The Orchards At Three Rivers
Inspection history, citations, penalties and survey trends for this long-term care facility in Three Rivers, Michigan.
- Location
- 55378 Wilbur Rd, Three Rivers, Michigan 49093
- CMS Provider Number
- 235354
- Inspections on file
- 22
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at The Orchards At Three Rivers during CMS and state inspections, most recent first.
Surveyors identified widespread environmental uncleanliness and poor housekeeping practices, including resident rooms with trash, dust, food debris, stained floor mats, and damaged surfaces, as well as shared bathrooms with unflushed urine, brown smears and splatters resembling fecal matter on toilets, walls, and floors, sticky floors, deteriorated grip strips, and buildup around toilet bases. In the memory care unit, hallways, dining areas, and wall-mounted fans had heavy dust and debris accumulations that persisted over multiple days, and spa/shower rooms contained dust, dead bugs, crusted debris on shower chairs, ants, and other visible soil. Some residents with dementia and cognitive communication deficits were observed in these dirty environments, while cognitively intact residents reported dissatisfaction with room cleanliness and infrequent bedding changes. The Ombudsman reported ongoing cleanliness complaints from residents and families, and housekeeping staff stated that only two housekeepers cleaned the entire building daily and that CNAs were expected to clean visible bowel and urine contamination before housekeeping would disinfect, while a CNA reported leaving a resident alone in the bathroom and not returning to assist with cleanup.
A resident with severe cognitive impairment and multiple comorbidities developed a UTI confirmed by abnormal urine labs and culture, leading the physician to order daily IM ceftriaxone. Nursing staff documented administration of the IM antibiotics over several days without adverse reactions, but there was no documentation that the resident’s POA/responsible party was notified of the abnormal lab results, UTI diagnosis, or new antibiotic orders. The POA later learned of the treatment only when the resident mentioned receiving injections, and facility staff acknowledged that resident representatives should be notified of new infections, changes in condition, new orders, and abnormal labs for cognitively impaired residents.
Multiple deficiencies were identified in food safety and sanitation, including improper food labeling and storage, inadequate hand hygiene, inaccessible handwashing sinks, and poor monitoring of refrigerator temperatures. Dietary staff were observed not following required practices such as wearing hair restraints, washing hands between tasks, and ensuring food items were properly cooled, labeled, and stored. Structural and cleanliness issues in kitchen and storage areas further contributed to unsafe food handling conditions.
The facility did not effectively manage its staffing and meal service, leading to insufficient staff coverage, long call light wait times, missed showers, and inadequate assistance for residents. Residents and staff reported poor food quality, small portions, missing dietary supplements, and inconsistencies between posted menus and actual meals. Despite repeated concerns raised to management, no effective corrective actions were implemented.
Multiple residents experienced missed or uncomfortable showers due to persistent hot water shortages, and several reported or were observed living in rooms with peeling paint, debris, and unsanitary conditions. Staff interviews confirmed ongoing hot water issues and inadequate maintenance, while observations revealed additional facility-wide cleanliness and maintenance deficiencies.
Several residents with significant physical and cognitive needs did not receive showers or baths as scheduled according to their care plans, with missed bathing days, lack of hot water, and short-staffing contributing to the deficiency. Residents and families reported dissatisfaction with hygiene care, and facility documentation was inconsistent regarding missed or refused showers.
Multiple residents reported missed showers, long call light wait times, and unmet personal care needs due to insufficient staffing. Staff interviews confirmed frequent unfilled positions, minimal management intervention, and routine omission of essential care tasks when short-staffed. Facility documentation and policies indicated higher staffing expectations than what was provided, resulting in delayed or omitted care.
The facility did not consistently follow the scheduled menu, failed to clearly post the current menu cycle for residents, and did not update the menu when changes occurred. A resident with multiple health conditions reported frequent inconsistencies between the posted menu and meals served, and dietary staff confirmed confusion about the menu cycle and substitutions based on ingredient availability.
Multiple residents and family members reported that meals were often bland, unrecognizable, served in small portions, and delivered at temperatures below recommended levels. Staff interviews and test tray observations confirmed that food was frequently cold, lacked flavor, and that dietary shortages led to substitutions and missing supplements. These deficiencies resulted in widespread dissatisfaction and inconsistent provision of appropriate diets.
A resident with severe cognitive impairment was prescribed and administered multiple psychotropic medications without documented informed consent from the resident's representative. Family members were not notified of medication changes and only learned about the medications after reviewing a list provided by the facility. Facility staff confirmed the absence of signed consent forms for these medications, and verbal consent was only documented after the medications had already been administered.
Two residents did not receive their ordered medications on time due to administrative delays and lack of timely authorization or prescription signatures. One resident with a severe infection missed all doses of a prescribed IV antibiotic, leading to worsening symptoms and hospital transfer, while another resident with a seizure disorder missed multiple doses of an anti-seizure medication because of delays in obtaining a signed prescription.
A resident with severe cognitive impairment and dementia was prescribed Haldol and Olanzapine without a proper psychiatric diagnosis or adequate documentation. Staff administered these psychotropic medications without consistently attempting non-pharmacological interventions or monitoring for side effects, leading to increased sedation, weight loss, falls, and decreased ability to communicate. The resident's guardian was not properly informed of medication changes, and care plans lacked necessary details, resulting in significant harm including dehydration and hospitalization.
The facility did not complete required annual performance reviews for three CNAs who had been employed for over a year, as confirmed by personnel file reviews and staff interviews. This omission resulted in the potential for unidentified staff performance concerns and unmet training needs, contrary to facility policy.
The facility did not ensure its QAPI program identified and corrected quality deficiencies, particularly in dementia care. A resident with dementia did not receive individualized care despite interventions provided by her DPOA, and staff lacked knowledge on managing her stress responses. The QAPI committee failed to review data or develop action plans for identified concerns, and issues such as psychotropic medication use and staff training were not adequately monitored.
The facility did not ensure that the medical director or a designee attended QAPI committee meetings at least quarterly, as required by policy. Sign-in sheets confirmed no attendance by the medical director or designee over several months, with management turnover and a change in medical directors contributing to the deficiency.
The facility did not maintain an effective staff training program, resulting in missing documentation and lack of required training in areas such as QAPI, infection control, compliance and ethics, communication, and resident rights for multiple employees. The DON and NHA confirmed that training was not tracked and that no performance improvement plan was in place to address these deficiencies.
The facility did not implement or document an effective in-service training program for CNAs, resulting in a lack of evidence for the required 12 hours of annual training. The DON reported the absence of a staff educator and no current training plan, while the NHA confirmed non-compliance with training requirements. Personnel files reviewed did not show completion of mandatory training.
A resident with severe cognitive impairment and high ADL assistance needs was repeatedly observed with a call light placed out of sight and reach, either under the sheet or clipped at the head of the bed. The unit manager confirmed staff intentionally positioned the call light this way, but acknowledged it should have been accessible.
A resident with severe cognitive and visual impairments did not receive individualized, meaningful activities to support leisure needs. Documentation inaccurately reflected participation in activities that the resident was unable to perform, and staff did not consult the resident's DPOA for past interests. Interviews confirmed the resident required one-on-one support and was not engaged in appropriate activities, highlighting a lack of resident-centered programming in the memory care unit.
A resident with severe cognitive impairment and vascular dementia experienced ongoing wandering, frustration, and stress due to the facility's failure to implement individualized dementia care interventions, incorporate input from the resident's DPOA, and provide appropriate activities or staff training. The care plan was incomplete and did not address known triggers or effective calming techniques, and staff reported insufficient training and resources to meet the needs of dementia residents.
A resident with severe cognitive impairment and multiple diagnoses was inaccurately documented as participating in group activities and outings, including after discharge, despite staff and DPOA statements confirming non-participation. The care plan also listed an incorrect nickname, and the activity attendance records contained errors acknowledged by the Activity Director.
A resident requiring dialysis did not receive safe and appropriate dialysis care and services, as the facility failed to meet established standards for such care.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
Staff failed to use a gait belt when assisting a resident with ambulation despite the resident's history of weakness and hip fracture, and another resident with severe cognitive impairment was transported in a wheelchair without footrests in place. Staff interviews confirmed that both actions were contrary to facility policy and training.
