Villa At Beecher Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Flint, Michigan.
- Location
- G 3201 Beecher Rd, Flint, Michigan 48532
- CMS Provider Number
- 235363
- Inspections on file
- 39
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Villa At Beecher Place during CMS and state inspections, most recent first.
An RN left her assigned floor during the night shift without waiting for relief, leaving 41 residents without licensed nursing coverage for over two hours while only two CNAs remained on the unit. The RN handed medication and narcotic keys to a receptionist instead of another nurse, and a nurse on another floor declined to assume responsibility due to an already heavy census. During the period without an RN, no 6 AM meds, assessments, or treatments were provided, resulting in missed nebulizer treatments for a resident with respiratory needs and missed suctioning and PEG tube pain meds for a resident with cancer-related pain. Review of controlled substance shift inventories showed incomplete documentation and lack of required dual nurse signatures, and staff interviews confirmed that the absence of licensed nursing staff and missed 6 AM med pass occurred.
An RN left a unit with 41 residents for over two hours without licensed nurse coverage, leaving only CNAs and resulting in no nurse being available to administer scheduled early‑morning meds, PRN meds, or treatments, or to respond to potential emergencies. During this period, multiple residents with serious conditions such as COPD, acute respiratory failure, malignant neoplasms, quadriplegia with trach and PEG, DM with CKD, heart failure, and hypertension did not receive ordered nebulizer treatments, suctioning, PEG‑tube meds, insulin, antihypertensives, diuretics, pain meds, antidepressants, and nutritional supplements, and required assessments such as pain checks, BP monitoring, and turning/repositioning were not documented as done. Narcotic shift counts lacked required dual signatures, late entries by the DON were made about two weeks after the incident instead of contemporaneous charting, and requested policies and accurate hospital transfer lists were not provided or did not match the clinical record.
Surveyors found that controlled medication practices on the 4th floor were deficient when a Lorazepam blister pack on one cart showed 5 tablets remaining while the narcotic log documented 7, and the assigned nurse stated she had planned to document administrations later despite policy requiring immediate documentation. On the same unit, narcotic shift counts on one cart had only a single nurse’s signature instead of two, and on the other cart no count was recorded for a morning shift. An RN had left mid‑shift while responsible for multiple residents, handed medication cart keys to a non‑licensed staff member rather than another nurse, and the scheduled early‑morning med pass was not completed.
A resident with aphasia, right‑sided hemiplegia, dementia with agitation, depression, and moderate cognitive impairment had episodes of loud, combative behavior, including kicking a door, shaking a fist at others, and later punching another resident’s arm. After being sent to the hospital twice for behavioral evaluation, hospital staff determined on both occasions that the resident did not meet criteria for medical or psychiatric admission and discharged him back. Facility staff, including the UM and liaison, reported that management had directed that the resident not be accepted back due to perceived danger to residents and staff, and EMS was not allowed to re‑enter the building with the resident. No formal eviction or discharge notice was issued, the Ombudsman was not notified, and required transfer documentation was missing, despite the facility’s own guidelines requiring notice, preparation, and appeal rights. The resident’s family was told he could not return and was asked to remove his belongings, while the resident remained in the hospital pending alternate placement.
Two residents were physically assaulted on separate occasions by the same behaviorally unstable resident, who staff described as easily agitated, delusional, and unpredictable. In one event, a severely cognitively impaired resident was punched in the face multiple times in a dining room, with a CNA also struck while intervening, yet no post‑incident nursing assessment, injury documentation, pain assessment, or psych referral was entered in the victim’s record. In the second event, a cognitively intact resident with PTSD and schizophrenia reported being repeatedly hit in the head, pulled from a chair, and kicked, with subsequent findings of facial redness, oral bleeding, a loosened tooth, and a documented pain score of 10/10, but with limited pain documentation and no immediate psych follow‑up. Despite staff witnessing the altercations and a police report noting the aggressor’s admission to punching the victim, the DON and abuse coordinator deemed the incidents unsubstantiated and not reportable, delayed completion of investigations, and failed to report the allegations as required by facility policy and federal and state law.
The facility failed to promptly investigate, document, and report two separate resident‑to‑resident physical altercations involving the same aggressor and two different victims. In the first event, a cognitively impaired resident seated in a dining room was punched in the face multiple times by another resident, with a CNA also struck while intervening; the DON was notified hours later, no post‑incident assessments or progress notes were documented for the victim, and the investigation summary was not completed for about two months, with no report submitted to state authorities. In the second event, a cognitively intact resident with PTSD and psychiatric diagnoses reported being repeatedly punched and kicked by the same aggressor in a day room, with nursing documentation, a CNA account, and a police report all describing a physical assault and observed facial redness, yet the DON and abuse coordinator deemed the allegation unsubstantiated, delayed the investigation, could not produce staff written statements, and did not report the incident as required by the facility’s abuse policy and federal/state reporting timelines.
Two residents with cognitive impairment and psychiatric diagnoses were involved in a witnessed physical altercation in a dining room, during which one resident struck another in the face multiple times and then attempted to strike additional residents and staff. Despite documented facial bruising and known behavioral issues, there was no timely post‑incident nursing or provider assessment, no documentation of physical or emotional status, no pain assessment, and no prompt behavioral health or social services referrals or evaluations for either resident. The social services director later acknowledged not being aware of the incident at the time and not initiating referrals, and the facility’s behavior management program requirements for residents with harmful behaviors were not followed.
A resident with multiple medical conditions developed a new wound and was started on antibiotics, but the responsible party was not notified as required by facility policy. The wound care nurse confirmed there was no documentation of notification, and the resident's family reported being unaware of the new wound, antibiotic treatment, and a previous fall.
A resident with a history of cellulitis, peripheral vascular disease, and multiple skin wounds had several new wounds documented in the EMR, but the care plan for skin integrity was not updated to reflect these changes. The care plan had not been revised since earlier in the year, despite facility policy requiring updates with changes in condition. Staff confirmed the care plan should have been updated but was missed.
A resident with multiple medical conditions, including bilateral lower extremity amputations, was left in soiled linens for extended periods and experienced delayed responses to call lights. The resident reported harsh treatment by a CNA and described feeling anxious and blamed after voicing concerns. Outside agency visitors confirmed witnessing the resident left on urine-saturated linen and observed staff ignoring call lights while socializing. These actions were inconsistent with facility policies requiring dignity, respect, and prompt grievance resolution.
Multiple residents experienced excessive heat and discomfort due to inoperable air conditioning units in both common areas and individual rooms. Staff and residents reported ongoing issues with high temperatures, and some fans provided as alternatives were dirty or not functioning. Maintenance staff did not consistently monitor room temperatures or maintain a list of affected rooms, and leadership confirmed that repairs and replacements for the cooling systems were delayed, resulting in prolonged discomfort for residents.
Four residents were not protected from verbal and physical abuse during two separate altercations. In one case, a resident with dementia and alcohol abuse history became agitated and engaged in a physical fight with another resident, resulting in injuries to both. In another case, two cognitively impaired roommates had a violent confrontation involving racial slurs and physical assault, leading to serious injuries and hospitalization. The facility did not update care plans or provide education after these incidents, and lacked a formal process for roommate placement or timely intervention.
