The Springs At Rochester Hills Rehab And Nursing C
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester Hills, Michigan.
- Location
- 1480 Walton Blvd, Rochester Hills, Michigan 48309
- CMS Provider Number
- 235036
- Inspections on file
- 29
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at The Springs At Rochester Hills Rehab And Nursing C during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and significant psychiatric and medical histories were involved in a resident‑to‑resident assault when a wheelchair user appeared to roll over an ambulatory resident’s foot, after which the ambulatory resident intentionally punched the wheelchair user in the nose with a closed fist. Witnesses, including a CNA and an LPN, reported the punch, the aggressor’s statement that he “meant to do it,” and immediate nasal bleeding and distress, and the aggressor later admitted to staff and law enforcement that he struck the other resident. The injured resident, who had dementia, bipolar disorder, prior brain bleed, and was on hospice, sustained bilateral nasal fractures, experienced 10/10 pain requiring PRN analgesics, showed anxiety and agitation, and later reported ongoing head and ear pain, bruising, and feeling unsafe. Records showed the aggressor had previously assaulted another female resident with a closed fist, and the facility’s abuse policy defined such willful hitting as abuse and required protection and care plan revision after abuse; however, the facility’s investigation did not verify abuse and the injured resident’s care plan was not updated to address protection or psychosocial needs following the incident.
The facility failed to maintain a comfortable, homelike environment by not ensuring consistent availability of towels, washcloths, and personal clothing for multiple residents. CNAs reported chronic linen shortages, starting some shifts with no linens and resorting to using cut bath blankets, pillowcases, wipes, and draw sheets for hygiene care. Several residents stated they were not provided towels or washcloths, had to wait to be cleaned while staff searched for linens, or had to "fight" for scheduled showers. Observations of clean utility rooms showed minimal or no towels and washcloths, and some residents’ rooms lacked any linens or personal clothing, as confirmed by family members and staff. At the same time, surveyors discovered large quantities of new towels and washcloths stored unopened on a closed construction unit inaccessible to floor staff. The housekeeping and laundry staff cited being short-handed and lacking a clear system, and the facility had no written linen or laundry policy addressing how linens and residents’ clothing should be laundered and distributed.
The facility failed to provide adequate supervision to prevent multiple resident-to-resident altercations involving cognitively impaired and behaviorally complex residents. In one case, a resident with severe cognitive impairment and a history of aggression was heard yelling at another resident and was then observed kicking that resident while they were on the floor in his room, causing minor injuries and pain. In another case, staff placed two residents together as roommates despite staff concerns about one resident’s known aggressive behavior and dislike of roommates; shortly after the move, the other resident reported being hit and expressed feeling unsafe in that room. Additional incidents involved a resident who did not like others entering his room physically engaging with a resident who frequently climbed into other residents’ beds, and a separate hallway altercation where two cognitively impaired residents struck each other after one accused the other of stealing. These events occurred despite a written staffing policy stating that adequate licensed nursing and CNA coverage would be maintained to meet residents’ needs and provide necessary supervision.
The facility failed to consistently provide and offer evening and HS snacks as required by its own policy. A bedbound, oriented resident reported never being offered facility snacks and relying on family-provided food, while another oriented resident in a wheelchair stated they often missed evening snacks because they had to be at the nurses’ station at the right time and some days received no snack despite wanting one daily. A nonverbal resident’s family member reported the resident appeared hungry at night, requested double portions that were often not received, and had not been offered a grievance form. The Dietary Manager stated that various snacks were prepared and sent to the unit but acknowledged that snacks disappeared quickly, possibly due to residents hoarding them or staff taking them, and snacks were also kept in the dietary office. These observations and interviews showed that snacks were not reliably offered or made accessible to all residents in line with facility policy.
Multiple residents reported prolonged waits, often an hour or more, for toileting, incontinence care, transfers, water, and medications, with one bedbound resident describing inadequate perineal care that left stool caked on until morning and another bedbound resident waiting 1–2 hours for brief changes after using the call light. Two alert, oriented residents using wheelchairs stated they frequently waited in bed for assistance with bathroom needs and medications, while a family member repeatedly found their relative soaked in urine during visits. CNAs reported that when only two aides were assigned per floor of about 40 residents, especially on the night shift, they could not complete two-hour check-and-change care or timely feeding, and staffing records confirmed multiple nights with only two aides despite many residents requiring lift assistance, contrary to the facility’s own policy to maintain adequate staffing to meet resident needs.
Surveyors found that the facility did not consistently provide meaningful, person-centered activities as posted on the activity calendar. Two residents reported that scheduled activities such as BINGO and brain games, especially on weekends, were frequently missed or started very late, that music did not match their preferences, that room visits were not occurring, and that they were often not included in community outings. Observations confirmed that a scheduled BINGO session did not begin at the posted time, leaving residents waiting without explanation, and that some weekend and Sunday activities were not occurring despite being listed. Activity logs showed gaps in documented activities, no refusals, and minimal Sunday programming, while the Activity Director acknowledged late and missed activities and difficulty covering simultaneous activities on multiple floors with limited staff.
Multiple incidents of resident-to-resident physical abuse occurred, including one resident punching another and breaking her jaw, and another incident where a resident was pushed to the floor, kicked, and struck with a wheelchair. Staff witness statements and medical records documented more severe injuries and aggression than what was reported to the State Agency. Some staff did not report observed abuse incidents, and there were discrepancies between internal documentation and official reports, indicating a failure to accurately document and respond to abuse as required by facility policy.
The facility did not ensure timely and accurate reporting of suspected abuse incidents involving multiple residents, with staff failing to promptly notify authorities and accurately document the extent of injuries. A nurse admitted to not reporting all observed altercations and lacked training on abuse protocols, while the Administrator delayed reporting based on incomplete information. The facility could not provide evidence that all staff had received required abuse reporting education.
Insufficient nursing staff resulted in residents not receiving water for two days, incorrect meal tray delivery, lack of supervision for residents with dementia who wandered into other rooms, and staff confusion about assignments. Multiple residents with cognitive impairments were affected, and staff interviews confirmed delays in basic care due to heavy workloads and unclear responsibilities.
Facility administration did not follow its grievance policy after a family raised concerns about a resident with epilepsy, dementia, and cognitive communication deficit who required staff assistance for all ADLs. The family was not provided with documented follow-up or updates regarding their concerns about care, despite policy requirements for timely and ongoing communication.
The facility did not have effective or consistently enforced policies and procedures to prevent abuse, neglect, and theft. Surveyors found gaps in staff training, inconsistent documentation, and unclear reporting mechanisms, resulting in inadequate protection for residents.
A resident with cognitive impairment and a care plan requiring staff assistance for grooming was observed with significant facial hair, despite CNA documentation indicating that shaving had been completed. The resident's care plan included a family request for the individual to be kept clean shaven, but direct observation revealed this was not done as required.
Two residents with cognitive impairment and on hospice care were physically assaulted by another resident with severe cognitive and psychiatric conditions, resulting in pain and swelling. Despite documented injuries and staff witness accounts, the facility did not substantiate abuse, citing lack of intent due to the aggressor's cognitive status.
A resident with multiple complex diagnoses was administered Lorazepam for anxiety without a documented anxiety diagnosis, targeted behaviors, or evidence of nonpharmacological interventions being attempted first. The care plan lacked person-centered behavioral interventions, and a behavioral health consultation was ordered but not completed, in violation of facility policy requiring proper assessment and alternative measures before psychotropic drug use.
A resident at an LTC facility experienced two falls, resulting in multiple femur fractures that were not reported to the hospital upon admission. The facility failed to fully investigate the falls, did not complete recommended follow-up radiographs, and did not ensure correct interventions were in place. Documentation was incomplete, and staff interviews revealed a lack of awareness and communication regarding the resident's condition and necessary follow-up actions.
The facility failed to prevent and manage pressure ulcers for two residents, leading to the worsening of their conditions. One resident developed a stage IV ulcer with osteomyelitis due to inadequate repositioning and delayed medical oversight, while another developed an unstageable ulcer due to prolonged wheelchair use against physician orders. Documentation inconsistencies and untimely treatments were noted.
A resident experienced an 11.67% weight loss over six months, which the facility failed to identify and address in a timely manner. Observations showed the resident with an uneaten breakfast tray and no staff present. The facility did not update nutritional interventions since 2023, and the resident was not weighed weekly as required by policy. The new RD acknowledged the delay in addressing the weight loss.
The facility failed to maintain sanitary conditions in the kitchen, with raw chicken improperly thawed in a sink and several undated food items in the walk-in cooler. Dietary Staff M confirmed the chicken was thawed incorrectly and that food items should have been dated, violating the 2017 FDA Food Code.
A facility licensed for 126 residents failed to employ a full-time qualified social worker, leading to deficiencies in social services such as improper documentation of advance directives, unsafe discharge planning, and incomplete PASRR assessments. The facility had not employed a full-time social worker since March, with various individuals assisting part-time since a change in ownership in August. A new social worker was scheduled to start in September.