A narcotic medication intended for a resident was left unattended in a medication cup on top of a medication cart in a secure unit's common area, with multiple residents and staff present but not monitoring the cart. The medication, identified as Lorazepam, remained out of staff supervision for 37 minutes, contrary to facility policy requiring direct observation or secure storage of controlled substances.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not ensure the dietary manager had the necessary skills and presence to manage food and nutrition services, resulting in missed menu items, use of emergency food supplies, and lack of essential dietary products. Staff were unclear about food ordering processes, and both the dietary manager and interim manager were only PRN, leading to inconsistent oversight and potential unmet nutrition and hydration needs for residents.
Dietary staff were unable to follow planned menus due to insufficient food supplies and made unapproved substitutions without notifying the RD or documenting changes. The RD had not been present or informed of substitutions, and required oversight and documentation were lacking, resulting in unmet nutritional needs for residents.
The facility did not ensure that a qualified Infection Preventionist was dedicated at least part-time to infection control duties, as the staff member assigned to this role was also serving as ADON and Unit Manager, with significant additional responsibilities. This resulted in limited time for infection control activities, insufficient staff education on PPE use for Enhanced Barrier Precautions, and audits that did not assess staff compliance, leading to a failure in properly managing the infection prevention and control program.
A resident with severe cognitive impairment and a Foley catheter did not have a care plan addressing enhanced barrier precautions, despite staff and facility expectations that such precautions should be implemented and care planned. The care plan only addressed fall risk and urinary retention, omitting necessary interventions for infection prevention related to the catheter.
A resident with severe cognitive impairment and a history of traumatic brain injury had changes in diet and hydration orders, but the care plan was not updated to reflect these changes. Staff interviews and observations revealed outdated care plan documentation, confusion over responsibility for updates, and discrepancies between current orders, visual cues, and the care plan, resulting in an inaccurate description of the resident's care needs.
Two residents with physical disabilities did not receive scheduled showers for extended periods, with documentation showing gaps of up to 12 days between showers and no recorded refusals. Staff interviews revealed that showers were often missed during busy or understaffed shifts, and the only documentation method was through shower sheets signed by nurses. The DON confirmed that staffing issues were not an acceptable reason to skip showers, but the facility failed to ensure consistent ADL care.
Three residents with cognitive impairments experienced incidents including altercations and an elopement due to the facility's failure to provide adequate supervision, update care plans, and maintain environmental controls such as locked doors. Staff were unaware of or did not implement necessary interventions, and documentation of incidents and behavioral issues was incomplete.
Two residents with indwelling medical devices requiring enhanced barrier precautions were not provided appropriate PPE use by staff during high-contact care activities. Despite facility policy, posted signage, and staff education, staff were observed assisting these residents without donning gowns or gloves, and interviews revealed confusion and noncompliance regarding EBP requirements.
The facility failed to implement an active infection prevention and control program for legionella and other pathogens. Observations revealed that water samples had not been tested in over a year, and the Water Management Plan was not being followed. The Maintenance Director was unsure about control measures and the status of water lines, indicating a lack of systematic monitoring and documentation.
The facility failed to maintain cleanliness and repair, with issues such as direct wastewater connections in the kitchen, missing light shields, and raw wood storage racks. Debris accumulation was found in resident and dining areas, and housekeeping staff shortages affected cleanliness. The beauty shop lacked a vacuum breaker, risking potable water safety.
The facility failed to provide annual abuse prevention education for all employees, affecting 73 residents. The ADON was unaware of her training responsibilities and lacked access to the electronic training program. The DON reported that the facility could not continue the previous owners' training program, leading to 91 out of 128 staff members missing required training.
The facility failed to control hot water temperatures, leading to a risk of scalding and burns for residents. During a tour, hot water temperatures in various areas, including the Riverside Spa and Meadowlane Spa, were found to exceed 120°F, with some reaching up to 135°F. The Maintenance Director noted usual temperatures between 116°F and 118°F, but the boiler was set at 140°F, affecting the entire building. Staff were observed adjusting water temperatures manually for residents. The surveyor informed the ADON of the increased risk of harm.
The facility failed to properly document and notify regarding resident transfers, using incorrect forms for a resident-initiated discharge and not notifying the local ombudsman. A resident with significant health issues was sent to the ER with an incomplete transfer form, lacking destination and reason details.
The facility failed to update care plans for two residents, leading to deficiencies in fall prevention and contracture management. A resident with paraplegia did not have a necessary bolster intervention added to their care plan after a fall, while another resident's care plan incorrectly indicated the use of a discontinued soft hand splint. Observations and staff interviews confirmed these discrepancies.
A facility failed to maintain nebulizer equipment for a resident with COPD, leading to potential risks of infection. Observations showed the nebulizer machine and tubing were improperly stored and outdated. Staff interviews confirmed that equipment should be changed weekly and stored properly, but the outdated kit was used during a respiratory distress episode, resulting in the resident's transfer to acute care. Facility policy required equipment changes every 72 hours and proper storage.
The facility failed to obtain COVID-19 vaccination consents or declinations for two residents, leading to a deficiency in ensuring informed consent. A severely cognitively impaired resident received a Pfizer Booster without her POAs being contacted, while a cognitively intact resident refused the Moderna Booster without being provided a consent form. The Assistant Director of Nursing admitted that correct consent forms were unavailable until late October, contributing to the documentation failure.
The facility failed to provide required behavioral health and dementia training to 68 out of 128 staff members. The ADON was unaware of her training responsibilities, and the facility lacked access to an electronic training program due to ownership changes. The facility relied on in-person education, but records showed non-compliance with training requirements, leading to a deficiency report.
A resident with severe cognitive impairment and high elopement risk was found unsupervised in the parking lot of an LTC facility. Despite lacking authorization to leave, the incident was not reported as an elopement, and no investigation was conducted. Staff interviews revealed the resident was disoriented and had a history of wandering and falls, making it unsafe for him to be outside alone.
A facility failed to create a person-centered care plan for a resident at high risk for elopement, leading to the resident exiting the building unsupervised. The resident, who was severely cognitively impaired and used a wheelchair, was found confused in the parking lot. Despite being assessed as high risk for elopement, no specific interventions were included in the care plan to address this risk.
A facility failed to prevent an elopement of a cognitively impaired resident and did not maintain a mechanical lift, leading to a resident's fall. The resident at high risk for elopement was found unsupervised outside, and the facility did not follow its elopement protocol. Another resident suffered a head injury due to a poorly maintained lift. The facility lacked a maintenance schedule and inventory system for equipment, contributing to these deficiencies.
The facility failed to assess an acute change of condition in one resident and provide appropriate wound care for another. Despite multiple reports from CNAs, the LPN did not perform an assessment or notify the physician in a timely manner, leading to severe dehydration and hypernatremia. Another resident's wound care was inconsistently documented and administered, increasing the risk of infection.
Widespread Environmental Uncleanliness and Poor Housekeeping Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, orderly, and homelike environment in resident rooms, shared bathrooms, hallways, and common areas, as well as inadequate housekeeping response to visible soil and bodily substances. Multiple cognitively intact residents reported dissatisfaction with the cleanliness of their rooms, including one resident whose window had a long streak of old tape and residue that had been present since admission, and another who had tied bags of soiled linens and trash left on the floor near her bed along with trash and debris under and around the beds. Other residents’ rooms were observed with visibly soiled floors, paper and food debris, dust and trash accumulations under beds and along walls, and soiled floor mats with dried stains that remained unchanged over multiple days. In one room, a large dried spill or stain was present on the floor near dialysis equipment, and a wall gouge was noted near the bed. Additional observations showed that several residents with dementia, cognitive communication deficits, and muscle weakness were living in rooms with dirty floor mats, crumbs and debris in mat seams, and stained walls adjacent to their beds. Shared bathrooms between resident rooms were repeatedly observed with unflushed urine in toilets, brown smears and splatters resembling fecal matter on toilet seats, bowls, walls, and floors, sticky/tacky floors, dust and debris around perimeters and baseboards, deteriorated grip strips that were torn and peeling, and darkened buildup or damaged caulk around toilet bases. These unsanitary conditions persisted across multiple observations on different days, including one bathroom that continued to have dirt, debris, stale urine odor, sticky floors, and dried brown splatter resembling fecal matter on and around the toilet despite prior similar findings. The memory care unit and spa/shower rooms were also found in unclean condition. In the locked memory care unit, surveyors observed heavy accumulations of dust and debris at double doors, in the dining room corners and along walls, and on wall-mounted fan blade guards, with these accumulations remaining unchanged on subsequent days. Hallways outside resident rooms contained trash, broken plastic pieces, and large dust balls. In spa and shower rooms, there were dust and dead bugs in the bottom of a spa tub, brown crusted debris on a shower chair, dozens of small ants on the floor emerging from floor junctures, and white wet debris resembling toilet paper on another shower chair. During a confidential resident council meeting, most residents present reported that rooms and shared spaces were not consistently kept clean and some reported bedding was not changed frequently enough. The Ombudsman reported ongoing complaints from residents and families about facility cleanliness over several months. Housekeeping staff stated that only two housekeepers were responsible for cleaning all resident rooms and the locked unit daily, and described a process in which CNAs were expected to clean visible bowel movements and urine before housekeeping would disinfect, while a CNA acknowledged leaving a resident unsupervised in the bathroom and not returning to assist with cleanup after toileting.
