The Villa At The Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Petoskey, Michigan.
- Location
- 1500 Spring Street, Petoskey, Michigan 49770
- CMS Provider Number
- 235429
- Inspections on file
- 32
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Villa At The Bay during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow the dietitian-approved pureed menus for several residents on pureed diets. A resident reported being repeatedly served mashed potatoes and stated that requests for different food were not honored, while another resident complained that her pureed meal was the same “mush” every day despite being able to chew. Observation of a lunch meal showed that residents on pureed diets received pureed peas, mashed potatoes, chicken, and ice cream instead of the planned pureed chicken soft tacos, refried beans, chef’s choice vegetable, and churros. The Dietary Manager and dietary staff confirmed that the cook did not follow the written pureed menu or recipes and substituted items, including replacing pureed refried beans with mashed potatoes and pureed churros with ice cream.
A resident with chronic pain and major depressive disorder, prescribed Zubsolv sublingual tablets three times daily for pain and opioid dependence, did not receive scheduled morning doses on two separate days because the medication was not available at the facility. Nursing notes documented that Zubsolv was awaiting delivery or on order from the pharmacy, and the MAR showed the 8:00 AM doses as not available. Pharmacy and facility records indicated that staff later picked up the medication from a local pharmacy and administered it in the afternoon as the 1:00 PM dose, outside the facility’s policy requiring medications to be given within 60 minutes of the scheduled time.
A resident with alcohol withdrawal did not receive prescribed Librium due to lack of facility stock, resulting in persistent withdrawal symptoms, repeated hospitalizations, and staff feeling unprepared to manage the situation. Additionally, another resident with diabetes experienced multiple hypoglycemic episodes without proper documentation, physician notification, or follow-up blood glucose checks, contrary to facility policy.
Two residents experienced the development and worsening of pressure ulcers due to the facility's failure to consistently identify, monitor, and manage skin integrity. One resident, at very high risk, was not regularly repositioned and developed multiple facility-acquired pressure ulcers, while another resident with severe cognitive impairment had a significant lapse in skin assessments, resulting in a stage 3 ulcer progressing to stage 4. Required protocols for skin observation and documentation were not followed, leading to inadequate pressure ulcer care.
The facility did not provide required written notifications or bed-hold policy information to residents or their representatives prior to hospital transfers, nor did it notify the State LTC Ombudsman as required. This deficiency was confirmed through interviews and record reviews for several residents who experienced transfers, with staff acknowledging the lack of a system for these notifications.
The facility did not serve meals according to the posted menu, as multiple residents reported frequent inconsistencies and dissatisfaction with meal choices. Observations confirmed that dietary staff used an outdated menu cycle, and the correct menus were not distributed or posted with accurate dates. Facility leadership acknowledged the issue, and review of facility policy showed that required menu procedures were not followed.
The facility did not consistently serve meals and snacks at scheduled times, resulting in residents experiencing significant delays, missed meals, and dissatisfaction. Multiple residents reported late meal delivery, with some refusing to eat due to the delays, and several did not consistently receive evening snacks. Observations confirmed that food carts and tray delivery were often late, and residents requiring assistance sometimes waited extended periods before receiving help. Facility staff were unaware of regulatory requirements regarding meal timing, and resident council feedback documented ongoing issues with meal and snack service.
Surveyors found expired and improperly labeled foods, inadequately cleaned food preparation equipment and utensils, and improper sanitizing procedures in the kitchen and nourishment rooms. The Dietary Manager acknowledged several lapses, including unclean can openers, wet-stacked pans, and food debris on utensils and equipment, as well as a lack of sanitizer in the three-compartment sink. These deficiencies in food storage, preparation, and sanitation could impact all residents receiving food services.
The facility did not maintain an operable emergency power system during a prolonged outage, resulting in a complete loss of power. Staff were unable to access electronic medical records, emergency lighting was initially unavailable, and a resident requiring high-flow oxygen was transferred to the hospital due to the inability to provide necessary care. The facility did not follow its emergency procedures to obtain a backup generator, affecting all residents.
During a power and generator outage, residents were left without a functioning call system or adequate emergency communication devices, such as flashlights, bells, or whistles. Staff and leadership confirmed that emergency procedures were not followed, emergency supplies were initially inaccessible, and residents were unable to alert staff to their needs during the incident.
The facility did not ensure that advance directive forms were properly completed for four residents with legal representatives. In these cases, forms were either signed by the resident despite incapacity, verbally acknowledged by a guardian without proper witnessing, or lacked required signatures, contrary to policy and state guidelines. The absence of a social worker contributed to inconsistent handling of advance directive documentation.
The facility did not consistently provide scheduled showers for several dependent residents, as confirmed by resident interviews, observations, and medical record review. Some residents went up to two weeks without a shower, and documentation showed repeated missed opportunities for bathing, despite facility policy and scheduled care. The DON acknowledged a communication breakdown between the computer system and CNAs, resulting in many missed showers.
Three residents with moderately impaired cognition were found with medications, including oral pills, topical creams, and controlled substances, left at their bedsides without required assessments or physician orders for self-administration. Staff interviews confirmed the absence of interdisciplinary team evaluations and documentation, and facility policy requiring such assessments and secure storage was not followed.
Three residents reported missing personal items to staff, but their grievances were not documented or addressed according to facility policy. Staff acknowledged awareness of the missing items, yet no formal grievance forms or investigation records were found, reflecting a failure to follow the required grievance process.
A resident with a history of stroke, quadriplegia, and dysphagia had their feeding tube removed and was transitioned to a pureed, honey-thick diet, but the care plan was not updated to reflect this change. The care plan continued to reference tube feeding and NPO status, despite the resident no longer receiving nutrition via PEG tube, and staff confirmed the tube had been removed months prior.
A resident with a history of stroke, quadriplegia, and cerebral palsy was not provided with restorative nursing services to maintain or improve range of motion, despite recommendations and physician orders. The resident reported not receiving assistance from staff to work on his hands, and interviews confirmed the facility lacked a restorative program and did not have designated restorative staff, contrary to facility policy.
A resident with an indwelling urinary catheter was observed on multiple occasions with the catheter bag and drainage tube in direct contact with the ground, both outside and inside the facility. The DON confirmed that catheter bags should be kept off the floor and in a privacy bag, but the facility's catheter care policy did not specify this requirement.
Three residents requiring respiratory care were found with improperly stored, undated, or unclean respiratory equipment, including oxygen tubing and nebulizers. Staff interviews revealed inconsistent practices and lack of clarity regarding equipment maintenance, and no facility respiratory care policy was available.
Staff failed to follow proper hand hygiene protocols during wound dressing changes for a resident. An LPN repeatedly changed gloves without hand sanitization, washed hands for less than the required time, and handled wound care products without proper hand hygiene. A CNA also assisted with dressing changes without reapplying gloves after handling soiled linens. These actions did not comply with the facility's infection prevention and control policy.
The facility did not maintain current emergency evacuation policies or formal transportation agreements, relying instead on the county emergency operations center without a written understanding. This deficiency was confirmed by facility leadership and could impact all occupants during an emergency.
During a utility power outage, the facility's emergency generator failed, resulting in a loss of power. When repairs were needed, the generator was shut down for several hours, and the facility did not secure a temporary backup generator as required by policy, leaving the building without emergency power.