A resident with bilateral amputations and multiple comorbidities was provided a wheelchair missing a right-side brake, which was not identified or addressed by therapy or facility staff. The resident, who was cognitively intact and able to self-propel, was unable to use public transportation due to the unsafe condition of the wheelchair. Staff interviews revealed a lack of clarity regarding responsibility for wheelchair inspection and maintenance.
The facility was unable to produce a letter of reliability for its natural gas emergency generator during a record review, leaving its backup power supply vulnerable to fuel supply issues. This deficiency was confirmed by the maintenance director.
The facility did not maintain required documentation for monthly testing of emergency battery back-up lights for both 30 seconds and 90 minutes, and a battery back-up emergency light in the generator room was found to be nonfunctional during observation. These issues were confirmed by the maintenance director.
Surveyors identified that the fire alarm system was not properly tested and maintained, with a standing supervisory alarm and trouble alarm present on the main panel, a tamper switch in the riser room not wired to any system, and a pull station near the dining room exit blocked by a display board, all confirmed by the maintenance director.
Surveyors identified multiple deficiencies in the facility's sprinkler system maintenance and testing, including a dirty sprinkler head, overdue testing of several sprinkler components, missing maintenance tools, and overdue system flushes and valve checks. These issues were confirmed through observation, record review, and interview with the maintenance director.
The facility was unable to provide documentation confirming that the mandatory four-year HVAC damper inspection had been completed, as discovered during a record review and confirmed by the maintenance director. This left the operational status of the dampers unverified.
The facility did not provide documentation for required first shift, first quarter fire drills, as confirmed by record review and interview with the maintenance director. This failure means staff may not have participated in or been prepared for mandated fire emergency procedures.
Surveyors observed that double rated fire doors on the 3rd floor did not close when released from magnetic hold open devices, resulting in smoke barriers not meeting the required 1/2-hour fire resistance rating. This deficiency was confirmed by the maintenance director and could impact 40 occupants by allowing smoke, heat, and fire to pass between compartments.
Surveyors found that two power strips were connected together in the social work office, which does not comply with NFPA standards for electrical system safety. This practice was confirmed by the maintenance director and could affect 15 occupants in the event of an electrical-related fire.
Three residents did not receive appropriate wound care and preventive interventions as ordered, including daily PEG tube dressing changes, use of Prafo boots, and proper wound assessment and documentation. Staff failed to follow care plans and physician orders, and did not consistently document wound treatments or apply required preventive measures.
A resident with a history of wandering and elopement risk was able to leave the facility unsupervised after his Wanderguard was removed due to swelling. Despite attempts to replace the device, the resident refused, and no additional safety measures were implemented. The resident exited the facility without triggering alarms and was later brought back inside by a transportation aide. Staff interviews revealed a lack of communication and coordination regarding the resident's safety measures.
A facility failed to document a catheter change and follow up on a positive urinalysis for a resident with a urinary catheter. The resident's catheter tubing and bag were discolored bluish purple, indicating a potential urinary tract infection, which was not initially recognized by staff. Despite a care plan requiring monitoring and documentation, there was no progress note for the catheter change or follow-up on the positive urinalysis.
A resident suffered multiple fractures and a shoulder dislocation after a mechanical lift strap broke during a transfer at an LTC facility. The sling used was defective, and staff failed to inspect it before use. The facility lacked a specific policy for the lifts in use, and the reference manual was incompatible with the equipment. The resident was in severe pain, but no pain relief was administered before hospital transfer.
Two residents in the facility developed or were at risk of worsening pressure ulcers due to inadequate care and documentation. One resident developed an unstageable pressure wound on the foot, with observations showing the foot against the bed's footboard, despite known risks. Another resident had multiple skin impairments, with delayed documentation and treatment not reflecting physician recommendations. The facility's wound care management policy was not followed, leading to deficiencies in care.
A resident with multiple medical conditions experienced neglect when a nurse failed to administer scheduled medications, including narcotics, leading to pain and suffering. The nurse signed out the medications but did not give them to the resident, altering the narcotics log and failing to notify the physician. The incident was discovered during a facility tour, and the nurse subsequently quit.
A resident with chronic pain did not receive scheduled doses of Hydrocodone-Acetaminophen, leading to unrelieved pain. Nurse K failed to administer the medication on time, despite it being signed out, and inaccurately documented the administration times. The DON was unaware of the issue until informed by the surveyor, and Nurse K later quit mid-shift.
The facility failed to provide sufficient staffing, including RN coverage, leading to delayed care for residents. Multiple residents reported long wait times for call light responses and unmet care needs. A resident with asthma and hypertension noted slow call light responses, while another with quadriplegia experienced 30-minute delays. A group meeting revealed concerns about inadequate staffing, particularly during the third shift, affecting medication administration and call light response times. Individual interviews confirmed these issues, with residents reporting wait times exceeding an hour.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including dirty and improperly dried food containers, chipped plates, moldy sub buns, and inadequate dish machine sanitizer concentration. Additionally, there were issues with uncovered food in the freezer, cracked cereal containers, and a leaking ice machine drain line, all of which posed potential contamination risks.
The facility failed to follow infection control standards by not effectively collecting, analyzing, and reporting infection data. Incomplete infection surveillance hindered trend identification. Additionally, the facility inadequately monitored Legionella in the water system, failing to re-sample positive locations or test additional rooms. Several residents with respiratory issues were transferred to the hospital, but their rooms were not tested for Legionella. The Medical Director was unaware of the Legionella presence, indicating a lack of communication and testing.
The facility failed to maintain resident dignity and rights, with issues such as threadbare gowns, inadequate linen, and long call light wait times. Residents reported frustration over unavailable snacks, particularly for diabetics, and staff were observed using personal phones during work hours. Specific incidents included a resident found on the floor without proper clothing and another left without pants, highlighting a lack of care and respect.
The facility failed to provide a clean and comfortable environment, with observations of cluttered and unclean rooms, including one with a strong odor of urine and full garbage cans. A resident reported that their bed was often unmade, requiring them to lay on a bare mattress. A CNA indicated linens are changed when residents shower or if visibly dirty, but could not explain why the bed was not made.
The facility failed to update care plans for several residents, resulting in unmet care needs. A resident's care plan did not address impaired hand function or a new toe wound. Another resident lacked hygiene assistance, and a third had improper catheter positioning. Significant weight loss in two residents was not addressed, and a care plan incorrectly included a removed catheter.
The facility failed to provide timely assistance with ADLs for several residents, leading to frustration and embarrassment. A resident with full cognitive abilities reported receiving only one shower in 30 days, despite being scheduled for twice-weekly showers. Another resident with moderate cognitive loss experienced long delays in response to call lights and inadequate assistance with changing briefs. Other residents also faced deficiencies in ADL care, such as unclean nails, missed showers, and being left in bed without assistance.
The facility failed to document a fall and complete neurological monitoring for a resident with a head injury, lacked supervision for an unsafe smoker, and did not update a care plan after a resident was found on the floor. Additionally, unsafe water temperatures were recorded without corrective action.
The facility failed to adhere to pharmaceutical standards, with expired medications and improper storage temperatures found across multiple floors. Refrigerators on the 2nd and 3rd floors exceeded acceptable temperature ranges, and medication carts were left unlocked. Expired medications and supplies were discovered, and the Director of Nursing was informed of these issues.
