The Willows At Okemos
Inspection history, citations, penalties and survey trends for this long-term care facility in Okemos, Michigan.
- Location
- 4830 Central Park Drive, Okemos, Michigan 48864
- CMS Provider Number
- 235701
- Inspections on file
- 24
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at The Willows At Okemos during CMS and state inspections, most recent first.
Food service equipment and surfaces were observed heavily soiled, including the exhaust vent, light assembly, ceiling surfaces, fryer, convection oven, stove, char broiler, steamer table, ice machine, and juice machine components. The ice machine had brown to black bacterial growth on the retention plate. Surveyors also observed the mechanical dish machine operating with wash and final rinse temperatures out of range, while facility policy required proper temperatures and accurate logging for sanitation.
Late Completion of Annual MDS Assessments: The facility failed to complete comprehensive annual MDS assessments on time for three residents. One resident with Alzheimer’s disease and COPD had an annual MDS finalized after the ARD, with the CAA process not completed and the MDS not transmitted; another resident with multiple chronic conditions had the CAA Summary signed late; and a third resident with obesity and anxiety had an annual MDS signed after the required completion date.
Quarterly MDS assessments were not completed on time for three residents. One resident had multiple chronic conditions including HF, CKD, DM2, AFib, epilepsy, chronic pain, OA, osteoporosis, obesity, and COPD with moderate cognitive impairment; another had PVD, AFib, HTN, osteoporosis, GERD, depression, dysphagia, insomnia, and a left AKA; and a third resident had COPD. The MDS nurse confirmed the overdue assessments and could not explain why they were not initiated or completed timely.
Inaccurate MDS Dental Coding: A resident with Alzheimer's disease and COPD had an Annual MDS that coded no oral dental concerns despite a BIMS score showing severe cognitive impairment and available coding options for broken dentures or edentulous status. The resident reported having dentures but not seeing them for months, and an LPN stated the dentures had been dropped and broken. The MDS nurse acknowledged the resident's dental status was not accurately coded.
A resident with hemiplegia and hemiparesis after CVA and moderate cognitive impairment had a care plan that was not revised to match current transfer needs. Staff reported the resident now required a hoyer lift with a 2-person assist, and the DON confirmed the resident had been downgraded because the resident could no longer bear weight, but the care plan still contained older transfer interventions.
Failure to implement pharmacy recommendations for lipid monitoring: A resident with severe cognitive impairment and multiple chronic conditions was receiving atorvastatin, and the pharmacist twice recommended adding a fasting lipid panel with the next lab draw and annually. Although the recommendations were marked accepted, no order or results for the lipid panel were found in the chart, and the DON confirmed the results were missing and could not explain why the recommendations were not completed.
A resident with severe cognitive impairment, stroke-related deficits, and Medicaid coverage reported a pending dental follow-up after being seen for tooth pain. The dental consult documented fractured and hopeless teeth and referred the resident to an oral surgeon for extractions, but an LPN stated the referral was never made.
Two residents with significant cognitive and physical impairments experienced falls with injury due to the facility's failure to provide adequate supervision and consistently implement individualized fall prevention interventions. Staff did not ensure the use of non-skid footwear, bolster mattresses, or maintain supervision as outlined in care plans, resulting in unwitnessed falls, injuries, and emergency medical treatment.
A resident with severe cognitive impairment and multiple health conditions was observed with long, dirty fingernails and eating with their hands, despite requiring substantial assistance with ADLs and hygiene. Staff and family interviews confirmed that nail care and hand hygiene were not consistently provided or documented, and care plan interventions for nail care were not followed.
The facility failed to ensure accurate MDS assessments for multiple residents, leading to discrepancies in their medical records. A resident was inaccurately coded for medications not prescribed, another was not coded for an antipsychotic medication they were taking, a third resident's hospice services were not reflected, and a fourth resident's discharge location was incorrectly documented.