The facility failed to implement consistent infection control practices, affecting all residents. The Infection Control Nurse, who had multiple roles, did not provide required monthly reports or maintain accurate infection mapping. An LPN did not follow proper hand hygiene during trach care for a resident, as confirmed by the DON. These issues highlight significant lapses in the facility's infection prevention and control program.
The facility failed to prevent falls for a resident with dementia, provide appropriate care assistance for a resident with severe cognitive impairment, and ensure supervision to prevent altercations involving a resident with aggressive behaviors. Inconsistent documentation and lack of effective interventions contributed to these deficiencies.
The facility failed to provide adequate social services to eight residents, including coordination of advance directives, discharge planning, and completion of PASARR assessments. Two residents lacked social service assessments despite having significant medical needs. A change in ownership led to a gap in full-time social worker employment, contributing to these deficiencies.
The facility failed to implement an effective antibiotic stewardship program, affecting multiple residents. A review of infection logs revealed a lack of documentation on whether infections met criteria, with antibiotics prescribed without confirming appropriateness. The Infection Control Nurse acknowledged the issue, noting a new program would address it, but concerns remained.
The facility failed to ensure effective communication regarding advanced directives for two residents. One resident's medical record indicated a DNR status, but a nurse believed they were a full code, leading to potential miscommunication. Another resident expressed a desire to be a DNR, but the facility's records listed them as a full code. These discrepancies highlight the facility's failure to maintain accurate records of residents' advanced directives.
A resident with psychotic disorder and dementia was involved in an incident where they poured coffee on another resident, causing injuries. Despite the incident being documented and reported internally, the facility failed to report the allegation to the State Agency as required by their policy.
The facility failed to investigate allegations of abuse and injuries for two residents. One resident was involved in multiple altercations, including pouring coffee on another resident, but these incidents were not reported or investigated. Another resident was found with a bruised and swollen eye, but no investigation or reporting was conducted. The facility's policy requires immediate investigation of such incidents, which was not followed.
A resident admitted with epilepsy and dementia did not receive a required Level II PASARR screening after staying beyond the 30-day exemption period. The facility's Administrator, acting as the Social Worker, acknowledged the oversight, attributing it to a focus on guardianship issues following a recent change in ownership.
A resident who only speaks Arabic was not provided with adequate communication interventions, as the facility failed to utilize available resources such as an interpreter hotline and an Arabic flip guide. The care plan relied on an activities aide or family for translation, but on the day of observation, the aide was off duty, leaving staff unable to communicate effectively with the resident.
A facility failed to ensure a safe discharge for a resident with a tracheostomy and PEG tube, who was released without home health care or adequate nutrition. The DON stated that discharge planning usually involves the IDT, but the facility lacked a social worker to coordinate with outside agencies. No discharge progress note or home health care agency was ordered in the resident's medical record. The identified home health care agency confirmed the resident was not on their caseload due to insurance issues, which was communicated to the facility.
The facility failed to coordinate follow-up appointments for two residents, one with breathing issues and another with a tracheostomy and PEG tube, as per hospital discharge instructions. Additionally, there were errors in transcribing medication orders for a resident, leading to discrepancies and unnecessary contact isolation. These deficiencies highlight issues in care coordination and medication management.
A resident with hearing difficulties did not receive timely follow-up on audiology recommendations, including medical clearance for hearing aids and wax removal. Despite multiple physician notes and an audiology consult indicating moderate to severe hearing loss, the facility failed to act on these recommendations, leaving the resident without necessary hearing aids.
A resident with a diagnosis of shortness of breath was observed receiving oxygen at 5 liters per minute, contrary to the physician's order of 4 liters. An LPN documented the incorrect oxygen level without verification. The DON confirmed that nurses should verify oxygen levels before documentation.
A resident with severe cognitive impairment and multiple medical conditions developed a Stage 2 pressure ulcer that worsened to Stage 4 with osteomyelitis due to a lack of timely physician oversight. The facility failed to ensure medical evaluations were conducted from the ulcer's identification until a new wound physician was contracted, highlighting a significant deficiency in care.
A resident was not seen by a physician or physician extender at least once every 30 days for the first 90 days after admission, despite significant health changes and hospital admission. The resident developed a pressure ulcer and was diagnosed with acute osteomyelitis, aspiration pneumonia, and sepsis. The DON confirmed the lack of timely evaluations.
A facility failed to evaluate a CNA's competency, resulting in unsafe care for a resident with severe medical needs. The CNA provided care alone, contrary to the care plan requiring two-person assistance, and admitted to not consulting care plans or nurses. The facility lacked documentation of competency evaluations for the CNA.
The facility failed to properly manage controlled medications, leading to inaccurate documentation and potential diversion. An LPN was observed using a blank form for morphine, not accounting for unopened bottles, and inaccurately documenting Klonopin removal. The facility's policies lacked specific procedures for controlled substances, contributing to the deficiency.
The facility did not follow its medication storage policy, as observed when a refrigerator temperature checklist was outdated and applesauce was stored with medications. The DON confirmed the lapse, noting nightshift nurses were responsible for temperature checks. The policy requires medications to be stored separately from foods.
A resident with intact cognition and diagnoses of pain and dysphagia required dental extractions for fractured teeth. Despite recommendations from dental evaluations in February and April, the facility failed to make the necessary referral to an oral surgeon. The resident expressed ongoing pain and concern, and a July appointment was not completed due to the absence of a guardian. The facility administrator cited the lack of a social worker as a reason for the oversight.
A facility failed to coordinate and document a hospice care plan for a hospice respite patient. The DON admitted that communication with the hospice company was only verbal, with no formal documentation or log. The issue was acknowledged, but no further information was provided by the survey exit.
The facility failed to educate and offer the pneumococcal immunization to two residents, as required by its policy. The medical records for these residents lacked documentation of education or offering of the vaccine, and there was no indication of medical contraindications or prior immunization. The ICN overseeing vaccinations could not provide the necessary documentation, highlighting a lapse in policy adherence.
The facility failed to educate and offer the COVID-19 vaccine to two residents, as required by their policy. Medical records for both residents lacked documentation of education or vaccine offers, and there was no indication of medical contraindications or prior vaccinations. The ICN confirmed the absence of documentation and mentioned a new process for handling immunization education and consents.
The facility did not provide necessary Medicare/Medicaid notifications to residents, failing to issue Advance Beneficiary Notices (ABNs) to three residents and Notices of Medicare Non-coverage (NONMCs) to two residents. The facility was unable to locate the required documents during the survey.
A resident with a tracheostomy and severely impaired cognition was known to be noncompliant with their trach care, frequently removing the trach collar and cannula. Despite this, the facility failed to implement effective interventions to manage the resident's behavior. The resident was found unresponsive with the trach collar and tubing on the floor, leading to CPR and hospital transfer. Interviews revealed that staff were aware of the noncompliance, but no adequate interventions were documented or implemented.
The facility failed to maintain a separate accounting system for residents' trust funds, resulting in delayed credits and lack of financial statements for a resident. The resident's guardian reported ongoing issues and confusion about the account status, which was confirmed by facility records and staff interviews.
The facility failed to report an incident where a resident with vascular dementia and severely impaired cognition punched another resident, causing a small red circle under the eye. The incident was documented and reported internally but was not reported to the State Agency as required. The Administrator was unaware of the incident until questioned and found no evidence of an investigation or report to the SA.