The facility failed to consistently provide substantial nighttime snacks to residents, including those with diabetes, leading to dissatisfaction and potential health risks. Residents reported that snacks were often unavailable due to others taking multiple items, and there was a long gap between dinner and breakfast. Staff interviews revealed procedural lapses in snack distribution, and a resident with multiple health issues was not consistently offered a nighttime snack, despite documented nutritional needs.
The facility failed to identify, analyze, and review resistance patterns of infectious organisms in their Antibiotic Stewardship Program, affecting all residents. The DON and new IPC Nurse I admitted the absence of monthly summary reports and antibiograms. Incomplete infection surveillance data from June 2023 to May 2024 hindered trend analysis, and there was no monitoring for multi-drug resistant organisms. The facility's policy on Infection Prevention and Control was not effectively implemented.
The facility exhibited numerous maintenance and sanitation deficiencies, including unsecured oxygen tanks, broken furniture, and strong odors of urine in several rooms. Observations revealed issues such as wet floors, unstable tables, and inadequate housekeeping, with dust and debris accumulating in ventilation systems. Essential supplies were missing in common areas, and maintenance problems like unsecured sinks and broken closet doors were prevalent.
The facility failed to accurately assess and document the code status for two residents, leading to potential miscommunication and inappropriate care. One resident disagreed with the Full Code status documented without their consent, while another had conflicting code status information due to an oversight during readmission. The social worker acknowledged these discrepancies and noted the need for updates.
A facility failed to complete and transmit a discharge MDS assessment on time for a resident with chronic conditions, leading to a deficiency. The resident was discharged, but the assessment was not completed until months later and was only transmitted after a significant delay. The MDS Coordinator, new to the role, was unsure why the assessment was not submitted timely, as it was not added to a batch for submission.
A resident with schizophrenia, major depressive disorder, and severe dementia did not receive the required yearly PASARR Level II Screening or exemption certification for three consecutive years. Despite indications of mental illness and medication use, the necessary documentation was not completed. Interviews with staff revealed confusion over responsibilities, and the deficiency was only addressed after being identified.
The facility failed to develop comprehensive care plans for two residents, one with an indwelling catheter and another with a tracheostomy and PEG tube. Observations showed an uncovered catheter bag and improperly managed tracheostomy and feeding equipment. The care plans lacked specific interventions, leading to potential unmet care needs.
The facility failed to prevent and manage pressure ulcers for residents, leading to new and worsening ulcers. A resident developed a new ulcer on the toe due to inconsistent use of heel boots, while another had multiple ulcers with incomplete wound care documentation. A third resident's positioning devices were not consistently used, contributing to worsening pressure injuries.
A resident with multiple medical conditions developed limited movement in his hand due to the facility's failure to implement necessary interventions for range of motion. Despite therapy orders, the interventions expired, and there was no plan to restore or prevent further decline. Staff interviews revealed a lack of a Restorative Nursing program, and the resident reported not receiving exercises or devices to aid his condition.
The facility failed to properly assess and maintain urinary catheters for three residents, leading to unmet care needs and potential infection risks. A resident had an indwelling catheter without proper documentation, another had a catheter lying flat with discolored urine, and a third had a suprapubic catheter with cloudy sediments. Care plans lacked necessary updates and monitoring, and there was a lack of documentation and testing for potential UTIs.
The facility failed to ensure proper nutrition and hydration for three residents, leading to significant weight loss and lack of access to fresh water. One resident was observed without water at the bedside, despite having a care plan for hydration monitoring. Another resident experienced a 6.78% weight loss, with no updates to the care plan or notification to the medical director. A third resident lost 7.41% of their weight, complained about cold food, and had no updates to their nutritional care plan. These deficiencies highlight issues in the facility's adherence to its policies.
Two residents in an LTC facility experienced deficiencies in enteral nutrition management. One resident received tube feeding at an incorrect rate, while another had unlabeled and undated feeding equipment, risking infection. The facility failed to document feeding administration and resident refusals, violating its policies on enteral nutrition care.
A facility failed to maintain proper respiratory care for two residents. One resident's tracheostomy equipment was not readily available or properly maintained, with outdated humidification and reused suction tubing. Another resident's nebulizer was improperly stored with residue left in the medication cup. Facility policies for tracheostomy care and nebulizer therapy were not followed, posing potential risks of infection and respiratory distress.
Unattended Unit Leaves 41 Residents Without RN Coverage and Missed 6 AM Med Pass
Penalty
Summary
The deficiency involves a nurse leaving her assigned unit and 41 residents without licensed nursing coverage, medication administration, or emergency care capability for over two hours during the night shift. According to the facility incident report and interviews, the RN assigned to the 4th floor (Nurse MI) clocked out and left the facility at 4:19 AM while responsible for 41 residents, with only two CNAs remaining on the floor. She did not wait for relief from another licensed nurse, did not provide a proper handoff, and did not notify the CNAs that she was leaving. Prior to leaving, she turned the medication cart and narcotic keys over to the front receptionist, a non-licensed staff member, instead of directly to another licensed nurse as required by facility policy. The report states that the receptionist, believing the keys should be held by licensed staff, took them to the 3rd floor nurse. The 3rd floor nurse, who already had 48 residents, refused to accept responsibility for the additional 41 residents and did not take the keys, stating it would be unsafe to be responsible for a total of 89 residents. No licensed nurse was present on the 4th floor from approximately 4:19 AM until about 6:30 AM, when the 4th floor unit manager arrived after being informed there had been no nurse on the unit for over two hours. During this period, only the two CNAs provided care, and they reported they were busy with resident care and did not realize the nurse had left until the morning nurse arrived. As a result of the absence of a licensed nurse, all 6:00 AM medications, assessments, and treatments for the 41 residents on the 4th floor were not administered or performed. Record review showed that one resident (R6) missed scheduled albuterol nebulizer treatments at midnight and 6:00 AM, and another resident (R5) did not receive scheduled suctioning by mouth at 6:00 AM, as well as scheduled PEG tube medications for cancer pain at 2:00 AM and 6:00 AM. A nurse who came on at 7:00 AM confirmed that 6:00 AM medications, vital signs due for medications, and nebulizer treatments were not given, and that she began the 8:00 AM medication pass upon starting her shift. Narcotic reconciliation records for the 4th floor medication carts showed missing or incomplete shift inventory documentation, including lack of a 7:00 AM shift entry for one cart and only a single nurse signature on multiple dates for the other cart, despite policy requiring two nurse signatures each shift. The facility’s resident rights policy and employee handbook, as cited in the report, specify residents’ rights to be free from neglect and require staff not to leave assigned workstations or leave work early without proper approval and handoff.