The facility failed to properly store and label medications, including narcotics, in two medication carts, leading to potential misuse and errors. Observations revealed unlocked carts, unlabeled medication cups, and improperly stored medications. The DON confirmed that these practices were against facility policy, which requires locked carts and proper labeling to prevent errors.
The facility failed to provide timely care and services for two residents, resulting in a delay in treatment and unmet care needs. One resident suffered a fracture during a transfer, which was not promptly addressed, leading to worsened mobility and increased pain. Another resident missed pain clinic appointments due to transportation issues, resulting in increased discomfort and reliance on medication.
A resident with diabetic retinopathy missed critical eye appointments due to the facility's transportation issues. The facility's bus was out of service, and alternative transportation was not arranged, leading to rescheduled appointments. The resident's guardian was not informed of the appointments, and there was a lack of documentation in the resident's medical record. Staff acknowledged the transportation and communication failures, resulting in a deficiency in providing timely ophthalmology services.
The facility failed to maintain accurate medical records for two residents. One resident's medication administration was not documented correctly, with discrepancies in the timing and identification of medications. Another resident missed critical ophthalmology appointments due to transportation issues, and the facility did not document these appointments or follow-up care properly. This highlights a deficiency in the facility's documentation practices.
A facility failed to provide scheduled showers and ADL care for a resident, leading to potential feelings of worthlessness and uncleanliness. The resident, who was cognitively intact and had multiple health issues, reported missed showers and unchanged bed sheets. Records showed ten missed showers over two months. Staff interviews revealed that showers were scheduled twice weekly, but missed showers were not properly communicated or documented.
A resident with diabetes and under hospice care experienced critically low blood sugar levels, but the facility failed to document these incidents and follow physician's orders for monitoring and treatment. Interviews revealed communication lapses among staff, leading to confusion about the resident's care plan. The resident was transferred to the hospital without proper documentation of the reasons or condition at the time.
Food Service Equipment Not Properly Cleaned and Dishmachine Temperatures Out of Range
Penalty
Summary
Food service equipment and surfaces were found to be heavily soiled during an initial tour of the kitchen with the Director of Food Services. In the dry storage room, the return air exhaust ventilation grill had accumulated and encrusted dust and dirt deposits, and food splash residue was observed on the overhead light assembly and ceiling surfaces near the equipment storage rack. The Director of Food Services stated he would have maintenance clean the ventilation grill and dietary staff clean and sanitize the light assembly and ceiling surfaces. Additional kitchen equipment was observed with accumulated and encrusted food residue. The Pitco fryer, South Bend convection oven, South Bend stove top and oven, South Bend char broiler, Cleveland steamer stainless steel support table, and Juice Machine under splash and drip tray assembly all had residue on interior or exterior surfaces. The Manitowac ice machine interior white resin retention plate had brown to black psychrophilic bacterial growth extending along the lower retention plate ridge, measuring approximately 1-inch-wide by 30-inches-long. The Director of Food Services stated he would have dietary staff clean and sanitize these items as soon as possible. During a comprehensive tour, the mechanical dish machine was observed with a wash temperature of 130 degrees Fahrenheit and a final rinse temperature of 168 degrees Fahrenheit, both out of range, while the PSI was 23 and in range. Record review showed the facility’s Dishmachine Guideline required specific wash and rinse temperatures and required low or abnormal temperatures to be reported, and the Dishmachine Temp/Sanitizer Guideline required temperatures and sanitizer concentration to be accurately recorded and dishmachine problems to be promptly addressed. Additional policy review showed cleaning procedures for the grill, oven, and ice machine.