Failure to Notify Responsible Party of UTI Diagnosis and Antibiotic Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a change in condition, specifically a newly identified urinary tract infection (UTI) and initiation of antibiotic treatment. The resident was an adult female with dementia, depression, muscle weakness, a cognitive communication deficit, and a documented need for assistance with personal care. Her MDS assessment showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The admission record identified a family member as the resident’s POA for care, first emergency contact, and responsible party. During an interview, this family member reported that the facility had not been consistently notifying her of changes in the resident’s condition and that she only learned of the UTI treatment when the resident mentioned she was receiving “shots” during a visit. Record review showed that on a specified date, the physician evaluated the resident’s urine after a nursing request and documented pyuria, bacteriuria, and a urine culture with more than 100,000 organisms of Proteus mirabilis, sensitive to Rocephin. The physician’s plan included Rocephin 1 g IM daily, and an order was entered for ceftriaxone IM once daily for five days for UTI. Nursing notes documented administration of IM antibiotic injections on multiple days with no adverse reactions. However, there was no documentation in the medical record that the responsible party was notified of the abnormal lab findings, confirmed UTI, or new antibiotic orders. The administrator confirmed the facility could not locate documentation of such notification, and both an LPN and an RN stated in interviews that for cognitively impaired residents or those who are not their own responsible party, the resident representative should be notified of newly identified infections, changes in condition, new physician orders, and abnormal lab results.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain professional standards of food service safety, as evidenced by multiple observations of improper food handling, storage, and sanitation practices. Dietary staff were observed not wearing required hair restraints during food service, and there was a lack of knowledge and documentation regarding the proper cooling and temperature monitoring of leftover foods. Open food items in various storage areas were frequently found without proper labeling, dating, or secure sealing, and some items were stored past their use-by or discard dates. Additionally, food was found stored open and exposed in the freezer, and some items requiring refrigeration were left unrefrigerated after opening. Sanitation and cleanliness issues were prevalent throughout the kitchen and nourishment rooms. Water leaks were observed in dry storage and pantry areas, with makeshift coverings such as blankets used to contain puddles. The walk-in cooler had structural deficiencies, including gaps at the floor juncture and a loose door latch, allowing for potential pest entry and cold air escape. Accumulations of dirt, debris, and food residue were noted on storage racks and floors, and clean pots and pans were found with encrusted grease. Air conditioning units above food preparation areas were heavily soiled, and the dish machine's pressure gauge was not being monitored as required, with staff unaware of proper temperature verification methods. Hand hygiene practices were inadequate, with staff observed failing to wash hands after changing tasks, touching their face masks, or using their phones, and one staff member was seen wearing artificial nails without gloves while handling food. Handwashing sinks were either out of order or blocked by carts, limiting accessibility. Refrigerator temperature logs showed repeated instances of temperatures above the safe threshold, with unclear responsibility among staff for monitoring and addressing these issues. There was also a lack of documentation when food was discarded due to unsafe temperatures. These deficiencies collectively created an environment with a potential for foodborne illness among residents consuming food from the kitchen.
Failure to Ensure Adequate Staffing and Meal Service
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, specifically regarding staffing and meal service. Multiple interviews and record reviews revealed ongoing issues with insufficient staffing, resulting in long call light wait times, missed showers, and inadequate assistance with transfers and care. Residents reported that aides were overworked, and staff often responded to call lights without returning to provide needed care. Staff interviews confirmed that holes in the schedule frequently went unfilled, with night shifts sometimes staffed by only one or two nurses for the entire building, including high-acuity units. Staff were reportedly discouraged from contacting the DON about staffing concerns, and showers were often not completed when staffing was low. Additionally, the facility failed to provide adequate meal service, with residents and staff reporting small portion sizes, unrecognizable or inedible food, and inconsistencies between the posted menu and actual meals served. There were instances where basic food items, such as bread and syrup, were unavailable, and dietary supplements were not consistently provided. Both residents and the Ombudsman reported that these concerns had been communicated to management, but no improvements were observed. The administration acknowledged awareness of these issues but did not implement effective corrective interventions, resulting in ongoing deficiencies impacting all residents.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for multiple residents, as evidenced by ongoing issues with hot water availability, unaddressed maintenance concerns, and unsanitary conditions. One male resident with Parkinson's disease, legal blindness, and dementia reported missing scheduled showers due to a lack of hot water, an issue persisting for months. Another female resident with cerebral palsy and muscle weakness also reported frequent hot water shortages during showers and was observed in a room with significant peeling paint and debris on the floor. A third male resident with diabetes and debility described his room as dirty upon admission, with chipped paint and a dirty pillow on the floor. Observations confirmed the presence of peeling paint, rusted door frames, chipped tiles, foul odors, and trash in common areas, as well as a damaged American flag and discarded gloves outside the facility. Staff interviews corroborated the residents' complaints, with an LPN acknowledging recent hot water issues in the shower room and the Maintenance Director stating that staff were instructed to let the water run to warm up. Despite these instructions, residents continued to experience discomfort and dissatisfaction with their living conditions, including missed showers and exposure to unclean and deteriorating environments.
Failure to Provide Showers/Baths per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide showers and baths according to resident preferences and care plans for four out of seven residents reviewed. Multiple residents with significant physical and cognitive impairments, including those with stroke, Parkinson's disease, cerebral palsy, and Huntington's disease, did not receive scheduled showers as documented in their care plans and physician orders. Documentation revealed missed showers on several scheduled days, with no record of completion or refusal, and residents reported not receiving the expected number of showers per week. Residents and their family members reported dissatisfaction with the frequency and quality of bathing, citing issues such as lack of hot water, short-staffing, and missed scheduled shower days. One resident reported that the facility had ongoing problems with hot water, resulting in missed showers or incomplete bathing experiences. Family members corroborated these concerns, noting that they sometimes had to provide showers themselves due to inadequate hygiene care at the facility. The facility's documentation practices were inconsistent, with some missed showers lacking any explanation or record. Staff interviews confirmed that shower schedules were in place and that documentation was expected, but there were gaps in both the provision of care and the recording of refusals or missed showers. These failures led to resident dissatisfaction and the potential for discomfort and impaired self-worth, as residents were not consistently assisted with activities of daily living as required by their care plans.
Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of long call light wait times, missed showers, and unmet personal care needs. Several residents, all cognitively intact, reported not receiving scheduled showers, experiencing delays in assistance, and being left in situations where their hygiene and dignity were compromised. Documentation confirmed missed showers for multiple residents, and interviews revealed that these issues were linked to both short-staffing and, in some cases, lack of hot water. Staff interviews consistently described inadequate staffing levels across various shifts and units, with frequent unfilled positions and minimal attempts by management to address these gaps. Nurses and CNAs reported that when staffing was low, essential care tasks such as showers were the first to be omitted, and residents often waited extended periods for assistance. Staff also indicated that management rarely assisted on the floor, and that holes in the schedule were common and not proactively filled, sometimes leaving only one CNA on a unit for several hours. The facility's own assessment and staffing policies outlined higher staffing expectations than what was routinely provided, particularly on the River and View Units. Despite these documented standards, actual staffing often fell below the stated requirements, with staff and residents both reporting that care was delayed or omitted as a result. The deficiency was further corroborated by the facility's policies, which require prompt response to call lights and sufficient staffing to meet resident needs, both of which were not consistently met according to the findings.