Unattended Unit Leads to Missed Early‑Morning Medications, Treatments, and Documentation Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure continuity of care and timely administration of medications and treatments for all 41 residents on the 4th floor when the only licensed nurse assigned to that unit left the building for over two hours without relief. According to the facility incident report and interviews, the RN assigned to the 4th floor clocked out and left at approximately 4:19 AM, leaving 41 residents with only two CNAs and no licensed nurse to assess, administer medications, or respond to medical needs and emergencies between 4:19 AM and about 6:30 AM. The nurse left the medication keys with the front receptionist instead of a licensed nurse, and the receptionist then attempted to give the keys to the 3rd floor nurse, who refused to assume responsibility for an additional 41 residents. The DON, who was the on‑call manager, did not respond to calls or texts at the time because she was asleep, and no other nurse manager or on‑call nurse responded, leaving the 4th floor without licensed nursing coverage during that period. Record review showed that during this time frame, multiple scheduled medications, PRN medications, and treatments due during the night and early morning were not administered or documented as given for numerous residents with significant medical conditions. One resident with pain, vascular angioplasty, malignant neoplasm of bone, and a pressure ulcer did not receive scheduled 6:00 AM medications including Lasix and omeprazole, and PRN hydrocodone for pain was not assessed or administered. Another resident with type 2 DM, COPD, and chronic pain did not receive scheduled famotidine and hydralazine doses, and PRN pain medication was not assessed. A resident with COPD, heart failure, and acute kidney failure did not receive scheduled ipratropium‑albuterol breathing treatments at midnight and 6:00 AM, and pain assessments and PRN pain medications were not documented. A resident with malignant neoplasm of the mandible, PEG tube, and need for routine suctioning did not receive scheduled suctioning, levothyroxine, gabapentin, ondansetron, or scheduled PEG‑tube pain medications during the night and early morning. Additional residents with acute respiratory failure, quadriplegia with tracheostomy and gastrostomy, chronic pain, diabetes, CKD stage 5, hypertension, heart failure, and other serious diagnoses also missed ordered treatments and medications. One resident missed albuterol nebulizer treatments at midnight and 6:00 AM and was later sent to the hospital for a change in condition on that date. Another resident did not receive scheduled lidocaine patches for knee pain. A quadriplegic resident with trach and PEG did not receive scheduled baclofen, nutritional supplement (Med Pass), tizanidine, or documented turning and repositioning every two hours. A resident with diabetes and CKD stage 5 did not receive scheduled insulin glargine at 6:00 AM. Other residents did not receive scheduled furosemide, omeprazole, sertraline, Ventolin inhaler doses, ipratropium‑albuterol breathing treatments, or ordered blood pressure checks and antihypertensive medication at 6:00 AM. Late entries by the DON were made approximately two weeks later, documenting generic assessments such as “no signs and symptoms of pain or discomfort noted,” without contemporaneous documentation from the date of the incident. The investigation also identified failures in narcotic control documentation and shift‑to‑shift reconciliation. Review of the controlled substance shift inventory for the 4th floor medication carts showed missing entries and lack of required two‑nurse signatures for narcotic counts on the relevant date and surrounding dates. The Unit Manager confirmed that policy requires two nurse signatures each shift to balance narcotics and that if it is not written, it did not happen. The facility’s charting and documentation policy requires that all services provided, progress toward care plan goals, and any changes in condition be documented in the EMR to facilitate communication among the interdisciplinary team, yet multiple services, assessments, and medication administrations during the period without a licensed nurse were not documented as provided. The administrator did not provide requested policies related to medication administration, scheduling, narcotic counts, change‑of‑shift duties, and missed medications at the time of surveyor request, and the list of residents sent to the hospital did not include the resident who was documented as having been sent out for a change in condition on the date in question.
Failure to Reconcile and Secure Controlled Medications on 4th Floor Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate reconciliation and secure handling of controlled medications on the 4th floor medication carts. During a narcotic count on the 4th floor East cart, the Unit Manager identified that a blister pack of Lorazepam 0.5 mg, ordered every 4 hours as needed for anxiety, contained only 5 tablets when the narcotic sign-off sheet documented 7 tablets on hand the previous day. The discrepancy of 2 tablets was confirmed by the Unit Manager, who verified that the written inventory did not match the actual blister pack count. When questioned, the nurse assigned to the resident stated she was planning to document the administrations, and the Unit Manager stated that nurses are required to sign for medications as soon as they are administered. Additional deficiencies were identified in the reconciliation of controlled substances on both the East and West 4th floor medication carts. Review of the West cart’s controlled substance inventory for a specific morning shift showed only one nurse’s signature instead of the required two signatures from the outgoing midnight nurse and incoming day nurse; the nurse who signed confirmed that the midnight nurse had left the building early and did not return, and she did not know with whom she had counted the narcotics. For the East cart, the February controlled substance shift inventory form showed no entry for the morning change of shift on the same date, indicating that no narcotic count was performed at that time. Employee records showed that the midnight nurse left the facility at 4:19 AM while responsible for 41 residents and gave the medication cart keys to a non-licensed staff member instead of directly to another licensed nurse, and the scheduled 6:00 AM medication pass was not completed as required.
Failure to Readmit Hospitalized Resident and Follow Required Transfer/Discharge Procedures
Penalty
Summary
The deficiency involves the facility’s failure to permit the readmission of a long‑term care resident following hospital evaluation and discharge, resulting in the resident remaining in the hospital while alternate placement was sought. The resident had been admitted to the facility with diagnoses including aphasia, right‑sided hemiplegia/hemiparesis after an intracerebral hemorrhage, dementia with agitation and hallucinations, major depression, a need for assistance with personal care, and a history of suicidal behavior. An MDS assessment showed a BIMS score of 11/15, indicating moderate cognitive impairment. The facility’s own transfer/discharge guideline states that residents have the right to remain in the facility and that transfer or discharge must follow specific notice, preparation, and appeal procedures, including notification to the State Long‑Term Care Ombudsman. In the days leading up to the refusal of readmission, the resident exhibited behavioral symptoms. Staff reported that the resident was sometimes combative, grunted loudly, and became frustrated when not understood. On one occasion, the resident kicked a conference room door where management was meeting, shook his fist at staff and other residents, and yelled in the dining area. The NHA stated that the resident could not be threatening other residents and needed to be sent out for a behavior evaluation. A transfer assessment dated for that episode cited increased behaviors, refusal of medication, being physical with staff, and being inconsolable and non‑compliant, although the unit manager later clarified that aside from the fist‑shaking gesture there was no physical contact with staff. The resident was sent to the hospital and returned the same day, and staff reported no new behavioral concerns upon his return. Subsequently, the resident was again in the dining area, became visibly upset, and yelled out a family member’s name. The regional director of clinical operations (RDC) interacted with him, during which he calmed and engaged in coloring and discussion about his communication frustrations. Later that day, while waiting for the elevator, the resident punched another resident in the arm as two residents exited the elevator; the struck resident was assessed and found to have no injuries. The unit manager and RDC reported that the medical director petitioned for a full psychiatric evaluation and the resident was sent to the hospital. However, the hospital social worker stated there was no petition sent from the facility and that on both behavioral presentations the resident was medically and psychiatrically evaluated and did not meet criteria for hospitalization. The hospital discharged the resident back to the facility, but EMS reported they were not permitted to enter the building with him and had to return him to the hospital. Multiple facility staff acknowledged that management had communicated that the resident was not to be accepted back. A nurse reported being told by the unit manager that if the ambulance brought the resident back, staff were not to accept him. The unit manager confirmed that when the hospital called late at night to report they had been told the facility would not accept the resident back, she referred them to upper management and later stated that staff were aware per the NHA that the resident was not to return. The NHA acknowledged that the resident had the right to return but stated that higher‑ups were concerned about safety and that other residents were afraid to come out of their rooms because of the resident’s behaviors. The facility liaison reportedly told the hospital that higher‑ups said the resident could not return because he was a danger to residents and staff. Despite repeated hospital requests, no formal eviction or discharge notice was provided. The resident’s family member reported being told that the resident could not come back and that they needed to collect his belongings, and she stated that his discharge did not align with his long‑term placement goals and that she wanted him to remain near her. The social worker at the facility confirmed that the resident’s discharge plan prior to these events was for him to remain at the facility because his daughter could not care for him at home. She also acknowledged that the resident attempted to readmit from the hospital and was not allowed to return due to behavior, and that she did not notify the Ombudsman. Documentation in the resident’s chart lacked a transfer assessment or progress note for the later hospital transfer, and the RDC acknowledged that no such note had been entered. The hospital social worker documented that the patient was appropriate for discharge back to the facility, but because the facility refused to accept him, he was subsequently admitted to the hospital. This sequence of actions and omissions shows that the facility did not follow its own transfer/discharge guideline and did not permit the resident’s readmission after hospital discharge, thereby failing to ensure a safe and appropriate discharge consistent with the resident’s needs and preferences.