Failure to Protect Resident From Physical Abuse and Address Psychosocial Impact After Resident‑to‑Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to address the abused resident’s subsequent psychosocial needs. On the evening of 1/10/26, one resident who ambulated without a device was walking in the hallway when another resident, who used a wheelchair, appeared to roll over the ambulatory resident’s foot. Witness statements from a CNA and an LPN indicated that the ambulatory resident then came around behind the wheelchair user near the elevator and punched the wheelchair user in the nose with a closed fist, causing immediate nasal bleeding, crying, and visible distress. The assaulted resident verbally stated that the other resident had hit her, and the aggressor resident was heard saying, “No, I meant to do it. These people are always touching me and rubbing on me. I'm tired of it.” The aggressor resident later told the NHA, DON, and surveyor that he had “knocked her in the face” or “punched her in the nose” after she ran over his foot or grabbed his pants, and acknowledged feeling angry and not liking to be touched. The assaulted resident had multiple diagnoses, including vascular dementia, generalized anxiety disorder, bipolar disorder, prior subarachnoid hemorrhage, muscle wasting, and malnutrition, and was severely cognitively impaired per a BIMS score of 6/15. Following the punch, she was emergently transferred to the hospital, where imaging confirmed bilateral nasal bone fractures. Progress notes and pain logs documented pain rated 10/10 requiring additional PRN acetaminophen, as well as visible anxiety and refusal of vital signs at the time of transfer. A subsequent physician note confirmed recent nasal fractures from being struck by another resident, described a small bruise on the bridge of the nose, and noted ongoing pain management with acetaminophen and morphine. The physician also documented that the resident was experiencing an acute psychotic episode with delusions and agitation in the context of recent trauma and hospitalization. The aggressor resident also had significant cognitive and psychiatric diagnoses, including dementia, schizophrenia, diabetic neuropathy, and an adjustment disorder with anxiety, and had a BIMS score of 6/15. Facility records showed a prior resident‑to‑resident assault by this same resident on another female resident months earlier, in which he struck her with a closed fist and police were contacted, with 15‑minute checks implemented for 48 hours. Despite this history and the facility’s abuse policy defining physical abuse as willful infliction of injury by non‑accidental means (including hitting and punching) and requiring immediate protection of residents and care plan revision when needs change as a result of abuse, the investigation documents indicated the facility did not verify that abuse occurred in the 1/10/26 incident. Additionally, review of the assaulted resident’s care plan showed no updates to address protection or psychosocial concerns after the event, even though the resident later reported feeling terrible about the incident, described ongoing head and ear pain, recounted bruising and attempts to cover it with makeup, and stated she did not feel safe in the facility and wanted to go home. A police report classified the event as a simple assault/battery, documented the aggressor’s admission that he punched the victim once in the face, and verified that a facility nurse witnessed the punch. The facility’s own abuse and neglect policy, updated 6/18/25, stated that abuse includes willful infliction of injury such as hitting and punching, and that any person, including other residents, may be a potential aggressor. The policy required immediate steps to assure resident protection and revision of the resident’s care plan if medical, nursing, physical, mental, or psychosocial needs changed as a result of an incident of abuse. In this case, the documented willful punch to the face by one resident against another, resulting in nasal fractures, severe pain, anxiety, and later expressed fear and lack of safety by the victim, along with the absence of care plan revisions to address the victim’s psychosocial needs, formed the basis of the deficiency for failure to protect the resident from abuse and to respond appropriately to the consequences of that abuse.
Failure to Ensure Consistent Availability of Linens and Laundry for Resident Hygiene and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not ensuring consistent availability of bath linens and adequate laundry services for multiple residents. An anonymous complaint alleged there were not enough linens to meet residents’ care needs. During interviews, several CNAs reported that linens, especially towels and washcloths, were short almost all the time, with some shifts starting with no linen available. CNAs described cutting bath blankets and using pillowcases to clean residents, and stated that shortages delayed resident care and showers. One CNA stated they did not understand the linen system and noted that laundry was typically done only in the morning, with no one staying to wash at night. Residents also reported not receiving necessary linens and hygiene items. One resident stated they did not get towels or washcloths and that staff had never offered them, relying instead on hygiene wipes brought by family and expressing a desire to use water for cleaning. Another resident reported that towels were short, they could not take showers as needed, and they had to “fight for a shower.” A resident described aides coming in and stating they were completely out of washcloths and towels and could not change the resident until they found some, resulting in the aides going on a “scavenger hunt” for linens. A family member reported that a resident had no laundry or clothes in the room, that a blanket brought from home had gone missing, and that most of the time the resident had no clothing available despite the family frequently refilling drawers. Observations of the clean utility linen supply closets on multiple units showed no washcloths and only a few towels, and no towels or washcloths were seen in residents’ rooms during interviews. The Housekeeping Supervisor reported that one laundry staff member had left and another had a broken arm, acknowledged that the laundry department was responsible for stocking clean utility rooms, and speculated that staff or residents might be keeping extra supplies in rooms. When the laundry room was toured, washers were running mainly with sheets, and there were no clean towels or washcloths in the clean laundry bins. A separate, closed construction unit—unavailable to floor staff—contained numerous unopened boxes of new towels and washcloths that were not in circulation; the Housekeeping Supervisor had no explanation for why these were not being used. The NHA later stated that this was considered emergency stock and that they believed staff had been delivering needed linens, although this was not supported by staff or resident reports or surveyor observations. Additional issues with residents’ personal clothing were identified. One resident, who was fully alert and oriented, reported frequently missing dresses and pants, and a room inspection with the NHA and Housekeeping Supervisor found only a few dresses and no pants. Another resident’s family member reported that the resident’s clothes and blanket repeatedly disappeared in laundry, that drawers were often empty of clothing, and that on the day of observation there were no clothes in the room except for a damp, urine-smelling shirt and pants that did not belong to the resident. The assigned CNA confirmed there were no clothes in the room and acknowledged ongoing shortages of washcloths, towels, and linens since starting work three months earlier, stating they had resorted to using wipes and draw sheets for care. The laundry aide reported linen shortages on the units, attributed mainly to being down two laundry staff, and stated that while supply was not the main problem, there was insufficient staff to get clothes and linens up to the floors. The facility had no written linen or laundry policy, and the only provided environmental services policy did not address laundering linens or residents’ clothing. Following the surveyor’s identification of concerns, later observations showed the clean utility rooms stocked with ample washcloths and towels, and no further shortages were reported during the remaining survey period. However, the deficiency centers on the period when residents and staff experienced ongoing shortages of towels, washcloths, and clothing, the lack of a defined linen/laundry policy, and the existence of substantial unused linen stock stored in an inaccessible construction area while residents lacked basic linens and adequate laundry support for personal hygiene and comfort.
Failure to Provide Adequate Supervision to Prevent Multiple Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure adequate supervision to prevent multiple resident-to-resident altercations involving cognitively impaired and behaviorally complex residents. In one incident, a nurse heard a resident with severe cognitive impairment and a history of aggression yell at another resident to get out of his room, followed by observation of the second resident on the floor in the first resident’s room. The nurse then witnessed the first resident kick the second resident twice in the back/shoulder area while staff were attempting to assist the resident from the floor. Both residents had documented histories of aggression toward others, and both had psychiatric and cognitive diagnoses, including traumatic brain injury, dementia, schizoaffective disorder, bipolar disorder, schizophrenia, PTSD, and anxiety. The facility’s own investigation acknowledged that physical contact occurred between the two residents, resulting in a scratch on one resident’s neck, a cut on the other resident’s arm, and reported back pain. In a separate incident, two roommates were involved in a physical altercation after one resident was moved into the other’s room despite staff concerns. One resident, who was described by staff as aggressive and known not to like having roommates, was placed with another resident who was described as nice and who preferred the door open, in contrast to the aggressive resident’s preference for a closed door. Shortly after the room change, the second resident exited the room distressed and reported being hit by the roommate, initially stating they were hit in the face with a hand and also reporting being struck with a bathrobe related to a misunderstanding over clothing. The resident reported feeling unsafe in that room and only feeling safe after being moved, and staff confirmed that they had previously expressed concerns to administration that this roommate pairing would not be a good fit due to the aggressive behaviors of the first resident. Two additional incidents involved a resident with marked cognitive impairment who did not like others entering his room and another cognitively impaired resident who had a behavior of climbing into other residents’ beds, as well as a separate altercation between the same resident and another cognitively impaired resident in a hallway. In the first of these, staff responded to yelling and found one resident partially on the bed and the other resident in a wheelchair holding the first resident’s wrist and making physical contact. In the second, the resident who believed another resident had stolen his items confronted that resident in the hallway, and both residents struck each other in the face after the confrontation escalated. In all of these events, the residents involved had documented cognitive impairments and behavioral histories, and physical contact between residents was observed or confirmed by staff, demonstrating that supervision and monitoring were insufficient to prevent repeated resident-to-resident altercations. The facility’s staffing policy stated that adequate staffing would be maintained on each shift to ensure residents’ needs and services were met, including supervision and monitoring by licensed nurses and CNAs. Despite this, multiple resident-to-resident physical interactions occurred across different dates and units, involving residents with known behavioral issues and cognitive impairments. Staff interviews indicated that some concerns about roommate compatibility and aggressive behaviors were known prior to at least one of the incidents, yet the room assignment proceeded and an altercation followed. The pattern of events described in the report shows that the facility did not provide adequate supervision or environmental management to prevent these resident-to-resident altercations, resulting in physical contact, minor injuries, and distress for the residents involved.
Failure to Consistently Provide and Offer Required Evening Snacks
Penalty
Summary
The facility failed to ensure the consistent provision and availability of evening and bedtime snacks in accordance with residents’ needs and preferences. One resident, who was alert and oriented and restricted to bed, reported that they had never been provided or offered a snack by the facility and relied on family to bring snacks, expressing a desire to at least be offered something to see if there was an item they liked. Another alert and oriented resident in a wheelchair stated they were missing snacks at times, especially in the evenings, and explained that if they were not at the nurses’ station when snacks were passed out, they did not receive one. This resident described that snacks such as peanut butter and jelly sandwiches, pudding, and chips were available but that residents had to “run to that desk” to get them, and there were days they did not receive a snack despite wanting one daily. A family member of a nonverbal resident reported they were not aware of the resident receiving snacks and stated the resident seemed hungry during visits, leading the family member to request double food portions, which were often not received. During the interview, the nonverbal resident, who used a manual wheelchair, indicated through nonverbal cues (pointing to the surveyor’s and their own stomach and grimacing) that they were hungry at night, which the family member said occurred often. The family member had not been offered a grievance or concern form regarding snacks until prompted during the survey. The Dietary Manager reported that snacks such as chips, cookies, Jello, pudding, sandwiches, and rice crispy treats were prepared and sent to the unit on a tray, but acknowledged awareness of residents stealing and hoarding snacks and stated it was possible staff were taking snacks as they disappeared quickly. Although dry snacks were observed in the Dietary Manager’s office, residents’ reports and staff statements demonstrated that snacks were not reliably offered or made accessible to all residents as required by the facility’s policy, which states that all residents on regular diets are to be offered a bedtime snack each evening and that such snacks must be documented as offered.
