting in the potential for unmet emotional or mental health needs. The evaluation was completed but not sent to the facility, and the Social Service Director was unaware of the missing documentation.
The facility failed to develop and implement a baseline care plan within 72 hours of admission for a resident with multiple diagnoses, resulting in unmet care needs and social isolation. The resident was observed in a neglected state, and staff were unaware of the specific care needs due to the absence of a baseline care plan.
The facility failed to review and revise care plans for a resident with a history of falls and multiple medical conditions. Despite multiple falls and a significant injury, the care plans were not consistently updated with new interventions to prevent future falls, leading to continued falls and the development of pressure ulcers.
A resident with multiple diagnoses, including heart failure and diabetes, developed two facility-acquired pressure ulcers due to the improper fit of a left knee immobilizer and immobility. The facility failed to follow its policy on pressure ulcer risk assessment, leading to the development of Stage 2 pressure ulcers on the resident's left outer ankle and right outer heel.
A resident with multiple diagnoses had their PEG tube removal delayed due to transportation issues and miscommunication among staff, despite transitioning to an oral diet and gaining weight. The tube was not regularly flushed, and necessary supplies were often missing, leading to unmet care needs and feelings of hopelessness for the resident.
The facility failed to ensure proper communication and documentation of hospice services for two residents, resulting in the absence of progress notes, assessments, and care plans in the medical record. This led to incomplete medical records and potential gaps in the coordination of care for residents receiving hospice services.
The facility failed to ensure accurate and updated daily nurse staffing postings, resulting in discrepancies between posted and actual staffing hours. CNAs working in the office without direct care assignments were counted as direct care staff, and the BIPA program used for documentation had inaccuracies. Additionally, postings were not updated over weekends.
Failure to Assess and Provide Ongoing Treatment for Ankle Wound Leading to Severe Infection and Amputation
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and provide ordered wound treatment to a resident’s left ankle wound. The resident was admitted with multiple serious conditions, including acute osteomyelitis of the left ankle and foot, a non‑pressure chronic ulcer of the left lower leg, diabetes with neuropathy, and a prior right below‑knee amputation. On 1/20, the practitioner assessed a swollen left ankle, anesthetized the area, lanced it, and drained approximately 60 cc of serosanguinous fluid. An X‑ray was ordered, the resident was made non‑weight bearing, an immobilizer was ordered, a culture was obtained, and the resident was noted to already be on antibiotics. The wound care assessment from that date documented an open ankle wound with instructions to cleanse with wound cleanser, apply xeroform, and cover with kerlix or border foam, with dressing changes daily and as needed. Subsequent diagnostic results and assessments documented ongoing ankle pathology and an open wound, but nursing documentation did not reflect consistent wound care. On 1/21, an X‑ray showed deformity of the tibiotalar joint, diffuse soft tissue edema, and pockets of air collections in the soft tissues, with underlying cellulitis considered. On 1/23, a nursing progress note again described a swollen left ankle, lancing with purulent drainage, a culture (later reported as showing no organism detected), and an X‑ray indicating Charcot foot. A wound care assessment on 1/27 described Wound #2 on the left lateral ankle, acquired in‑house on 1/20, as an eroded open area at the aspiration site with white, pink‑yellow granulation tissue, fatty debris partially removed by sharp dissection, scant to moderate serous exudate, undermining from 11:00 to 3:00 up to 1.8 cm, mild subcutaneous emphysema, and apparent tendon exposure, but noted no signs of infection. Despite these findings, the Treatment Administration Record and orders showed that a specific order for daily dressing changes to the left ankle with Medi honey, ABD pad, and kerlix was not entered until 1/27, and only one dressing change was documented on 1/28. There were no documented dressing changes or wound treatments to the left ankle between 1/20, when the ankle was first lanced and became an open wound, and 1/27, when the wound care team reassessed it. Facility assessments and progress notes did not identify or document the worsening of the ankle wound during this period. The DON acknowledged concerns with the lack of assessment, monitoring, and timely treatment orders when the skin condition worsened, and facility policies required licensed nurses to consistently monitor skin, inspect and document breaks in skin, and ensure residents with ulcers receive necessary treatment and services to promote healing and prevent infection. A review of hospital records showed that when the resident was sent out from an orthopedic appointment to the hospital, imaging and clinical evaluation identified extensive gas in the soft tissues around the ankle, severe deformity, and findings concerning for necrotizing soft tissue infection. The ER physician documented infection on the lateral ankle with complete degeneration of the joint and purulent drainage, and the resident underwent emergent ankle disarticulation followed by a left below‑knee amputation and later a left above‑knee amputation, with postoperative diagnosis of necrotizing fasciitis of the left lower extremity.
Failure to Submit Quarterly PBJ Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate payroll-based, direct care staffing information to CMS for the fourth fiscal quarter of 2025 (July 1–September 30), as required. A review of the Payroll Based Journal (PBJ) Staffing Data Report for that quarter showed a triggered concern labeled “Failed to Submit Data for the Quarter,” defined as no data submitted for the quarter. This PBJ data is intended to identify the type, number, and hours worked for clinical staff providing care to residents. During an interview, the Administrator stated that the corporate office was responsible for submitting the staffing documents to CMS and acknowledged that the information was not sent. The Administrator also confirmed awareness that submission of payroll-based direct care staffing data to CMS every quarter is required.
Improper Food Labeling, Storage, and Hot Holding
Penalty
Summary
Food service practices were not maintained in accordance with professional standards in multiple areas of the kitchen and resident dining room refrigerator. On 03/02/2026, surveyors observed an open bag of fresh cut salad in the walk-in cooler with no open date and a use-by date of 2/28/26, and a container of fruit cocktail in the kitchen two-door refrigerator without a label or date. In the resident refrigerator in the dining room, surveyors found three lemons cut in half in a plastic bag and lettuce in a plastic bag without date marking, an open package of bologna in a plastic bag with a receive date of 1/12/26 but no open or discard date, a container with an orange substance without a label identifying the contents and dated 2/7/26, and an opened hot dog package dated 2/9/26 without a discard date. The Dietary Manager stated the hot dogs should have been thrown away by then. During lunch service on 03/02/2026, surveyors observed two quarter pans sitting above the steam table. The pureed turkey temperature was 179 F and the meat patties were 180 F at 12:09 PM, but by 12:35 PM the pureed turkey had dropped to 120-122 F and the meat patties to 107-122 F. The Dietary Manager stated at 12:43 PM that food on the steam table should be 145 F or higher. Record review showed facility policies requiring food to be covered, labeled, and dated, and the Dietary Manager stated dates should be marked seven days after opening. The report also cited the 2022 FDA Food Code requiring ready-to-eat TCS food held at 41 F or less to be date marked for up to 7 days and hot food to be maintained at 135 F or above.