Failure to Protect Residents From Repeated Resident‑to‑Resident Physical Abuse and to Report and Assess Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse and to respond appropriately to resident‑to‑resident altercations involving one resident with a history of agitation and two other residents. In the first incident, a cognitively impaired resident with a BIMS score of 0 was sitting in the first‑floor dining room when another resident, described by staff as easily agitated, swearing, yelling, and unpredictable, came into the area and struck him in the face three times. A CNA witnessed the assault, intervened, and was punched in the face by the aggressor, who then attempted to swing at other residents and staff. Staff reported visible bruising to the victim’s face and overhead paging for help, but there was no documentation in the victim’s medical record of any post‑incident nursing assessment, description of injuries, pain assessment, or physician/NP/PA evaluation, and no psych or therapy referral was documented for either resident following this event. The same aggressor resident, who had mild cognitive impairment (BIMS 11) and was receiving psychotropic medications for dementia‑related psychotic/agitated behaviors and mood stabilization, was involved in a second altercation with another resident who was cognitively intact (BIMS 13) and had diagnoses including PTSD, major depressive disorder, schizophrenia, and anxiety disorder. In this second incident, the cognitively intact resident reported being assaulted multiple times in the head while seated in a day room, with her glasses knocked off and being pulled from her chair and kicked on the floor. A CNA responded to calls for help and found the victim on the floor next to her chair with the aggressor at the edge of his wheelchair, arms in motion as if to strike, and separated them. Nurse’s notes documented that the resident was attacked in the day room, and a police officer later documented slight redness on the victim’s face and that the aggressor admitted punching her. Subsequent nursing notes recorded blood on the victim’s sheets, a slightly loose tooth with old blood around it, and later a pain score of 10/10, but there was no detailed documentation of pain location, quality, or specific pain interventions. Across both incidents, the facility failed to follow its abuse policy requiring prompt, thorough investigation and immediate reporting of abuse allegations. For the first incident, the DON was notified approximately two hours after the event, and the facility did not complete its Verification of Investigation Summary until 60 days later. For the second incident, the DON was notified by phone on the day of the event but did not complete the risk management documentation and investigation until several days later, and the Verification of Investigation Summary was not completed until 31 days after the incident. The abuse coordinator and DON determined both incidents were not reportable and unsubstantiated, despite a staff‑witnessed assault, observed injuries, and a police report documenting the aggressor’s admission to punching the victim. There was no timely psych or behavioral referral documented for the involved residents after either incident, and the social worker reported not being informed of the first incident and learning of the second incident nearly a week later, resulting in no immediate psychosocial follow‑up for the victims. The facility’s own policy required that abuse allegations be reported immediately, but the administrator later acknowledged that both resident‑to‑resident physical altercations should have been reported and taken seriously by the abuse coordinator.
Failure to Timely Investigate and Report Resident‑to‑Resident Physical Altercations
Penalty
Summary
The deficiency involves the facility’s failure to promptly and thoroughly investigate and report two resident‑to‑resident physical altercations, and to document and follow up on the affected residents’ status, as required by facility policy and federal and state law. In the first incident on 12/7/25, one resident (R402) struck another resident (R403) three times in the face in the first‑floor dining room while R403 was seated and unable to fight back. A CNA intervened, was punched in the face by R402, and reported that R402 then attempted to strike other residents and staff. The facility’s risk management report documented that the DON was notified approximately two hours after the incident. Despite staff witnessing the altercation and observing apparent facial bruising on R403, the abuse coordinator determined the event was not reportable, concluding that abuse was not substantiated because R403 was considered unharmed and gave a thumbs‑up when asked if he was okay. R403’s clinical record showed significant cognitive impairment and multiple psychiatric and neurologic diagnoses. His BIMS score was 0/15, indicating severe cognitive impairment, and he had a history of hemiplegia and hemiparesis after an intracranial bleed, major depression, and anxiety disorder, and was receiving paroxetine, divalproex, and Seroquel. Despite this vulnerability and the reported facial bruising, there were no progress note entries, follow‑up assessments, physician or NP evaluations, or psychiatric referrals documented for R403 between 12/8/25 and 12/30/25 related to the altercation. The corporate nurse and DON confirmed that no post‑incident documentation or follow‑up assessments were entered in R403’s record. The facility’s Verification of Investigation Summary for this incident was not completed until 2/5/26, approximately 60 days after the event, and the incident was not reported to the state FRI submission site, contrary to the facility’s abuse policy requiring prompt investigation and immediate reporting, but not later than two hours after an alleged violation is made. The second incident occurred on 12/27/25 and involved another resident (R401) and the same aggressor resident (R402). Nurse’s notes documented that R401 was attacked in the day room by R402, who entered very angry and agitated, struck R401 in the face, and knocked off her glasses. A CNA responded to calls for help and found R401 on the floor next to her chair, with R402 at the edge of his wheelchair over her, arms in motion as if to strike; she separated them and assisted R401 back to her chair, then reported the event to the nurse and 911 was called. The nurse documented that R401 was “scared to death,” and the police report recorded that R401 stated she had been punched in the face, with the officer observing slight redness on the right side of her face. The officer’s report also documented that when asked if he punched R401, R402 answered yes and mimed a punching motion. R401, who had a BIMS score of 13/15 (cognitively intact) and diagnoses including bilateral knee osteoarthritis, PTSD, major depressive disorder, schizophrenia, and anxiety disorder, later told the surveyor she was hit 10–12 times, pulled from her chair, kicked on the floor, bled from her mouth, and was afraid to leave her room afterward. Despite these accounts, the DON and Administrator/Abuse Coordinator concluded that no abuse occurred and deemed the incident not reportable, stating there was no witness that R401 was assaulted. The DON did not begin the facility risk management documentation and investigation until 1/2/26, seven days after the incident, and the Verification of Investigation Summary was not completed until 1/27/26, 31 days after the event. Staff reported that written statements about the incident had been completed and turned over to management, but the DON was unable to locate them when requested by the surveyor. One nurse who documented the incident reported receiving verbal education and a write‑up from management about her documentation and did not answer when asked if she had been asked to change, modify, or delete her note. The facility did not submit either of the two resident‑to‑resident altercation incidents to the state FRI submission site, despite its written abuse policy stating that all abuse allegations, including resident‑to‑resident altercations and injuries of unknown source, must be promptly and thoroughly investigated and reported immediately, but not later than two hours after the alleged violation is made.