Failure to Follow and Clearly Post Current Menu Cycle
Penalty
Summary
The facility failed to follow the posted menu and serve food items as scheduled, did not post the current menu in a manner accessible for residents to review, and did not update the menu with changes when they occurred. Observations revealed that the menu posted in the main dining room was not clearly marked to indicate the current week of the menu cycle, requiring residents to flip through multiple pages to determine what meals were scheduled. There were no dates on the menu to clarify which week was current, and the menu visible was consistently for Week 4, regardless of the actual week. Interviews with dietary staff confirmed that meals served did not always match the scheduled menu due to issues such as missing ingredients and confusion among newer staff about which week of the menu cycle was being followed. A resident with cerebral palsy, major depression, muscle weakness, and a need for assistance with personal care reported that the food served was often inconsistent with the posted menu and that she was frequently unaware of what would be served until the meal tray arrived. Dietary staff acknowledged serving meals from different weeks and substituting menu items based on availability, rather than following the planned menu. These actions resulted in inconsistencies in meal service and a lack of clear communication to residents regarding their meal options.
Failure to Provide Palatable, Adequate, and Properly Tempered Meals
Penalty
Summary
The facility failed to provide adequate portions of palatable food, served at an appetizing temperature, to multiple residents. Residents and their family members reported dissatisfaction with the quality, temperature, and portion sizes of the meals. Specific complaints included food being bland, flavorless, unrecognizable, and often served lukewarm or cold. Some residents, including those with visual impairments, were unable to identify their food, and staff were reportedly unable to provide information about the meals being served. There were also reports of food items being substituted due to shortages, such as sandwiches being made with hamburger buns instead of bread, and waffles being served without syrup due to lack of supplies. Observations and interviews revealed that residents frequently received small portion sizes, with some meals described as insufficient, such as a breakfast consisting of half a glass of orange juice, a hard-boiled egg, and a piece of toast. Residents with specific dietary needs, such as those requiring supplements or extra portions due to medical conditions, did not consistently receive appropriate food or supplements. There were also instances where residents received food inconsistent with their ordered diets, and staff had to improvise to make the food suitable for consumption, such as moistening dry ground meat with mayonnaise packets when gravy was unavailable. Test tray observations confirmed that food was served at temperatures below recommended levels, with hot foods such as chicken tenders, green beans, and stuffing measured at 104°F, 113°F, and 128°F, respectively, upon delivery to the unit. Dietary staff acknowledged shortages of key items like Magic Cups and yogurt, and nursing staff reported ongoing issues with cold food, small portions, and missing supplements. These findings were corroborated by multiple interviews with residents, family members, dietary staff, and nursing staff, all indicating persistent problems with food quality, temperature, and adequacy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration and changes of psychotropic medications for one resident with severe cognitive impairment. The resident, who had diagnoses including psychotic disorder with delusions, depression, and unspecified dementia with agitation, was prescribed multiple psychotropic medications such as Duloxetine, Mirtazapine, Olanzapine, and Quetiapine. Despite the resident's cognitive status, there was no evidence that informed consent was obtained from the resident's representative prior to the initiation or adjustment of these medications. Family members reported they were not notified about changes to the resident's medications and only became aware of the use of certain psychotropic drugs after reviewing a medication list provided by the facility. The family expressed concern and confusion regarding the reasons for the prescriptions, indicating a lack of communication and education from the facility regarding the resident's medication regimen. The resident's spouse/guardian was not fully informed about all medications until a care conference was held, well after the medications had been prescribed and administered. Interviews with facility staff, including the social worker and the nursing home administrator, confirmed that there were no signed consent forms for the psychotropic medications in the resident's medical record, except for verbal consent documented during a care conference. The social worker acknowledged that, given the resident's severe cognitive impairment, consent should have been obtained from the spouse/guardian rather than the resident. The director of nursing also confirmed that consent is required for the administration of psychotropic medications, but such documentation was not present.
Failure to Administer Ordered Medications Timely for Two Residents
Penalty
Summary
The facility failed to ensure that ordered medications were administered timely according to physician orders for two residents, resulting in delays in care. One resident, who had multiple serious diagnoses including MRSA infection, sepsis, and peripheral vascular disease, was admitted with orders for intravenous antibiotics. Despite the physician's order for Ceftaroline Fosamil to be administered every eight hours, the resident did not receive any doses during his stay because the medication was not available. The pharmacy required payment authorization due to the high cost, and the facility did not provide this authorization until several days after the order was placed. During this period, the resident's condition worsened, with increased pain and significant discoloration and necrosis of his toes, ultimately leading to a hospital transfer and subsequent above-the-knee amputation. Another resident, admitted with a seizure disorder, diabetes, and hypertension, also experienced a delay in receiving a critical medication. The resident was ordered to receive Lacosamide for seizure control twice daily, but missed a total of ten scheduled doses over several days. The delay was due to the lack of a signed prescription, which was not obtained promptly from the physician. Nursing staff documented that the medication was on order and that the physician was aware, but the prescription was not signed and accepted by the pharmacy until several days after admission. During this time, the resident did not receive the ordered seizure medication. In both cases, the facility did not follow its own policy requiring medications to be administered in accordance with physician orders. The delays were attributed to administrative and communication failures between the facility, pharmacy, and physician, resulting in missed doses of essential medications for both residents. The documentation shows that staff were aware of the missed doses and the reasons for the delays, but did not ensure timely resolution to provide the necessary care as ordered.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
A resident with severe cognitive impairment and a history of cerebral infarction, dementia, and behavioral disturbances was prescribed psychotropic medications, specifically Haldol (haloperidol) and Olanzapine (Zyprexa), without an adequate psychiatric diagnosis to justify their use. The medications were initiated and increased over time, despite the absence of documented psychiatric conditions such as schizophrenia or bipolar disorder. The care plan did not include a mental health diagnosis or PASARR documentation to support the use of antipsychotic medications, and non-pharmacological interventions were not developed or implemented prior to the administration of these drugs. Staff interviews and record reviews revealed that the resident began experiencing increased sedation, weight loss, decreased ability to communicate, and multiple falls after the initiation of the psychotropic medications. Documentation showed that Haldol was administered even after the resident was no longer agitated, and there was a lack of evidence that non-pharmacological interventions were attempted before resorting to medication. Progress notes and medication administration records indicated that PRN Haldol was given multiple times without proper documentation of the behaviors leading to its use or the effectiveness of alternative interventions. The resident's guardian was not adequately informed about medication changes, and consent forms lacked critical information such as dosage, route, frequency, and expected benefits or side effects. Observations and interviews with staff highlighted issues of short staffing, lack of individualized care, and insufficient monitoring of the resident's condition, including hydration and nutritional status. The resident was found to be lethargic, unable to eat or drink, and had significant weight loss and dehydration, ultimately requiring transfer to a hospital. The facility's interdisciplinary team and medical director were not fully aware of the extent of the psychotropic medication regimen, and there was a failure to ensure appropriate oversight and monitoring of the resident's response to these medications.
Removal Plan
- Obtain an order from the facility Psychiatrist/Resident's Physician to discontinue medication.
- Add 1:1 for safety of self and other residents due to increased aggression.
- Complete a chart audit on all residents currently prescribed an antipsychotic medication to ensure an adequate indication for use and appropriate documentation is present to support use of the medication.
- Audit all residents who receive antipsychotic medication.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three Certified Nursing Assistants (CNAs) who had been employed for more than 12 months. Personnel file reviews for these CNAs showed no evidence of annual performance evaluations within the past year. This was confirmed by both the Business Office Manager (BOM) and the Nursing Home Administrator (NHA), who acknowledged that the required evaluations had not been conducted or documented as per facility policy. Interviews with facility staff further confirmed the absence of these reviews, with the BOM stating that performance evaluations are expected annually and should be maintained in employee files. The facility's policy specifies that additional training should be provided based on areas of weakness identified in performance reviews, and that such education should be completed within 90 days of the appraisal. The lack of completed performance reviews resulted in the potential for unidentified performance concerns and unmet training needs for the CNAs involved.