Inadequate Nursing Staff, RN Coverage, and Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff, including RNs, LPNs, and CNAs, to meet residents’ needs and to ensure required RN coverage, resulting in resident reports of long call light response times, delays in ADL assistance, and cold meals. During a confidential group interview with seven cognitively intact residents, all participants reported concerns with call light response, including waiting up to an hour for staff to respond, nurses not answering call lights, call lights being turned off without care being provided, and staff stating they would return but not doing so. The group stated these problems occurred at all times of day and were worse during shift changes. They also reported that staff frequently left the building to smoke, including CNAs who verbalized needing a cigarette after difficult care encounters, and that these concerns had been raised multiple times in Resident Council without resolution. Residents provided specific examples of unmet care needs related to inadequate staffing. One resident reported there were not enough staff to help during mealtimes, describing meal carts sitting in the hall for up to 40 minutes before trays were passed. Another resident described a roommate who needed help sitting up and with tray setup; the tray reportedly sat for about 45 minutes and was close to an hour before staff came in, by which time the food was believed to be cold. Another resident reported that their roommate required feeding assistance but staff were sometimes not available to provide this. Individual interviews corroborated these group concerns: one resident with heart failure, respiratory disorder, anemia, deep vein thrombosis, and hypertension, who was cognitively intact and dependent for transfers, toileting, dressing, and required maximum assistance with bathing, stated there were not enough people to answer call lights and expressed frustration with long waits for care. Another cognitively intact resident needing assistance with all care reported waiting 45 minutes in the bathroom for staff to answer a call light and believed food was cold when delivered due to insufficient staffing. A third cognitively intact resident needing assistance with all care reported multiple instances of long waits for call light response, sometimes up to an hour. A newly admitted resident who needed assistance with care stated that call lights were not always answered timely on both day and night shifts. Record review and staff interviews showed systemic issues with staffing levels, RN coverage, and required staffing documentation. The posted Daily Staffing Report near the front office was dated five days prior to the surveyor’s observation and was not updated daily as required. The DON reported that the corporate office was responsible for submitting PBJ staffing data to CMS and acknowledged that the facility’s PBJ report for the 4th fiscal quarter (July–September 2025) had not been submitted. The DON also stated that several nurses had left recently and in fall 2025, that many staff were working beyond 12-hour shifts and extra days, and that she herself frequently worked on the floor as a nurse, sometimes for 12-hour shifts and then again later the same day. The Administrator confirmed awareness that the PBJ report for the 4th quarter had not been submitted, acknowledged that the Daily Staffing Report was supposed to be updated daily but was not current, and agreed that some nurses had left and the DON was working many days on the floor. Further review of clinical staffing documents revealed missing Daily Staffing Reports and schedules for multiple days across several months, including days immediately prior to survey entry. Many Daily Staffing Reports did not identify whether nurses were RNs or LPNs and simply listed "Nurse" with counts for day and night shifts. On specific dates, documentation showed low numbers of clinical staff and lack of RN coverage, such as one nurse on night shift for over 60 residents, two aides on night shift for 68 residents, and days where only LPNs were listed with no RN identified. On one date, the schedule showed one night-shift nurse leaving at 2:00 a.m., leaving a single nurse alone for four hours. Multiple dates in late 2025 and early 2026 lacked any documented RN coverage on the Daily Staffing Reports. These documented staffing patterns, combined with resident reports of long call light response times, delayed ADL and toileting assistance, and delayed meal delivery, demonstrate the facility’s failure to ensure adequate nursing staff and required RN coverage to meet residents’ needs.
Failure to Maintain Resident Dignity During Care and Meal Service
Penalty
Summary
The facility failed to support a resident’s dignity during meal service and failed to provide dignified care for another resident, while also receiving multiple resident reports of ongoing dignity concerns. One resident with schizophrenia, dementia, and multifocal motor neuropathy with borderline intellectual function was observed during lunch with three bowls on the tray, two of them empty. A CNA mixed the turkey, mashed potatoes, and vegetable blend together in one bowl with a spoon and then fed the resident the mixed food items. The resident’s care plan stated the resident could be independent with eating sometimes depending on mood and should be assisted with eating when required. Later, another CNA assisted the same resident with lunch using separate food items on the plate and separate bites, and the first CNA stated the resident chewed and swallowed better with mixed textures. The DON stated that mixing all food together was not the facility’s procedure unless it was care planned that way. A second resident reported that a CNA made comments about the resident’s surgeon before a planned surgery, telling the resident the doctor was not any good and expressing negative opinions about the doctor. The resident stated this upset her and made her feel uncomfortable and nervous before surgery. A nurse later acknowledged awareness of the situation and stated the CNA should not have given her opinion, describing it as a customer service issue rather than abuse. A confidential group of residents also reported multiple ongoing concerns affecting dignity and daily care. The group described hallways blocked with items and equipment on both sides, residents with behaviors wandering into rooms or touching items without staff intervention, staff using personal phones, earbuds, Facetime, and music while providing care, rude or disrespectful staff behavior, staff not knocking before entering rooms, delayed call light response, and staff leaving the building to smoke. Resident Council minutes documented repeated complaints over several months about staff on phones, rude attitudes, disrespectful comments, lack of quiet during nighttime hours, and equipment left in hallways. The DON and NHA acknowledged awareness of several of these concerns during interviews.
Unclean environment with persistent odors and soiled privacy curtains
Penalty
Summary
The facility failed to ensure a clean, sanitary, and homelike environment for residents. During a confidential group meeting, residents reported foul odors in the hallways and rooms, describing smells like urine and bowel movement, and stated that dirty briefs were left in trash containers and garbage was not being emptied. Residents also reported toilets that were clogged or not working, including one toilet used by four residents that had become clogged and another toilet that staff told a resident to use even though it needed to be plunged. Observations confirmed multiple environmental concerns throughout the facility. A room occupied by two residents had a strong urine odor in the room and hallway, and the floor appeared freshly mopped and partially or completely wet during several observations. Resident #37 was observed in bed with two privacy curtains surrounding the bed, and both curtains had reddish/purple stains over large areas. The soiled curtains remained in the room later that day, and new clean curtains were not observed until the following day. Additional observations showed trash on the floor near Resident #11's bed, repeated urine odors in the north hallway, and a ceiling vent in the main hallway that appeared to be falling out of the ceiling and not secured. The facility also had bathrooms marked out of order, including one near the administrator's office that had a strong sewer gas odor when opened. The administrator stated the smell might be coming from outside the building through the circulation system, but outside air was observed to be fresh and normal while the sewer odor remained strong inside the hallways and day room.
Failure to Timely Resolve Repeated Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were addressed in a timely manner for a group of seven residents who repeatedly voiced concerns during Resident Council meetings. During a group interview, all seven residents reported that concerns had been brought up multiple times and were still recurring, including hallways blocked with items and equipment, staff using phones or earbuds while providing care, rude or disrespectful staff behavior, staff saying "not my job," delayed call light response, staff leaving the building to smoke, and inconsistent delivery of fresh water to resident rooms. The residents stated that these issues were discussed at Resident Council meetings but continued to happen, and all seven indicated there had been no resolution to their voiced concerns. Resident Council minutes documented the same concerns over multiple months, including staff on phones during shifts, call lights not being answered, staff attitudes and rude behavior, staff not knocking before entering rooms, quiet time not being respected, hallways obstructed by wheelchairs, hoyers, and carts, and water passes still being inconsistent. The minutes also reflected repeated complaints that concerns were being raised again and again at meetings without resolution. Several concern forms associated with the minutes were incomplete, with multiple sections left blank, including questions about when the problem occurred, who knew about it, whether it was ongoing, and whether the resident had contacted the facility before. In several forms, the outcome or satisfaction level section was not completed. During interviews, the NHA stated that concerns were discussed at monthly Town Hall meetings and that activity staff completed concern forms, while the DON stated that guardian rounds and other monitoring efforts were inconsistent and that the facility was not always seeing the issues residents reported. The facility policy stated that residents have the right to voice grievances without discrimination or reprisal and that the facility must make prompt efforts to resolve grievances. The concern/grievance policy also identified the Administrator as the Grievance Official responsible for receiving, tracking, and resolving grievances through conclusion and issuing written grievance decisions to residents.
Oxygen Supply and Nebulizer Storage Deficiencies
Penalty
Summary
The facility failed to ensure that oxygen tanks were available for resident use for a resident on continuous oxygen and for a confidential group of residents, and failed to store nebulizer equipment appropriately for a resident receiving breathing treatments. During a group meeting, a resident using oxygen by concentrator had an alarm sound on the machine and stated he was in trouble if the concentrator was not working. He had an E-tank on the back of his wheelchair, but it was reported to be empty. Another resident stated there were no oxygen tanks available throughout the facility, and the resident reported he could not freely wander through the facility without an available E-tank with oxygen because he needed oxygen all the time and had to stay in his room until delivery arrived. The DON confirmed there was a lack of oxygen in the portable tanks and stated the tanks had not been left because there was no key to the shed where they were stored. The DON also stated the crash cart had a tank available if needed, but observation showed the crash cart tank was on red, indicating it was empty. For another resident with COPD and an order for ipratropium-albuterol nebulizer solution every 8 hours, nebulizer equipment was observed next to the bed with condensation in the medication cup and hanging on a towel bar on the nightstand, not covered. The same storage condition was observed again the next day. The resident stated the last nebulizer treatment had been given that morning. An LPN stated the last treatment appeared to be a PRN albuterol treatment and described the process as cleaning the nebulizer and placing it back at the bedside, while being informed that the equipment was being stored on a towel bar. Record review showed the March 2026 MAR had no nebulizer treatment signed out that month.