Late Completion of Annual Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive annual assessments timely for three residents reviewed. For one resident with Alzheimer’s disease and COPD, the annual MDS had an ARD of 3/4/26 and the resident was observed seated in a wheelchair in the dining room on 4/15/26; the MDS was finalized on 4/16/26, and the Section V CAA Summary was signed on 4/16/26. During interview, the MDS nurse stated Section Z was signed timely, but the CAAs had been worked on on 3/18/26 and were never completed, so the MDS was not transmitted. The report cited CMS guidance stating that comprehensive assessments require completion of both the MDS and CAA process, as well as care planning, and that the MDS completion date and CAA completion date must be no later than 14 days after the ARD. For another resident with insomnia, left above-the-knee amputation, CKD, severe protein malnutrition, type 2 diabetes, hypothyroidism, hyperlipidemia, urinary retention, anemia, PVD, GERD, and dementia, the annual MDS had an ARD of 1/29/26 and the Section V CAA Summary was not completed by a registered nurse coordinator for the CAA process until 2/20/26. The MDS nurse confirmed that the signature date of 2/20/26 indicated the MDS was completed late. For a third resident with obesity and anxiety, the annual comprehensive MDS had an ARD of 2/13/26 and a signed completion date of 3/1/26; the float MDS nurse stated the completion date should have been 2/27/26 and could not explain why the assessment was not completed timely.
Quarterly MDS Assessments Not Completed Timely
Penalty
Summary
The facility failed to complete quarterly MDS assessments for three of seventeen residents reviewed for comprehensive assessments. Resident #49 was admitted with diagnoses including heart failure, chronic kidney disease, type 2 diabetes, atrial fibrillation, epilepsy, chronic pain, osteoarthritis, osteoporosis, obesity, and COPD, and had a BIMS score of 9 indicating moderate cognitive impairment. The record showed the last MDS had an ARD of 11/25/2025, and the MDS nurse confirmed that no quarterly MDS had been completed since that assessment date. Resident #61 was admitted with diagnoses including PVD, atrial fibrillation, hypertension, osteoporosis, hyperlipidemia, GERD, depression, dysphagia, insomnia, and a left above-knee amputation. The last MDS had an ARD of 12/05/2025, and the MDS nurse stated the resident was due for a quarterly MDS on 03/07/2026 but could not explain why it was not initiated. Resident #51, a female resident with COPD, had a quarterly MDS with an ARD of 03/06/2026 and a signed completion date of 04/13/2026; during interview, the MDS float nurse stated it should have been signed by 03/20/2026 and could not explain why the former MDS nurse did not complete it timely.
Inaccurate MDS Dental Coding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident, R12, on the Annual MDS with an Assessment Reference Date of 3/4/26. R12 was admitted with diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease (COPD), and the MDS reflected a BIMS score of 4 out of 15, indicating severe cognitive impairment, while also coding that there were no applicable oral dental concerns. However, the MDS included coding options for broken or loosely fitting full or partial dentures and for being edentulous. On 4/14/26, R12 was observed seated in a wheelchair in his room and reported that he had dentures but had not seen them in a few months and did not know what happened to them. An LPN stated that R12 dropped and broke his dentures one to two months earlier, and the MDS nurse acknowledged that a quarterly observation and data collection dated 2/5/26 reflected that R12 had dentures and that his dental status was not accurately coded on the Annual MDS.
Care Plan Not Updated for Current Transfer Status
Penalty
Summary
The facility failed to revise R9’s care plan to reflect the resident’s current transfer status. R9 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and the Significant Change in Status MDS with an ARD of 1/22/26 showed moderate cognitive impairment with a BIMS score of 8 out of 15. During observation on 04/14/2026, R9 was lying in bed. In interview, a CNA reported that R9 transferred via hoyer lift with a two-person assist and stated that transfer status was included in the care plan. However, the care plan still contained older interventions for pivot transfers with one-person assistance and stand-and-pivot transfers to the right side, along with an intervention dated 4/12/23 for hoyer lift with two-person assistance. A physician order dated 1/23/26 reflected hoyer lift transfers with two-person assistance, and the DON reported that R9 had been downgraded to a hoyer lift because the resident could no longer bear weight and that the care plan should have been updated.