Failure to Implement Effective QAPI Program and Address Dementia Care Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively identified and corrected quality deficiencies, particularly in the dementia care unit. Interviews and record reviews revealed that the QAPI committee did not consistently review or analyze data, nor did it develop plans of action when concerns were identified. The QAPI plan document was incomplete, lacking essential information such as the facility name, vision, mission, and purpose. The Nursing Home Administrator, who served as the QAPI Coordinator, acknowledged that records of ongoing data review and analysis were limited, and necessary reports were not being generated due to significant management turnover. As a result, issues such as the use of psychotropic medications and staff training deficiencies were not adequately monitored or addressed. A resident with dementia did not receive individualized care despite interventions provided by her Durable Power of Attorney (DPOA) to reduce stress responses. Staff interviews indicated a lack of knowledge regarding effective interventions for this resident, and concerns raised by staff were not acted upon. The QAPI committee was aware of deficiencies in staff performance evaluations and training but did not implement a Performance Improvement Plan (PIP). The facility was unaware of non-compliance related to psychotropic medication use until it was identified during the survey.
Failure to Ensure Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the medical director or their designee attended the Quality Assurance and Performance Improvement (QAPI) committee meetings at least quarterly, as required by facility policy. Review of QAPI committee sign-in sheets showed that neither the medical director nor a designee attended any meetings from April to August 2025. During an interview, the Nursing Home Administrator (NHA) stated that significant management turnover and a change in medical directors contributed to the lack of attendance, with the former medical director not attending as required and the new medical director missing meetings due to scheduling issues. Facility policy specifies that the QAPI committee must be interdisciplinary and include the medical director or designee, meeting at least quarterly.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all new and existing staff members, as evidenced by interviews and record reviews. The Director of Nursing (DON) reported that the facility previously used a computer-based training platform, but after discontinuing the service, they lost access to records of completed staff training. There was no current staff training program in place, and any training that was completed was supposed to be recorded in employee files. However, a review of employee files for several CNAs revealed no documentation of training related to Quality Assurance and Performance Improvement (QAPI), Infection Control, Compliance and Ethics, Communication, or Resident Rights within the past 12 months. Further interviews with the Nursing Home Administrator (NHA) confirmed that the facility had not been tracking staff training and was aware that some training requirements had not been met. The NHA also stated that there was no Performance Improvement Plan in place to address the lack of annual staff training. A review of the facility's assessment indicated that the training program was supposed to include ongoing training for existing staff, covering topics such as effective communication, resident rights, infection control, QAPI, and compliance and ethics, but this was not being implemented as described.
Failure to Provide and Document Required CNA In-Service Training
Penalty
Summary
The facility failed to implement an effective in-service training program for nurse aides, specifically not supporting mandatory attendance, tracking participation, or ensuring continuing competence. Review of personnel files for three CNAs revealed that documentation did not reflect the required 12 hours of annual training. The Director of Nursing reported that the facility had been without a staff educator and that she was attempting to cover those responsibilities, but had not yet established a staff training plan. Additionally, the facility had discontinued use of a computer-based training system and could not access previous staff training records. The Business Office Manager confirmed that the personnel files for the reviewed CNAs lacked evidence of the required annual training. The Nursing Home Administrator acknowledged awareness of the non-compliance with the 12-hour annual training requirement and confirmed that there was no current staff training plan in place. These findings indicate that the facility did not maintain an appropriate and effective nurse aide in-service training program as required by policy.
Call Light Accessibility Not Ensured for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident who was severely cognitively impaired and required assistance with most activities of daily living, as documented in the Minimum Data Set. Multiple observations showed that the resident's soft-touch call light was either under the sheet at waist level or clipped to the fitted sheet at the head of the bed, both out of the resident's sight and reach. During interviews, the unit manager acknowledged that the call light should have been accessible and explained that staff placed it under the sheet so the resident might activate it by rolling onto it, but confirmed that staff should not have done this.
Failure to Provide Resident-Centered Activities for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide resident-centered activities designed to support the leisure needs of a resident with severe cognitive and visual impairments. The resident, who had diagnoses including vascular dementia with behavioral disturbances, adjustment disorder, and sequelae of cerebral infarction, was assessed as severely cognitively impaired and highly visually impaired. Documentation indicated that the resident was dependent on staff for mobility and unable to participate in traditional leisure activities due to these deficits. Despite this, the activity attendance log showed minimal participation in sensory stimulation and inaccurately documented independent engagement in activities such as religious study and jigsaw puzzles, which the resident's durable power of attorney (DPOA) and staff interviews confirmed were not possible due to the resident's limitations and lack of interest. Interviews with the DPOA revealed that staff never consulted her regarding the resident's past leisure interests, and she stated the resident could not accurately express his preferences. The DPOA also reported that the resident could not engage in activities like reading, puzzles, or watching television, and that religion was not important to him, contradicting the activity records. Staff interviews further confirmed that the resident required one-on-one assistance for any leisure activity and was rarely observed participating in any activities. The activity assistant reported not being informed of the resident's preferences and resorted to placing various supplies in front of the resident to gauge interest, but noted the resident appeared emotionally distressed and unable to participate in group activities. Additional interviews with facility staff, including the activity director and former social services director, highlighted concerns about the quality and quantity of individualized activities offered in the memory care unit. The activity director acknowledged that documentation of self-propelling a wheelchair or looking out the window was inaccurately recorded as leisure activity participation. The nursing home administrator confirmed awareness of the need for more individualized activities in the memory care setting, as current practices did not adequately address the resident's needs for meaningful engagement.
Failure to Provide Person-Centered Dementia Care and Activities
Penalty
Summary
The facility failed to develop and implement person-centered dementia care interventions for a resident diagnosed with vascular dementia and severe cognitive impairment. The resident exhibited behaviors such as wandering, disorientation, emotional frustration, and stress, but the care plan did not accurately reflect the resident's needs or preferences. The care plan included an incorrect nickname, omitted specific non-pharmacological interventions suggested by the resident's DPOA, and did not address known triggers or effective calming techniques such as gentle handling of the resident's hands or back rubs. Additionally, the care plan did not document the resident's preference for napping after breakfast, which was known to reduce agitation. Observations revealed that the resident spent extended periods in bed with no access to preferred items such as a radio, books, or magazines, and the call light was out of reach. The activity attendance log showed minimal participation in sensory stimulation activities, and interviews with staff indicated a lack of knowledge about the resident's preferences and effective interventions. Staff members, including LPNs and activity assistants, reported not receiving dementia care training and expressed difficulty in managing the resident's behaviors. The resident's DPOA and guardian reported that their input regarding triggers and calming strategies was not incorporated into the care plan or daily care practices. The facility's dementia care policy required individualized, person-centered care and staff training, but these standards were not met. There were no planned activities for men or for residents on the locked dementia unit after certain hours, and staffing levels were insufficient to provide appropriate care and activities, especially in the evenings. Staff interviews confirmed that residents with dementia were not receiving adequate attention, activities, or individualized interventions, contributing to ongoing behavioral issues and emotional distress for the resident.