Surveyors observed that smoke barrier doors near a resident room and by a nurses station leading to the dining room did not fully close and latch to a smoke-tight fit as required by LSC. The Maintenance Director confirmed these findings.
A 15-second delayed egress door by a resident room was found without the required signage indicating the door could be opened after 15 seconds, as required by NFPA 101. This deficiency was confirmed by the Maintenance Director and could affect all occupants in the affected wing.
Electrical wiring was observed taped to a sprinkler pipe in the outdoor water storage room, and this was confirmed by the Maintenance Director. This failure to maintain the sprinkler system as required by NFPA 25 could impact all occupants in the affected wing.
During an inspection, it was observed that the clean linen doors in the 300 wing did not close and latch properly when tested, failing to meet requirements for resisting the passage of smoke. This issue was confirmed by the Maintenance Director and could affect all occupants in the area.
A deficiency was identified when it was observed that the basement maintenance shop and mechanical room had only one exit, failing to meet the requirement for at least two remote and accessible exits from every part of every story and smoke compartment. This was confirmed by the Maintenance Director and could affect three occupants in the event of a fire.
Five unsecured oxygen cylinders were found in the oxygen storage room, as confirmed by the Maintenance Director. This failure to secure gas cylinders did not meet NFPA 99 requirements for gas storage safety.
A resident was admitted with a colostomy, surgical drains, and a PICC line, requiring specific care. The facility failed to double-check admission orders, leading to missed antibiotic doses and a post-surgical infection. The resident's colostomy was mismanaged, causing stool contamination of surgical sites. The resident was found in critical condition, covered in feces, with a dislodged PICC line, and was transferred to the hospital with septic shock and respiratory distress, eventually leading to death. The facility also failed to notify the family of the resident's declining condition.
A resident with serious medical conditions was transferred to a hospital in critical condition without the facility notifying the family or attending physician. The LPN responsible did not inform the necessary parties, and the resident's emergency contact learned of the situation from the hospital. The facility's policy on notification was not adhered to.
A resident in a facility was found in critical condition due to insufficient staffing and poor communication among nursing staff. The resident, who required complex care for a colostomy and surgical incision, was transferred to the hospital in septic shock. Interviews with staff revealed that high acuity and inadequate nurse-to-nurse reporting contributed to the resident's decline.
A resident in a long-term care facility was found in critical condition due to inadequate care, including improper colostomy management, leading to septic shock and VRE infection. Staff interviews revealed issues with staffing levels, communication, and care coordination, contributing to the resident's neglect. The facility's policy on staffing adjustments based on acuity was not effectively implemented.
A resident did not receive scheduled doses of Cefazolin following admission from a hospital due to errors in entering medication administration times. The admitting nurse failed to have the orders verified by a second nurse, leading to a 19-hour gap without the antibiotic. Staff interviews confirmed the lapse in the verification process.
Two residents in an LTC facility were not provided with proper pressure ulcer prevention measures. One resident's air mattress was not functioning due to being unplugged, and staff failed to use appropriate PPE during wound care. Another resident's air mattress was also found unplugged, and the CNA was unsure how to operate it. These deficiencies contributed to the development and progression of pressure ulcers.
The facility failed to maintain food safety and hygiene standards, with issues including improper cooling and storage of leftovers, expired food items, inadequate sanitization practices, and poor temperature control during meal service. Staff were observed handling food without washing hands and not using proper hair restraints. Additionally, paper placemats were reused without replacement, and the kitchen exhaust hood was turned off during cooking, leading to potential contamination.
The facility failed to report accurate PBJ information to CMS, leading to inaccurate staffing level reports. The CMS PBJ Staffing Data Report for FY Quarter 2 2024 showed excessively low weekend staffing with daily infractions. The NHA indicated that corporate is responsible for data submission and confirmed the use of agency staffing. The facility assessment lacked specific data sources for identifying necessary staff types.
The facility failed to maintain a safe and sanitary environment, exposing 77 residents to potential hazards. Observations revealed exposed pipes, non-functioning night lights, and uncleanable countertops. Residents expressed discomfort due to inadequate lighting. The Maintenance Supervisor acknowledged these issues but was unaware of the reasons for the deficiencies.
The facility failed to honor food preferences and dietary needs for several residents, leading to dissatisfaction and potential nutritional issues. A resident with a medical condition received vegetables he couldn't eat, while others faced extended wait times and incorrect meal items. Residents reported frequent shortages of requested food items and a lack of condiments, impacting their dining experience.
A resident with mild cognitive impairment and physical limitations sustained burns due to unsafe smoking habits. Despite having a care plan requiring supervision and a cigarette extender, staff failed to implement these interventions, resulting in the resident holding a cigarette and receiving second-degree burns on their fingers.
Two residents experienced significant weight loss due to the facility's failure to monitor weights and follow physician dietary orders. One resident lost 25% of their weight without timely reweighing, while another did not receive meals per standing orders, leading to a 10% weight loss. Miscommunication and non-adherence to dietary guidelines contributed to these deficiencies.
Two residents with severe cognitive impairments and specific dietary orders were given fluids of inappropriate consistency, contrary to their prescribed nectar-thick liquids. An LPN confirmed the inconsistency for one resident, while a Hospitality Aide admitted to lacking formal training in preparing thickened liquids. The DON verified that Hospitality Aides should not be responsible for this task, as they are not trained, and the facility's policy supports this.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with pressure-induced deep tissue damage, as required by CDC and CMS guidelines. Observations revealed no EBP signage or PPE in the resident's room, and nurses did not use PPE during wound care. The Director of Nursing mistakenly believed EBP was unnecessary, risking infection transmission to all residents.
The facility failed to resolve resident grievances, including slow call light response, lack of staff during meal times, and infrequent water distribution. Despite repeated complaints in Resident Council meetings, the only intervention was staff education, which did not resolve the issues. Interviews with residents and staff confirmed the ongoing problems and lack of effective action.
The facility failed to provide sufficient CNA staffing, leading to long wait times for call light responses and inadequate assistance with daily activities for residents. Interviews and Resident Council Meeting minutes consistently documented these issues, and a review of actual CNA PPD revealed frequent shortfalls in staffing levels.
A resident identified as high risk for falls experienced multiple falls without the facility developing a comprehensive care plan or implementing specific interventions to minimize fall risks. The facility also failed to complete necessary root cause analysis and post-fall investigations as required by their policy.
Failure to Follow Dietitian-Approved Pureed Menus for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow menus prepared in advance and approved by a Registered Dietitian for residents on pureed diets. A complaint was received alleging that one resident on a pureed diet had been served mashed potatoes for two meals per day for a year, and that the resident’s requests for different meal options were not honored. During observation in the dining room, this resident stated that the food was getting better but that he still received a lot of mashed potatoes. Another resident on a pureed diet pointed to her plate and complained that her meal was “all mush” and “the same mush every day,” stating that she could chew. Her plate contained pureed peas, pureed mashed potatoes, and pureed chicken. Further review of the lunch meal service showed that residents on pureed diets, including six identified residents, were served pureed peas, pureed mashed potatoes, pureed chicken, and ice cream for dessert, while other residents received chicken soft tacos, refried beans, corn, and churros. The Dietary Manager presented the planned menu and pureed diet extension, which specified pureed chicken soft tacos, pureed refried beans, pureed chef’s choice vegetable (not corn), and pureed churros. The Dietary Manager acknowledged that the cook had not followed the menu, substituting mashed potatoes for pureed refried beans. Dietary staff confirmed that the cook did not follow the pureed chicken soft tacos recipe, did not prepare pureed refried beans, and instead made mashed potatoes, and that residents on pureed diets did not receive the planned pureed churros dessert but were given ice cream cups. The Registered Dietitian–prepared menu and recipes, which provided variety for pureed diets, were reviewed and it was agreed they had not been followed.