Inconsistent Fresh Water Provision and Water Passes
Penalty
Summary
The facility failed to provide fresh water for five reviewed residents and a confidential group of residents. During a confidential group meeting, residents reported that menus were not being followed and that fresh water was not consistently passed to rooms. One resident said they had to go to the dining room to get fresh water, another stated they were told to drink more water because their urine was dark but were not given water, and the group reported that on some weekends the same cup could remain from Friday to Monday. The group also stated they had raised the issue at Resident Council meetings and that it continued to be a problem. Resident Council minutes documented repeated concerns about water passes not being completed or being inconsistent, including comments that fresh water was still not being given at times, water passes were a hit or miss, certain staff never took care of it, and some residents had no water in their room to take medication or sip water if needed for a cough. During interviews, one resident had a Styrofoam cup of water dated 2/28/26 and stated staff said they ran out of cups and refilled old cups over and over, while another resident had a cup dated 2/27/26 and stated they did not always get fresh water. A dietary manager stated cups were ordered by kitchen and central supply, and central supply staff stated there had been an issue with not having enough cups a few months earlier and that aides were not always passing water timely or labeling and dating cups correctly. At the time of observation, one resident had a Styrofoam cup dated 2/22/26 with a small amount of soda in it, and the nightstand contained old beverages and no fresh cups. Another resident had a cup with a tea stain and a small amount of tea, stated they could not take a drink because they could not find a straw, and had no other cup or straws available. A third resident stated they got water sometimes and sometimes did not. The facility policy stated fresh bedside drinking water should be available at all times unless contraindicated, and residents should be assisted to periodically take a drink throughout the day.
Infection Control Failures in Respiratory Illness, PPE Use, Laundry, Ice Handling, and Water Management
Penalty
Summary
The facility failed to follow CDC guidance for managing residents with respiratory illness for three residents reviewed. The Infection Control Preventionist reported that residents with cough, congestion, dry cough, and other respiratory symptoms were tested for COVID-19 but not for influenza, and stated the facility did not have an influenza policy and would rely on the physician’s recommendations. The ICP also acknowledged that CDC guidance recommends testing symptomatic residents for both SARS-CoV-2 and influenza. Resident #60 had diagnoses including acute and chronic respiratory failure, COPD, atrial fibrillation, heart failure, chronic kidney disease, prior stroke, pneumonia history, hypothyroidism, hypertension, and anxiety, and was observed on oxygen at 4 liters by nasal cannula with an empty humidification container. The resident’s record showed cough, low oxygen saturations in the 80s, a chest x-ray with right lung infiltrates, antibiotics, breathing treatment, prednisone, and transfer out after oxygen saturation dropped to 76%. The facility also failed to prevent cross contamination involving ice scoopers and ice containers and failed to provide a workspace that prevented cross contamination of linen. During a group meeting, residents reported that other residents were getting into hallway ice buckets and using the ice scooper, including one resident seen picking their nose and then getting into the ice containers. The ICP stated staff were supposed to send the ice back to dietary to be cleaned, and acknowledged that residents getting into the ice was an issue. In the laundry area, the washing machine was positioned adjacent to and facing the hopper, with the door handle on the side opposite the walkway, requiring staff to move past the hopper to access it. The DOHS stated the hopper was used frequently and that the tight space made it difficult for staff to work around and load linen. The facility failed to follow CDC guidance for Transmission Based Precautions and PPE use during wound care for Resident #45. The resident had a very large sacral wound with a history of infection with a multidrug-resistant organism and an indwelling urinary catheter, and was on Enhanced Barrier Precautions. During wound care, the nurse wore gloves and an isolation gown, cleansed the wound, removed gloves, performed hand hygiene, replaced gloves, and packed the wound with Dakins-soaked rolled gauze. She then used her hands to pack the gauze into the wound with deep tunneling, did not remove gloves and perform hand hygiene before applying the top dressing, and later went to the treatment cart in the hallway while still wearing a soiled gown. The facility also did not have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. Observations found a bathroom out of order with a leak, a main hall med room sink with no water flow and dried brown substance in a bin under the plumbing, tubs that were used but whose flushing status was unknown, yellow discolored water from a tub faucet, a hopper with a pool of water and a slow stream from the hot water line, a spray hose shut off, and a bathroom sink that discharged black particulates before running clear. Interviews showed the water management team had not met, flushing was done only when prompted by Tels, and there was no flushing log.
Outdated Daily Nurse Staffing Report Not Updated or Accessible
Penalty
Summary
The facility failed to provide an updated daily nurse staffing report as required. On 3/02/2026 at 9:05 AM, surveyors observed the DAILY STAFFING REPORT posted on the wall in the main entry and found it was dated 2/26/2026, making it four days out of date. As a result, residents, visitors, and staff did not have access to current information about which staff members were working on that day, because the only posted staffing list was outdated.
Survey Results and Plan of Correction Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the most recent State survey results and plans of correction were readily accessible to residents, resident representatives, visitors, and staff. During a group meeting with seven residents, several residents stated they were unaware of any survey book available for residents and families to review, while others reported that the survey results had previously been kept in a binder near the front office but had not been seen for a while and appeared to be missing. On interview, the DON stated the survey book was usually stored in a wire rack on the wall by the front office, but the binder was not in the rack or nearby. The DON also noted that the wire rack was higher than what a resident in a wheelchair could easily reach. The NHA was later interviewed and was shown the same wire rack without the survey binder present; the NHA stated she would have it fixed that day and would try to locate the binder. The facility policy titled Resident Rights stated that residents have the right to examine the results of the most recent survey and any plan of correction in effect.
Failure to Provide Life Enrichment Activities and Care Plan Interventions
Penalty
Summary
The facility failed to provide life enrichment activities and care plan interventions for two residents, resulting in no activities being provided for either resident. Resident #43 was observed lying in bed in a dark room with the TV off on multiple occasions, and although the resident indicated wanting the TV on, staff did not initially assist. The resident had diagnoses including aphasia, mood disorder, and stroke, required extensive assistance with ADLs, and had severely impaired cognition. The record review showed no life enrichment care plan, and the most recent life enrichment assessment dated 10/17/2025 listed preferences such as watching TV, reading, observing others, exercise, and in-room activities. Activity notes showed only a few visits, with no visits in January and the last note on 2/25/2026. Resident #11 was observed resting in bed with their wife at the bedside and stated they would like to get up when asked. The resident had diagnoses including head injury, dementia, and psychotic disturbance, required extensive assistance with all ADLs, and had severely impaired cognition. The care plan included preferences for person-centered 1:1 or self-directed activities, watching sports, golf, TV, movies, news, and visits with pets, and noted that the wife should be involved in care discussions. However, the activity notes showed no activities had been provided since admission, and the Life Enrichment Director acknowledged the resident's wife visits weekly and stated education would be done for not seeing the resident.
Failure to Prevent Left Heel Pressure Injury
Penalty
Summary
The facility failed to implement interventions to prevent the development of a pressure injury for a resident with left-sided hemiplegia, type 2 diabetes mellitus, and hemiparesis following cerebral infarction. The resident had a BIMS score of 15 and was cognitively intact. A Braden Scale assessment showed a score of 16, indicating mild risk for pressure injuries, and the care plan identified the resident as dependent on staff for frequent turning and repositioning in bed because of left-sided weakness and limited physical mobility. The resident reported that a blister on the left heel developed at the facility and that the heel boots in the room were not in good shape. Observation showed two heel boots sitting on top of the closet. Wound care staff stated the resident currently had an open blister on the left heel, that the blister had previously closed and reopened, and that it was acquired in the facility on 1/12/26. Wound care staff also stated the resident had heel boots on when the blister developed, that the resident would sometimes have the boots off in the morning, and that the resident used a low air loss mattress and restorative services. Record review showed a care plan for the left heel blister dated 1/12/26 stating a left soft heel boot was put in place on 1/8/26, with the intervention for the boot being on at all times later resolved. Weekly skin assessments documented a left heel pressure injury described as a 4 cm x 4 cm x 0 cm suspected deep tissue injury with a left heel boot applied, and later noted that the left heel blister had opened again. The DON stated the area was dark and purple when first seen and that the resident rubbed the left foot back and forth on the bed. The resident stated the purple spot developed from resting on the bed and then turned into a blister, and that staff did not give heel boots or elevate the heels before the blister developed.