Failure to Provide Timely ADL and Incontinence Care Due to Inadequate Staffing
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision of activities of daily living (ADL) care, including toileting and incontinence care, for multiple dependent residents. An anonymous complaint alleged short staffing, residents remaining in wet or soiled briefs for extended periods, and staff sleeping on the night shift, resulting in neglect of basic care needs. CNAs reported that when only two aides were scheduled instead of three on a floor of about 40 residents, they were unable to provide needed care, including timely feeding and two-hour check-and-change incontinence care, particularly on the midnight shift. Facility schedules showed multiple midnight shifts with only two aides assigned per floor despite a census in the 80s and 22 residents requiring lift assistance. Several residents described prolonged waits for assistance with toileting, incontinence care, and other basic needs. One bedbound, fully dependent resident reported that call lights often took up to two hours to be answered, that staff sometimes turned off the call light and said they would return but did not, and that some aides told them they went to the bathroom too often or were not “wet enough” to be changed despite the resident being on Lasix. This resident recounted an incident where a midnight aide performed inadequate perineal care, leaving stool that became hard and caked on by morning, which made the resident feel awful. Another bedbound, fully dependent resident reported waiting 1–2 hours after activating the call light to be changed, which caused frustration. Two alert, oriented residents who used manual wheelchairs reported frequently waiting about an hour or longer in bed for help with transfers, toileting, water, and medication, including an instance of waiting about an hour and a half for tray pickup and ice, and over an hour for an anxiolytic medication. Another resident’s family member reported repeatedly finding the resident “soaked” in urine during visits, including on the morning of the survey, and the resident nonverbally confirmed distress about being wet. These accounts, combined with staff interviews and staffing records, demonstrated that residents’ ADL and incontinence care needs were not being met in a timely manner, contrary to the facility’s written staffing policy stating that adequate staff would be maintained on each shift to meet residents’ needs and services.
Failure to Provide Consistent, Person-Centered Activities as Scheduled
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent, meaningful, person-centered activities as scheduled and in accordance with residents’ preferences. One resident reported that the Activity Director posted monthly activity calendars but did not follow them, resulting in missed activities, particularly on weekends, such as BINGO and brain games. This resident stated that activity staff never conducted room visits, that music activities did not reflect their preferences, and that they were usually not taken on community outings when other residents went into the community. The resident described being bored on weekends and said they would attend activities if they were consistently offered. They also reported not being notified when activities were cancelled or times were changed, which caused frustration and upset. Surveyor observations corroborated these concerns. The activity calendar in the resident’s room showed a scheduled Brain Games activity on a Saturday, but the resident reported that when they went to attend, no one came to the activity room. The first-floor activity calendar posted in the dining room showed BINGO scheduled at a specific time, but when the surveyor observed the room during that period, there was no BINGO activity and no activity staff present. Another resident was observed waiting in their wheelchair in the dining room for BINGO to start and reported that activity staff were always late, that activities did not start on time, and that there were no activities on Sundays and some Saturdays. This resident stated that BINGO, previously held three times a week, was now only on Mondays and expressed frustration with the delays and missed activities. Further observations showed that the resident who had been waiting for BINGO left after waiting approximately 40 minutes, along with at least three other residents, and no activity staff or BINGO activity were present during that time. BINGO was later observed to have just started nearly an hour after the scheduled time. The Activity Director acknowledged that BINGO started late and attributed delays and missed activities to staffing shortages, a no call/no show by an activity aide, and the need to cover activities on both floors with limited staff. The Activity Director also acknowledged that activities were getting missed more often on the first floor, where residents were more independent, and that there were simultaneous activities scheduled on both floors that could not be covered by the available staff. Review of activity logs for the two residents showed participation on only a portion of days in the look-back period, similar dates with no activities documented, no refusals recorded, and minimal Sunday activities, despite a posted calendar indicating a full schedule. The facility’s policy stated that residents would be informed of activities through posted calendars, announcements, and individual communication, and that assistance would be provided to residents who wished to participate but could not get to activities on their own, but the documented and observed practices did not align with these procedures.
Failure to Protect Residents from Physical Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in multiple resident-to-resident altercations that caused significant harm. One incident involved a resident with moderate cognitive impairment and a history of behavioral disturbances punching another resident in the face twice, breaking the victim's jaw. Witness statements and medical records confirmed that the altercation was witnessed by staff, and the injured resident reported severe facial pain and was subsequently transferred to the hospital for evaluation and treatment. The facility's documentation submitted to the State Agency did not accurately reflect the severity of the incident, as more detailed accounts in witness statements and the electronic medical record described greater injury and aggression than initially reported. Another incident involved the same resident who sustained the jaw fracture later pushing a third resident to the floor, then kicking and attempting to run over the resident with a wheelchair. Witness statements from nursing staff described observing the aggressor kicking the fallen resident and running into her with the wheelchair. The clinical record for the aggressor documented a history of combative and aggressive behaviors toward both residents and staff, including entering other residents' rooms, rummaging through belongings, and being verbally and physically aggressive. Despite this documented pattern, the facility's reporting to the State Agency again did not fully capture the extent of the altercation as described in internal records and staff statements. Interviews with staff revealed that some incidents of resident-to-resident aggression were not reported to facility leadership or the State Agency, and that staff had not received additional training on abuse reporting expectations. Staff also reported overhearing inappropriate comments from other staff members regarding the incidents, and there was acknowledgment of discrepancies between witness statements and the facility's official investigation documentation. The facility's abuse and neglect policy defined physical abuse and willful actions but did not appear to be consistently followed in practice, as evidenced by the incomplete and inaccurate reporting of serious resident-to-resident abuse events.
Failure to Timely Report and Accurately Document Suspected Abuse Incidents
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to ensure the timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act. In multiple incidents involving three residents, staff did not accurately or promptly report resident-to-resident physical altercations to the appropriate authorities. Documentation submitted to the State Agency did not fully represent the extent of the events as recorded in witness statements and the electronic medical record (EMR). For example, an incident where one resident struck another in the face was not reported to the Administrator until approximately seven hours after it occurred, and the initial report did not reflect the severity of the injury, which was later determined to be a fractured jaw. Further review revealed that staff, including a nurse who witnessed the incidents, did not consistently report all observed altercations. The nurse described witnessing additional aggressive interactions between residents, including physical assaults, but admitted to not reporting some of these events. The nurse also indicated a lack of training regarding the facility's abuse reporting protocols and expectations. There was no evidence that this nurse had received any abuse prevention or reporting education from the facility, despite the facility's claim of recent staff education efforts. Interviews with the Administrator and DON confirmed gaps in understanding and execution of reporting requirements. The Administrator delayed reporting an incident based on an initial assessment that there was no injury, only reporting after learning of a serious injury. The facility's own policy required immediate reporting of all allegations or suspicions of abuse to the Administrator and state agencies, but this was not followed. Additionally, the facility could not provide evidence that all staff, including agency nurses, had received the required training on abuse reporting procedures.
Insufficient Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents on the second floor, as evidenced by multiple observations and interviews. On the day in question, only two CNAs were present for the first part of the shift due to a third CNA arriving late, and staff were unclear about their assignments. As a result, residents did not receive fresh water for two days, meal trays were delivered incorrectly or left in rooms for extended periods, and staff were unaware of which residents they were responsible for. Several residents, many with dementia or Alzheimer's disease, were observed without water within reach, with empty or outdated cups, or with no water available at all. Additionally, residents with a history of wandering were not redirected by staff, despite being observed entering and exiting multiple rooms that were not their own. Staff present in the hallway did not intervene or provide supervision. Interviews with CNAs and the RN assigned to the unit revealed that the workload was heavy, and tasks such as passing water and meal trays were delayed or not completed. The RN reported that medications were sometimes not given timely due to the workload, and agency CNAs were unfamiliar with their assignments and had not provided basic care such as water or meals to residents by mid-morning. The staffing coordinator and unit manager both confirmed that staffing was based solely on census rather than resident acuity, and that agency staff were used to fill gaps due to retention challenges. The facility's own policy stated that adequate staffing should be maintained to meet residents' needs, but this was not achieved. The administrator and unit manager acknowledged that the lack of fresh water and delayed care should have been identified and addressed, but it was not recognized until brought to their attention during the survey.