Failure to Provide Timely Access to Prescribed Zubsolv
Penalty
Summary
The deficiency involves the facility’s failure to provide timely pharmaceutical services for a resident prescribed Zubsolv, a medication used for opioid dependence and ordered for pain management. The resident was admitted with diagnoses including right ankle and foot joint pain, major depressive disorder, and chronic pain syndrome, and had a physician’s order for Zubsolv 5.7-1.4 mg sublingual tablets to be given three times daily. Nursing progress notes documented on two separate dates that Zubsolv was “awaiting delivery from pharmacy” and “on order from pharmacy,” indicating the medication was not available as scheduled. The medication administration record showed that on both dates, the 8:00 AM dose of Zubsolv was marked as not available. Further review and interviews revealed that the pharmacy had to pull Zubsolv from its backup supply on those dates and send it to the facility, whereas the usual practice was for facility staff to pick it up. Documentation from the facility showed that staff picked up the medication from a local pharmacy in the afternoon on both occasions, and the drug was administered later that day as the 1:00 PM dose, rather than at the scheduled 8:00 AM time. The facility’s own policy stated that medications are to be administered as prescribed and within 60 minutes of the scheduled time, but Zubsolv was unavailable and not administered within that timeframe on the two documented mornings.
Failure to Provide Required Care for Alcohol Withdrawal and Diabetes Management
Penalty
Summary
The facility failed to provide all necessary care and services for a resident admitted with multiple right rib fractures and alcohol dependence with withdrawal. Upon admission, the resident was prescribed a Librium taper to manage alcohol withdrawal symptoms, but the facility was unable to provide the medication as it was not stocked and the resident did not bring it from the hospital. Instead, the resident was given Ativan, but his withdrawal symptoms persisted, including agitation, tremors, delusions, and aggressive behaviors. The resident was hospitalized three times due to these unmanaged symptoms, and staff reported feeling unprepared and untrained to care for residents experiencing withdrawal. Interviews with staff and review of care plans confirmed that no additional education or resources were provided for managing alcohol withdrawal, and the facility lacked an alcohol withdrawal assessment protocol. Another deficiency was identified in the management of diabetes and hypoglycemia for a resident with a primary diagnosis of diabetes mellitus. The resident experienced multiple episodes of low blood glucose, with documented readings below 70 mg/dL on several occasions. Despite these low readings, there were no progress notes, no evidence of physician notification, and no documentation of follow-up interventions or repeat blood glucose checks until levels normalized. The facility's policy required immediate follow-up and physician notification for blood glucose results below 70 mg/dL, but this was not followed in practice. Interviews with the DON confirmed the expectation that nursing staff should document communication with the physician, interventions taken, and repeat blood glucose monitoring for hypoglycemic events. However, the medical record review showed a lack of compliance with these expectations, as there was no documentation of appropriate actions taken in response to the resident's hypoglycemic episodes. The failure to follow established protocols and provide necessary care contributed to the deficiencies cited during the survey.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to properly identify, monitor, and prevent the development and worsening of pressure ulcers for two residents. One resident, with intact cognition and a very high risk for pressure ulcers as indicated by a Braden assessment, was observed lying in bed with both heels touching the bed and without protective boots. The resident reported not being turned or repositioned since the previous night, despite care plans requiring repositioning at least every two hours. Multiple pressure ulcers, including stage 3 and unstageable wounds, were documented as facility-acquired, and there was a lack of consistent and accurate wound documentation. Staff interviews confirmed that wound documentation was incomplete and that the resident's pressure ulcers should not have developed or worsened. Another resident, with severe cognitive impairment and a history of dementia and aphasia, experienced a lapse in routine skin assessments, with an 18-day gap between documented assessments. This resident developed a stage 3 pressure ulcer on the right ischial tuberosity, which progressed to a stage 4 ulcer. The resident's care plan included weekly skin assessments, but documentation showed that these were not consistently performed. The resident's family reported that the deterioration of the wound contributed to the resident's overall decline and eventual enrollment in hospice care. Facility policy required daily skin observation during care and weekly assessments by licensed nurses for patients without skin issues. However, the records and interviews revealed that these protocols were not followed, leading to delayed identification and inadequate management of pressure ulcers. The deficiency resulted in the development and worsening of pressure ulcers, including infection and deterioration of wounds, for the affected residents.
Failure to Provide Required Transfer Notifications and Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide required written notifications and documentation related to transfers or discharges for five residents who were transferred to hospitals. Specifically, there was no evidence in the medical records that written notifications of transfer or the facility's bed-hold policy were given to the residents or their responsible parties prior to or at the time of transfer. This deficiency was identified for multiple residents who had been transferred out of the facility on several occasions, as confirmed through interviews with the residents and review of their medical records. Additionally, the facility did not have a system in place to notify the Office of the State LTC Ombudsman of these transfers, as required by policy. Interviews with the DON and the Regional Clinical Consultant RN confirmed the absence of documentation and processes for providing written transfer notifications, bed-hold policy information, and ombudsman notifications. Facility policies reviewed indicated that such notifications should be provided at admission and before hospital transfers, but these procedures were not followed for the residents involved.
Failure to Serve Meals According to Posted Menu
Penalty
Summary
The facility failed to serve meals in accordance with the posted menu, as evidenced by multiple resident complaints and direct observations. During a confidential resident council meeting, more than half of the participants reported that the facility frequently did not follow the posted meal plans, with one resident stating that inconsistencies occurred daily and unpredictably. Additional residents expressed dissatisfaction with the meals, specifically noting that the kitchen did not serve what was listed on the menu and that anticipated meals were substituted with different items without notice. Observations in the kitchen revealed that the dietary staff were serving meals from an outdated menu cycle, while residents had been provided with a different, current menu. The Dietary Manager acknowledged the error, admitting that the correct menus had not been distributed and that the posted menu dates were not updated. Review of the posted menus confirmed discrepancies, including missing menu items and incorrect dates. Facility leadership, including the Nursing Home Administrator and Director of Nursing, acknowledged that residents had reported these issues. The facility's own policy requires menus to be planned in advance by a dietitian, dated, and posted in visible locations, which was not followed.