Inaccurate Medical Record Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and complications from a stroke. The resident's care plan inaccurately listed a nickname that was not used by the resident, and the Durable Power of Attorney (DPOA) confirmed that using this nickname would cause confusion. The DPOA also stated that the resident could not participate in traditional leisure activities and had not attended any outings, which would have required her permission. Multiple staff interviews corroborated that the resident did not participate in group activities due to cognitive deficits. Despite this, the activity attendance record documented the resident as having participated in various group activities and outings, including after the resident had already been discharged to an acute care setting. The Activity Director acknowledged that some activities recorded, such as self-propelling a wheelchair or looking out a window, did not meet the definition of leisure activities and confirmed that outings were not offered by the facility. The Activity Director also noted that the activity assistant responsible for documentation had difficulty accurately recording attendance, likely resulting in erroneous entries. These inaccuracies resulted in a medical record that was not factual, accurate, complete, or current.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that a resident in need of dialysis received care and services that met safety and appropriateness standards. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Implement Gait Belt Use and Wheelchair Footrest Safety
Penalty
Summary
The facility failed to ensure proper accident prevention measures were implemented for two residents. For one resident with a history of muscle weakness and a displaced intertrochanteric fracture of the left femur, a Physical Therapy Assistant (PTA) was observed assisting her to ambulate in the hallway without the use of a gait belt. Multiple staff interviews, including those with the Therapy Director, Certified Nurse Assistants, and the Director of Nursing, confirmed that facility policy and staff orientation require the use of a gait belt when assisting any resident with ambulation in the hallway, regardless of their independence in their room. The resident's care plan indicated a need for supervision and assistance with ambulation due to a history of falls and weakness, but the intervention was not followed during the observed event. In a separate incident, another resident with Alzheimer's disease, muscle weakness, and severe cognitive impairment was transported in a wheelchair by a Physical Therapist without footrests in place. The therapist was observed pushing the resident down the hallway, then leaving her unattended to retrieve the footrests, during which time the resident placed her feet on the floor. Staff interviews confirmed that the expectation is for footrests to be in place whenever a resident is transported in a wheelchair. Both incidents demonstrate a failure to follow established safety protocols for ambulation and wheelchair transport, as observed and confirmed by staff and record review.
Unattended Narcotic Medication Left on Medication Cart
Penalty
Summary
A narcotic medication, specifically Lorazepam, was observed left unattended in a plastic medication cup on top of a medication cart in the common area of the secure unit. The cup, labeled with a resident's name and containing a white substance submerged in liquid, was left next to a plastic drinking cup of tan colored liquid. This situation occurred while there were seven residents present in the room, including one resident who was ambulatory, and a CNA who was not monitoring the medication cart. The medication and supplement remained unattended and out of staff line of sight for a total of 37 minutes, during which time staff and visitors moved in and out of the area. Interviews with staff confirmed that the assigned nurse, RN R, had left the medication unattended while off the unit for approximately 15 minutes. RN R acknowledged the medication was a prescription narcotic intended for a resident present in the area and admitted it should not have been left unattended. Additional staff interviews and review of facility policy confirmed that medications, especially controlled substances, are required to be under direct observation or locked at all times. The facility's policy also specifies that all drugs and biologicals must be stored in locked compartments, and controlled substances must be double-locked, which was not followed in this instance.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Inadequate Dietary Management Leads to Disrupted Meal Service
Penalty
Summary
The facility failed to ensure that the dietary manager had the necessary competencies and skill set to manage the food and nutrition service, resulting in the potential for unmet nutrition and hydration needs for all residents dependent on the facility kitchen. During a kitchen tour, dietary staff reported that recent food deliveries were insufficient, consisting only of milk, eggs, and a few loaves of bread, and that menu items could not be served as planned due to missing ingredients. Staff described having to use emergency food supplies, which were not replenished, and substituting menu items due to lack of availability. There was also a reported shortage of thickened juice required for therapeutic diets, and staff were unclear about when the dietary manager or interim manager would be present, as both were PRN and not full-time. Further interviews revealed confusion and lack of oversight in the ordering process, with the interim dietary manager admitting to not knowing how to place food orders and relying on training that had not yet occurred. The registered dietitian clarified that she was not overseeing daily kitchen operations and would not be present daily, despite being named as the full-time dietitian. The previous dietary manager confirmed she was no longer responsible for the kitchen and had only briefly assisted with food ordering. Observations also noted expired food items in the kitchen. These findings demonstrate a lack of competent and consistent management in the dietary department, leading to disruptions in meal service and potential unmet nutritional needs for residents.
Failure to Follow Menus and Obtain Dietitian Approval for Substitutions
Penalty
Summary
The facility failed to follow its planned menus, resulting in the potential for inadequate nutritional value and unmet nutritional needs for all residents consuming food from the kitchen. During a kitchen tour, dietary staff reported that recent food deliveries were insufficient, providing only milk, eggs, and bread, and that there was not enough of certain items, such as bread and bacon, to fulfill the menu requirements. Staff described having to make unapproved substitutions, such as serving scrambled eggs and toast instead of sausage gravy and biscuits, and using ham in place of pot roast because the latter was not thawed. The dietary staff indicated that they often had to be creative with meal preparation due to unavailable menu items, and that the dietary manager or interim manager, both PRN staff, were responsible for approving substitutions, though their presence in the facility was inconsistent. Further investigation revealed that the registered dietitian had not been notified of menu substitutions and had not visited the facility during the relevant period. The dietitian confirmed she had not approved any substitutions or signed off on a substitution log, as required. Staff interviews indicated a lack of awareness or use of a substitution log, and the dietary manager was not present to oversee or document menu changes. The administrator reported that some food items, such as sausage gravy, were unusable due to damage, necessitating substitutions that were not properly communicated or documented. This lack of adherence to menu planning and required oversight by the dietitian led to the cited deficiency.
Inadequate Time and Oversight for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was dedicated at least part-time to the infection prevention and control program, and that the IP was provided sufficient time to fulfill the responsibilities of the role. The individual assigned as IP was also serving as the Assistant Director of Nursing (ADON) and, more recently, as the Unit Manager (UM) for the rehab unit. This staff member reported being pulled to cover open shifts on the floor, being on call, and handling additional administrative and clinical duties, which significantly limited the time available for infection control tasks. The IP estimated spending only about 3 hours per week on infection control, despite stating that 20 to 25 hours per week would be appropriate for the role. Interviews and record reviews revealed that the IP's infection control activities were limited, with audits focusing only on the availability of gowns and gloves rather than staff compliance with personal protective equipment (PPE) use. The IP acknowledged that staff were not compliant with PPE requirements for residents on Enhanced Barrier Precautions (EBP) and that there had been insufficient time to reeducate staff on proper PPE use. The last infection control education provided to staff was several months prior, and the IP had only recently completed uploading resident immunization data from the previous fall. The facility's own assessment and job descriptions indicated that the IP role was intended to be a distinct responsibility, but in practice, it was combined with multiple other roles, resulting in inadequate oversight and management of the infection prevention and control program.
Failure to Develop Person-Centered Care Plan for Foley Catheter and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a person-centered care plan that accurately reflected the current care needs of a resident with severe cognitive impairment and a history of psychotic disorder with delusions and dementia with behavioral disturbances. The resident was observed with a Foley catheter in place, and medical orders indicated the need for regular assessment of catheter patency. However, the care plan only addressed fall risk related to incontinence and the use of a Foley catheter for urinary retention, without including any focus, goals, or interventions for enhanced barrier precautions associated with the presence of the catheter. Interviews with facility staff, including the ADON/Unit Manager/Infection Preventionist, LPN Supervisor, and DON, confirmed that enhanced barrier precautions should have been implemented and care planned for any resident with a Foley catheter. Staff acknowledged that the resident did not have a care plan in place for enhanced barrier precautions, despite the presence of the catheter and the facility's expectations and protocols. This omission resulted in an inaccurate reflection of the resident's current care needs and the potential for unmet care needs.