Failure to Identify and Arrange Timely Podiatry Care
Penalty
Summary
The facility failed to properly assess and identify the need for podiatry services for a resident with diabetes, chronic peripheral venous insufficiency, hypertension, and paranoid schizophrenia. The resident’s MDS indicated full cognitive abilities with a BIMS score of 15/15 and need for assistance with lower body care, including personal hygiene. The care plan included interventions to refer the resident to a podiatrist to monitor and document foot care needs and to cut long nails, but the Kardex did not mention nail care or toenail care. A social services note indicated the resident was added to podiatry, and a podiatry note showed the resident was seen and toenails were trimmed, with recall listed as medically necessary but no sooner than 60 days. During observation, the resident was found in bed with very long toenails, some curled over the ends of the toes, chipped and breaking, and the resident stated she did not know when they had last been trimmed and wanted them trimmed. The resident also had several scabbed areas on the lower right leg, later observed as bloody open areas, and broken pieces of toenails were found on the bed sheet near both feet. Nursing staff were interviewed about the toenails, and the DON stated the resident could be seen sooner than 60 days and that someone should have identified the need for trimming. The last skin assessment did not mention the scabs, bleeding areas, or toenails in need of trimming.
Failure to Supervise Wandering Resident Led to Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision for a resident with cognitive communication deficit, dementia, unspecified psychosis, and paranoid personality disorder, resulting in a resident-to-resident altercation. The resident had a documented history of wandering into other residents’ rooms, and progress notes showed she required repeated redirection and at times one-to-one watching during the night. A behavior note stated she was wandering into other residents’ rooms and trying to get into bed with them, with aides and a nurse rotating to watch her one-to-one throughout the night. The resident was involved in an unwitnessed altercation with a male resident after she entered his room and startled him, and he struck her in the face. Staff statements indicated no staff was present at the time of the incident, and the DON stated an aide was nearby but did not witness it. The resident later developed bruising. The DON also stated the resident opened the room door of the male resident, who got up and hit her in the face. Survey observations showed the resident continued to wander independently throughout the facility without consistent monitoring. She was observed entering other residents’ rooms, moving through the dining room without nursing staff present, approaching residents who did not want contact, and entering areas such as the kitchen and other resident rooms before staff redirected her. Social work staff stated her behaviors were mostly at night, that they had discussed possible alternate placement with the daughter, and that one-to-one observation was not being used due to staffing and the small size of the building.
Incomplete Foley Care and Documentation
Penalty
Summary
Failure to provide necessary care for an indwelling urinary catheter was identified for Resident #45, who was admitted with diagnoses including a history of wound infection with multi-drug-resistant organisms, osteomyelitis, a sacral wound, respiratory failure, diabetes, and hypertension. The resident’s MDS indicated full cognitive abilities with a BIMS score of 15/15 and that he needed some assistance with all care. On observation, the resident’s Foley catheter was seen hanging on the side of the bed with sediment in the tubing, and later the catheter was observed lying flat on the floor rather than being positioned to allow urine to flow freely into the bag and to avoid contamination from the floor. Physician orders required Foley catheter care every shift and as needed, catheter checks every shift, and Foley output documentation every shift. Review of the February 2026 TAR showed missing documentation for catheter care, catheter checks, and Foley output on multiple days and shifts. During interview, the DON acknowledged that catheter care should have been completed and documented and that urinary output should have been recorded every shift. The facility policy stated that routine catheter care helps prevent infections and complications, that the catheter and tubing should be inspected periodically for compression or kinking, and that the collection bag should be emptied at least every 8 hours.
Delayed Pain Medication Administration and Incomplete Pain Care Planning
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident who had a history of stroke, diabetes, hypothyroidism, hydronephrosis, urinary stents, digestive surgeries, GERD, chronic sinusitis, right foot drop, a sacral pressure ulcer, recurrent urinary tract infections, bronchitis, and hypertension. The resident had full cognitive abilities with a BIMS score of 15/15 and reported that when she first arrived, the facility did not have her pain medication and she had to wait over 24 hours to receive it. She stated that Tylenol was offered but did not work well, that she kept asking for pain medication, and that she could not sleep because of the pain. She also reported that she had been taking a different pain medication at the prior facility before admission. Record review showed the resident was admitted at approximately 5:30 PM and had an order for Tylenol on the evening of admission, followed by Tramadol the next day and later Norco. The MAR showed the first dose of pain medication was not given until about 28 hours after admission, when Tramadol was administered for pain rated 6/10. Tylenol was given only once several days later, and Norco was not first administered until several days after it was ordered and after Tramadol was discontinued. Transfer documents showed the resident had been receiving Tramadol 50 mg every 4 hours as needed before admission. The nursing admission assessment documented pain, but the care plan only included observing and reporting complaints of pain or requests for pain treatment and did not mention providing pain medication or other pain management interventions.
Menu Items Not Followed During Meal Service
Penalty
Summary
The facility failed to provide listed menu items to residents in the dining room, including bread at the lunch meal. During a confidential resident group meeting, seven residents discussed concerns that menu items were not being followed. Residents stated that substitutions were made without notice, that they did not receive menus, and that a dedicated person who previously reviewed menus with them was no longer available. One resident gave an example that scalloped potatoes were listed but mashed potatoes were served instead, and four residents in the group said this bothered them. During lunch meal observation in the main dining room, residents were served their meals, but no bread was offered to any resident and not all residents received peach cobbler. The posted lunch menu listed seasoned baked fish, Parmesan pasta, Normandy blend vegetables, bread/margarine, fruit cobbler, and beverage. A staff member stated that residents get bread and butter sometimes but not always when it is on the menu. When asked about the bread, the Dietary Manager stated the facility had bread, and a server stated they forgot to provide it and confirmed it was their responsibility to do so.
Failure to Explain Arbitration Agreements Clearly
Penalty
Summary
The facility failed to explain arbitration agreements in a manner that could be understood for four residents who signed admission arbitration agreements. The social worker responsible for admission paperwork stated that he asks residents whether they understand arbitration, then explains that it is a way to resolve issues with a mediator and that signing is not required for admission. He also stated that he completes admission contracts and arbitration agreements for residents and had been doing so since February 20, 2025. During interviews, the residents expressed confusion about the agreements they signed. One resident stated she had prior knowledge of arbitration but did not feel the facility representative explained it very well and said, "I probably shouldn't have signed it." Another resident had no recollection of signing an arbitration agreement and did not know what it was for. A third resident did not remember signing the agreement and was unsure what it was, and a fourth resident stated she was not aware of what the arbitration agreement was and usually relied on her daughter to help with such matters. After hearing the resident interviews, the social worker stated he typically has residents sign paperwork on admission but maybe should give them more time to adjust and have them sign the agreement the next day when things settle down.