Failure to Provide Timely Meals and Consistent Snacks
Penalty
Summary
The facility failed to consistently provide meals and snacks in a timely manner and in accordance with residents’ needs, preferences, and requests. Multiple residents reported and were observed experiencing significant delays in meal service, with lunch and breakfast often served well after the posted mealtimes. For example, one resident expressed frustration at having to wait until 1:45 p.m. for lunch and ultimately refused to eat due to the delay. Another resident stated that breakfast was often served so late that it was nearly time for lunch by the time it arrived. Observations confirmed that food carts and tray delivery to various halls and units were frequently delayed, with some residents waiting up to 30 minutes after the posted mealtime for their food. Residents on the secured dementia unit were also affected, with one resident requiring total assistance for eating left with a tray for over 20 minutes before receiving help. Resident council meetings and interviews further revealed widespread dissatisfaction with the timeliness and quality of meals and snacks. Several residents reported that evening snacks were not consistently offered, and some had to request snacks but did not always receive them. Review of snack distribution records showed that certain residents were not offered evening snacks on multiple occasions within a 30-day period. Resident council minutes repeatedly documented poor ratings for snack quality, tray passing, and meal timing, with residents expressing that meals were often late and snacks and water passes were needed more frequently at night. The facility’s dietary manager was unaware of regulatory requirements regarding meal service hours, specifically the rule that no more than 14 hours should elapse between the evening meal and breakfast unless a nourishing snack is provided and agreed upon by residents. There was no evidence that residents had been consulted about extending the meal span to 16 hours. Facility policies stated that meal schedules should be posted and that residents needing assistance should be served last, but observations showed that assistance was not provided promptly. The failure to adhere to posted meal times, provide timely assistance, and consistently offer snacks resulted in residents experiencing long gaps between meals, dissatisfaction, and missed meals.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and sanitation practices within the facility's kitchen and nourishment rooms. Expired foods, such as vanilla yogurt and picante sauce, were found in refrigerators, with staff acknowledging that these items were past their use-by dates. Additionally, containers of vanilla and molasses stored under the prep counter were visibly soiled with residue and described as unacceptable by the Dietary Manager. In the nourishment room, several resident food items, including salad, sour cream, pudding, orange juice, and supplement containers, were found without proper labeling or dating, and some were uncovered or outdated. Food preparation equipment and utensils were not properly cleaned or stored. The hand crank can opener had a brown sticky substance on the blade, and the Dietary Manager admitted it had not been cleaned as required. Quarter steamtable pans were stacked while still wet, which the Dietary Manager recognized could promote bacterial growth. Utensil bins contained serving scoops, measuring cups, and other utensils with visible dried food particles, and the bins themselves had crumbs and debris. Knives on the clean rack were found lying in bits of paper and food debris. Several pieces of equipment, including the microwave, mixer, and meat slicer, were observed with dried food remnants, indicating inadequate cleaning after use. Sanitizing procedures were also deficient. The three-compartment sink, intended for sanitizing utensils and equipment, was found to contain no sanitizer in the designated compartment, and the Dietary Manager was unsure if it had been filled correctly or if the system was functioning. These findings demonstrate a failure to follow professional standards for food safety, as outlined in the FDA Food Code, and have the potential to affect all residents receiving food services in the facility.
Failure to Maintain Emergency Power System During Outage
Penalty
Summary
The facility failed to maintain an operable emergency electrical power system, resulting in a complete loss of power for an extended period following an ice storm. The generator, which was supposed to supply power to the entire facility during outages, ceased functioning and was not promptly replaced with a backup generator as outlined in the facility's emergency procedures. During the outage, staff were unable to access electronic medical records due to insufficient battery backup, and the backup computer could not support both the laptop and printer simultaneously. Emergency kits containing flashlights were initially inaccessible, leading staff to use personal phones for lighting until the kits could be reached. One resident who required 10 liters of oxygen was sent to the hospital for the duration of the outage because the facility was unable to provide adequate care without power. Other residents who relied on specialized air mattresses were switched to standard mattresses. Interviews with the NHA, DON, and a regional clinical RN confirmed that the facility did not follow its emergency procedures for obtaining a backup generator and that there were multiple instances where the generator failed to function properly, impacting the care and safety of all 82 residents.
Failure to Provide Resident Communication During Power and Generator Outage
Penalty
Summary
During a power outage and subsequent generator failure caused by an ice storm, the facility failed to provide residents with a means to communicate with staff, as the call system was nonfunctional. Residents reported being left in the dark without sufficient flashlights, bells, or whistles to alert staff to their needs. Staff interviews confirmed that there were not enough flashlights for everyone, and the call system was out of service. Residents described feeling isolated and unable to summon assistance during the emergency. Facility leadership, including the NHA, DON, and a regional clinical RN, acknowledged that emergency procedures were not followed, specifically the failure to obtain a backup generator and the inability to distribute emergency communication devices to residents. Emergency kits containing flashlights were initially inaccessible due to locked doors, and staff had to rely on personal phones for light. Additionally, staff could not access electronic medical records due to a failed computer backup battery. The facility's emergency plan required the distribution of bells and whistles and access to emergency equipment, but these measures were not implemented during the incident.
Failure to Ensure Accurate Completion of Advance Directives for Residents with Legal Representatives
Penalty
Summary
The facility failed to ensure that advance directive documentation was accurately completed for four residents who had legal representatives in place. In each case, the required (State)-POST (Physician Orders for Scope of Treatment) forms were either signed by the resident despite a legal guardian or DPOA being designated, or were acknowledged verbally by a guardian without proper witnessing or follow-up signatures. Specifically, one resident's POST form was signed by the resident instead of their legal guardian, another had a verbal order from a guardian documented by an LPN without witness signatures, and a third resident, deemed incapacitated by two physicians, signed their own POST form instead of their DPOA. For the fourth resident, the POST form was verbally acknowledged by the guardian, but the documentation did not meet the required standards for validity. Interviews and record reviews revealed that the facility lacked a social worker, resulting in a team approach to handling social services responsibilities, including advance directive completion. The facility's policy and state guidelines require that advance directives be signed by the appropriate legal representative when a resident lacks decision-making capacity, and that verbal or telephone orders be properly witnessed and signed by the attending health professional within a specified timeframe. These requirements were not met in the cases reviewed, leading to inaccurate and incomplete advance directive documentation.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers for multiple residents who were unable to perform activities of daily living (ADLs) independently. During a resident council meeting, several residents reported not receiving showers on a consistent basis, with one resident stating they sometimes went up to two weeks without a shower, despite being scheduled for two showers per week. Another resident indicated they received only one shower per week, and a third noted that showers were often canceled when the facility was short-staffed. Direct observations and interviews confirmed these reports. One resident was found in bed with uncombed, greasy hair and stated they had missed a scheduled shower due to short staffing, at one point going 18 days without a shower. Medical records for this resident showed that out of 25 scheduled shower opportunities, 23 were missed, with a documented period of 19 consecutive days without a shower. This resident had a history of type 2 diabetes mellitus and moderately impaired cognition. Another resident, who was cognitively intact and had a diagnosis of osteomyelitis, was observed complaining about not having had a shower for about 10 days and was attempting to relieve itching with wet washcloths. Documentation confirmed that this resident had not received a shower for at least 16 days. The Director of Nursing acknowledged that while showers were scheduled, there was a breakdown in communication between the computer system and CNAs, resulting in many missed showers. Facility policy required the provision of hygiene care, including bathing, in accordance with resident assessments and preferences, but this was not consistently followed for the affected residents.
Failure to Assess and Authorize Safe Self-Administration of Medications
Penalty
Summary
The facility failed to complete required assessments and obtain physician orders to ensure the safe self-administration of medications for three residents with moderately impaired cognition. Observations revealed that medications, including controlled substances and topical treatments, were left at the bedside of these residents without proper authorization or documentation. In each case, there was no evidence of an interdisciplinary team assessment or a physician order permitting self-administration, as required by facility policy. One resident with a history of respiratory failure and a BIMS score indicating moderately impaired cognition was found with a medication cup containing six oral pills, including a controlled pain medication, and a high-calorie supplement at the bedside. Staff interviews confirmed that no assessment or physician order for self-administration existed for this resident, and the resident's care plan did not indicate a desire or ability to self-medicate. Another resident with dementia and a similar BIMS score was observed with a medication cup containing a white powder on the bedside dresser. Staff were unable to identify the substance, and there was no assessment or order for self-administration, nor any documentation of a related treatment. A third resident with heart failure and moderately impaired cognition was found with a tube of nystatin cream at the bedside, which the resident reported using daily. Staff confirmed there was no assessment or physician order for self-administration, and the medication was not documented in the medical record. Facility policy requires that residents may only self-administer medications if deemed safe and appropriate by the interdisciplinary team, with proper documentation and secure storage, none of which were followed in these cases.
