The Orchards At Samaritan
Inspection history, citations, penalties and survey trends for this long-term care facility in Detroit, Michigan.
- Location
- 5555 Conner Avenue, Suite 4000, Detroit, Michigan 48213
- CMS Provider Number
- 235632
- Inspections on file
- 31
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Orchards At Samaritan during CMS and state inspections, most recent first.
A resident with a history of cerebral infarction and malignant neoplasm reported missing funds from a debit card, and facility records and financial documentation showed that a CNA used the resident’s debit card without consent, resulting in $981 in unauthorized charges. The NHA confirmed that the internal investigation identified the CNA as the individual who misused the card, in violation of the facility’s abuse and neglect policy that prohibits misappropriation of resident property.
A resident with diagnoses including cerebral infarction and malignant neoplasm, and with intact cognition but needing max assistance for personal hygiene, developed unexplained facial bruising and right eye discoloration with swelling after being observed in bed with involuntary rapid movements and abrupt head movements. The admission skin assessment had shown no facial bruising. An LPN obtained orders for neuro checks, PRN Tylenol, and ice for the bruise, and another LPN/unit manager was informed that the facial bruising was unexplained and unwitnessed. However, neither LPN reported these suspicious, unexplained injuries to the administrator/abuse coordinator as required by facility policy, and the injury of unknown origin was not reported to the State Agency.
A resident with chronic systolic CHF, acute kidney failure, and a traumatic subarachnoid hemorrhage, and with intact cognition, had a physician order for a one-time Albuterol nebulizer treatment for SOB. The MAR showed the treatment was given as ordered, but a subsequent nursing note documented that an additional breathing treatment was administered when the resident was found short of breath, with the nurse explaining it as part of new prednisone therapy. There was no physician order for this repeat nebulizer treatment, and facility policy required medications to be given only on clear, complete, signed prescriber orders.
A resident with severe cognitive impairment and a history of right shoulder dislocation was physically abused by a CNA, who forcefully twisted the resident's arm during care, resulting in a dislocated shoulder and hospitalization. The incident was witnessed by another CNA, who delayed reporting due to fear of retaliation. The resident required two-person assistance, but this protocol was not followed at the time of the incident.
A resident with severe cognitive impairment and a recent shoulder injury was subjected to physical abuse by a CNA, who forcefully twisted the resident's arm during care. The incident was not immediately reported to the charge nurse due to fear of retaliation, and there was a delay in notifying the NHA and state authorities as required by facility policy. The resident sustained a dislocated shoulder and required hospital treatment, while the facility failed to report the involved CNA's license to the state agency.
A CNA engaged in a loud verbal altercation with two residents, one with cancer and intact cognition and another with severe dementia, using profane, derogatory, and racially charged language. The incident was witnessed and documented by staff, and the facility's policy prohibits such abuse. Leadership acknowledged the behavior was not in line with facility standards.
The facility did not maintain RN coverage for eight consecutive hours daily, as required, with a specific lapse on a day in October 2024. The staffing coordinator admitted challenges in weekend RN coverage, and the DON sometimes filled in, though this did not meet requirements when the census was over 60 residents. The facility lacked a specific RN coverage policy, relying instead on CMS guidelines.
The facility failed to employ sufficient dietary staff, leading to inadequate sanitation in the kitchen, potentially affecting 99 of 104 residents. Observations revealed understaffing, with the Food Service Supervisor performing multiple tasks due to a staff shortage. A cleaning schedule was not provided, and the dietary department was consistently understaffed, particularly on Mondays and Fridays. The Administrator acknowledged staffing was under review, but no explanation was given for the lack of monitoring and oversight.
The facility's kitchen was found to be unsanitary, with improper use of beard restraints by a cook, unsafe food temperatures, and unclean equipment. Potato salad was stored at 60°F without proper cooling, and the kitchen's exhaust hoods were heavily soiled. The Food Service Supervisor could not provide recent cleaning documentation, indicating a lack of oversight.