Failure to Implement Pharmacy Recommendations for Lipid Monitoring
Penalty
Summary
The facility failed to implement pharmacy recommendations for one resident reviewed for pharmacy services. The resident was admitted with diagnoses including right ulna fracture, dysphagia, depression, insomnia, anxiety, stroke, type 2 diabetes, hypertension, and pain. The most recent MDS showed a BIMS score of 07, indicating severe cognitive impairment. A Pharmacist Drug Regimen Review dated 07/29/2025 stated that the resident was receiving atorvastatin and recommended adding a fasting lipid panel with the next lab draw and annually; the response was marked accepted, but no order or results for a fasting lipid panel were found in the medical record. A second Pharmacist Drug Regimen Review dated 09/16/2025 repeated the recommendation to add a fasting lipid panel with the next lab draw and annually, and the response was again marked accepted. During interview, the DON stated that a fasting lipid panel should have been completed based on the pharmacy recommendations and confirmed that results were not present in the resident's record. The DON later stated she was unable to find the results and could not explain why the pharmacy recommendations had not been ordered or completed.
Delayed Oral Surgeon Referral After Dental Consult
Penalty
Summary
The facility failed to ensure a timely dental services referral for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and vascular dementia, and the Quarterly MDS reflected severe cognitive impairment with a BIMS score of 3 out of 15. The resident had Medicaid as the payer source. During observation, the resident stated she had seen the dentist for a problem with a tooth on the lower left side of her mouth and said she was supposed to have a follow-up but had not heard anything yet. The dental consult documented severe pain with pressure in the lower left and some pain in the upper anterior left corner, noted fractured and hopeless teeth, and recommended removal of remaining upper teeth and lower fractured teeth by an oral surgeon, specifically referring the resident for removal of teeth #10, 11, and 18. In interview, an LPN stated the referral to the oral surgeon was never made after the dental appointment.
Failure to Implement and Communicate Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement resident-centered care plan interventions for fall prevention for two residents with known fall risks. One resident, who was legally blind, hard of hearing, and had dementia, experienced multiple unwitnessed falls, including falling out of bed and later from a wheelchair in the hallway. Despite care plan interventions such as non-skid footwear, staff assistance with transfers, and the use of a bolster mattress, these measures were not consistently implemented. The resident was found wearing regular socks instead of non-skid footwear and was placed in a wheelchair in the hallway for supervision after a fall, but was left unattended while staff attended to other residents. This resulted in a second fall, causing a head laceration that required emergency medical treatment and sutures. Another resident, with severe cognitive impairment and a history of falls and hip fractures, also experienced a fall resulting in a major injury. The care plan for this resident included interventions such as keeping the call light within reach, staff assistance with transfers, and ensuring the floor was free of hazards. However, the resident was found on the floor in their room, undressed, and without staff present. The resident's family expressed concerns about the lack of monitoring and the unclear circumstances surrounding the fall. Documentation indicated that the resident was unable to use the call light due to cognitive impairment, and staff did not provide adequate supervision or implement all care plan interventions, such as the use of a winged mattress to help define space. Interviews with staff and family members revealed gaps in staff awareness and execution of planned interventions. Staff were unable to explain why certain interventions, such as non-skid footwear and bolster mattresses, were not in place at the time of the falls. Additionally, staffing levels and assignments contributed to periods when high-risk residents were left unsupervised. The lack of consistent implementation of individualized fall prevention strategies and insufficient supervision directly led to residents experiencing preventable falls with injury.