Failure to Update Resident Care Plan for Dietary and Hydration Needs
Penalty
Summary
The facility failed to revise and maintain an accurate, person-centered care plan for a resident with a history of traumatic subdural hemorrhage and severe cognitive impairment. The resident's diet and hydration needs had changed, including advancement of diet and discontinuation of G-tube feedings, but the care plan continued to reflect outdated interventions such as a pureed diet and nectar thick liquids. Observations and interviews revealed that visual cues and current orders indicated the resident was on a mechanical soft diet with honey thick liquids, but these changes were not reflected in the care plan. Multiple staff interviews confirmed that the care plan had not been updated to match the resident's current needs, and there was confusion regarding responsibility for updating the care plan due to the absence of a dietary manager and changes in unit management. The deficiency was identified through review of records, staff interviews, and direct observation, which showed discrepancies between the resident's current dietary orders, visual staff cues, and the documented care plan. The care plan was not revised in a timely manner to reflect the resident's current nutritional and hydration requirements, resulting in an inaccurate and incomplete description of the resident's care needs. This failure created the potential for unmet care needs due to staff relying on outdated care plan information.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled activities of daily living (ADL) care, specifically showers, to dependent residents who required assistance. Two residents with significant physical disabilities and cognitive intactness reported not receiving showers as scheduled, with one resident going up to a week and a half without a shower and another going about nine days without one. Review of facility records confirmed gaps in shower documentation, with periods of 7 to 12 days between documented showers for both residents. There were no documented refusals for showers during these periods, and the residents' care plans indicated they were to receive showers twice weekly on specific days. Interviews with staff revealed that showers were often missed during busy or understaffed shifts, with CNAs prioritizing other tasks such as passing dinner trays, feeding residents, and putting residents to bed. Staff reported that showers were documented only on shower sheets, which were then signed off by nurses, and that refusals were to be documented in progress notes. The Director of Nursing confirmed that short staffing was not an acceptable reason to skip scheduled showers and that the standard of care was two showers per week. Despite these expectations, the facility did not ensure that dependent residents consistently received their scheduled showers.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards for three residents, resulting in multiple incidents. One resident with severe cognitive impairment and a history of psychotic disorder and dementia was involved in repeated altercations with another resident who was moderately cognitively impaired and had a history of behavioral disturbances. These altercations included verbal aggression, physical contact, and spitting. Despite these incidents, there were no specific interventions documented or implemented to address the ongoing conflict between the two residents, and staff were largely unaware of any required actions to prevent further incidents. Behavior logs and care plans lacked updates or targeted interventions following the altercations, and incident reports were not consistently completed or documented in progress notes. Another resident, who was severely cognitively impaired and identified as an elopement risk due to a traumatic brain injury, was able to exit the building unsupervised. Although the care plan indicated the need for one-to-one supervision during waking hours, this intervention was not consistently implemented due to staffing challenges. On the night of the elopement, the resident was left unsupervised when the assigned CNA was attending to other residents, and the facility's front door was found to be unlocked, allowing the resident to leave the premises. Staff interviews confirmed that one-to-one supervision was difficult to maintain and that the door security was not consistently enforced prior to the incident. Facility policies required the identification of hazards, implementation of targeted interventions, and communication of these interventions to all relevant staff. However, the report shows that interventions were not effectively communicated or consistently put into action. Staff members, including CNAs, nurses, and the social services director, were either unaware of or did not implement new interventions following incidents. Documentation was incomplete or missing regarding both the altercations and the elopement, and the required supervision and environmental controls were not reliably maintained.
Failure to Ensure PPE Use for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP), as observed with two residents who had indwelling medical devices. One resident, who was severely cognitively impaired and had a Foley catheter, was not care planned for EBP and was observed being assisted by staff without the use of gown or gloves during care activities. Interviews with nursing staff and leadership confirmed that EBP should have been implemented for this resident, and that staff were expected to use PPE during care, but this was not followed in practice. Another resident, also severely cognitively impaired and with a gastrostomy tube, had signage indicating EBP and orders specifying the use of gown and gloves for high-contact care activities. Despite this, staff were observed providing care, such as adjusting linens and assisting with transfers, without donning PPE. Interviews revealed confusion among staff regarding the need for EBP, with some staff unaware that the resident was on EBP or misunderstanding when PPE was required. The infection preventionist acknowledged that staff were noncompliant with PPE use despite education and posted signage. Review of facility policy and CDC guidance confirmed that residents with indwelling medical devices require EBP during high-contact care activities, and that monitoring of staff adherence was expected. However, observations and staff interviews demonstrated a lack of compliance with these requirements, resulting in a failure to implement the infection prevention and control program as intended for residents at risk.
Failure to Implement Water Management Plan for Legionella Control
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program specifically targeting the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During an observation, it was noted that the facility was in the process of removing unused hoppers and stagnant lines, but there was no evidence of a systematic approach to flushing minimal use or unused fixtures. The Maintenance Director (MD) Z indicated that water samples for legionella had not been tested in a year or two, and there were no current sampling activities for any pathogens. Further investigation revealed that the facility's Water Management Plan (WMP) was not being implemented as designed. The plan required specific control measures to be applied, monitored, and documented, but none of these actions were being carried out. MD Z was unable to confirm whether control measures were in place to reduce the risk of legionella or OPPP, and there was uncertainty about the status of water lines in the Meadowlane Spa room. The lack of documentation and tracking of control measures as outlined in the WMP contributed to the deficiency.
Facility Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises, which increased the potential for contamination and decreased resident satisfaction. During a kitchen tour, it was observed that the three-compartment sink and the one-compartment sink on the preparation table were directly connected to the wastewater drain without an air gap, contrary to the 2022 FDA Food Code. The Certified Dietary Manager indicated that the one-compartment sink was used for discarding ice and water from canned goods, and there was no preparation sink available for thawing products. Additionally, the Riverside Spa room was missing a light shield on one of the light ballasts, posing a risk of broken glass contamination. Further observations revealed multiple cleanliness and maintenance issues throughout the facility. Resident rooms had chipping paint and scratches, and the TV/Brief room had storage racks made of raw wood, which were not easily cleanable and showed dark staining. The Meadowlane dining room had lounge chairs with debris accumulation, including trash and food spills. The central supply room and laundry room had raw wood shelves and missing light shields, respectively. The beauty shop lacked an in-line atmospheric vacuum breaker on the hair spray rinse sink, increasing the risk to the potable water supply. Housekeeping staff shortages were noted, affecting the cleanliness of the memory care unit.
Failure to Provide Annual Abuse Prevention Training
Penalty
Summary
The facility failed to provide the required annual abuse prevention education for all employees, which has the potential to affect all 73 residents residing in the facility. The Assistant Director of Nursing (ADON) was unaware of her responsibility for training employee education and did not have access to the electronic training program to track education completion. The Director of Nursing (DON) reported that the facility previously used an electronic training program owned by the facility's previous owners, but the new owners did not continue the contract, leading to a lack of assigned trainings. The facility's assessment and employee training records revealed that 91 out of 128 staff members did not receive the required annual abuse prevention training. The facility's policy on abuse, neglect, and exploitation outlined the need for new employees to be educated during initial orientation and for existing staff to receive annual education through planned in-services. However, the facility was unable to provide evidence of compliance with this policy, resulting in a deficiency noted by the surveyors.
Excessive Hot Water Temperatures Pose Scalding Risk
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F, which increased the risk of injury among residents. During a tour of the Riverside Spa, the hot water from the hand sink was found to reach 123°F, as measured by a Thermoworks rapid read digital thermometer. The Maintenance Director (MD Z) stated that the usual hot water temperatures range from 116°F to 118°F. In the boiler room, the boiler was set at 140°F, and the domestic hot water flowed through a thermostatic mixing valve, showing an outgoing temperature of 125°F. MD Z confirmed that there were no other hot water systems in the building and that the kitchen and laundry received hot water directly from this source before it was mixed down. He also mentioned that he typically takes hot water temperatures in the morning. Further observations revealed that the hot water temperature in the Meadowlane Spa reached 135°F, and a Certified Nursing Assistant (CNA I) noted that staff generally turn the water on as hot as it will go and then dial it back for residents. Additional observations in shared bathrooms between resident rooms showed hot water temperatures ranging from 128°F to 134°F. In the Valley Court Spa, the hot water in the sink reached 135°F, and the shower reached 126°F. The surveyor informed the Assistant Director of Nursing (ADON E) about the excess hot water temperatures and the increased concern for resident harm due to scalding and burning. A subsequent review of the Valley Court Spa room found the hot water from the sink reached 118°F.
Improper Transfer Documentation and Notification
Penalty
Summary
The facility failed to provide proper documentation and notification regarding the transfer or discharge of residents, specifically for two residents. Resident #72, who had a traumatic hemorrhage of the cerebrum and a non-displaced fracture of the seventh cervical vertebra, was discharged to home by choice. However, the facility incorrectly used an involuntary transfer form, which was not appropriate since the discharge was resident-initiated. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Social Work Director (SWD) revealed confusion and miscommunication regarding the correct forms and procedures for resident-initiated discharges. Additionally, the facility failed to notify the local ombudsman of resident transfers, as required. None of the staff, including the Nursing Home Administrator (NHA), DON, ADON, or SWD, took responsibility for providing the monthly transfer notice list to the ombudsman's office. This lack of communication and responsibility resulted in the ombudsman not receiving the necessary notifications. Furthermore, for Resident #40, who had Alzheimer's disease and other significant health issues, the facility used an incomplete involuntary transfer form when the resident was sent to the ER after a fall, failing to document the destination and reason for the transfer.