Failure to Follow Full Code Status, Timely Activate EMS, and Use AED During Cardiac Arrest
Penalty
Summary
The deficiency involves the facility’s failure to correctly identify a resident’s code status, promptly notify EMS, and use an available AED during a cardiac arrest event. The resident had multiple serious diagnoses, including metabolic encephalopathy, COPD, heart disease, PVD, epilepsy, dementia, kidney failure, anemia, and aphasia, and was severely cognitively impaired per the MDS, requiring assistance with all care. Documentation in the EMR, including a Code Status/Do Not Resuscitate Directive form, physician orders, and the care plan, all indicated that the resident was a Full Code, with instructions that the resident wished to receive CPR and other life-sustaining treatments. Despite this, when the resident was found unresponsive and not breathing, staff became confused about whether the resident was a Full Code or DNR. When the Code Blue was called, Nurse C began CPR based on her report sheet, which indicated Full Code, and the crash cart was brought to the room. Nurse D went to the nurses’ station to verify the code status and misinterpreted the documentation that stated “Full code by default,” leading to confusion among staff. During this time, a nurse aide overheard the misinterpretation and communicated to EMS that the resident was a DNR, resulting in cancellation of EMS response. Multiple staff interviews, including those of Nurse D, Nurse Aide E, the HR Manager, and a confidential witness, described the scene as hectic and chaotic, with uncertainty among staff about the resident’s code status and repeated calls to 911 in which staff alternately reported that EMS was needed, then not needed, and that the resident was a DNR before later stating he was a Full Code. EMS records and interviews confirmed that the facility first called 911 reporting an unresponsive resident, then cancelled the request, then called again to say EMS was not needed because the resident was DNR, and finally called back later stating the resident was a Full Code and deceased. When EMS arrived, they found staff performing CPR with a BVM in use, but the CPR backboard was placed under the lumbar area instead of the thoracic area, and the crash cart drawers had not been opened. The AED present on the crash cart had not been opened or applied to the resident, despite being available. Review of staff CPR credentials showed that not all nurses present had current AHA BLS for Healthcare Provider certification, and some had only standard or non–healthcare-provider CPR training without clear AED training. The facility also lacked a specific CPR policy, and the DON stated that nurses were expected to follow their training, which did not ensure consistent BLS for healthcare providers, including early AED use, during this emergent event. The facility’s own Advance Directives Policy stated that Full Code status meant the resident would receive full resuscitation and life-sustaining treatment, including CPR, and that Full Code status was indicated on the Code Status/Do Not Resuscitate Directive form. Despite this, staff did not consistently follow the documented Full Code status during the event. The combination of misinterpretation of code status documentation, delayed and inconsistent communication with EMS, failure to use the AED, and improper CPR technique as observed by EMS contributed to the deficiency related to providing basic life support, including CPR, prior to the arrival of emergency medical personnel, in accordance with physician orders and the resident’s advance directives.
Failure to Provide and Monitor Adequate Meals and Snacks for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate and accurately monitored nutrition and hydration for two residents, including one who became ill with a respiratory infection and another who received hemodialysis. For the first resident, who had a history of stroke, depression, anxiety, hypothyroidism, and severe cognitive impairment (BIMS 5/15) and required assistance with all care, the care plan identified a potential for altered nutrition and hydration and directed staff to monitor and record how much the resident ate. In December, this resident developed an excessive cough and was later assessed with a respiratory infection, with an x-ray and antibiotics recommended. Progress notes show that the resident was transferred to the ER for right leg weakness and possible stroke and was diagnosed with low sodium, low potassium, weakness, and dehydration, treated with IV fluids, and then returned to the facility. A detailed review of the electronic "Nutrition – Amount Eaten" task documentation for this resident from late December through early January revealed erratic and inconsistent charting that did not reliably capture meal intake. There were two separate intake documents with overlapping and contradictory entries, including multiple meals charted at the same time, meals documented before typical meal times, and conflicting percentages for the same time entry. On some days, only one meal was documented, and on other days there was no documentation at all, despite the resident being present in the facility and expected to receive three meals. Some entries were charted in batches and prior to meals, making it impossible to determine actual meal times or whether the resident received and consumed three meals per day. The registered dietitian reported she had last seen the resident in early December before the respiratory illness, had not reviewed the late December/early January intake documentation, and was unaware of the ER visit for low sodium, low potassium, and dehydration. For the second resident, who had diabetes, end-stage renal disease on hemodialysis, heart disease, anemia, depression, anxiety, and a humerus fracture, the facility failed to ensure that breakfast or snacks were provided in relation to early-morning dialysis treatments. This resident was cognitively intact (BIMS 13/15) and required assistance with care. A confidential interview indicated the resident left for dialysis around 4:45 a.m., returned mid- to late morning, and did not receive a meal or food before leaving, nor a sack lunch or food to take along. The same source reported that the resident sometimes did not receive an evening snack and could go from the evening meal until nearly lunchtime the next day without food, and that the resident sometimes had to ask for the evening snack and did not always receive it. Dialysis communication forms repeatedly showed "Meal/Snack Sent" as "None," "No," or left blank, and the dialysis center’s documentation showed snack intake of 0 on those days, except for one dialysis supplement. Further review of this dialysis resident’s records showed that the "Nutrition – HS Snacks" task documentation was not consistently completed, with multiple dates missing any record of whether a snack was taken and some dates marked "Not applicable." The resident’s care plans for diabetes, altered nutrition/hydration related to renal diet and fluid restriction, and hemodialysis three times weekly did not include interventions to provide HS snacks, pre-dialysis meals, or snacks/lunches to take to dialysis. The kitchen manager stated the resident left before the kitchen opened and that nothing was prepared the night before because she believed the resident did not want anything, but she did not know if this was true for each dialysis day. The registered dietitian stated sack lunches were available and believed the resident did not want one, and acknowledged that the care plan did not address nutrition from supper the night before dialysis through the time before or after breakfast, nor did it mention HS snacks. Overall, the documented practices and omissions show that the facility did not consistently offer or document meals and snacks necessary to maintain these residents’ nutrition and hydration as required by their conditions and care plans.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, leading to cross-contamination among residents. On multiple occasions, staff members were observed not performing hand hygiene or wearing appropriate Personal Protective Equipment (PPE) during resident care. For instance, a CNA assisted a resident with their meal, picked up a dropped pillow, and continued feeding without washing hands. Another CNA was seen performing incontinence care without a protective gown, despite enhanced barrier precautions being in place. Additionally, a nurse used a personal pulse oximetry machine on a resident and returned it to their pocket without cleaning it. Further observations revealed improper handling and cleaning of medical equipment. A nurse performed glucose monitoring in the hallway, placed the monitor on a medication cart, and returned it to a drawer without cleaning it. The nurse was unsure of the facility's policy on cleaning glucose monitors between resident uses. The Director of Nursing later confirmed that the monitors should be cleaned with disinfectant wipes after each use, but this practice was not followed. Additionally, blood draw equipment was left unsupervised on a treatment cart in the hallway, with capped needles and blood specimens exposed. The lab technician responsible for the equipment admitted to leaving it out and not securing it, which was against proper protocol. This lack of supervision and improper storage of medical equipment further contributed to the risk of cross-contamination and infection spread within the facility.
Staff Use of Personal Phones During Resident Care
Penalty
Summary
The facility failed to ensure that residents were treated in a respectful and dignified manner, as evidenced by staff using personal cell phones while in residents' rooms and during the provision of care. During an interview with a group of residents, it was reported that staff members were talking on personal phones and using ear buds, leading to confusion and embarrassment for residents who mistakenly believed the staff were speaking to them. This behavior was described as disrespectful and an invasion of privacy, with residents feeling ignored and upset when staff did not acknowledge them due to being engaged in personal calls. The Director of Nursing acknowledged the issue, noting it was more prevalent during off shifts and weekends when administration was not present. The facility's policy prohibits the use of personal cell phones in resident care areas to prevent privacy violations, yet this policy was not being adhered to. The residents expressed a desire for this behavior to stop, highlighting the ongoing nature of the problem and the impact on their dignity and privacy.
Failure to Accurately Code Pressure Ulcer on MDS
Penalty
Summary
The facility failed to accurately code a pressure ulcer on the Minimum Data Set (MDS) for a resident, identified as R44, who was admitted with multiple diagnoses including congestive heart failure, major depressive disorder, generalized anxiety disorder, and metabolic encephalopathy. During a record review, it was found that R44 had an unstageable pressure ulcer on the right heel, which was acquired at the facility. This pressure ulcer was not documented in Section M (skin conditions) of the quarterly MDS Assessment dated January 7, 2025. Interviews conducted with the wound care nurse and the Director of Nursing (DON) revealed that the pressure ulcer began as a hematoma on November 19, 2024, and later developed into an unstageable pressure ulcer. The DON confirmed that the MDS Nurse should have coded the pressure ulcer in the MDS assessment but was unsure why it was not done. The facility's policy on MDS Accuracy emphasizes the importance of accurate assessments by qualified staff, ensuring that the MDS reflects the resident's status accurately, and requires interdisciplinary team members to validate and certify the accuracy of the MDS.