Failure to Document and Resolve Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to follow its grievance procedure and make prompt efforts to resolve grievances regarding missing personal items for three residents. One resident with intact cognition reported missing multiple clothing items and stated she had informed staff but received no follow-up or resolution. Review of the facility's grievance log revealed no documentation of her concerns, despite a registered nurse recalling that a missing item slip had been completed previously. Another resident with moderately impaired cognition was overheard by a nurse complaining about a missing sweater, and a third resident with intact cognition reported missing several clothing items to multiple staff members. In both cases, there was no record of these grievances in the facility's grievance log. Interviews with staff confirmed awareness of the missing items, but there was inconsistency in documenting and following up on these grievances. The facility's policy requires that all grievances be logged, investigated, and resolved promptly, with communication maintained with the resident throughout the process. However, no grievance forms or documentation were found for the missing items reported by the three residents, indicating a failure to adhere to the established grievance policy and procedures.
Failure to Update Care Plan After Change in Nutritional Status
Penalty
Summary
The facility failed to revise and update the care plan to reflect the current status of a resident who had experienced significant changes in nutritional management. The resident, who had a history of stroke, quadriplegia, dysphagia, protein-calorie malnutrition, and anemia, was initially admitted with a feeding tube in place. Documentation showed that the feeding tube was removed, and the resident was transitioned to a regular, pureed, honey-thick diet, with the patient or guardian declining replacement of the tube. Despite these changes, the care plan continued to reference tube feeding and NPO status, with goals and interventions that were no longer applicable to the resident's current condition. Interview with an LPN confirmed that the resident had not received food or fluids through a PEG tube for several months. Review of the care plan revealed it still included interventions for tube feeding and NPO status, rather than reflecting the resident's current oral intake and dietary needs. The facility's own policy required care plans to be revised with changes in condition, but this was not done in this case, resulting in a care plan that did not accurately represent the resident's current nutritional status or care requirements.
Failure to Provide Restorative Nursing Services for Range of Motion
Penalty
Summary
The facility failed to provide restorative nursing services to maintain or improve range of motion (ROM) for a resident with significant physical limitations. The resident, who had a history of stroke, quadriplegia, cerebral palsy, and traumatic brain injury, was observed with severely contracted hands and reported that staff did not assist him with exercises to improve his hand function. Although the resident had a physician's order for a left hand splint and a recommendation for a ROM program following discharge from occupational and physical therapy, he stated that he did not consistently wear the splint and had not received help from staff to work on his hands. Interviews with facility staff revealed that while therapy staff had recommended a restorative program and completed a referral to nursing, the facility did not have an established restorative program, nor did it employ a restorative nurse or restorative CNA. The Director of Nursing confirmed the absence of such a program, despite the facility's policy stating that residents should receive restorative nursing care as needed. Documentation showed that the resident's therapy had ended several months prior, and no restorative interventions were implemented by nursing staff to address his ongoing needs.
Failure to Maintain Proper Catheter Care and Infection Control
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with an indwelling urinary catheter. The resident, who had a diagnosis of neuromuscular dysfunction of the bladder and no cognitive impairment, was observed on two separate occasions with her catheter urinary collection bag and drainage tube in direct contact with the ground. On one occasion, the resident was being assisted outside by staff, and the catheter bag was seen dragging on the pavement beneath the wheelchair, with the drainage tube tip also hitting the pavement. On another occasion, the resident was asleep in her wheelchair in the dining room, and the catheter bag and drainage tube tip were again observed touching the floor. The Director of Nursing confirmed during an interview that catheter bags should remain off the floor and in a privacy bag. However, a review of the facility's catheter care policy revealed that it did not specify that urinary catheter bags should be kept off the floor. These observations and the lack of clear policy guidance contributed to the deficient practice identified by surveyors.
Failure to Maintain Sanitary Respiratory Equipment
Penalty
Summary
The facility failed to ensure sanitary storage, labeling, and cleaning of respiratory equipment for three residents who required respiratory services. For one resident with COPD and chronic respiratory failure, oxygen tubing was repeatedly observed undated and improperly stored, including being left uncovered in a wheelchair and resting on the floor, with nasal cannula prongs in contact with an unclean soaker pad. There was no documented order for weekly oxygen tubing changes for this resident, and staff interviews revealed inconsistent knowledge and practices regarding equipment maintenance and storage expectations. Another resident with pneumonia was found with an undated nebulizer left on the bedside table with visible condensation in the medication cup, which had not been rinsed since the previous night. A third resident with dementia had oxygen tubing and a nebulizer both dated nearly two months prior, with no evidence in the treatment administration record of weekly changes as claimed by staff. Interviews with CNAs and nursing staff indicated a lack of clarity and responsibility regarding the maintenance and dating of respiratory equipment. Additionally, the facility did not have a respiratory care policy available upon request.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during wound dressing changes for a resident. During the observed dressing change, a CNA handled a used coffee cup that the resident had used as a urinal and placed it on the bedside table. Multiple lapses in hand hygiene were observed by an LPN, including changing gloves without hand sanitization, washing hands for less than the required fifteen seconds, turning water on and off with bare hands, and applying wound care products without proper hand hygiene. The LPN also exited and re-entered the room in PPE, put on new gloves without sanitizing hands, and failed to change gloves after removing a dressing. The CNA also assisted with dressing changes without reapplying new gloves after handling soiled linens. Review of the facility's hand hygiene policy revealed that staff are required to wash hands for at least fifteen seconds after removing gloves, handling soiled items, and before donning new gloves. The policy also specifies the use of alcohol-based hand rubs when hands are not visibly soiled and outlines proper procedures for handwashing, including turning off faucets with a clean paper towel. The observed practices did not align with these policy requirements, resulting in a failure to maintain appropriate infection prevention and control measures during resident care.
Failure to Maintain Updated Emergency Evacuation Agreements and Procedures
Penalty
Summary
The facility failed to develop and implement comprehensive emergency preparedness policies and procedures for safe evacuation, as required by federal regulations. Specifically, the facility's documentation indicated reliance on a specific bussing company for resident evacuation during emergencies. However, upon review and interview, it was revealed that the facility no longer uses this company and instead depends on the county emergency operations center for evacuation arrangements. Further investigation showed that the facility did not have a contract or written letter of understanding with the county emergency operations center to confirm the availability of transportation agreements. This lack of formal agreements and updated policies was confirmed by both the Maintenance Director and the Administrator during the survey. The deficiency could potentially affect all occupants in the event of an emergency, as the facility did not have established procedures addressing transportation, staff responsibilities, evacuation locations, and communication methods.