A facility failed to ensure proper cleaning and disposal of loose medications in a medication cart. An observation revealed 19 loose pills of various shapes, colors, and sizes scattered in the drawers of the 400 Hall medication cart, along with dried stains, lint, and dust. Nurse G acknowledged the cart should have been clean and stated that loose pills should be discarded. The DON confirmed that nurse managers were responsible for maintaining the cleanliness of medication carts. The facility's policy required medication storage areas to be clean and clutter-free.
A resident's room in the facility had a hole in the floor that was not repaired for a year, leading to frustration and a potential hazard. The Maintenance Supervisor acknowledged the issue but had not created a work order, and the facility lacked a formal work order system. The Nursing Home Administrator recognized the tripping hazard, especially given the resident's moderately impaired cognition and weak ambulation. The facility's policy on regular room maintenance was not adhered to, resulting in this deficiency.
A resident receiving oxygen therapy was found with an unsecured oxygen tank at their bedside, posing a potential safety hazard. The tank was fully pressurized and not stored in a medical rack or stand, contrary to the facility's policy. The resident had a complex medical history but intact cognitive function. The DON acknowledged the risk associated with the free-standing tank.
The facility failed to properly manage oxygen therapy for two residents. One resident's oxygen tubing was not labeled, and the concentrator was unclean, despite care plan instructions. Another resident wore oxygen without a physician's order, and the tubing was also unlabeled. Both residents had intact cognitive function and significant medical histories.
A facility failed to address MRR recommendations timely, resulting in unnecessary medications for a resident with intact cognition and multiple diagnoses. Duplicate orders for Famotidine were administered, and Lidoderm patch usage exceeded recommended duration. The DON acknowledged the physician's lack of response to the pharmacist's irregularity reports.
The facility failed to prevent unnecessary medications for two residents, leading to potential adverse effects. One resident received prolonged Guaifenesin without a stop date, while another had duplicate Famotidine orders. The DON acknowledged the issues, and the facility lacked an unnecessary medication policy.
Surveyors found that the facility did not maintain a clean and safe environment, with heavily soiled kitchen vents, broken and dirty equipment, missing or stained ceiling tiles, and unclean resident rooms. Observations included food residue, debris, and unsanitary conditions in both common areas and resident rooms, with staff interviews confirming lapses in cleaning procedures and maintenance responsibilities.
A resident with oral cancer experienced uncontrolled pain due to the facility's failure to administer Oxycodone as prescribed. The resident's pain medication was delayed or withheld without proper justification, leading to significant distress and eventual discharge against medical advice. Interviews and records revealed lapses in following medication administration policies.
A facility failed to report an allegation of employee-to-resident abuse to the State Agency, involving a cognitively intact resident who was allegedly slapped by a staff member. Despite complaints being reported to the state hotline, the facility did not submit a Facility Reported Incident (FRI). The Nursing Home Administrator concluded the incident did not occur and did not report it, contrary to the facility's policy requiring timely reporting of such allegations.
A resident with a history of multiple health conditions experienced critical anemia symptoms and lab results, but the facility failed to timely address these issues. Despite discontinued iron supplements and decreased iron levels, no changes were made to the care plan, leading to hospitalization for anemia, fluid overload, and acute kidney injury. The DON and physician could not explain the delay in intervention, and the facility's policy on acute change in condition was not followed.
A resident with multiple diagnoses, including chronic pain, was prescribed Oxycodone HCl. An LPN signed out two tablets from the Pyxis system, although only one was administered, citing preparation for the next shift. The DON confirmed this was against standard practice, as narcotics should be signed out only at the time of administration.
A resident with severe cognitive impairment exited the facility without staff knowledge, despite being last seen at a bingo event. The resident was found the next morning by police, having left through the main elevator. Staff interviews confirmed the resident was reported missing later in the evening, highlighting a lapse in supervision.
The facility failed to provide timely incontinence care for a resident, resulting in a strong urine smell and heavily saturated briefs on multiple occasions. Despite the care plan requiring checks and changes every two hours, staff interviews and observations confirmed that this protocol was not followed.