Failure to Provide Timely Behavioral Health Follow-Up After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide timely behavioral health assessments and services following a witnessed resident‑to‑resident physical altercation. On 12/7/25, a CNA observed one resident (R402) strike another resident (R403) in the face three times while R403 was seated in the dining room. The CNA intervened, was struck in the face by R402, and reported that after the residents were separated, R402 began swinging at other residents and staff. A facility Risk Management Report documented that R403 was hit in the face three times by another resident while in the dining room and that he was unable to provide a description of the event. R403 had a BIMS score of 0/15, indicating severe cognitive impairment, and diagnoses including hemiplegia/hemiparesis after intracranial bleed, major depression, and anxiety disorder, and was receiving paroxetine, divalproex, and Seroquel. R402 had a BIMS score of 11/15, indicating mild cognitive impairment, and was receiving Seroquel, Depakote, and sertraline for dementia with psychotic/agitated behaviors, mood stabilization, and depression. Despite the altercation and reported visible facial bruising on R403, review of both residents’ clinical records from 12/7/25 through 12/30/25 showed no post‑assault nursing or provider assessments, no documentation of physical findings such as redness, bruising, or discoloration, no assessment of pain, and no progress notes addressing either resident’s physical, social, or emotional status related to the incident. Record review further showed that no timely behavioral health or social services interventions were initiated for either resident after the incident. There was no evidence of psych referrals, evaluations, or therapy referrals for the post‑incident period for either resident, and no social services documentation or visits addressing the altercation for the entire month of December. The Social Services Director acknowledged she did not see R402 after the incident, did not send referrals after the physical altercation, and was unaware of or did not remember being informed of the event involving R403. The facility’s Behavior Management Program policy, which calls for behavior management team involvement for residents with reportable incidents and behaviors harmful to others or interfering with function or care, was not implemented for these residents following the 12/7/25 altercation.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one resident, resulting in the family not being informed of the development of a new wound and the initiation of antibiotic treatment. The resident, who had a history of cellulitis, peripheral vascular disease, and local skin infection, developed a new wound on the left foot and was started on antibiotics for a wound infection. Review of the electronic medical record showed no documentation that the family was notified of these changes. The wound care nurse, who also served as the unit manager, confirmed during an interview that there was no documentation of notification and attributed the omission to an oversight. Further interview with the resident's daughter revealed that she was not made aware of the new wound on the left foot, the initiation of antibiotics, or a previous wound on the buttocks. The daughter also stated she was not informed about a prior fall. Facility policy requires prompt notification of the resident's representative when there is a significant change in the resident's condition or when treatment is altered, but this was not followed in this case.
Failure to Update Care Plan for Skin Integrity After New Wounds Identified
Penalty
Summary
The facility failed to revise and update the care plan for a resident with multiple wounds, resulting in the care plan not accurately reflecting the resident's current skin integrity status. The resident, who has a history of cellulitis in both lower legs, adult failure to thrive, peripheral vascular disease, and local skin infections, was found to have several wounds identified on different dates, including wounds on the right and left dorsal foot, left proximal lower leg, left lower leg anterior, and left buttocks. Despite these new wounds being documented in the electronic medical record, the resident's skin integrity care plan had not been updated since an earlier date, even though four new wounds had been identified since then. During an interview, the wound care nurse confirmed that the care plan should have been updated to reflect the resident's new wounds and acknowledged that this update was missed. The facility's policy requires care plans to be revised to reflect the current status of the resident and to be reviewed throughout the resident's stay, including upon admission, quarterly, and with changes in condition. However, the care plan for this resident was not revised as required, leading to a discrepancy between the resident's documented condition and the care plan.
Failure to Maintain Resident Dignity and Timely Incontinence Care
Penalty
Summary
A resident with a history of type 2 diabetes, morbid obesity, and bilateral lower extremity amputations was found to have her dignity and respect compromised due to delayed response to call lights and incontinence care. The resident, who was alert and oriented, reported being left in bed soiled with feces for nearly four hours on more than one occasion. She specifically identified a CNA who failed to provide timely assistance with activities of daily living and responded to her requests for help in a harsh and dismissive manner. The resident also described experiencing severe pain and spasms, requiring assistance for toileting, and reported her concerns to various staff members, including nurses and the ombudsman. Interviews with staff and outside agency visitors corroborated the resident's account. The charge nurse recalled the resident reporting being left soiled for prolonged periods and confirmed that the CNA in question was subsequently removed from assignment to the resident's floor. Outside agency representatives witnessed the resident lying on urine-saturated linen, with staff placing a dry pad on top due to a reported linen shortage. These agency visitors also observed delayed call light responses, with the resident left waiting for over 40 minutes while staff were seen socializing at the nurses' station. The resident expressed feeling retaliated against and blamed by staff after voicing her concerns. Facility policy reviews indicated that residents are to be treated with dignity and respect at all times, and that grievances should be addressed promptly without discrimination or reprisal. Despite these policies, the resident's experiences and the observations of outside agencies demonstrated a failure to uphold these standards, resulting in the resident being left in soiled conditions and feeling disrespected and anxious.
Failure to Maintain Safe and Comfortable Environment Due to Inoperable Air Conditioning
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, staff, and the public by not ensuring that air conditioning units were operational throughout the building. Multiple observations revealed that both common areas and individual resident rooms were excessively warm, with temperatures frequently exceeding the facility's stated acceptable range of 72 to 81 degrees Fahrenheit. In several instances, wall units displayed temperatures as high as 90 degrees, and residents and staff consistently reported discomfort due to the heat. Many air conditioning units (PTACs) in resident rooms were not functioning, and the main building cooling system had been out of order for an extended period, reportedly for one to two months. Stand-up fans were used as a temporary measure, but some were not operational or were dirty with built-up debris, further compromising comfort and cleanliness. Residents were directly affected by the high temperatures, with several voicing complaints about the heat and discomfort in their rooms and common areas. Some residents had personal fans, but these were not always effective or clean, and not all residents had access to them. Staff interviews confirmed ongoing issues with the air conditioning, and maintenance staff acknowledged that they had not been consistently monitoring room temperatures or maintaining a list of rooms with non-functioning units. The lack of systematic temperature monitoring and insufficient provision of alternative cooling measures contributed to the ongoing discomfort experienced by residents. Record reviews and interviews with facility leadership confirmed that the main cooling system and many individual room units were awaiting repair or replacement, with 32 new PTAC units ordered but not yet received. Documentation showed that temperature logs were maintained for some common areas, but not for all resident rooms, and that the facility was aware of the temperature issues for an extended period. The State Ombudsman also received complaints from residents about the excessive heat, and observations confirmed that the environment was uncomfortably warm. The facility's failure to maintain operational air conditioning and to ensure a clean and comfortable environment resulted in a deficiency affecting multiple residents.