Failure to Provide Emergency Power During Generator Outage
Penalty
Summary
The facility experienced a failure of its emergency generator during a utility power outage, resulting in a loss of power to the building. The generator initially failed on March 30, 2025, at approximately 7:00 PM, leaving the building without power until staff were able to restart the generator at 8:24 PM. The facility identified the cause of the failure as an issue with the generator's computer board and placed an emergency order for repair parts with their generator contractor. On April 1, 2025, the generator contractor arrived onsite to perform repairs, which required the generator to be shut down. During this planned shutdown, the building was again left without power from approximately 10:50 AM until 1:00 PM, when the generator was fixed and power was restored. Despite being aware of the need for a planned shutdown, the facility did not secure a temporary backup generator to maintain emergency power during this period. Review of facility policies and interviews with the Administrator and Maintenance Director confirmed that the facility's procedures required securing a backup generator in the event of a primary generator failure. However, the facility failed to follow this policy during the planned repair shutdown, resulting in the building being without emergency power for over two hours.
Smoke Barrier Doors Failed to Achieve Smoke-Tight Fit
Penalty
Summary
The facility failed to ensure that smoke barrier doors met the requirements of the Life Safety Code (LSC). During observations, surveyors found that the smoke barrier doors near room 203 and by the 300 wing nurses station leading into the dining room did not completely close and latch to achieve a smoke-tight fit as required. These deficiencies were confirmed by the Maintenance Director at the time of discovery. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Missing Required Signage on Delayed Egress Door
Penalty
Summary
Surveyors observed that a door in a required means of egress, specifically the 15-second delayed egress door by room 301, did not have the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS" as mandated by NFPA 101, 7.2.1.6.1.1 (4). This observation was made during a facility inspection and was confirmed by the Maintenance Director at the time of discovery. The lack of appropriate signage on the delayed egress door constitutes a failure to comply with regulations regarding special locking arrangements for egress doors. The deficiency was identified on the 300 wing and could potentially affect all occupants in that area in the event of an emergency. No specific residents or patient medical histories were mentioned in the report.
Improper Maintenance of Sprinkler System Due to Electrical Wiring on Sprinkler Pipe
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler system in accordance with NFPA 25 requirements. During an observation in the outdoor water storage room, electrical wiring was found taped to the sprinkler pipe. This issue was confirmed by the Maintenance Director at the time of observation. The deficiency was identified as potentially affecting all occupants of the 300 wing in the event of a fire, as proper maintenance and testing records were not adequately upheld.
Corridor Door Deficiency: Failure to Close and Latch
Penalty
Summary
The facility failed to ensure that doors protecting corridor openings were capable of resisting the passage of smoke as required by NFPA 19.3.6.3. During an observation on the 300 wing, it was found that the clean linen doors did not close and latch properly when the coordinating device was tested. This deficiency was directly observed and confirmed by the Maintenance Director at the time of discovery. The report specifies that this issue could affect all occupants of the 300 wing in the event of a fire. The deficiency was identified through direct observation and interview, with no mention of specific residents or their medical conditions at the time of the event. The report does not provide further details about any individuals directly impacted during the incident.
Insufficient Exits in Basement Maintenance and Mechanical Areas
Penalty
Summary
The facility failed to provide at least two remote and accessible exits from every part of every story and smoke compartment, as required by regulations. During an observation on May 21, 2025, it was found that the basement maintenance shop and mechanical room had only one exit. This observation was confirmed by the Maintenance Director at the time of discovery. This deficiency could affect three occupants in the event of a fire, as noted in the report. No additional information about the medical history or condition of the affected individuals was provided.
Unsecured Oxygen Cylinders in Storage Room
Penalty
Summary
The facility failed to ensure that the storage of nonflammable gases, specifically oxygen cylinders, met all requirements outlined in NFPA 99. During an observation conducted on May 21, 2025, five unsecured oxygen cylinders were found in the oxygen storage room. This observation was confirmed by the Maintenance Director at the time of the survey. The deficiency was identified as a failure to secure oxygen cylinders as required, which is necessary to comply with safety standards for gas storage. The report notes that this practice could affect three occupants in the event of a fire, but does not provide further details about the individuals involved or their medical conditions.
Failure to Provide Proper Care and Treatment
Penalty
Summary
The facility failed to ensure proper care and treatment for a resident, leading to severe health complications and eventual death. The resident was admitted to the facility with a colostomy, surgical drains, and a PICC line, requiring specific medical care and monitoring. However, the facility did not double-check new admission orders, resulting in missed doses of critical antibiotics. The resident did not receive antibiotics for 19 hours, which contributed to the development of a post-surgical infection. Additionally, the facility did not provide appropriate assessments and wound care. The resident's colostomy was not properly managed, leading to stool contamination of surgical incisions and drains. The resident was found in critical condition, covered in feces, with a dislodged PICC line, and was transferred to the hospital with septic shock, respiratory distress, and low blood pressure. The facility staff failed to conduct thorough assessments, document changes in the resident's condition, or notify the physician of significant health declines. The facility also failed to communicate effectively with the resident's family and did not notify them of the resident's declining condition. Family members reported concerns about the resident's care, noting issues with feeding assistance and the resident's overall appearance. The lack of proper care and communication resulted in the resident's transfer to the hospital in critical condition, where they later died.
Failure to Notify Family and Physician of Resident's Critical Condition
Penalty
Summary
The facility failed to notify a resident's emergency contact and attending physician of a significant change in condition, resulting in a deficiency. The resident, who had medical diagnoses including hypertension, perforation of the intestine, and a colostomy, was transferred to a local hospital in critical condition after a four-day admission to the facility. The family was not informed of the transfer by the facility, and instead, learned of the situation from the hospital's ICU doctor. The resident's condition had deteriorated significantly, with low blood pressure and oxygen saturation, and they were unresponsive at the time of transfer. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) who managed the resident's transfer did not notify the family or the physician about the resident's declining condition. The Nurse Practitioner on call was also not informed of the resident's respiratory distress or pain. The Nursing Home Administrator confirmed that both the physician and the family should have been notified. The facility's policy on notification of changes, which requires immediate communication with the resident's representative and physician in the event of significant changes, was not followed in this instance.
Inadequate Staffing Leads to Resident's Critical Condition
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care needs of a resident, leading to severe health consequences. The resident, who had been admitted for rehabilitation, was found in critical condition multiple times due to inadequate care of his colostomy and surgical incision. The resident was transferred to the hospital in septic shock with positive blood cultures for VRE, indicating a severe infection likely exacerbated by the lack of proper wound and colostomy care. Interviews with nursing staff revealed significant issues with staffing and communication. Licensed Practical Nurse (LPN) H reported being overwhelmed with the number of residents to care for, which hindered the ability to perform thorough assessments. Registered Nurse (RN) I and LPN B both noted the resident's high acuity and the challenges in providing adequate care due to insufficient staffing and poor nurse-to-nurse communication. The resident's condition was not adequately monitored, and critical information about his care needs was not effectively communicated between shifts. The facility's policies on staffing and acuity assessment were not effectively implemented, as evidenced by the staff's inability to manage the resident's complex medical needs. The lack of a structured nurse-to-nurse reporting system and insufficient staffing levels contributed to the resident's decline. The Regional Nurse Consultant acknowledged the problem and indicated that a past non-compliance issue was being addressed, but it was not yet completed at the time of the report.