Failure to Protect Resident From Misappropriation of Debit Card by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property by an employee. A complaint alleging misappropriation was received by the State Agency on 3/16/2026. Review of the facility’s incident and investigation reports showed that on 2/3/2026 the resident reported that $981 was missing from her debit card. The Nursing Home Administrator reviewed financial records from the debit card company with the resident’s family friend, which identified a Certified Nursing Assistant as having used the resident’s debit card without the resident’s consent. The facility’s Abuse and Neglect Prohibition Policy, last reviewed on 2/17/2020, states that each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, and misappropriation of property. The resident’s EHR showed admission on 1/27/2026 and discharge on 2/9/2026, with diagnoses including cerebral infarction and malignant neoplasm. Attempts by the surveyor on 4/24/2026 to contact the CNA involved were unsuccessful, and attempts to contact the resident by phone were also unsuccessful due to a non-working number and no other contact numbers in the medical record. During interview, the Nursing Home Administrator confirmed that the internal investigation determined the CNA had used the resident’s debit card without consent and stated that the expectation is that residents be protected from misappropriation of property.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to implement its policies and procedures for reporting an injury of unknown origin to the State Agency for one resident. A resident was admitted with diagnoses including cerebral infarction and malignant neoplasm, with an admission MDS indicating intact cognition and a need for maximal assistance with personal hygiene. The admission skin assessment did not show any facial bruising. On a later date, a progress note documented a new physician order for neuro checks every six hours for three days, Tylenol 650 mg every six hours as needed, and application of ice due to a bruise on the left side of the resident’s forehead at the eyebrow. An unwitnessed incident report documented that the resident was observed in bed experiencing involuntary rapid movements, hitting the right eye and attempting to hold the right arm with the left hand, with uncontrollable movements at times, and right eye discoloration with swelling. The resident was described as having involuntary head movements, swinging the head abruptly especially when speaking, being bedridden, and unable to provide a consistent description of whether a fall had occurred. Despite these unexplained facial injuries and the facility’s policy requiring staff to report all allegations of abuse, neglect, misappropriation of property, and injuries of unknown origin to the administrator immediately, the required reporting did not occur. An LPN/unit manager stated that another LPN had notified her of unexplained facial bruising that was not witnessed, and acknowledged that she did not report this injury to the abuse coordinator, although she believed she should have. The nursing home administrator confirmed that neither of the involved LPNs reported the resident’s facial injuries to her, contrary to the facility’s Abuse and Neglect Prohibition Policy, which specifies that the administrator is responsible for overseeing investigations and reporting alleged violations, including injuries of unknown origin, to the State Agency. As a result, the injury of unknown origin was not reported to the State Agency as required.
Unauthorized Repeat Administration of Nebulizer Treatment Without Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer medications according to physician orders for one resident. The resident had diagnoses including chronic systolic congestive heart failure, acute kidney failure, and traumatic subarachnoid hemorrhage, and had an intact cognition score of 15/15 on the Brief Interview for Mental Status. A physician’s order dated 2/17/26 directed that Albuterol Sulfate Inhalation Nebulization (2.5 mg/3 mL 0.083%) be given as one vial via nebulizer one time only for shortness of breath for one day. The February 2026 medication administration record showed that this nebulizer treatment was administered on 2/17/25 in accordance with the order. However, a nursing progress note dated 2/18/2026 at 20:03 documented that the resident was found sitting in a chair with pants off and experiencing some shortness of breath, and that the writer (nurse) administered a breathing treatment and explained to the resident that the doctor had started them on a new medication, prednisone, to help reduce shortness of breath and help their lungs. The note further documented that the resident tolerated the medications well, could make needs known, was continent of bowel and bladder, and had vital signs recorded. There was no physician order for an additional breathing treatment beyond the original one-time-only nebulizer order, and the DON confirmed that the order was for one time only and should not have been given again without a physician’s order. The facility’s Medication Orders Policy stated that medications are to be administered only upon the clear, complete, and signed order of an authorized prescriber.
Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including dementia and polyneuropathy, required total assistance with activities of daily living. On the night in question, a Certified Nursing Assistant (CNA) was observed by another CNA forcefully twisting the resident's right arm behind their back during care, after expressing frustration and making an inappropriate comment. The resident was noted to be squirming and attempting to free their arm, and the incident was not immediately reported to the charge nurse due to fear of retaliation. Following the incident, the resident was assessed by a registered nurse, who initially found no injuries and noted the resident could move both arms without apparent pain. However, a subsequent assessment revealed slight bruising and pain when the right arm was raised. Diagnostic imaging later confirmed a dislocated right shoulder, and the resident was transferred to the hospital for treatment. The incident was reported to law enforcement, and the CNA involved was suspended and later terminated. The facility's documentation and interviews revealed that the resident required two-person assistance for care, but the incident occurred with only one CNA present initially. The other CNA, who witnessed the abuse, did not immediately report the event due to concerns about retaliation, resulting in a delay in addressing the situation. The resident's medical record indicated a history of right shoulder dislocation, and the incident led to further injury and hospitalization.
Failure to Timely Report Suspected Physical Abuse and Injury
Penalty
Summary
The facility failed to implement its policies and procedures for the timely reporting of a reasonable suspicion of physical abuse involving a resident with severe cognitive impairment and multiple medical conditions, including dementia and a recent right shoulder dislocation. On the night in question, a CNA observed another CNA forcefully twisting the resident's right arm behind their back during care, causing the resident to squirm and attempt to free themselves. The observing CNA did not immediately report the incident to the unit charge nurse due to fear of retaliation and instead reported it to the Nursing Home Administrator (NHA) approximately two hours later. The resident was later found to have a dislocated shoulder and was transferred to the hospital for treatment. The facility's policy required immediate reporting of abuse allegations to the Administrator and the State Agency, especially when serious bodily injury is involved. However, the incident was not reported to the appropriate authorities within the required timeframe, and the NHA did not report the involved CNA's license to the state agency as required. The delay in reporting and failure to follow established procedures resulted in the abuse going unreported in a timely manner, placing the resident at further risk.
Failure to Prevent Verbal Abuse by CNA Toward Two Residents
Penalty
Summary
The facility failed to prevent verbal abuse involving two residents, one with intact cognition and a diagnosis of ovarian cancer, and another with severe cognitive impairment and dementia. On the date of the incident, a Certified Nursing Assistant (CNA) was witnessed by another CNA and documented by a Registered Nurse (RN) to have engaged in a loud verbal altercation with the residents, using profane and derogatory language. The CNA directed explicit insults and threats toward both residents, including referencing one resident's terminal illness in a disparaging manner and using racial and gender-based slurs. The incident was reported by the affected resident to an LPN, and corroborated by staff witness statements and written documentation. The resident with intact cognition provided a detailed written account of the incident, while the resident with dementia was unable to recall the event during interview. Staff interviews and written statements confirmed the occurrence of the verbal abuse, with the RN noting the CNA's continued aggression until being removed from the unit. The facility's policy prohibits all forms of abuse, including verbal abuse defined as the use of disparaging or derogatory language toward residents. The actions of the CNA were acknowledged by facility leadership as inappropriate and not in accordance with established standards or policy.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week, as required. This deficiency was identified during a review of the nurses' schedule for October, November, and December 2024, which revealed a lack of RN coverage on October 20th, 2024. The staffing coordinator acknowledged difficulties in securing RN coverage for weekends and noted that the Director of Nursing (DON) sometimes covered shifts. However, the staffing coordinator was unaware that the DON's coverage does not count towards RN coverage when the facility census exceeds 60 residents. The DON confirmed that there were instances when an RN was unavailable and acknowledged the necessity of RN supervision for the resident population. Additionally, the facility lacked a specific RN coverage policy and instead referred to the Center for Medicare and Medicaid Services guidelines.