Failure to Protect Residents from Abuse During Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect four residents from verbal and physical abuse during two separate resident-to-resident altercations. In the first incident, one resident with a history of stroke, dementia, and alcohol abuse returned from a leave of absence visibly intoxicated and became agitated when staff attempted to take his medications. This resident and another resident, who has paraplegia and a history of nerve pain, engaged in a physical altercation in the lobby. Both residents sustained injuries, including a swollen eye, laceration, and redness on the chest and face. Staff interviews revealed that both residents had prior histories of aggressive or inappropriate behaviors, and the care plans for these residents were not updated following the incident. There was no documentation of education or counseling provided to either resident regarding their aggressive behaviors after the altercation. In the second incident, two roommates, both with significant cognitive impairments and complex psychiatric and medical histories, were involved in a physical and verbal altercation in their shared room. One resident, who was severely cognitively impaired and on hospice, was struck multiple times with a shoehorn by his roommate after a verbal exchange that included racial slurs and threats. The injured resident sustained a scalp laceration, a fractured right shoulder, and a fractured right humerus, requiring hospital treatment. Staff interviews and documentation indicated that the residents had ongoing interpersonal issues, but there was no evidence of proactive intervention or reassessment of their compatibility as roommates prior to the incident. The facility lacked a formal policy for roommate placement and relied on informal assessments and staff familiarity with residents. There was no evidence that the interdisciplinary team reviewed or revised care plans or interventions following these altercations, nor was there documentation of timely or adequate staff response to escalating behaviors. The incidents resulted in significant injuries, emergency room visits, and ongoing feelings of vulnerability and fear among the residents involved.
Wheelchair Provided Without Functional Brake
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including bilateral below-the-knee amputations, diabetes, peripheral vascular disease, COPD, dementia, and muscle weakness, was observed using a wheelchair that was missing a right-side brake. The resident, who was cognitively intact and able to self-transfer and operate his wheelchair, reported dissatisfaction with the wheelchair provided by the Therapy department, specifically noting the absence of the right brake. The missing brake prevented the resident from using public transportation, as the bus driver deemed the wheelchair unsafe. The resident was unsure how long the brake had been missing. Interviews with therapy staff revealed uncertainty regarding the status of the wheelchair's repair, with one therapist indicating a work order may have been placed, but the Therapy Manager was not aware of the missing brake until the issue was brought to her attention. The resident's care plan identified an increased risk for falls and included interventions related to wheelchair safety, but there was no clear process in place for inspecting wheelchairs to ensure they were in safe working order. The DON and Administrator confirmed that while the Therapy department provided wheelchairs, they were unsure who was responsible for their inspection and maintenance.
Failure to Provide Letter of Reliability for Emergency Generator Fuel Supply
Penalty
Summary
The facility failed to implement emergency and standby power systems in accordance with regulatory requirements. Specifically, during a record review, it was found that the facility could not produce a letter of reliability for its natural gas generator. This documentation is necessary to demonstrate that the generator's fuel supply is dependable and that the emergency power system will function as required during an emergency. The absence of this letter means the facility cannot verify the reliability of its backup power supply. This deficiency was confirmed during an interview with the maintenance director at the time of the record review. The lack of a documented plan or evidence regarding the reliability of the onsite fuel source for the emergency generator leaves the facility's emergency power system potentially vulnerable in the event of a power loss. No information about specific residents or their conditions was provided in the report.
Failure to Maintain and Test Emergency Lighting
Penalty
Summary
The facility failed to ensure that automatic emergency lighting was provided and maintained in accordance with regulatory requirements. During record review, it was found that the facility could not produce documentation verifying that emergency battery back-up lights were tested monthly for 30 seconds or for 90 minutes, as required. Additionally, observation revealed that the battery back-up emergency light in the generator room did not function when tested. These findings were confirmed through interviews with the maintenance director at the time of record review and observation.
Fire Alarm System Testing and Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure the fire alarm system was properly tested and maintained in accordance with NFPA 70 and NFPA 72 standards. Observations revealed a standing supervisory alarm on the main fire alarm panel for a tamper switch in the main riser room, as well as a standing trouble alarm on the fire alarm system. Additionally, a tamper switch in the riser room was found not wired into anything, and a pull station near the dining room exit door was blocked by a display board, making it not visible. These deficiencies were confirmed through interview with the maintenance director at the time of observation.
Deficient Sprinkler System Maintenance and Testing
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler and standpipe systems in accordance with NFPA 25 standards. During an observation, a dirty sprinkler head was found in the scheduler's office, which could prevent the sprinkler from functioning properly in the event of a fire. Record reviews revealed that several required maintenance and testing tasks were overdue, including testing of horizontal sidewall sprinkler heads, testing of the dry pendant sprinkler in the freezer, and replacement of fire sprinkler system gauges. Additionally, the spare sprinkler head cabinet was missing the proper wrench needed for maintenance. Further review showed that the Pre-Action fire suppression system was overdue for internal and check valve testing, and the Pre-Action fire protection system was past due for a required three-year full flush. These deficiencies were confirmed through interviews with the maintenance director at the time of observation and record review. No information about specific residents or their conditions was provided in the report.
Lack of Documentation for Required HVAC Damper Inspection
Penalty
Summary
The facility failed to provide documentation verifying completion of the required four-year damper inspection for its heating, ventilation, and air conditioning (HVAC) system, as mandated by regulatory standards. During a record review, it was found that the facility could not produce evidence that this inspection had been performed. This deficiency was confirmed through an interview with the maintenance director at the time of the review. The absence of this documentation means the facility could not confirm whether the dampers were in working condition.
Failure to Conduct and Document Required Fire Drills
Penalty
Summary
The facility failed to conduct fire drills as required by regulations 19.7.1.4 through 19.7.1.7. During a record review on May 21, 2025, it was found that the facility could not provide documentation showing that the required first shift, first quarter fire drills had been conducted. This deficiency was confirmed through an interview with the maintenance director at the time of the record review. The lack of documentation indicates that staff may not have participated in or been prepared for fire emergency procedures as mandated.
Failure of Fire Doors to Close Compromises Smoke Barrier Integrity
Penalty
Summary
During an observation on the 3rd floor, it was found that the double rated fire doors did not close when released from their magnetic hold open devices. This failure means that the smoke barriers were not constructed or maintained to provide the required minimum 1/2-hour fire resistance rating, as specified by the applicable codes. The issue was confirmed through an interview with the maintenance director at the time of observation. This deficiency could potentially affect 40 occupants in the event of a fire, as it may allow smoke, heat, and fire to pass from one compartment to another.
Improper Use of Power Strips in Office Area
Penalty
Summary
Surveyors observed that the facility failed to comply with requirements for electrical systems, specifically regarding the use of power strips. During an inspection, it was found that two power strips were connected together in the social work office. This practice is not in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards, which govern the maintenance and testing of essential electrical systems and are designed to prevent electrical hazards. The observation was made on May 21, 2025, at approximately 10:50 AM, and the findings were confirmed through an interview with the maintenance director at the time of observation. The report notes that this deficient practice could affect 15 occupants in the event of an electrical-related fire. No additional details about specific residents or their medical conditions were provided in the report.