Failure to Provide ADL and Hygiene Care for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's disease, dementia, and recent femur fractures, was observed with long, uneven fingernails containing a dark, unknown substance underneath. The resident, who required substantial to maximum assistance with activities of daily living (ADLs) and moderate assistance with transfers, was seen eating with their hands in the dining room, using their fingers to pick up food. Staff interviews confirmed that the resident needed cueing and assistance for all tasks, including eating and hygiene, due to significant cognitive decline. The resident was also noted to have had a recent episode involving a large bowel movement and was described as having their hands in the BM, further emphasizing the need for hand hygiene support. Despite a care plan indicating that nail care should be provided on shower days and as needed, there was no documentation in the electronic medical record regarding the completion of nail care or hand hygiene for this resident. Family concerns were also raised about the lack of nail maintenance, with reports that requests for nail trimming had not been fulfilled. Facility policy on ADL documentation did not specifically address the provision of hygiene care, and direct care staff acknowledged the issue only after it was pointed out during the survey.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their medical records. Resident #4 was inaccurately coded as taking anticoagulant and opioid medications, despite physician orders indicating otherwise. Similarly, Resident #42 was not coded for taking an antipsychotic medication, which was confirmed by physician orders. These inaccuracies were acknowledged by the MDS coordinator upon review. Resident #34's MDS did not reflect that the resident was receiving hospice services, despite physician orders indicating the initiation of such services. The MDS staff acknowledged this oversight. Additionally, Resident #67's discharge MDS inaccurately indicated a discharge to the hospital, while documentation by a Nurse Practitioner confirmed the resident was discharged home. This error was identified during a review with the social worker, who confirmed the mistake.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and labeling of medications, including narcotics, in two of five medication carts, which could lead to potential misuse and medication administration errors. During an observation, a medication cart on the 100 hall was found unlocked and unattended, with non-nurse staff passing by. A Registered Nurse (RN) was observed retrieving an unlabeled medication cup containing unidentified pills from the cart, which she claimed were for a resident's scheduled medication. The cart also contained a blister pack of Levoquin without a name and a pharmacy-packaged Levaquin with a resident's name, which the RN could not explain. Additionally, several open eye drops with no open dates were found in the cart. The RN left the cart unlocked while attending to another resident, contrary to the facility's policy that requires medication carts to be locked when unattended. In another instance, a medication cart was found with a medication cup containing six unidentified pills and a piece of paper with a possible resident name. The Director of Nursing (DON) confirmed that medication carts should be locked when unattended, controlled drugs should be double locked, and medications should not be prepped in advance in unlabeled cups. The facility's policy mandates that medications be stored in containers that meet regulatory requirements and that only authorized personnel access medications. The observed practices deviated from these policies, increasing the risk of medication errors.
Failure to Provide Timely Care and Transportation
Penalty
Summary
The facility failed to provide appropriate care and services for two residents, resulting in a delay in treatment and unmet care needs. For one resident, a transfer incident led to a fracture in the right leg, which was not promptly addressed by the facility staff. Despite the resident's complaints of pain and a family member's insistence, the facility delayed sending the resident to the hospital for further evaluation. The resident's condition worsened, requiring a mechanical lift for transfers and increased pain medication, impacting her mobility and psychological well-being. The facility's investigation into the incident was inadequate, as it did not initially include an interview with the resident involved. The investigation also lacked proper documentation and signatures, raising concerns about the thoroughness of the facility's response. The staff involved in the transfer did not recall the resident's requests to stop the transfer, and there was a lack of immediate action to address the resident's pain and potential injury. For another resident, the facility failed to ensure timely transportation to scheduled pain clinic appointments due to the facility vehicle being out of commission. The resident, who relied on pain injections for chronic back pain, experienced increased discomfort and had to rely on additional medication due to missed appointments. The facility did not arrange alternative transportation, resulting in a delay in the resident receiving necessary pain management treatment.