Inadequate Dietary Staffing and Sanitation in Kitchen
Penalty
Summary
The facility failed to employ sufficient dietary staff and ensure operational consultation was provided to supervisory staff, resulting in inadequate sanitation in the kitchen. This deficiency had the potential to affect 99 of the 104 residents who consumed meals from the kitchen. On the morning of 3/24/25, the Food Service Supervisor (FSS) D was observed performing multiple tasks, including collecting trays, transporting food carts, and organizing the walk-in refrigerator and freezer, due to a staff shortage. FSS D reported that one employee had called in sick that morning, and a dietary aide position had been vacant since the previous month. During an observation, FSS D was unable to provide a cleaning schedule, indicating a lack of structured sanitation monitoring. Further investigation revealed that the dietary department was consistently understaffed, particularly on Mondays and Fridays, with only three dietary aides and one cook available for breakfast and lunch. The Area Manager (A.M.) F confirmed the staffing shortage and acknowledged that the facility had scheduled 55 hours instead of the initially reported 51 hours. However, no explanation was provided for why the additional hours did not address the sanitation issues. The Administrator mentioned that staffing was under review but did not explain the lack of monitoring and oversight in the kitchen. Upon exiting the facility, the audit form for the department was found to be blank, and no cleaning schedule was provided as requested.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment for food storage, preparation, and service, which could potentially lead to foodborne illnesses affecting 99 of the 104 residents. Observations revealed that a cook was improperly using a beard restraint, covering his beard but not his mustache, which was later corrected. Additionally, during a lunch meal observation, potato salad was found at an unsafe temperature of 60 degrees Fahrenheit, without any cooling device to maintain the required temperature of 41 degrees Fahrenheit or below, as per the 2023 Food Code. Further inspection of the facility's main kitchen revealed cracked and detached caulking along the dish machine's scrape table, with standing water, food debris, and a black mold-like substance present. The kitchen's exhaust hoods were heavily soiled with grease, lint, and food ash, and the last professional cleaning was recorded on January 7, 2025, with the next scheduled for July 15, 2025. The Food Service Supervisor was unable to provide documentation of recent cleaning schedules or tasks, indicating a lack of oversight and adherence to sanitation protocols. These deficiencies were acknowledged by the Area Manager during a walkthrough but remained unaddressed by the time of the survey exit.
Improper Cleaning and Disposal of Medications in Medication Cart
Penalty
Summary
The facility failed to ensure proper cleaning and disposal of loose medications for one of the four medication carts observed. During an observation and interview with Nurse G, it was found that the 400 Hall medication cart contained 19 loose pills scattered across the bottom of the first and second drawers. These pills varied in shapes, colors, and sizes. Additionally, the drawers had dried tan stains, lint, and dust. Nurse G acknowledged that the cart should have been clean and stated that their policy required loose pills to be discarded. The Director of Nursing confirmed that nurse managers were responsible for checking and cleaning the medication carts on their units. A review of the facility's policy on medication storage indicated that medication storage areas should be kept clean and free of clutter.
Failure to Repair Resident's Room Floor Creates Hazard
Penalty
Summary
The facility failed to maintain a safe and homelike environment for a resident, identified as R95, by not repairing a hole in the floor of their room. The resident expressed frustration over the issue, which had persisted for a year without being addressed. The hole, approximately six by four inches in size, was located near the foot of the resident's bed and was observed during an interview with the resident. The Maintenance Supervisor acknowledged the issue but admitted that no work order had been created, and the facility lacked a formal work order system. This oversight resulted in the repair not being completed in a timely manner. The Nursing Home Administrator also acknowledged the hole in the floor, agreeing that it posed a tripping hazard and could not be cleaned properly. The resident, who was admitted to the facility with diagnoses including chronic heart failure and age-related physical debility, had a moderately impaired cognition as indicated by a BIMS score of 12/15. Additionally, the resident was assessed as a weak ambulator, which further emphasized the potential risk posed by the unrepaired floor. The facility's policy on resident room maintenance, which requires regular inspections and maintenance, was not followed, contributing to the deficiency.