Failure to Follow Grievance Policy and Provide Family Follow-Up
Penalty
Summary
Facility administration failed to adhere to its grievance policy regarding a resident with epilepsy, dementia, and cognitive communication deficit, who required staff assistance for all activities of daily living. The resident's family, who are also the legal guardians, submitted concerns about the frequency of changing and catheter monitoring. The facility's grievance documentation indicated that the family was not satisfied with the resolution and requested continued updates. However, there was no documented follow-up with the family after their concerns were verbalized. The facility's grievance policy requires the administrator or designee to contact the concerned party within 24 hours of receiving a grievance, provide written and oral explanations of findings within three to seven days, and maintain frequent contact until resolution. In this case, the administrator acknowledged that the follow-up was not completed, attributing the lapse to being off duty and leaving the responsibility to the DON, who was also unavailable. No further explanation or documentation of follow-up was provided by the end of the survey.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training, inconsistent documentation, and a lack of clear reporting mechanisms for suspected incidents. As a result, the facility was unable to demonstrate that it had taken adequate steps to protect residents from potential harm related to abuse, neglect, or theft.
Failure to Provide Grooming Assistance as Required by Care Plan
Penalty
Summary
A deficiency was identified when staff failed to provide necessary assistance with grooming for a resident who required help with activities of daily living (ADLs). The resident, who had diagnoses including epilepsy, dementia, and cognitive communication deficit, was assessed as having moderately impaired cognition and required staff assistance for all ADLs. The care plan specifically included an intervention, at the family's request, for the resident to be kept clean shaven. Despite this, the resident was observed with significant facial hair and in need of a shave during a surveyor's visit. Review of the medical record and CNA documentation showed that personal hygiene tasks, including shaving, were marked as completed multiple times on the days in question. However, direct observation contradicted these records, as the resident's facial grooming had not been performed according to the care plan. The unit manager confirmed that staff were expected to shave the resident during morning care, but no further explanation or documentation was provided regarding the discrepancy between the documentation and the resident's observed condition.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two separate incidents where one resident physically assaulted two other residents. In the first incident, a resident with severe cognitive impairment and multiple psychiatric diagnoses punched another resident in the face with a closed fist, resulting in swelling and pain near the lower jaw. The assaulted resident, who was receiving hospice care and had severe cognitive impairment, reported pain and swelling but was unable to provide a pain scale rating. In the second incident, the same resident exited his room while agitated and yelling, and punched another resident in the right cheek with a closed fist. This second victim was also on hospice care and had moderate cognitive impairment. Progress notes documented the physical assault and subsequent pain experienced by the resident. The aggressor was later placed on 1:1 supervision and transferred to a hospital following continued aggressive behavior. Despite clear documentation of physical contact and resulting pain and swelling, the facility concluded that abuse could not be substantiated, citing lack of intent due to the aggressor's poor cognition and the victims' inability to recall the incidents. The facility's policy defines abuse as causing physical harm, pain, or mental anguish, regardless of the perpetrator's mental or physical condition, and specifies that 'willful' refers to deliberate action, not necessarily intent to harm.
Failure to Implement Nonpharmacological Interventions and Behavioral Health Services Prior to Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that nonpharmacological interventions were implemented and utilized before administering pharmacological interventions for a resident with a history of traumatic brain injury, acute respiratory failure, acute embolism and thrombosis, and major depressive disorder. The care plan for fall risk included offering PRN anxiolytic medication for increased anxiety, despite the absence of an anxiety diagnosis for the resident. Documentation showed that Lorazepam was administered without evidence of targeted behaviors or moods warranting its use, and there was no record of consent for starting the medication. Additionally, there was no documentation of non-pharmacological interventions attempted prior to medication administration, nor was there a care plan for anxiety in place. A behavioral consultation was ordered but not completed, and the resident was not seen by behavioral health services as required. Facility policies require that psychoactive drugs only be used with a diagnosed specific condition and after alternative measures or consultation with appropriate health professionals. The facility did not follow these protocols, as evidenced by the lack of behavioral health service provision, absence of a person-centered behavioral care plan, and failure to document or attempt non-pharmacological interventions before administering a psychotropic medication.
Failure to Investigate Falls and Ensure Correct Interventions
Penalty
Summary
The facility failed to fully investigate two falls involving a resident, R804, and did not ensure that correct interventions were in place. R804 was transferred to the hospital emergency room due to low blood pressure, where it was discovered that the resident had multiple fractures in both femurs. The facility did not report these injuries to the hospital upon admission, and the incident was later addressed as an injury of unknown origin. R804's clinical record indicated a high risk of falls, with a Fall Risk Assessment score of 20. Despite this, the facility did not complete recommended follow-up radiographs after initial x-rays showed abnormal findings. The resident experienced two falls, one on 12/6/24 and another on 12/10/24, during transfers. The facility's documentation was incomplete, lacking interviews with involved CNAs and failing to identify all staff present during the incidents. Additionally, the care plan intervention to use a two-person assist for ambulation was not consistently documented or followed. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition and the necessary follow-up actions. Nurse F was unaware of the need for additional x-rays, and the Director of Nursing did not believe the falls caused the fractures, despite the lack of thorough investigation. The facility's fall prevention policy was not effectively implemented, as evidenced by the inadequate tracking and intervention for R804's falls.
Plan Of Correction
1. Resident 804 no longer resides in the facility. 2. All residents that are categorized as “High Risk for Falls” based on their most recent fall assessment, or residents that have sustained a fall in the last 30 days, have the potential to be affected by the alleged deficient practice. By 3/7/2025, these identified residents will have their fall Care Plan reviewed by the Clinical IDT team to ensure appropriate fall interventions were in place and updated as needed. Any resident that has sustained a fall in the last 30 days will have their chart reviewed to ensure an IDT RCA along with a complete physical assessment of the resident has been completed and documented. 3. By 3/7/2025, the DON/designee will provide the following to all Clinical IDT members and licensed nurses: a. Fall Investigation Education with specific attention on determining and documenting the root cause of fall. b. Fall Prevention Education with specific attention on implementation of appropriate interventions. 4. The DON/designee will review 5 residents with sustained falls to ensure that a root cause analysis has been completed and documented, with immediate implementation of post-fall intervention along with a complete physical assessment of the resident. This review will occur 5 days per week for 4 weeks, then monthly thereafter for 3 months, or until substantial compliance has been maintained. Results will be presented monthly at the QAPI meeting for committee review. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 3/7/2025 and for sustained compliance thereafter.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for two residents, R58 and R22, and did not implement treatments in a timely manner or according to physician orders. Resident R58 developed a stage II pressure ulcer that progressed to a stage IV with acute osteomyelitis, while R22 developed an unstageable pressure ulcer. Observations revealed that R58 was consistently positioned on his back without appropriate off-loading devices, and there was a lack of timely medical provider oversight after the development of the pressure ulcer. R58 was admitted with severe cognitive impairment and was dependent on staff for mobility. Despite being at high risk for pressure ulcers, as indicated by a Braden Scale score, the facility did not adequately assess or document the progression of R58's wounds. There were inconsistencies in the documentation regarding the location and treatment of the pressure ulcers, and treatments were not administered as ordered. R58 was not evaluated by a medical provider after the development of the pressure ulcer until much later, contributing to the worsening of the condition. For R22, the facility failed to follow physician orders to keep the resident out of a wheelchair to prevent pressure ulcers. R22 was observed seated for extended periods, contrary to orders. The facility's documentation was inconsistent, with a pressure ulcer being identified as unstageable without prior documentation of its development. The facility's policy required weekly skin assessments and timely treatment, which were not adhered to, resulting in the development of an unstageable pressure ulcer.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to timely identify and address significant weight loss in a resident, referred to as R25, who experienced an 11.67% weight loss over six months. Observations revealed that R25 was found in bed with an uneaten breakfast tray and was not responsive to questions, although they continued to sip milk. The facility did not have staff present in the room at the time of observation. A review of R25's records showed a gradual weight loss from April to August 2024, which was not promptly identified or addressed by the facility staff. The care plans lacked updated nutritional interventions since 2023, and the facility's policy on nutrition monitoring was not followed, as R25 was not weighed weekly despite meeting the criteria for significant weight loss. The Registered Dietician (RD) C, who began working at the facility in August 2024, acknowledged the delay in identifying R25's weight loss and implementing interventions. RD C stated that they could not account for the actions of the previous dietician but took steps to address the issue once they became aware of it. The facility's policy required that any resident experiencing significant weight loss be evaluated by the Interdisciplinary Team and weighed weekly, but these measures were not in place for R25 at the time of the survey. No further explanation or documentation was provided by the facility by the end of the survey.
Sanitation Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Raw chicken was found under running water directly inside the sink basin of a two-compartment sink, with an internal temperature of 67 degrees Fahrenheit. Dietary Staff M indicated that the chicken was initially in the walk-in cooler but was still frozen, leading to its placement in the sink for thawing. However, no explanation was provided for why the chicken remained in the sink at such a high temperature, which is inconsistent with the 2017 FDA Food Code requirements for thawing potentially hazardous food. Additionally, in the walk-in cooler, several food items were found undated, including pans of leftover enchiladas, white sauce, gravy, an opened package of bologna, and containers of Italian, ranch, and creamy Caesar dressings. Dietary Staff M confirmed that these items should have been dated upon opening. According to the 2017 FDA Food Code, ready-to-eat, potentially hazardous food held for more than 24 hours must be clearly marked with the date by which it should be consumed or discarded, which was not adhered to in this instance.