Inadequate Staffing and Care Lead to Resident's Critical Condition
Penalty
Summary
The facility failed to ensure competent staff to provide adequate care for a resident, leading to severe health deterioration. The resident, who had been admitted for rehabilitation, was found in critical condition with a colostomy that was not properly cared for, resulting in stool contamination of surgical incisions and drains. This neglect led to the resident developing septic shock and positive blood cultures for vancomycin-resistant enterococcus (VRE). The resident was transferred to a local hospital in critical condition multiple times due to inadequate care at the facility. Interviews with facility staff revealed significant issues with staffing and communication. A Licensed Practical Nurse (LPN) reported being overwhelmed with the number of residents to care for and admitted to not performing a thorough assessment of the resident. A Registered Nurse (RN) acknowledged the resident's high acuity and did not complete necessary dressing changes. Another LPN noted that the resident was too critical for the facility and missed a dose of antibiotics due to an order entry error. The staff expressed concerns about the high acuity of residents and the lack of adequate time and resources to complete necessary tasks. The facility's policy on staffing and acuity levels was reviewed, indicating that the facility should adjust staffing based on resident needs. However, the staff interviews highlighted a lack of adequate staffing and communication, contributing to the resident's neglect and subsequent critical condition. The Nurse Practitioner was not informed of the resident's decline, indicating a breakdown in communication and care coordination within the facility.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to administer physician-ordered antibiotic medication to a resident, identified as Resident #3, following their admission from a local hospital. The resident was discharged with an order for Cefazolin to be administered every 8 hours, with the last dose given at 5:00 PM before discharge. Upon admission to the facility, the resident did not receive the scheduled doses at 1:00 AM and 9:00 AM, resulting in a 19-hour gap without the antibiotic. This lapse was due to an error in entering the medication administration times into the system. Interviews with facility staff revealed that the process for verifying new admission medication orders was not followed. The admitting nurse, RN D, entered the orders but did not have them verified by a second nurse, as required. LPN B acknowledged that the resident missed the first dose due to incorrect administration times being entered. The Nurse Practitioner, NP F, and the Regional Nurse Consultant confirmed that orders should be double-checked by another nurse to ensure accuracy, which did not occur in this instance.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement and maintain interventions to prevent the development and progression of pressure ulcers for two residents. Resident #18 was admitted with a right tibia fracture, right fibula fracture, and nutritional deficiency, and was at risk of developing pressure ulcers. Despite having an air mattress as an intervention, it was observed that the air mattress pump was not turned on or plugged in during multiple observations. The Director of Nursing confirmed that the pressure ulcer on Resident #18's right heel was facility-acquired due to a brace placed after surgery and that the air mattress should have been functioning. Additionally, during a wound care observation, the staff did not use further Personal Protective Equipment (PPE) as the wound was closed, and they did not perform measurements of the wound. Resident #9 was admitted with diagnoses including heart failure, neurogenic bladder, obstructive uropathy, and COPD, and was dependent on staff for toileting and personal hygiene. The resident was also at risk for pressure ulcers and required a pressure-relieving mattress. An observation revealed that the air mattress was not functioning as it was not plugged in, and the Certified Nursing Assistant (CNA) was unsure how to operate the control panel. The CNA confirmed the mattress was not functioning and could not state how long it had been unplugged. The deficiencies in care for both residents highlight a failure to ensure that prescribed interventions, such as air mattresses, were properly utilized to prevent pressure ulcers. The lack of functioning air mattresses and the absence of appropriate PPE during wound care contributed to the development and progression of pressure ulcers in these residents.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. Leftover food, including chicken pot pie, chicken parmesan, and cheese soup, was found in the refrigerator without proper cooling logs, contrary to company policy that prohibits saving leftovers. Additionally, large chunks of uncovered cooked turkey were found in the walk-in cooler without a cooling log, and the preparation of this turkey was unplanned. Expired food items, such as horseradish and bologna, were also found in storage, with unclear labeling practices contributing to the confusion. Sanitization practices were inadequate, as demonstrated by the improper testing of sanitizing solutions. The Regional Dietary Manager (RDM) failed to follow the correct procedure for testing the concentration of the sanitizing solution, leading to inaccurate results. Furthermore, during meal service, food items like scrambled eggs and sausage patties were held at temperatures below the required 135°F, posing a risk of foodborne illness. The Kitchen Manager (KM) was observed handling electrical cords and paper towels without washing hands before returning to food preparation, and staff members were seen without proper hair restraints, further compromising food safety. The facility also exhibited poor practices in maintaining cleanliness and hygiene in the dining area. Paper placemats that had fallen on the floor were placed on tables, and the same placemats were reused for multiple meals without being replaced. Additionally, the exhaust hood in the kitchen was turned off during cooking operations, leading to excessive steam and potential contamination in the food preparation area. These deficiencies highlight significant lapses in food safety protocols and hygiene practices within the facility.
Failure to Report Accurate Staffing Data to CMS
Penalty
Summary
The facility failed to report Payroll Based Journal (PBJ) information to the Centers for Medicare and Medicaid Services (CMS), resulting in inaccurate reporting of staffing levels. This deficiency was identified through a review of the CMS PBJ Staffing Data Report for the fiscal year Quarter 2 of 2024, which revealed excessively low weekend staffing triggered with daily infractions from January 1 to March 31, 2024. During an interview, the Nursing Home Administrator (NHA) stated that the corporate office is responsible for submitting the data to the CMS PBJ report and confirmed the use of agency staffing to meet resident needs. The facility assessment, which was undated, failed to provide a clear identification of the type of staff needed to support and care for residents, as it lacked specific data sources such as staffing records, organization charts, and PBJ reports.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment, potentially exposing all 77 residents to unsafe and unsanitary conditions. Observations revealed exposed pipes running along the floor in certain resident rooms, which were identified as originating from wall-mounted air conditioning units. The Maintenance Supervisor (MS) acknowledged that the pipes should have been boxed in and sealed but was unaware of why this had not been done. Additionally, resident rooms on the South and North units were found without functioning night lights, with the MS admitting that the lights on the South unit were burned out and replacements were needed. The North unit's lighting was inadequate, with most lights not working and those that did providing insufficient illumination. Further observations noted that the clean utility rooms on both the North and South units had chipped and delaminating plastic laminate countertops, making them uncleanable and unsanitary for food storage and handwashing. The Spa room on the North unit had missing ceramic floor tiles where a spa tub had been removed months prior, with the facility unable to repair or find a contractor for the work. During a resident council meeting, residents expressed discomfort due to the lack of night lights in their rooms, which affected their ability to see at night.
Failure to Honor Resident Food Preferences and Dietary Needs
Penalty
Summary
The facility failed to honor food preferences and dietary needs for several residents, leading to dissatisfaction and potential nutritional issues. Resident R17, who had a medical condition preventing him from eating broccoli and cauliflower, repeatedly received these vegetables despite his meal card indicating his dislike for them. Additionally, R17 experienced extended wait times for his meals due to his location at the end of the hall, which resulted in him receiving his meal after his tablemates had finished. Another resident, who wished to remain anonymous, expressed frustration over not receiving a requested sandwich and having to wait for condiments like salt, syrup, and mayonnaise. This resident's request for a tomato or bacon sandwich was not fulfilled, and when the sandwich finally arrived, it was missing tomatoes, which were reportedly out of stock. Similarly, R20 experienced issues with receiving incorrect meal items, such as being served eggs despite a no-egg preference, and had to wait for a grilled cheese sandwich. R27 also faced issues with meal preferences, as he was served items he could not eat, such as bread and mashed potatoes, and had to wait for an alternate meal. R5 reported that her meals were bland due to the absence of salt, which was not restricted in her diet order. During a resident group meeting, several residents, including R6, reported that the kitchen frequently ran out of items like yogurt and tomatoes, and they were not receiving the food they ordered. The residents also expressed a desire for more fresh fruit options for snacks and meals.