Improper Storage of Oxygen Tank Poses Safety Hazard
Penalty
Summary
The facility failed to properly store an oxygen tank for one resident receiving oxygen therapy, which resulted in a potential safety hazard. During an observation, the resident was found in bed using oxygen via a nasal cannula, with the oxygen set at 2 liters through a concentrator. Next to the resident's bed was a green cylinder oxygen tank, which was fully pressurized but not secured in a medical rack or stand. This improper storage posed a risk of the tank tipping over, potentially causing damage or leaks. The oxygen tubing also lacked a date label, which is necessary for tracking and safety purposes. The resident involved had a complex medical history, including conditions such as stroke, seizures, atrial fibrillation, asthma, chronic obstructive pulmonary disease, diabetes type II, heart disease, and chronic pain. Despite these conditions, the resident had an intact cognitive function, as indicated by a Brief Interview for Mental Status score of 15/15. The Director of Nursing acknowledged the issue, noting that a free-standing oxygen tank could be dangerous. The facility's policy on oxygen use safety, revised in December 2009, clearly states that oxygen cylinders must be stored in racks, sturdy portable carts, or approved stands and should not be left free-standing or stored in resident rooms or living areas.
Deficiencies in Oxygen Therapy Management for Residents
Penalty
Summary
The facility failed to properly manage and document the use of oxygen therapy for two residents, R9 and R33. For R9, the oxygen tubing was not labeled with a date, and the resident was unsure of how frequently the tubing was changed. Additionally, the oxygen concentrator was observed to be unclean, with a thick white substance and dust debris present. R9's care plan and physician orders indicated that the oxygen tubing should be changed weekly and dated, but this was not adhered to. R9 has a history of morbid obesity, seizure disorder, COPD, diabetes mellitus type 2, anxiety, and heart failure, with an intact cognitive function as indicated by a BIMS score of 15/15. For R33, the oxygen tubing was also not labeled with a date, and there was no physician's order for supplemental oxygen therapy in the resident's electronic medical record. Despite wearing oxygen via nasal cannula, R33's care plan did not include an order for oxygen therapy. R33 has a medical history of stroke, seizures, atrial fibrillation, asthma, COPD, diabetes type II, heart disease, smoking, and chronic pain, with a BIMS score of 15/15 indicating intact cognitive function. The Director of Nursing acknowledged the deficiencies and stated that the issues would be addressed.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to address Medication Regimen Review (MRR) recommendations in a timely manner for a resident, resulting in the continuation of unnecessary medications and a lack of communication between the pharmacist and physician. The resident, who had intact cognition, was admitted with diagnoses including cerebral infarction, major depressive disorder, and anxiety disorder. The review of the resident's Electronic Health Record (EHR) revealed duplicate orders for Famotidine (Pepcid) 20mg, with one order written on 12/12/24 and another on 1/8/25. Both medications were administered until 2/24/25, despite being the same medication, indicating a failure to address the pharmacist's irregularity report. Additionally, the facility did not adhere to the pharmacist's recommendation regarding the use of Lidoderm patches, which should only be worn for 12 hours to avoid local adverse events. The Director of Nursing (DON) acknowledged that the physician did not respond to the irregularity reports and confirmed the oversight in the medication orders. The lack of timely response and communication regarding the pharmacist's recommendations contributed to the deficiency in the resident's medication management.
Failure to Prevent Unnecessary Medications for Residents
Penalty
Summary
The facility failed to ensure that two residents, R4 and R5, did not receive unnecessary medications, which could potentially increase the risk of adverse drug effects. Resident R5, who had severe cognitive impairment and required extensive assistance with activities of daily living, was administered Guaifenesin Oral Syrup for an extended period without a documented stop date or documented need for continued use. The Director of Nursing (DON) could not provide an explanation for the prolonged use of the cough syrup, which was initially prescribed for a cough related to COPD and congestion. The nurse practitioner did not respond to inquiries regarding the necessity of the medication. Resident R4, who had intact cognition and was diagnosed with cerebral infarction, major depressive disorder, and anxiety disorder, was found to have duplicate orders for Famotidine (Pepcid) 20mg. The duplicate medication was not discontinued until over a month after the irregularity was identified in a pharmacist's report. The DON acknowledged that the physician did not provide a timely response to the irregularity report, and the Nursing Home Administrator confirmed that the facility lacked an unnecessary medication policy.