Failure to Employ Full-Time Social Worker Leads to Deficiencies
Penalty
Summary
The facility, licensed to care for 126 residents, failed to employ a full-time qualified social worker, resulting in multiple deficiencies in social services. These deficiencies included inadequate coordination of advance directives, leading to improper documentation of residents' desired code status in their clinical records. Additionally, there was a failure in discharge planning, which resulted in an unsafe discharge without necessary home health care services. The facility also did not complete Preadmission Screening and Resident Review (PASRR) assessments and failed to facilitate ancillary services such as dental and audiology, as well as assess residents for their social service needs. During an onsite annual recertification survey, it was revealed that the facility had a change in ownership on August 1, 2024, and had not employed a qualified social worker since the previous social worker's last day on March 28, 2024. The Human Resources Director and Corporate HR confirmed that various individuals were assisting with social services since the change in ownership, but none were onsite full-time. A new social worker was scheduled to start on September 4, 2024, but until then, the facility was without a full-time social worker, affecting the care of all 62 residents residing in the facility.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to consistently implement infection control standards and practices, affecting all 62 residents during the survey period. The Infection Control Nurse (ICN), who also served as the facility's Infection Preventionist, was responsible for the infection control program but was unable to provide monthly Infection Control Analysis reports for May, June, or July 2024, and there was no surveillance log for July 2024. The ICN, who had multiple roles including staff development coordinator and unit manager, devoted only four hours per shift to the infection control program and was unaware of the requirements for the analysis report. Additionally, the facility's infection mapping was inaccurate, as evidenced by discrepancies in the July 2024 antibiotic audit. A specific incident involving a resident with a tracheostomy tube and PEG tube highlighted further infection control deficiencies. During trach care, an LPN failed to perform hand hygiene between glove changes, moving from a dirty to a clean procedure, which was against the facility's infection control policy. The Director of Nursing confirmed that the LPN should have changed gloves and performed hand hygiene between cleaning secretions and applying clean gauze. This incident, along with the overall lack of effective infection control practices, demonstrates significant lapses in the facility's infection prevention and control program.
Deficiencies in Fall Prevention, Care Assistance, and Resident Supervision
Penalty
Summary
The facility failed to identify the root cause of multiple falls and implement effective interventions to prevent falls for a resident, resulting in multiple falls with injuries. The resident, who had dementia and severely impaired cognition, was observed in various positions and settings without consistent interventions to prevent falls. Despite being identified as a fall risk, the facility did not conduct thorough investigations or implement new interventions after each fall. The facility's documentation was inconsistent, with missing incident reports and follow-up assessments for several falls. Another deficiency involved the facility's failure to provide care according to a resident's assessed level of assistance. A resident with severe cognitive impairment and multiple medical conditions, including a tracheostomy and PEG tube, required assistance from two staff members for bed mobility. However, a CNA was observed providing care alone, contrary to the resident's care plan. The CNA reported not having access to care plans and deciding on the level of assistance independently, which was not in line with the facility's procedures. The facility also failed to ensure appropriate supervision to prevent resident-to-resident altercations. A resident with a history of aggressive behaviors and dementia was involved in multiple incidents of aggression towards other residents. Despite being identified as needing supervision, there were instances where the resident was left unsupervised, leading to altercations. The facility's lack of supervision and failure to implement effective interventions contributed to these incidents.
Deficiencies in Social Services Provision
Penalty
Summary
The facility failed to provide medically related social services to eight residents, as identified during an onsite annual recertification survey. The deficiencies included a lack of effective coordination of advance directives, resulting in improper documentation of residents' desired code status in their clinical records. Additionally, there was inadequate discharge planning, leading to an unsafe discharge without necessary home health care services. The facility also failed to complete PASARR assessments and did not facilitate necessary ancillary services such as dental and audiology, nor did they assess residents for their social service needs. For Resident #59, the medical record review revealed that despite being admitted with diagnoses of Bipolar disorder and Dementia, there were no completed social service assessments to identify any medical or psychosocial needs. The Director of Nursing confirmed the absence of such assessments. Similarly, Resident #60, who had diagnoses including Hemiplegia and Hemiparesis following a cerebral infarction, expressed a desire to speak with a social worker for assistance with discharge planning and applying for Social Security. However, no social service assessments were completed for this resident either. The facility experienced a change in ownership, and since the previous social worker's resignation, there was no qualified social worker employed full-time. Various individuals were assisting with social services, but not on a full-time or onsite basis. This lack of consistent social service support contributed to the deficiencies observed during the survey, as the facility failed to meet the social service needs of its residents, impacting their overall quality of life.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain and implement an effective antibiotic stewardship program, affecting multiple residents who were prescribed and administered antibiotics. The deficiency was identified through a review of infection surveillance logs from April, May, and June 2024, which revealed a lack of documentation on whether infections met the criteria for an infection. For instance, a resident was prescribed Cephalexin for swelling and pain from an IV site, but the antibiotic was discontinued after a hospital admission revealed no infection. Another resident was readmitted from the hospital with pneumonia and started on Doxycycline, yet there was no documentation reviewing the appropriateness of the antibiotic. Further deficiencies were noted in June and July 2024. A resident was administered Levaquin for an unspecified infection without documentation of the infection type or criteria. Another resident was prescribed Amoxicillin-Pot Clavulanate for a UTI, but there was no documentation of symptoms meeting UTI criteria or the appropriateness of the antibiotic. In July, an audit revealed a resident on Macrobid for a UTI without a completed surveillance log or documentation of infection criteria. The Infection Control Nurse acknowledged the lack of documentation and stated that a new program would address these issues, but concerns about infection criteria and antibiotic appropriateness remained.
Failure to Honor Advanced Directives for Two Residents
Penalty
Summary
The facility failed to ensure effective communication regarding advanced directives for two residents, R48 and R315. For R48, there was a discrepancy between the documented Do Not Resuscitate (DNR) order and the information available to the nursing staff. R48's medical record indicated a DNR status, signed by the resident's power of attorney and physician, yet Nurse D was under the impression that R48 was a full code, meaning they would perform full resuscitation if necessary. This inconsistency was noted during a conversation with the Administrator, who acknowledged the importance of aligning the profile page with the documented wishes to honor the resident's directives. For R315, there was a similar issue with the communication of code status. Although R315 expressed a desire to be a DNR and believed they had signed the necessary documents, the facility's records still listed them as a full code. The hospice nurse confirmed R315's DNR status, but the Director of Nursing (DON) was unaware of this and stated that the resident was a full code according to the hospice company. Upon further investigation, a signed DNR document for R315 was found in the hospice communication binder, indicating a lack of proper communication and documentation within the facility. These deficiencies highlight the facility's failure to maintain accurate and consistent records of residents' advanced directives, leading to potential miscommunication among staff and the risk of not honoring residents' end-of-life wishes. The discrepancies in the documentation and communication processes for both residents underscore the need for improved coordination and verification of advanced directives within the facility.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as R11, to the State Agency. R11, who had diagnoses including psychotic disorder with delusions, anxiety, and dementia, was involved in an incident where they poured coffee on another resident, R37, and grabbed them, resulting in an abrasion to R37's cheek and discoloration to their lower right arm. Despite the incident being documented in the nurses' notes and reported to the family, unit nurse, administrator, and medical doctor, the facility did not report the allegation to the State Agency as required by their policy. The facility's policy mandates that all allegations of abuse be reported to the Administrator immediately and subsequently to the appropriate State Agencies. However, during a review of the facility's reported incidents in the State Agency's electronic system, it was found that the incident involving R11 and R37 was not reported. The Administrator confirmed the lack of reporting and documentation to the State Agency, acknowledging that the incident should have been reported and investigated according to the facility's abuse and neglect policy.
Failure to Investigate Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and injuries of unknown origin for two residents, R11 and R25. For R11, the medical record revealed multiple incidents where the resident was involved in altercations with other residents, including an incident where R11 poured coffee on another resident and grabbed them, resulting in injuries. Despite these incidents being documented in the progress notes, the facility did not report them to the State Agency or conduct any investigations. The new Administrator, who started in August 2024, confirmed that these incidents were not reported or investigated. For R25, the resident was found with a bruised and swollen left eye and a cut on the side of the left eye, which required medical attention. The incident was documented in the facility's incident report, but there was no evidence of an investigation or reporting to the State Agency. The current Administrator, who was not in the position at the time of the incident, was unable to provide hospital records or evidence of an investigation. The previous Administrator also did not recall being informed of the incident and stated that they would have initiated an investigation if they had known. The facility's policy on abuse and neglect requires immediate investigation of all allegations and incidents, but this was not followed in the cases of R11 and R25. The lack of investigation and reporting for these incidents represents a failure to comply with the facility's own policies and regulatory requirements, resulting in deficiencies in handling allegations of abuse and injuries of unknown origin.