Failure to Timely Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise care plans in a timely manner for two residents, resulting in inaccurate care plans. Resident #30, who is cognitively intact, had a signed physician's order for a Do Not Resuscitate (DNR) status, but the care plan inaccurately reflected a preference for full resuscitation. The Social Service Director, responsible for updating care plans related to code status, acknowledged the oversight and stated that the care plan had not been updated due to being busy with other updates. Resident #44, who has severe cognitive impairment, developed an unstageable pressure ulcer on the right heel, which was facility-acquired. The wound was identified on a specific date, but the care plan for wound management was not initiated until several days later. The Director of Nursing was unable to explain the delay, although the wound care nurse is typically responsible for updating care plans. The facility's policy requires care plans to be reviewed and revised as changes in the resident's care occur.
Deficiency in Feeding Tube Care and Documentation
Penalty
Summary
The facility failed to ensure accurate orders and proper maintenance for a feeding tube that was not being used for a resident. The resident, who had full cognitive abilities, was observed with a reddened and painful feeding tube insertion site, with dried red drainage present. The resident reported that the tube was not routinely flushed with water, and there was no equipment available in the room for flushing the tube. Despite the resident taking medications and food orally, the tube was scheduled for removal, but the orders still included instructions for flushing the tube with water during medication passes. The Medication Administration Record/Treatment Administration Record (MAR/TAR) showed inconsistencies in the documentation of tube flushing and care. Nurses documented that the tube was flushed with water on some occasions, while on others, it was noted as not flushed or refused by the resident. There was no additional documentation explaining the refusals or any contact with the provider. The care plan for the resident was outdated, still indicating dependence on tube feedings, despite the resident no longer receiving them. The facility's failure to update the care plans and ensure accurate documentation and care of the feeding tube led to the deficiency. The resident's complaints of discomfort and the presence of redness and drainage at the tube site were not adequately addressed, and the care plans did not reflect the resident's current status or needs. The Director of Nursing acknowledged the inaccuracies in orders and documentation, indicating a need for improvement in the facility's processes.
Failure to Follow PICC Line Care Protocols
Penalty
Summary
The facility failed to adhere to standards of practice for the assessment, monitoring, and dressing changes of a PICC line for a resident. The resident, who was admitted with a PICC line, did not have a baseline care plan initiated upon admission. The dressing for the PICC line was not changed within 24 hours of admission as required, and subsequent dressing changes were not consistently documented every 7 days as per the facility's protocol. Specifically, the dressing was documented as changed on 2/28/25, but not on 3/7/25, and there was no measurement of the PICC line documented during these changes. The Director of Nursing (DON) and a nurse confirmed the lack of documentation and adherence to the facility's standards of care, which were based on an external manual. The manual required the measurement of the external length of the catheter to ensure it had not migrated, but this was not documented in the resident's medical record. Additionally, the facility did not have a specific policy for PICC line care, and the admission assessment lacked documentation of the PICC line measurements. These oversights contributed to the deficiency in providing safe and appropriate administration of IV fluids for the resident.
Medication Administration Failures Lead to Resident Health Issues
Penalty
Summary
The facility failed to ensure the proper acquisition and administration of medications for two residents, resulting in significant health issues. Resident #34, who had a history of epilepsy and severely impaired cognition, did not receive prescribed seizure medications, including Fycompa, Briviact, and Zonisamide, on multiple occasions across January, February, and March 2025. This failure led to an increase in seizure activity, a fall, and subsequent hospitalization. The Director of Nursing (DON) acknowledged the delay in acquiring the medications and the lack of documentation regarding communication with the resident's neurologist. Resident #56, who had multiple diagnoses including end-stage renal disease and convulsions, also experienced medication administration failures. The resident's Sevelamer Carbonate, Amlodipine Besy-Benazepril, Donepezil, and Gabapentin were not administered as prescribed, with numerous doses missed due to unavailability. The Unit Manager (UM) was unaware of these issues and indicated that proper procedures for reordering medications were not followed, leading to the shortages. The facility's policy on medication shortages was not adhered to, as evidenced by the lack of timely communication with the pharmacy and failure to utilize emergency medication supplies. Documentation in the progress notes highlighted repeated instances of medications being on order or awaiting delivery, but there was insufficient action taken to resolve these shortages promptly. The report underscores the facility's systemic issues in managing medication orders and ensuring residents receive their prescribed treatments.
Failure to Provide Meals and Snacks as Per Menu
Penalty
Summary
The facility failed to provide meals according to the menu for four residents, resulting in incomplete meals being offered. Resident #24 was observed eating a lunch meal that lacked rice, vegetables, and cake, with the CNA unable to explain the absence of these items. Resident #1's breakfast meal was missing several items listed on the meal ticket, including a hash brown patty, egg, cereal, and muffin. The Dietary Manager was unable to provide a clear explanation for these omissions, indicating a lack of proper communication and documentation regarding resident preferences. Resident #26 did not receive a roll or dessert with their lunch meal, and another resident in the same room also complained about not receiving a roll. Similarly, Resident #17 did not receive a dinner roll with their meal. A review of the menu confirmed that these items were supposed to be included. A large container of uneaten dinner rolls was found in the dining room, and the Dietary Aide's response suggested a lack of attention to detail in meal distribution. Additionally, a group of residents reported not consistently receiving their evening snacks, with some staff and residents taking snacks intended for others. The Dietary Manager and DON were both unaware of the issue, indicating a breakdown in the process of distributing snacks. Resident #8 was also observed not receiving a roll or cake with their meal, as indicated on their meal ticket, and expressed dissatisfaction. The DON acknowledged the issue and planned to address it with the dietary department.
Failure to Provide Fresh Water to Residents
Penalty
Summary
The facility failed to ensure that residents received fresh fluids at their bedside in a timely manner, as observed with Resident #11 and other residents in the East hallway. Resident #11, who has a history of traumatic brain injury, dementia, seizure disorder, schizophrenia, and peripheral vascular disease, was found with a Styrofoam cup dated from the previous day, containing warm water without ice. The resident was unaware of when the water was last provided, indicating a lack of fresh water supply. Observations revealed that several residents had water cups dated from the previous day or undated, all containing warm water without ice, except for one resident who had a cup dated with the current date and ice. Staff member K was observed refilling water cups and stated that residents received a new cup each day at 2:00 PM, with refills occurring throughout the day. However, the Director of Nursing confirmed that the practice involved using the same Styrofoam cup for 24 hours, with refills scheduled at specific times. Despite this schedule, residents were found without fresh water at the designated refill time. Additionally, residents expressed dissatisfaction with the use of Styrofoam cups and reported instances of other residents attempting to access water and ice from the hallway cart, potentially leading to contamination. The facility's policy outlined a water pass schedule, but the observed practices did not align with ensuring fresh water availability for residents.
Failure to Properly Label and Dispose of Expired Foods
Penalty
Summary
The facility failed to properly label, date, and dispose of expired foods in both the walk-in refrigerator/freezer and the resident refrigerator/freezer, which could potentially lead to foodborne illness. Observations revealed that several items, including a bag of frozen zucchini squash, a can of french onion dip, and a package of hot dogs, lacked expiration or use-by dates. Additionally, a box of blueberries, tomatoes, celery, and a bag of onions were found with labels indicating they should have been used by specific dates. In the resident refrigerator/freezer, items such as jam, ice cream, popsicles, a jar of pickles, and a jug of oat milk were found without resident identifiers or proper labeling. The dietary manager confirmed these findings and stated that dietary aides are responsible for ensuring expired items are discarded and resident food is labeled and disposed of after three days. However, despite a cleaning schedule indicating that dietary staff were checking for expired items, the policy for safe storage and handling of outside food was not followed. This policy requires food brought in for residents to be labeled with the resident's name and the date it was brought in, and any food not consumed within three days should be discarded. The failure to adhere to these procedures was verified through interviews and record reviews.
Failure to Enact Physician Orders Following Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that physician's orders were enacted for a resident who experienced a change in condition. The resident, who had a history of an enlarged heart, anxiety, depression, Barrett's Esophagus, GERD, and debility, was admitted with full cognitive abilities and required some assistance with care. The resident developed shortness of breath, low oxygen saturation, and was later transferred to the hospital, where he was diagnosed with pneumonia and other complications. The physician had evaluated the resident and documented a chief complaint of cough and chest congestion with brown sputum. During this visit, the physician intended to order a chest x-ray and start an expectorant, but there was no evidence in the medical record that these orders were entered or carried out. The resident already had an as-needed order for Guaifenesin cough syrup, but it was not administered. Additionally, there was no care plan addressing the resident's respiratory symptoms, cough, or congestion. Interviews with nursing staff and the physician revealed a lack of communication and follow-through regarding the physician's intended orders. Nurses were not aware of the chest x-ray order, and the physician typically rounded with the receptionist rather than nursing staff, leading to missed or uncommunicated orders. The absence of nursing assessments following the physician's visit and prior to the resident's acute decline further contributed to the failure to provide appropriate treatment and care according to the physician's orders and the resident's needs.