Failure to Maintain Sanitary and Safe Environment in Kitchen and Resident Rooms
Penalty
Summary
The facility failed to maintain a safe and sanitary physical environment, particularly in the kitchen and several resident rooms. Observations revealed that multiple ceiling vents and covers in the kitchen, storeroom, emergency supply storage, and paper supply room were heavily soiled with soot, ash, and grease. Walls and storage areas for food carts were marked with black rubber scarring and had broken, chipped areas with exposed cement blocks. The dish room had soiled ceiling tiles and corroded metal strips, while several ceiling tiles in storage areas were stained or missing. Kitchen equipment, including a convection oven, stove, and deep fryer, was found to be cracked, missing parts, and covered in burnt food residue and grease. Floor tiles were broken or missing, allowing debris to collect, and floor drains and dish machine areas were dirty with food residue. The cleaning schedule and sanitation audits were not provided, and maintenance staff were unaware of their responsibilities regarding vent cleaning and tile replacement. In addition to the kitchen deficiencies, the facility failed to maintain cleanliness in specific resident rooms. One room had a ripped floor mat, dried substances on the floor, a tube feeding pole with dried yellowish residue, and a wall with broken plaster covered by tape. Housekeeping staff reported that mats should be sanitized daily and removed if damaged, and that tube feeding poles should be cleaned, especially if soiled. Another room was observed to have a dirty floor with debris, soiled tissues, food, garbage, piles of clothes and linen, and a sticky substance on the floor. The bathroom in this room had paper on the floor, a toilet with thick black debris, a shower floor covered with scum, and a sink with brown stains. The resident in this room expressed dissatisfaction with the frequency and quality of cleaning. Interviews with housekeeping and nursing staff confirmed that cleaning procedures were not consistently followed, with staff acknowledging the need for better cleaning of corners, removal of damaged mats, and immediate cleaning of spills. The facility's cleaning policy outlined specific steps for disinfecting and cleaning resident rooms and restrooms, but observations indicated these procedures were not being adhered to, resulting in unsanitary conditions in both common and resident-specific areas.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer scheduled and as-needed pain medications per the physician's orders for a resident, resulting in uncontrolled pain and emotional distress. The resident, who had a history of oral cancer and related pain, was admitted to the facility with a prescription for Oxycodone to manage his pain. However, upon review, it was found that the resident did not receive his pain medication for 17 hours after his last dose, leading to significant discomfort and distress. The resident's clinical records and nurse progress notes revealed multiple instances where pain medication was either not administered on time or withheld without proper justification. On one occasion, the resident's pain medication was not available due to a pharmacy issue, and on another, it was withheld due to undocumented behaviors. The resident expressed feelings of helplessness and frustration due to the lack of timely pain management, which was corroborated by complaints made to the state agency complaint hotline. Interviews with the Director of Nursing and the resident highlighted the facility's failure to adhere to its own policies on medication administration and pain management. The Director of Nursing acknowledged that behaviors should not justify withholding pain medication and that non-pharmacological interventions should have been attempted. The resident ultimately left the facility against medical advice due to inadequate pain management, further emphasizing the severity of the deficiency.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse to the State Agency for one resident, resulting in a deficiency. The incident involved a resident who was allegedly attacked by a female staff member, with the complainants reporting that the resident was slapped on the arm several times. Despite the complaints being reported to the state complaint hotline, the facility did not submit a Facility Reported Incident (FRI) for the allegation. The Nursing Home Administrator (NHA) was notified of the allegation but concluded that the incident did not occur and, therefore, did not report it to the state agency. The resident involved was admitted to the facility with multiple diagnoses, including malignant neoplasm of the mouth, dysarthria, and generalized anxiety disorder, among others. The resident was cognitively intact and required limited assistance with activities of daily living. The facility's policy required the Administrator or designee to report all alleged violations involving abuse to the State Agency within specified timeframes, depending on the severity of the allegation. However, the NHA stated that they were instructed not to report the incident, leading to a failure in compliance with the facility's policy and state regulations.