Failure to Complete Level II PASARR Screening for Resident
Penalty
Summary
The facility failed to ensure a Level II PASARR screening was completed for a resident who remained in the facility beyond the 30-day exemption period. The resident, who was admitted with diagnoses including epilepsy and dementia, was initially given a hospital exemption discharge with a Level I screening indicating mental illness and recent use of antipsychotic or antidepressant medications. Despite the resident's extended stay, the facility did not submit a subsequent Level II screening as required. During an interview, the facility's Administrator, who was temporarily fulfilling the role of the Social Worker, acknowledged the oversight. The Administrator, recently hired following a change in facility ownership, admitted that their focus had been on addressing guardianship issues, which led to the neglect of the PASARR screening requirement. The Administrator confirmed that the resident should have undergone another screening after the initial 30-day period.
Failure to Implement Language Barrier Interventions
Penalty
Summary
The facility failed to implement adequate care plan interventions for a resident with a language barrier, specifically for a resident who only speaks Arabic. During an observation, the resident was seen in a wheelchair, and an attempt to interview them was unsuccessful due to the language barrier. A Certified Nursing Assistant (CNA) confirmed that the resident only speaks Arabic and stated that communication was typically facilitated through an activities aide who speaks Arabic or the resident's family. However, on the day of the observation, the activities aide was off duty, leaving the CNA without a means to communicate effectively with the resident. The resident's care plan, created on 8/30/23, included interventions such as providing a translator as needed, with the translator being the family or activities aide. However, the care plan did not include the use of an interpreter hotline, which the facility had available. The Administrator acknowledged the existence of the interpreter hotline but noted that it was not included in the care plan and that the CNA was unaware of it. Additionally, the facility had a flip guide in Arabic, which was also not utilized. This oversight led to a deficiency in the care provided to the resident, as the staff was not equipped with the necessary resources to communicate effectively with the resident.
Improper Discharge of Resident with Tracheostomy and PEG Tube
Penalty
Summary
The facility failed to facilitate a safe and coordinated discharge for a resident with a tracheostomy and PEG tube. The complaint alleged that the resident was improperly discharged into the community without home health care or adequate nutrition. During an interview, the Director of Nursing (DON) explained that discharge planning typically involves the interdisciplinary team (IDT) to discuss the resident's needs and necessary community resources. However, the facility lacked a social worker to effectively coordinate with outside agencies. It was noted that there was no discharge progress note or home health care agency ordered in the resident's medical record. The home health care agency identified by the DON confirmed that the resident was not on their caseload due to insurance coverage issues, which had been communicated to the facility.
Deficiencies in Follow-Up Care and Medication Transcription
Penalty
Summary
The facility failed to coordinate follow-up appointments for two residents, leading to a deficiency in providing appropriate treatment and care according to orders and residents' preferences and goals. One resident, who had been hospitalized for breathing issues, was supposed to have follow-up appointments with cardiology and pulmonology as per discharge instructions. However, the facility did not assist in making these appointments, and there was no documentation of a medical justification for not following through with the cardiologist and pulmonologist. The resident continued to experience shortness of breath and discomfort, indicating a lack of proper follow-up care. Another resident, who had a tracheostomy tube and PEG tube, was discharged from the hospital with instructions to follow up with a gastrointestinal specialist within 1 to 2 weeks. The facility failed to make this appointment, as confirmed by the Director of Nursing. This oversight in coordinating necessary follow-up care for residents with complex medical needs highlights a significant deficiency in the facility's care coordination processes. Additionally, the facility failed to properly transcribe hospital discharge orders for a resident, leading to medication discrepancies. The resident was placed in contact isolation based on hospital diagnoses, but upon review, it was found that the resident had completed their antibiotics and no longer required isolation. Furthermore, there were errors in transcribing medication orders from the hospital discharge paperwork, including incorrect indications for use and missing orders for prescribed medications. This lack of accurate transcription and verification of medication orders upon admission contributed to the deficiency in care provided to the resident.
Failure to Follow Up on Audiology Recommendations
Penalty
Summary
The facility failed to follow up on audiology recommendations and services for a resident who was hard of hearing. The resident, who was admitted in 2016 with diagnoses including major depressive disorder and Parkinson's disease, had a documented intact cognition with a BIMS score of 14. Despite multiple physician notes indicating the resident's hearing difficulties, there was no record of an audiology assessment or examination in the medical record. An audiology consult from February 2024 noted moderate to severe sensorineural hearing loss in both ears and recommended medical clearance for hearing aids and wax removal, but these recommendations were not followed up. The resident expressed difficulty in obtaining hearing aids and was not directed to the appropriate resources by the facility staff. The Administrator, who was also assisting with social work duties, was unaware of any audiology appointments for the resident until prompted by the surveyor. The Director of Nursing, recently hired, acknowledged the lack of follow-up and added the resident to the audiology list. However, no further documentation or explanation was provided before the end of the survey, indicating a deficiency in the facility's process for ensuring timely follow-up on audiology services.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident identified as R315. On the morning of August 27, 2024, an LPN was observed administering morning medications to R315 and documented the resident's oxygen saturation level as 97% on 4 liters of oxygen. However, upon inspection, the oxygen concentrator was found to be set at 5 liters. When questioned, the LPN acknowledged the error and adjusted the oxygen level to 4 liters, as per the physician's order. The LPN admitted to signing off on the oxygen level without verifying the actual administration level. The resident, R315, was admitted with a diagnosis of shortness of breath and had a physician's order for oxygen at 4 liters per minute via nasal cannula. There was no documentation in the medical record explaining why the oxygen level was increased to 5 liters. The Director of Nursing was informed of the incident and stated that nurses should verify the oxygen levels ordered by the physician before documenting them in the electronic record. The facility's policy on oxygen administration requires that oxygen therapy be administered as ordered by the physician or as an emergency measure until an order can be obtained.
Lack of Physician Oversight for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure physician oversight for a resident with pressure ulcers, leading to a significant deficiency. The resident, who had severe cognitive impairment and was dependent on staff for mobility and hygiene, developed a Stage 2 pressure ulcer that worsened to a Stage 4 with acute osteomyelitis. Despite the progression of the ulcer, there was no documented medical evaluation by a physician from the time the ulcer was first identified on July 4th until August 13th, when a newly contracted wound physician began seeing residents. This lack of timely medical evaluation contributed to the deterioration of the resident's condition. The resident was admitted with multiple complex medical conditions, including traumatic brain injury, respiratory failure, diabetes, and seizures. The facility's records indicated that the resident did not have any pressure ulcers upon admission. However, the facility's documentation and interviews revealed inconsistencies and delays in physician evaluations for pressure ulcers. The Director of Nursing acknowledged issues with timely physician visits, and the LPN responsible for wound care was uncertain about the evaluation process in the absence of a wound provider. This deficiency highlights a critical lapse in medical oversight and documentation for residents with pressure ulcers.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician or physician extender at least once every 30 days for the first 90 days after admission. The resident was initially seen by a physician for a competency evaluation and a History and Physical (H&P) shortly after admission. However, there was no documented evaluation by a medical provider after this initial visit, despite significant changes in the resident's condition, including a hospital admission and the development of a pressure ulcer. The resident experienced several health issues, including staring blankly, yellowish sputum, fever, and eventually required hospital transfer due to severe symptoms. The resident was diagnosed with acute osteomyelitis, aspiration pneumonia, and sepsis upon hospital admission. Additionally, the resident developed a pressure ulcer that worsened over time. The Director of Nursing confirmed the lack of timely physician evaluations and acknowledged the issue with physicians not seeing residents promptly.
Failure to Ensure CNA Competency Leads to Unsafe Resident Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) was evaluated for the necessary skills and techniques to care for residents appropriately. This deficiency was observed when CNA 'H' provided care to a resident, R58, in an unsafe manner that did not align with the resident's assessed needs. R58, who had a tracheostomy tube and a PEG tube, was dependent on staff for all activities of daily living due to severely impaired cognition and other medical conditions, including diffuse traumatic brain injury and acute respiratory failure. Despite these needs, CNA 'H' performed tasks such as changing R58's brief and repositioning the resident alone, without the required assistance of a second staff member as indicated in the care plan. CNA 'H' admitted to not having access to care plans or instructions and relied on personal judgment for the level of assistance needed, stating that he did not consult with the nurse because he had been caring for the resident for a long time. A review of CNA 'H's personnel file revealed no competency evaluation or skills checklist to verify that he was evaluated before working with residents. The facility's administrator acknowledged the lack of completed competency evaluations and performance reviews, indicating a systemic issue in ensuring staff competency.