Failure to Provide Timely Ophthalmology Services Due to Transportation Issues
Penalty
Summary
The facility failed to ensure timely ophthalmology services for a resident, resulting in missed treatments. The resident, a male with a history of type 2 diabetes mellitus with unspecified diabetic retinopathy, hypertension, chronic kidney disease, and depression, had a moderately impaired ability to make daily decisions. He reported missing two to three eye appointments, including necessary eye injections, due to the facility's transportation issues. The facility's bus had been out of service for months, and alternative transportation arrangements were not made, leading to the rescheduling of critical eye appointments. The resident's ophthalmology office confirmed that his last appointment was on December 23, 2024, and subsequent appointments were rescheduled due to transportation issues. The resident's guardian was unaware of the December 23 appointment and the need for follow-up appointments, indicating a lack of communication from the facility. The facility's Activities/Transportation staff confirmed the transportation issues and the failure to arrange alternative transportation, which was the responsibility of the nursing staff. The Director of Nursing and other staff members acknowledged the lack of documentation in the resident's electronic medical record regarding missed appointments and follow-up notes from ophthalmology visits. The facility's failure to arrange transportation and ensure proper documentation and communication with the resident's guardian contributed to the deficiency in providing timely ophthalmology services.
Deficiency in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R7 and R49, as observed during a survey. For Resident R7, the issue involved the administration and documentation of controlled medications. On the morning of January 28, 2025, a review of the narcotic record binder showed that R7 was documented as having received Norco, Xanax, and Tramadol at 11:00 a.m. However, an observation revealed an unlabeled medication cup with unidentified pills in the medication cart, which the nurse claimed were R7's 11:00 a.m. medications. This discrepancy indicates a failure to document medication administration accurately and in a timely manner, as expected by the Director of Nursing. For Resident R49, the deficiency involved incomplete documentation of ophthalmology appointments and follow-up care. R49, a male resident with a history of diabetes, hypertension, and chronic kidney disease, reported missing several eye appointments due to transportation issues, which were crucial for his ongoing treatment plan. The facility's records lacked evidence of consult notes for appointments on November 25, 2024, and December 23, 2024. Additionally, there was no documentation of a missed appointment on January 22, 2025. Interviews with staff revealed that the nursing staff was expected to obtain and document consult visit notes, but this was not done, leading to incomplete medical records for R49. The failure to maintain accurate and complete medical records for both residents highlights a significant deficiency in the facility's documentation practices. The lack of proper documentation for medication administration and follow-up care appointments could potentially impact the residents' treatment and care plans. The Director of Nursing acknowledged the absence of necessary documentation and the need to follow up with the ophthalmology office for missing consult notes.
Failure to Provide Scheduled Showers and ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically bathing and showering, for a dependent resident, resulting in potential feelings of worthlessness and uncleanliness. The resident, a cognitively intact female with multiple diagnoses including hypertension, venous insufficiency, cirrhosis of the liver, a stage III pressure ulcer, and depression, was observed to be upset and un-groomed. She reported that staff had not changed her bed sheets for two weeks and that she missed her scheduled shower the previous day. A review of the resident's electronic medical records indicated that she had missed ten showers over a two-month period, with several entries noting that the activity did not occur. The resident's care plan required assistance with ADLs, including supervision with bathing. Interviews with facility staff revealed that showers were scheduled twice weekly, but if staff were unable to provide a shower, they were expected to communicate this to the next shift. The Director of Nursing acknowledged noticing missed showers in the resident's documentation and stated that staff had been educated on the issue.
Failure to Document and Follow Physician's Orders for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident's physician's orders and treatment were correctly documented and followed. The resident, who was admitted with a diagnosis of diabetes and later to hospice care, had specific orders for blood sugar monitoring and insulin administration. However, there were significant lapses in documentation and execution of these orders. On multiple occasions, the resident's blood sugar levels were critically low, yet there was no corresponding documentation in the progress notes or medication administration record (MAR). Additionally, there was a lack of communication and documentation regarding changes in the resident's care plan, such as the discontinuation of blood sugar checks and the administration of glucose. Interviews with nursing staff and the nurse practitioner revealed discrepancies in the communication and understanding of the resident's care needs. The nurse practitioner was not informed of the resident's critically low blood sugar levels, and there was confusion about whether blood sugar monitoring should continue. Furthermore, the resident was transferred to the hospital without proper documentation of the reasons for the transfer or the resident's condition at the time. These failures in documentation and communication contributed to the deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
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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