Failure to Address Critical Lab Findings and Delay in Treatment
Penalty
Summary
The facility failed to address changes in laboratory findings in a timely manner for a resident, resulting in significant critical laboratory values, delay in treatment, and hospitalization. The resident, who had a history of atrial fibrillation, breast cancer, diabetes, heart attack, hypertension, Covid-19, and anemia, was observed with mild edema in both lower legs and reported feeling weak, dizzy, and short of breath. Despite these symptoms and critical lab results indicating severe anemia, there was no change in the resident's plan of care or implementation of interventions to address the decreased iron levels. The resident's electronic medical record showed that their iron supplement was discontinued in July, and subsequent lab results in July indicated a decrease in hemoglobin and iron levels. However, there was no evidence of a change in the plan of care or involvement of a dietitian to address the low iron levels. The resident experienced symptoms of anemia, such as shortness of breath and dizziness, but the facility did not take timely action to address these issues. The Director of Nursing and Physician D were unable to provide a satisfactory explanation for the lack of timely intervention. The resident was eventually sent to the hospital after experiencing critical symptoms and lab results, where they were diagnosed with anemia, fluid overload, and acute kidney injury, and received a blood transfusion. The facility's policy on acute change in condition was not followed, contributing to the delay in treatment and hospitalization.
Improper Storage of Narcotic Medication
Penalty
Summary
The facility failed to ensure the proper storage of a narcotic medication for a resident, identified as R103, which potentially resulted in a missed dose, medication waste, and misappropriation. The resident was admitted with multiple diagnoses, including malignant neoplasm of the mouth, chronic kidney disease, and generalized anxiety disorder, and was cognitively intact, requiring limited assistance with daily activities. The resident was on a scheduled and PRN pain regimen, which included Oxycodone HCl, a controlled drug. On a specific date, the resident's medication was not delivered, and the pharmacy was contacted. Subsequently, a physician's order was sent, and the resident was administered one 5mg tablet of Oxycodone at 9:30 am. However, the Pyxis record showed that two 5mg Oxycodone tablets were signed out by an LPN, although only one tablet was administered. During an interview, the LPN stated that the extra tablet was pulled from the backup supply for the next dose or shift. The Director of Nursing (DON) confirmed that it was not standard practice to pull and store extra narcotics for future use, and narcotics should be signed out at the time of administration. The facility's policy on medication storage emphasized that medications should be stored safely and securely, accessible only to authorized personnel.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident with severe cognitive impairment, resulting in the resident exiting the facility without staff knowledge. The resident, who had diagnoses of Dementia and Alcohol Dependence with Alcohol-Induced Persisting Dementia, was last observed at a bingo event on the brown unit at 8:45 p.m. Staff noticed the resident was missing during rounds while passing medications. Despite a thorough search of the entire building, the resident could not be located, and the administrator, DON, and physician were notified. The resident returned to the facility the next morning, accompanied by a police officer, with empty alcohol bottles and unopened beer cans. The resident was confused but demonstrated how they exited the building. Interviews with staff revealed that the resident was last seen on the brown unit and was reported missing at 9:40 p.m. The Nursing Home Administrator confirmed that the resident exited through the main elevator near the receptionist desk. The facility's policy on elopement was reviewed, which stated that residents with cognitive loss who leave without authorization are considered an elopement risk.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident (R53), resulting in the potential for skin breakdown and infection. On two separate occasions, surveyors observed that R53's room had a strong urine smell, and the resident's brief was heavily saturated with urine. The first observation occurred on 2/27/24 at 11:52 a.m., and the second observation was on 2/29/24 at 8:13 a.m. In both instances, the resident's bed pad was also soiled. Interviews with CNAs and the LPN confirmed that R53 was not being checked and changed every two hours as required by the care plan and facility policy. R53 was admitted to the facility with diagnoses including Dementia and Atopic Dermatitis. The care plan for R53 specified that the resident should be checked and changed at least every two hours during the day. However, observations and staff interviews revealed that this protocol was not being followed. CNA D reported that R53 was last checked and changed at 7 a.m. and 12 p.m. on 2/27/24, while CNA E reported that R53 was changed for the first time that morning on 2/29/24. The Director of Nursing confirmed that incontinent residents should be checked and changed every two hours and as needed, which was not adhered to in R53's case.
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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