Failure to Prevent Falls and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure appropriate interventions and supervision to prevent falls for Resident #56, who had a history of multiple falls and significant medical conditions including heart failure, diabetes, and arthritis. Despite the resident's high fall risk, the care plans were not consistently updated with effective interventions after each fall. The resident experienced seven falls from September 2023 to April 2024, all of which were unwitnessed, and the interventions implemented were often basic and reactive rather than proactive. On 4/29/2024, Resident #56 was observed attempting to reach her lunch tray from a low bed position, indicating inadequate supervision and assistance. The resident's care plan included interventions such as keeping the bed in a low position and monitoring due to high fall risk, but these measures were insufficient to prevent further falls. The resident's falls occurred primarily in the late afternoon, evening, and night, yet there was no specific mention of increased supervision during these times. The facility's policies on accidents and incidents, as well as maintaining a safe environment, were not effectively implemented for Resident #56. The Director of Nursing and Administrator acknowledged the multiple falls and the need for better fall prevention strategies. However, the lack of timely and appropriate interventions contributed to the resident's repeated falls and eventual femur fracture, highlighting a significant deficiency in the facility's fall prevention and supervision practices.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in potential unmet care needs. Resident #217, who was admitted with diagnoses including weakness, anemia, hypertension, epilepsy, and obstructive sleep apnea, did not have a care plan in place for the use of oxygen despite a physician's order to start oxygen at 2L. The MDS Coordinator acknowledged the oversight in updating the care plan for the resident's oxygen use. Resident #221, admitted with diagnoses of hypertension, dementia, Alzheimer's disease, and rheumatoid arthritis, was observed with a Wanderguard on their foot without a care plan or rationale for its use. Additionally, there were no care plans for the resident's activities of daily living (ADLs) or hospice care, which was confirmed by the CNA and DON. The MDS Coordinator admitted that the care plans were missed and not communicated to the CNAs. Resident #4, admitted with diagnoses including delusional disorders, dementia, psychotic disorder, PTSD, and mood disorder, lacked documentation of the required Level II Evaluation and recommendations as per PASARR guidelines. The resident's care plan did not include a focus, goal, or interventions for the PASARR yearly evaluations or the need for Level II Evaluation, leading to a deficiency in meeting the resident's specialized mental health service needs.
Insufficient Nursing Staff Leading to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, resulting in multiple instances of inadequate care and supervision. Residents reported long call light response times and insufficient assistance with daily activities such as eating and toileting. For example, one resident indicated they did not receive help to eat and had their call light ignored, while another resident was found in bed without clothes and unable to reach their call light, which was on the floor. Staff interviews confirmed that the facility often operated with fewer nurses and CNAs than required, leading to delays in care and supervision. Confidential staff interviews revealed that the facility frequently had fewer nurses and CNAs than scheduled, particularly during night shifts. Staff reported that call-ins and no-shows were common, and positions were often not filled, resulting in increased workloads and compromised resident safety. One staff member indicated that they did not feel it was safe due to issues with falls, hospital transfers, and late medication passes. Another staff member reported that CNA's were often unable to complete incontinence care within the required two-hour intervals due to being short-staffed. Specific incidents highlighted the impact of insufficient staffing on resident safety. One resident fell and hit their head, resulting in significant bleeding and subsequent death. The investigation revealed that only two nurses were on duty at the time, instead of the usual three. Another resident expressed concerns about not receiving help after midnight, stating that call lights were often ignored for extended periods. A review of staffing assignments confirmed that the facility frequently operated below its ideal staffing levels, with discrepancies between posted and actual working hours for CNAs.
Failure to Ensure Proper Labeling and Secure Storage of Medical Supplies and Medications
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medical supplies and medications. Observations revealed that treatment carts in the Main Hall area and near a specific room were left unattended and unlocked, containing supplies for wound dressings and prescription treatments. Additionally, laboratory supplies, including needles for blood draws, were not secured. Opened containers of wound packing strips, Eucerin cream, and peroxide were found without open dates or expiration dates. Eye drops and urinalysis test strips were also found opened without proper dating, and three controlled substances were discovered on the side of a medication cart, not properly disposed of as per facility policy. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the treatment carts should have been locked and that opened medical supplies should have been dated. The DON acknowledged that the eye drops should be dated with an open date and that wound packing strips should have an open date and discard date. The facility's policies on medication storage, administering medications, and discarding and destroying medications were reviewed, revealing that the facility did not adhere to its own policies, resulting in the potential for decreased efficacy of medications and supplies, drug diversion, and inaccurate medical results.
Failure to Ensure Understanding of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents, responsible parties, and staff had a clear understanding of the facility's binding arbitration agreement prior to signing it. During an entrance conference, the Administrator mentioned that arbitration agreements were offered on admission but were not mandatory to sign. However, the Business Office Assistant later provided a large stack of signed arbitration agreements, indicating that all residents had signed them. The arbitration agreements were found to be confusing, with references to a pharmacy that did not align with the rest of the document. Interviews with residents revealed that they did not fully understand the arbitration agreements, and some were not aware they had signed them. The Administrator admitted that several staff members presented the agreements without necessarily having received proper education on the subject, and no policy for arbitration agreements was provided upon request. Interviews with multiple residents confirmed that they did not have a thorough understanding of the arbitration agreements they had signed. One resident believed the agreement was about the right to refuse care, while another did not recall signing an arbitration agreement at all. During a resident council meeting, the group expressed confusion about what arbitration agreements were, with some remembering signing the agreement but not understanding it, and others having no recollection of it. The facility's failure to ensure proper explanation and understanding of the arbitration agreements led to residents and their representatives not being fully informed of their rights.
Infection Control Deficiency
Penalty
Summary
The facility failed to ensure Infection Prevention and Control standards of practice were followed for Transmission-Based Precautions (TBP). During a tour, it was observed that several rooms with Enhanced Barrier Precautions had expired hand sanitizer, and one was empty. Additionally, on the East hall, rooms with multiple residents had Contact Precautions signs without indicating which resident required the precautions, and there were no waste receptacles outside the doors for disposing of isolation gowns. Staff were observed entering and exiting rooms without using the necessary PPE, and there was confusion among staff about which precautions were in place for certain residents. Resident #44 was admitted with multiple diagnoses, including cellulitis, diabetes, sepsis, and a pressure ulcer. The resident had an order for Enhanced Barrier Precautions, but the sign on the door indicated Contact Precautions. Staff were observed entering the room without donning PPE, and there was no garbage available to dispose of PPE upon exiting the room. The nurse administering insulin to the resident did not follow proper PPE protocol and did not sanitize hands after removing PPE. A CNA was unaware of the need for PPE despite the Contact Precautions sign on the door. The Wound Care Nurse was also unsure about the correct precautions for Resident #44 and followed the incorrect Contact Precautions sign. There was no readily available garbage receptacle or hand sanitizer outside the room. The Director of Nursing confirmed that the resident should have been on Enhanced Precautions and not Contact Precautions, indicating a lapse in communication and proper signage. The incorrect sign was removed, and the correct Enhanced Precautions sign was posted, but staff confusion and improper PPE use were evident throughout the observations.