Deficiency in Controlled Medication Management
Penalty
Summary
The facility failed to establish and implement an effective system for managing controlled medications, which resulted in inaccurate documentation and potential medication diversion. During an observation, an LPN was seen preparing morning medications for a resident and was found to be using a blank controlled form for morphine medication. The LPN stated that unopened morphine bottles were not accounted for until opened, and the facility's staff only counted opened bottles, leading to discrepancies in the medication count. The facility's policy on controlled medications was reviewed and found lacking in specific procedures for receiving and accounting for controlled substances, contributing to the deficiency. Additionally, another incident involved an LPN inaccurately documenting the removal of a controlled substance, Klonopin, for a resident. The LPN recorded the removal of a pill on the count sheet two hours after it was supposedly administered, without actually removing a tablet at the time of documentation. The LPN admitted to not following the appropriate process for accounting for controlled substances, which should have been documented at the time of removal and administration. The DON confirmed that the facility's protocol required immediate documentation of any controlled substance removed from the supply.
Medication Storage Policy Violation
Penalty
Summary
The facility failed to adhere to its policy on the maintenance and storage of medications and foods in the medication storage room. During an observation, it was noted that the refrigerator temperature checklist had not been updated since 8/20/24, indicating a lapse in monitoring. Additionally, two applesauce containers were found stored alongside medications and insulins in the refrigerator. The Director of Nursing (DON) confirmed these findings and acknowledged that the nightshift nurses were responsible for checking the refrigerator temperature. The facility's policy clearly states that refrigerated medications should be kept in closed and labeled containers, separate from foods such as applesauce, and that other foods should not be stored in the medication refrigerator.
Failure to Ensure Dental Referral for Resident
Penalty
Summary
The facility failed to ensure a dental oral surgery referral was made for a resident who required extractions of fractured teeth. The resident, who was admitted with diagnoses including pain and dysphagia, had a BIMS score indicating intact cognition. A dental evaluation in February recommended referral to an oral surgeon for surgical extractions of teeth #2 and #19 due to discomfort from fractured teeth. A subsequent evaluation in April reiterated the need for extraction of tooth #19, which was non-restorable and causing pain. Despite these recommendations, the necessary referral was not made. The resident expressed ongoing pain and concern about the lack of assistance from the facility in addressing their dental needs. A progress note from July indicated that the resident was unable to be seen by a dentist without a guardian present, and the appointment needed to be rescheduled. The facility administrator acknowledged the lack of a social worker to make the referrals and mentioned that a new social worker had been recently hired. This oversight resulted in the resident continuing to experience dental pain without the required surgical intervention.
Lack of Coordinated Hospice Care Plan
Penalty
Summary
The facility failed to ensure a coordinated and documented plan of care for hospice services for a resident identified as R315, who was a hospice respite patient. During an observation, R315 was found lying in bed with a family member present and mentioned being at the facility for a short period. An interview with the Director of Nursing (DON) revealed that communication with the hospice company was conducted verbally, without any formal documentation or log. The DON acknowledged the communication issue and mentioned informing the administrator about the need to communicate requirements and expectations to the hospice company. No additional information was provided by the exit of the survey.
Failure to Educate and Offer Pneumococcal Immunization
Penalty
Summary
The facility failed to provide education and offer the pneumococcal immunization to two residents, identified as R26 and R58, out of five residents reviewed for the pneumococcal immunization. For R26, there was no documentation in the medical record indicating that the resident or their representative had been educated about or offered the pneumococcal immunization. Additionally, there was no documentation showing that the immunization was medically contraindicated or that the resident had already been immunized. R26 was admitted to the facility on an unspecified date. Similarly, for R58, the medical record lacked documentation of education and offering of the pneumococcal immunization to the resident or their representative. There was also no documentation indicating a medical contraindication or prior immunization. R58 was admitted to the facility on an unspecified date and had a readmission on another unspecified date. The facility's policy, dated 8/1/24, states that all residents should be offered the pneumococcal vaccine upon admission, unless contraindicated or already vaccinated, and should receive education about the vaccine's benefits and potential side effects. The Infection Control Nurse (ICN) overseeing the vaccinations was unable to provide the necessary documentation for these residents, indicating a lapse in the facility's adherence to its own policy.
Failure to Educate and Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to provide education and offer the COVID-19 vaccine and/or booster to two residents, identified as R26 and R58, as part of their COVID-19 vaccination policy. Upon review of R26's medical record, there was no documentation indicating that the resident or their representative had been educated about or offered the COVID-19 vaccine. Additionally, there was no record of the vaccine being medically contraindicated or that the resident had already received the vaccine or booster. R26 was admitted to the facility on an unspecified date. Similarly, R58's medical record lacked documentation of education and an offer of the COVID-19 vaccine to the resident or their representative. There was also no indication of medical contraindication or prior vaccination. R58 was admitted and later readmitted to the facility on unspecified dates. The facility's policy, dated 9/23/23, mandates that all residents be offered COVID-19 vaccines unless contraindicated or already vaccinated, with prior education on benefits and side effects. The Infection Control Nurse (ICN) overseeing vaccinations confirmed the absence of documentation for both residents and mentioned a new process under new ownership to bundle education and consents for all immunizations.
Failure to Provide Required Medicare/Medicaid Notifications
Penalty
Summary
The facility failed to provide necessary notifications regarding Medicare and Medicaid coverage to residents, as required. Specifically, the facility did not issue an Advance Beneficiary Notice (ABN) to three residents and failed to provide a Notice of Medicare Non-coverage (NONMC) to two residents. During the survey, a Skilled Nursing Facility (SNF) Beneficiary Notification Review form was completed by the State Agency representative and given to the facility for completion and return. However, the facility administrator was unable to locate any of the requested ABNs and NONMCs for the residents in question by the time of the survey exit.
Failure to Implement Effective Tracheostomy Care and Supervision
Penalty
Summary
The facility failed to provide effective tracheostomy care and supervision for a resident with a tracheostomy, leading to a critical incident. The resident, who had diagnoses including respiratory failure, dysphagia, tracheostomy status, and autistic disorder, was documented to have severely impaired cognition and required assistance for all activities of daily living. The resident was known to be noncompliant with their tracheostomy, frequently removing the trach collar and cannula. Despite this, the facility did not implement adequate interventions to address the resident's noncompliance. On the day of the incident, the resident was found unresponsive on the floor with the trach collar and tubing on the floor, and only the inner cannula in place. CPR was initiated, and the resident was transferred to a hospital. Interviews with facility staff, including a registered nurse and the Director of Nursing, revealed awareness of the resident's noncompliance with their tracheostomy. However, no effective interventions were documented or implemented to manage the resident's behavior. The Director of Nursing acknowledged that continuous monitoring should have been added to the resident's care plan but was not. The lack of appropriate interventions and monitoring contributed to the resident's critical condition and subsequent transfer to the hospital.
Failure to Maintain Resident Trust Fund Accounting
Penalty
Summary
The facility failed to establish and maintain a system that assures complete and separate accounting for residents' trust funds from the facility's operating account. This deficiency was identified through a complaint received by the State Agency, which revealed that a resident's guardian had repeatedly requested financial statements and account audits since December 2023 but received no satisfactory response. The facility's business manager was fired, and the role was left unfilled for a period, leading to further delays and confusion. The resident's guardian reported ongoing issues with the trust fund, including being informed that the account was overdrawn despite having funds available, and not receiving any trust fund account statements for over a year. The facility's records confirmed that the monthly patient allowances were not credited timely to the resident's trust fund account, with a lump sum credit being made only in April 2024, just before the account was closed at the guardian's request. Interviews with the facility's business office manager in training and the regional business office manager revealed that the facility had a process for mailing out quarterly account statements, but the last statement was mailed in April for the period of January through March. The regional business office manager admitted that the facility had to move the credit from their operating account to the trust fund account, which was not done timely. The facility administrator confirmed that they had spoken with the resident's guardian multiple times but did not document these grievances. The administrator also acknowledged that the business office manager no longer worked at the facility and that the regional business office manager was assisting the guardian. The facility's policy on resident trust funds required accurate accounting and safe handling of resident funds, including timely crediting of funds and regular review of accounts. However, the facility failed to adhere to these policies, resulting in the resident's guardian being uninformed about the resident's personal funds and the potential for misuse of those funds. The facility's failure to provide timely financial statements and maintain a separate accounting system for the resident's trust funds led to significant confusion and concern for the resident's guardian.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident physical abuse to the State Agency (SA) within the required timeframe. The incident involved a resident with vascular dementia, anxiety disorder, and heart disease, who had severely impaired cognition. The resident was observed to have physically aggressive behavior towards other residents. On the day of the incident, a CNA reported that the resident punched another resident unprovoked, resulting in a small red circle under the other resident's left eye. Despite the incident being documented in nursing notes and reported to the doctor, Director of Nursing (DON), and Power of Attorney (POA), it was not reported to the SA as required by state and federal regulations. The Administrator, who served as the Abuse Coordinator, was unaware of the incident until questioned by the surveyor. Upon review, the Administrator found no evidence that the incident had been reported to the SA or that an investigation had been conducted. The Administrator explained that she had been on sick leave at the time, and the DON, who was the backup Abuse Coordinator, no longer worked at the facility. The Administrator also did not know the identity of the resident who was punched, as the LPN and Social Work Director (SWD) involved in the incident also no longer worked at the facility.
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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