Care Plan Deficiencies in Fall Prevention and Contracture Management
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in fall prevention and contracture management. Resident #225, who has paraplegia, was identified as a low risk for falls, but after a fall incident on 11/2/24, it was determined that a bolster should be used to prevent future falls. However, this intervention was not added to the resident's care plan or Kardex, despite the resident's tendency to stay close to the edge of the bed. Observations confirmed the bolster was in use, but the care plan was not updated to reflect this necessary intervention. Resident #35, diagnosed with Alzheimer's disease, dementia, and a contracture of the right hand, had a care plan that included the use of a soft hand splint. However, the physician's order to discontinue the splint was not reflected in the care plan, leading to confusion among staff. Observations showed the resident was not wearing the splint, and interviews with staff confirmed the order had been discontinued, yet the care plan still indicated its use. This discrepancy was only corrected after the surveyor's review.
Failure to Maintain Nebulizer Equipment for Resident with COPD
Penalty
Summary
The facility failed to maintain nebulizer equipment for a resident with chronic obstructive pulmonary disease (COPD), leading to potential risks of inconsistent equipment exchange, irregular cleaning, and respiratory infection. Observations over several days revealed that the nebulizer machine and tubing were left on the bedside dresser without a storage bag, and the tubing was dated from nearly a month prior. The resident, who was cognitively intact, reported uncertainty about the last use of the nebulizer. Physician orders indicated the resident required nebulizer treatments as needed for wheezing or shortness of breath. Interviews with nursing staff confirmed that oxygen supplies, including nebulizer kits, were supposed to be changed weekly and stored properly when not in use. However, the nebulizer kit at the resident's bedside was outdated and used during an episode of severe respiratory distress, after which the resident was transferred to an acute care setting. The facility's policy required nebulizer tubing and delivery devices to be changed every 72 hours or as needed if soiled or contaminated, and to be kept in a plastic bag when not in use.
Failure to Obtain COVID-19 Vaccination Consents
Penalty
Summary
The facility failed to obtain COVID-19 vaccination consents or declinations for two residents, leading to a deficiency in ensuring that residents or their representatives were informed about the vaccination and its associated risks and benefits. Resident #44, who was severely cognitively impaired with a BIMS score of 6, received a Pfizer Booster without any record of her dual POAs being contacted for consent. This oversight resulted in the resident's representatives being unaware of the vaccination and the risks/benefits involved. Resident #37, who was cognitively intact with a BIMS score of 15, refused the Moderna Booster, but the facility did not provide a consent or declination form that included the risks and benefits of the vaccine. The Assistant Director of Nursing, who also serves as the Infection Preventionist, acknowledged that the correct COVID-19 consent forms were not available until the end of October, which contributed to the failure in obtaining proper documentation. The facility's COVID-19 Vaccination policy required that residents or their representatives sign a consent form prior to vaccination, but this was not adhered to in these cases.
Deficiency in Behavioral Health and Dementia Training
Penalty
Summary
The facility failed to provide adequate training for behavioral health care and dementia to its staff, as required by the facility assessment. During interviews, the Assistant Director of Nursing (ADON) was unaware of her responsibility for employee education and lacked access to the electronic training program to track education completion. The Director of Nursing (DON) reported that the facility previously used an electronic training program owned by the previous owners, but the new owners did not continue the contract, leading to a reliance on in-person education and scheduled in-services. A review of the facility's employee training records revealed that 68 out of 128 staff members did not receive the required annual behavioral management and dementia training before the survey began. The facility assessment, reviewed with the Quality Assessment and Assurance (QAA) Committee, outlined the services and care offered based on residents' needs, including behavioral and mental health management. However, the facility was unable to provide evidence of compliance with these training requirements, resulting in a deficiency report.
Failure to Report and Investigate Resident Elopement
Penalty
Summary
The facility failed to immediately report an elopement incident involving a resident with severe cognitive impairment and did not submit an investigation report to the State Agency within the required 5-day period. The resident, who was at high risk for elopement due to conditions such as unspecified dementia and cognitive communication deficit, was found unsupervised in the facility's parking lot. Despite the resident's cognitive impairments and lack of authorization to leave the facility, the incident was not reported as an elopement, and no investigation was conducted. Interviews with staff revealed that the resident was seen walking alone outside the facility by an LPN, who reported the situation to a CNA. The CNA then informed an RN, who found the resident in the parking lot looking for his car and wife. The resident was disoriented and had a history of wandering and falls, making it unsafe for him to be outside unsupervised. The Director of Nursing acknowledged that the resident did not have authorization to leave the building alone, and the Medical Director confirmed that no medical authorization was given for the resident to exit the facility unsupervised.
Failure to Develop Elopement Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was at high risk for elopement, resulting in the resident exiting the building unsupervised. The resident, who was severely cognitively impaired with a BIMS score of 3/15, had a history of delusions, used a wheelchair for mobility, and was at high risk for falls due to conditions such as unspecified dementia and osteopenia. Despite these risks, the care plan did not include any focus, goal, or interventions related to the resident's risk for elopement. On a specific occasion, the resident was found standing in the parking lot, confused and lost, indicating an elopement incident. Interviews with facility staff revealed that the resident frequently wandered and expressed a desire to leave, yet no specific care plan interventions were in place to address the risk of elopement. The Nursing Supervisor confirmed that the resident's high-risk elopement assessment should have prompted the development of a person-centered care plan to mitigate the risk of elopement.
Deficiencies in Safety Protocols and Equipment Maintenance
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards, resulting in an elopement incident involving a resident with severe cognitive impairment. The resident, who was at high risk for elopement, was found unsupervised in the parking lot after leaving the facility through unlocked lobby doors. Despite being identified as a high elopement risk, the resident's care plan did not address this risk, and the facility did not follow its own elopement protocol, failing to conduct a head count, assess the resident for injuries, or notify the resident's power of attorney. Another incident involved a resident who suffered a head laceration after falling from a mechanical lift that had not been properly maintained. The lift's hanger bar disconnected from the boom due to a loose screw, causing the resident to fall. The facility's maintenance program lacked a schedule for routine preventative maintenance on nursing equipment, and the Director of Maintenance admitted that no such maintenance had been performed in over a year. The facility also lacked an inventory system for nursing equipment and user manuals, further contributing to the failure to maintain the lift properly. Interviews with staff revealed a lack of communication and responsibility regarding equipment maintenance and elopement protocols. The Director of Nursing and other staff members were unaware of the necessary steps to prevent and respond to elopements, and the maintenance department did not have a system in place to ensure regular equipment checks. These deficiencies highlight significant lapses in the facility's safety protocols and preventative maintenance practices, leading to potential harm to residents.
Failure to Assess Change of Condition and Provide Wound Care
Penalty
Summary
The facility failed to assess an acute change of condition in one resident and failed to provide appropriate skin care for another. One resident, who had severe cognitive impairment and was on droplet isolation for COVID-19 exposure, experienced a significant decline in condition. Despite multiple reports from CNAs about the resident's deteriorating state, the assigned LPN did not perform an assessment or notify the physician in a timely manner. The resident was eventually sent to the hospital after family intervention, where she was diagnosed with severe dehydration, hypernatremia, and a urinary tract infection, conditions that were not identified or treated by the facility staff in a timely manner. Another resident, who also had severe cognitive impairment, suffered from multiple skin tears and abrasions. The facility failed to follow physician orders for wound care, resulting in inconsistent and inadequate treatment. Observations revealed that the resident had dressings on both shins that were not documented in the medical records, and the prescribed treatments were not administered as ordered. This lack of proper documentation and adherence to treatment protocols increased the risk of infection and further complications for the resident. Interviews with staff members highlighted a lack of communication and proper response to changes in residents' conditions. The LPN responsible for the first resident did not take appropriate actions despite being informed of the resident's worsening state by multiple CNAs. Similarly, the wound care for the second resident was not managed according to the physician's orders, indicating a systemic issue in the facility's ability to provide adequate care and documentation for its residents.
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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