Inaccessible Call Lights and Improper Oxygen Tank Storage
Penalty
Summary
The facility failed to ensure a safe environment by not maintaining accessible call lights for residents and improperly storing an oxygen tank. Resident #4, who had severely impaired cognition, was observed multiple times with the call light on the floor and out of reach. The CNA acknowledged the issue and mentioned the call light had no clip, which was confirmed by the Unit Manager who promised to get a clip. Similarly, Resident #12, with moderately impaired cognition, had their call light clipped to a privacy curtain, making it inaccessible. The CNA later corrected this by clipping the call light to the bed within reach of the resident. Resident #24, who also had severely impaired cognition, was found in bed with the call light cord on the wall and the apparatus on the floor, making it unreachable. The resident expressed difficulty in reaching the call light and mentioned it did not work. This situation was not immediately addressed by the staff. Additionally, Resident #44 had a small oxygen tank improperly stored in a cloth basket on top of plastic bins. The DON confirmed that the tank should have been placed in a holder and not stored in such a manner. These deficiencies resulted in residents' frustration and the inability to call for assistance, potentially leading to unmet care needs. The observations and interviews with the residents and staff highlighted the facility's failure to maintain a safe and accessible environment for its residents, particularly concerning the accessibility of call lights and proper storage of medical equipment.
Failure to Complete Annual Level II Evaluation for Resident
Penalty
Summary
The facility failed to ensure that an annual review for mental disorder, intellectual disability, or a related condition was completed with Level II Evaluation documentation for one resident. Resident #4, who had diagnoses including delusional disorders, dementia, psychotic disorder, PTSD, and mood disorder, was admitted to the facility and was prescribed antipsychotic medication. The resident's medical record indicated that a Level II Evaluation was required by April 26, 2023, but no such evaluation was found in the resident's medical record for that period. An interview with the Social Service Director (SSD) revealed that the SSD was unaware of the missing Level II Evaluation and had not been in the role at the time the evaluation was due. Upon contacting the Coordinator for the Michigan Department of Health and Human Services, it was confirmed that the Level II Evaluation had been completed but was not sent to the facility. The facility's policy requires that all new admissions be screened for mental disorders, intellectual disabilities, or related disorders, and that the Level II Evaluation be included in the resident's medical record, which was not adhered to in this case.
Failure to Implement Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 72 hours of admission for a resident, resulting in the potential for unmet care needs and social isolation. The resident, who was admitted with diagnoses of hypertension, dementia, Alzheimer's disease, and rheumatoid arthritis, was observed in a state that indicated neglect, such as being dressed inappropriately and having a smell of urine in the room. Additionally, the resident had a Wanderguard placed without proper documentation or rationale, despite being assessed as low risk for elopement. Interviews with staff revealed that the Certified Nursing Assistant (CNA) and the Director of Nursing (DON) were unaware of the specific care needs of the resident due to the absence of a baseline care plan. The Minimum Data Set (MDS) Coordinator admitted that the care plans were missing from the resident's health record and that the information was not relayed to the CNAs. This lack of communication and documentation led to the resident not having care plans for Activities of Daily Living (ADL), Wanderguards, or hospice care, which are essential for providing appropriate care.
Failure to Update Care Plans Following Resident Falls
Penalty
Summary
The facility failed to review and revise care plans with resident changes to ensure necessary interventions for care and services were provided. Resident #56, who had a history of falls and multiple medical conditions including heart failure, diabetes, and arthritis, was observed struggling to reach her lunch tray from a low bed position. Despite multiple falls and a significant injury resulting in a fractured left femur, the care plans were not consistently updated with new interventions to prevent future falls. The care plans often included basic fall prevention strategies that were not initiated until after the resident had already fallen multiple times. The resident's care plans were reviewed and discussed with the Director of Nursing and the Administrator, revealing a lack of effective interventions to prevent falls. The facility's policy required comprehensive, person-centered care plans that reflect current standards of practice and are revised as the resident's condition changes. However, the care plans for Resident #56 did not meet these standards, as they were not adequately updated following each fall, leading to continued falls and the development of pressure ulcers due to improper fitting of a knee immobilizer and immobility.
Failure to Prevent Facility-Acquired Pressure Ulcers
Penalty
Summary
The facility failed to ensure that interventions were in place to prevent facility-acquired pressure ulcers for a resident, resulting in the development of two pressure ulcers. The resident, who had multiple diagnoses including heart failure, diabetes, and obesity, was admitted to the facility and later fell, fracturing her left femur. She returned to the facility with a left knee immobilizer, which was not properly assessed for fit, leading to a Stage 2 pressure ulcer on her left outer ankle. Additionally, the resident developed a Stage 2 pressure ulcer on her right outer heel due to immobility and pressure from lying in bed. The facility's records indicated that the resident's left ankle wound was first identified as a dark scab and later assessed as a Stage 2 pressure ulcer. There was no assessment for the right outer heel wound. Physician orders for heel boots and wound care were issued after the pressure ulcers had already developed. The facility's policy on pressure ulcer risk assessment was not adequately followed, as there was no order to ensure the proper positioning of the left knee immobilizer to prevent skin breakdown.
Failure to Remove and Maintain PEG Tube
Penalty
Summary
The facility failed to ensure the timely removal and proper maintenance of a Percutaneous Endoscopic Gastrostomy (PEG) tube for a resident diagnosed with Guillain-Barre syndrome, acute respiratory failure, dysphagia, heart failure, and hypertension. Despite the resident transitioning to an oral diet and gaining weight, the PEG tube remained in place due to transportation issues and miscommunication among staff. The resident expressed frustration and feelings of hopelessness over the delay in removing the PEG tube, which had been approved for removal by the physician in February 2024. Observations revealed that the PEG tube was not being flushed regularly, and necessary supplies were often missing from the resident's room. The resident reported that the tube had not been flushed for weeks at a time, and there was no dressing over the PEG tube site. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) indicated that the main reason for the delay was difficulty in arranging transportation for the removal appointment. The DON also mentioned that the resident's weights had not been stable, which was another reason for the delay. Record reviews confirmed that the resident's weight had been stable and had even increased since February 2024. The Registered Dietitian (RD) also confirmed that the resident's weight was stable and that they were comfortable with the PEG tube being removed. Despite multiple progress notes and physician orders recommending the removal of the PEG tube, the facility failed to schedule and follow through with the necessary appointment, resulting in unmet care needs for the resident.
Failure to Document Hospice Services
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for two residents, resulting in the absence of progress notes, assessments, and care plans in the medical record. Resident #221, who has been receiving hospice services since March 15, 2024, was observed on April 30, 2024, without any hospice care plans, treatment notes, or progress notes in the electronic health record (EHR). The Social Services Director and the Director of Nursing confirmed the absence of these documents and stated that the hospice company is responsible for faxing over the necessary information, which should then be scanned into the EHR. However, this process had not been completed for Resident #221, leading to a lack of essential documentation in the resident's medical record. Similarly, Resident #38, who began hospice services for lung and stomach cancer, had missing hospice notes from April 11, 2024, to May 5, 2024. During a tour of the facility, it was noted that the hospice nurse visited the resident weekly, but the corresponding notes were not present in the medical record. The Director of Nursing acknowledged the absence of these notes and stated that they would request the hospice notes to be sent over from the hospice service. The hospice nurse confirmed the resident's condition and the care provided, but the documentation was not included in the resident's facility medical record to ensure coordination of care. The facility's policy and the hospice company contract both emphasize the importance of communication and documentation between the hospice service and the facility. The lack of hospice care plans, treatment notes, and progress notes in the EHR for both residents indicates a failure to adhere to these guidelines, resulting in incomplete medical records and potential gaps in the coordination of care for residents receiving hospice services.
Inaccurate and Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the required posting of daily nurse staffing was accurate and updated, resulting in a lack of accurate documentation of daily staffing and a lack of accessible staffing information for all 62 residents, their representatives, staff, and visitors. The deficiency was identified through observation, interview, and record review. The Scheduler/CNA Supervisor admitted that CNAs working in the office without direct resident care assignments were counted in the postings as direct care staff. Additionally, the BIPA program used for documenting staffing hours had inaccuracies, such as misrepresenting partial shifts as whole shifts and not updating for call-ins or no-shows. On multiple occasions, the posted nursing staffing hours did not match the actual assignments. For example, on March 1, 2024, a CNA listed as working 8 hours had only worked 4 hours, and on February 26, 2024, a call-in was not updated, resulting in an inaccurate posting of 32 hours instead of 28 hours. Furthermore, the required postings were not updated over weekends, as observed on May 6, 2024, when the posting dated May 3, 2024, was still displayed. The Scheduler admitted that the postings were sometimes left on her desk and not updated during weekends, and the DON acknowledged the need for a system to ensure daily postings, even on weekends.
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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