Failure to Prevent Smoking-Related Injury
Penalty
Summary
The facility failed to prevent an injury due to smoking for a resident with a history of unsafe smoking habits. The resident, who had a mild cognitive impairment and physical limitations, was observed with burns on their fingers. The resident's Smoking Risk Evaluation indicated several risk factors, including cognitive loss and dexterity problems, and a care plan was in place requiring supervision and the use of a cigarette extender. However, the staff did not follow the care plan, leading to the resident sustaining burns while smoking. The incident occurred when the resident was on the smoking patio with supervision, but the staff failed to ensure the use of a cigarette extender as per the care plan. The resident was found holding a cigarette that was no longer lit, resulting in second-degree burns on their fingers. The facility's Smoking Guideline policy required residents with restrictions to have direct supervision during smoking, but the care interventions were not properly implemented, contributing to the resident's injury.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in two residents, leading to potential health risks. Resident #66 was admitted with multiple diagnoses, including malnutrition, and required assistance with eating. Despite a significant weight loss of 25% from her baseline weight within 23 days, there was a lack of timely reweighing and documentation to verify the accuracy of the recorded weight. The facility's policy required reweighing when there was a significant weight variance, but this was not adhered to, resulting in delayed assessment and intervention. Resident #67, who had moderate cognitive impairment and required assistance with eating, also experienced a significant weight loss of 10% within 22 days of admission. Observations revealed that the resident was not receiving meals according to the physician's standing orders, which included specific dietary preferences and assistance with feeding. The resident's meal trays were missing essential components like steamed rice and oatmeal, which were part of the prescribed diet. The kitchen staff misunderstood the dietary orders, leading to inadequate meal provision. Interviews with the Registered Dietician and the Director of Nursing highlighted the lack of communication and adherence to dietary orders, contributing to the residents' weight loss. The facility's failure to follow physician orders and its own weight monitoring guidelines resulted in inadequate nutritional support for the residents, potentially impacting their health and recovery.
Failure to Provide Prescribed Fluid Consistency
Penalty
Summary
The facility failed to provide fluids in the prescribed texture/consistency for two residents, resulting in a deficiency. Resident #14, who has severe cognitive impairment, dementia, dysphagia, and COPD, was observed with a thin consistency water at her bedside, contrary to her physician's order for nectar-thick liquids. The Licensed Practical Nurse confirmed the inconsistency and noted that the thickening agent had settled at the bottom of the cup, indicating improper preparation. Similarly, Resident #37, with severe cognitive impairment, Alzheimer's Disease, nutritional deficiency, and failure to thrive, was also found with thin consistency water despite having an order for nectar-thick liquids. The Hospitality Aide responsible for delivering the water admitted to not having formal training in preparing thickened liquids and relied on informal tips. The Director of Nursing confirmed that Hospitality Aides should not be responsible for thickening liquids, as they are not trained for this task. The Speech Language Pathologist highlighted that properly prepared thickened liquids should not separate, and the facility's policy indicated that thickening should be done by food and nutrition or nursing services.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control standards by not correctly identifying, labeling, and using personal protective equipment (PPE) for Enhanced Barrier Precaution (EBP) rooms. This deficiency was observed in the case of a resident with pressure-induced deep tissue damage. The resident's electronic medical record indicated a diagnosis of pressure-induced deep tissue damage on the right heel and sacral region, with a suspected deep tissue injury marked in the facility's records. However, during observations, there was no signage on the resident's door indicating EBP, nor was any PPE available for use in the resident's room. During wound care treatment, registered nurses did not don any PPE, despite the resident having a deep tissue injury with eschar present. The Director of Nursing believed that EBP was not necessary because the wound was not open, which contradicts the guidance from the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) that recommend EBP for residents with chronic wounds during high-contact care activities. This oversight potentially exposed all 77 residents in the facility to the risk of infectious agent transmission.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure the resolution of resident grievances for four residents, as documented in the Resident Council Meeting minutes for February, March, and April 2024. The grievances included slow call light response, lack of staff during meal times, staff being loud at the nurses' station, and residents receiving fresh water only once per day. Despite these issues being raised repeatedly, the facility's only documented intervention was staff education, which did not resolve the concerns. The Resident Council consistently reported that their views were not considered, and grievances were not promptly addressed. Interviews with residents confirmed the ongoing issues. One resident mentioned having to wait long periods for call lights to be answered and receiving water only once daily. Another resident reported being left in a wheelchair for twelve hours without assistance, despite using the call light. Additional residents echoed these concerns, stating that the same problems were brought up every month in Resident Council meetings but were never resolved. Staff interviews revealed that the grievances were discussed in morning meetings with department heads and issued to the appropriate department head for Quality Assurance. However, no new interventions were implemented to address the residents' concerns. The Nursing Home Administrator acknowledged awareness of the issues but did not provide a response on why the concerns had not been addressed. The facility's policy on Residents' Rights emphasized the right to voice grievances without fear of discrimination or reprisal and the need for prompt resolution, which was not upheld in this case.
Insufficient CNA Staffing
Penalty
Summary
The facility failed to provide sufficient numbers of Certified Nursing Assistants (CNAs) to meet the needs of residents, as evidenced by interviews and record reviews. Four residents reported long wait times for call lights to be answered and inadequate assistance with daily activities such as transferring, toileting, and personal hygiene. One resident mentioned being left in a wheelchair for twelve hours without assistance, while another reported waiting up to 40 minutes for call light responses and having to eat meals in his room due to insufficient staff in the dining room. The Resident Council Meeting minutes from February to April 2024 consistently documented concerns about slow call light response times, lack of incontinence care during the night, and insufficient staff in the dining room during meals. The Nursing Home Administrator (NHA) confirmed that staffing levels were based on census and budgeted Per Patient Day (PPD) metrics. However, the Facility Assessment (FA) did not include the specific numbers of staff needed to meet each resident's needs, instead documenting staffing needs based on budgeted PPD. A review of actual CNA PPD from late April to early May 2024 revealed that the facility frequently fell short of the required 2.05 hours PPD, with some days having as low as 0.96 PPD. This deficiency had the potential to result in unmet care needs and inadequate care for all 69 residents in the facility.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to develop a care plan and implement interventions to reduce hazards and risks to prevent falls for one resident (R1). R1 was identified as high risk for falls upon admission, with contributing factors including weakness, poor mobility, confusion, and psychotropic medication use. Despite this, the facility did not create a comprehensive fall care plan until after R1 experienced multiple falls. The care plan that was eventually created lacked specific interventions to minimize fall risks and did not specify the nature of any injuries sustained by R1. The Director of Nursing (DON) confirmed that R1 had three falls, but only two incident reports were documented. The DON admitted that the fall care plan was not updated immediately after each fall, as required by the facility's policy. Additionally, the facility did not complete the necessary root cause analysis, care plan updates, and post-fall investigations as outlined in their Falls Investigation Guideline. This failure to follow established procedures contributed to the deficiency in providing adequate supervision and interventions to prevent falls for R1.
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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