Failure to Provide and Document Wound Care and Preventive Interventions
Penalty
Summary
The facility failed to provide adequate and appropriate wound care, assessment, monitoring, and documentation for three residents with wounds or at risk for skin breakdown. For one resident with a PEG tube, the dressing was not changed daily as ordered, with the dressing remaining dated several days prior to observation. The care plan did not specify daily dressing changes for the PEG site, and preventive measures for pressure ulcer prevention, such as heel elevation and protective devices, were not implemented as planned. Documentation in the electronic medical record indicated that the resident was dependent on staff for all activities of daily living and had a history of pressure ulcers, yet the required interventions were not consistently provided. Another resident, who was quadriplegic and required total assistance, was observed without prescribed Prafo boots and with feet not elevated, despite an active order and care plan specifying their use while in bed. During wound care, the wound nurse failed to measure wound depth, did not change gloves or perform hand hygiene after taking wound photographs, and did not apply treatment to scabs on the resident's feet. There was no documentation of refusal of the prescribed interventions, and the care plan for skin integrity was not followed. A third resident, recently readmitted after hospitalization, was found without Prafo boots while in bed, contrary to his care plan and wound care orders. The resident reported inconsistent application of the boots by staff. When a facility-acquired stage III pressure ulcer was first discovered, the wound nurse did not document the treatment provided in the nursing progress notes, Treatment Administration Record, or wound summary. The facility's policies required wound treatments to be provided and documented according to physician orders, with complete wound assessments including measurements and characteristics, but these requirements were not met for the residents reviewed.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to maintain the safety of a resident who was at risk for elopement due to wandering behavior. The resident, who had a history of vascular dementia, diabetes, hypertension, and mood disorder, was admitted with a Wanderguard device to prevent elopement. However, the device was removed due to swelling and discomfort, and attempts to replace it were unsuccessful as the resident refused to wear it. Despite being identified as at risk for elopement, no additional safety interventions were implemented to monitor the resident's safety after the removal of the Wanderguard. On the day of the incident, the resident was observed leaving his room and heading towards the elevator with another resident. He was able to exit the facility without triggering any alarms, as the Wanderguard was not in place. A housekeeper noticed the resident attempting to leave and tried to intervene but was unable to prevent him from going outside. The resident was eventually brought back inside by a transportation aide who noticed him sitting outside in his wheelchair. Interviews with staff revealed that there was a lack of communication and coordination regarding the resident's safety measures after the Wanderguard was removed. The nursing staff did not inform management about the removal of the device, and no plan was enacted to ensure the resident's safety through enhanced monitoring. The facility's policy on elopement and wandering residents was not adequately followed, as the resident did not receive the necessary supervision to prevent the incident.
Failure to Document Catheter Change and Follow Up on Positive Urinalysis
Penalty
Summary
The facility failed to document a urinary catheter change and follow up on a positive urinalysis for a resident with a urinary catheter. The resident, who had diagnoses including Multiple Sclerosis, Paraplegia, and Neuromuscular Dysfunction of the Bladder, was observed with a bluish purple tinged Foley catheter tubing and urinary drainage bag. Despite the strong smell of urine in the room, the nursing staff did not assess the color of the urine properly, as the urine could not be seen until the bag was emptied. The resident's care plan included monitoring for potential complications of indwelling catheter use and documenting any catheter changes. However, there was no correlating progress note documenting the catheter change or assessment of the catheter, despite the medication administration record indicating a catheter change. Additionally, a urinalysis from the previous month showed numerous bacteria, but there was no follow-up assessment or documentation from the physician or nurse practitioner regarding the positive result. The facility's infection control nurse and nurse practitioner were unsure about the cause of the bluish purple discoloration of the catheter supplies, initially attributing it to the resident's insurance company. However, a review of the manufacturer's information revealed that the supplies should be clear plastic. The discoloration was later identified as a potential indicator of a urinary tract infection, known as Purple Urine Bag Syndrome, which was not initially recognized or addressed by the facility staff.
Defective Sling Leads to Resident Injury During Transfer
Penalty
Summary
The facility failed to ensure the safety and proper maintenance of a mechanical lift used for transferring residents, resulting in a serious incident involving a resident. The incident occurred when a mechanical lift strap broke during a transfer, causing the resident to fall and sustain multiple fractures and a shoulder dislocation. The resident, who had a history of hemiplegia, diabetes, and chronic obstructive pulmonary disease, was totally dependent on staff for transfers and required the use of a mechanical lift with two staff members assisting. The investigation revealed that the sling used during the transfer was defective, with fraying and holes, which led to the strap breaking and the resident falling. The staff involved in the transfer did not inspect the condition of the sling before use, and one of the CNAs assisting was newly hired and had not received recent training on the use of the mechanical lift. The facility lacked a specific policy for the mechanical lifts in use, and the reference manual used for staff education was not compatible with the lifts available at the facility. Interviews with staff indicated that the resident was in severe pain following the fall, but no pain relief was administered before the resident was sent to the hospital. The facility's audit after the incident found additional damaged slings, highlighting a broader issue with equipment maintenance and staff training. The facility did not have a manufacturer or product manual for the lifts in use, further complicating the staff's ability to ensure safe and proper use of the equipment.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a pressure wound and implement timely interventions and documentation for two residents. Resident #10 developed an unstageable facility-acquired pressure wound on the left plantar foot. The resident was admitted with conditions including heart failure and diabetes and was at risk for pressure ulcers. Despite this, the resident's care plan was not adequately followed, as evidenced by the resident's foot being observed against the footboard of the bed, which was a known risk factor for pressure injuries. The wound care team noted the wound on 7/24/24, but interventions to prevent the resident from pressing against the footboard were not effectively implemented. Resident #9, who was admitted with severe cognitive impairment and multiple diagnoses, also experienced deficiencies in wound care management. The resident's care plan indicated multiple areas of skin impairment, but there were delays in documentation and treatment implementation. The wound nurse's notes were consistently entered late, and the treatment administration record did not reflect the wound physician's recommendations. This lack of timely and accurate documentation and treatment adherence contributed to the resident's risk of worsening skin conditions. The facility's policy on wound treatment management and documentation was not adhered to, as evidenced by the delayed documentation and failure to update care plans as wounds resolved or worsened. The Director of Nursing acknowledged the issues with documentation and treatment implementation, indicating a systemic problem in the facility's wound care management. These deficiencies highlight the facility's failure to provide adequate care and prevent the development and worsening of pressure ulcers in residents.
Neglect in Medication Administration
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, resulting in a resident having necessary medications, including narcotics, withheld without his knowledge or his physician's approval. The resident, who had a history of multiple medical conditions including stroke, epilepsy, dementia, and chronic pain, was observed in pain and discomfort, rubbing his legs and expressing that his knee and hip were causing him significant pain. Despite being scheduled to receive pain medication, the resident did not receive his medications as ordered, leading to pain and suffering. During a facility tour, a nurse was observed with the medication cart outside the resident's room. The nurse had signed out the narcotic pain medication, Norco, at 8:00 AM and 11:00 AM, but had not administered it to the resident. Instead, the medication was found in a cup in the medication cart, along with other medications that were supposed to be given at 7:00 AM. The nurse altered the narcotics log to change the time of administration and failed to notify the physician about the withheld medications. The Director of Nursing was unaware of the situation until informed by the surveyor. The nurse involved, who was a Nurse Manager, quit in the middle of her shift after the incident. The facility's policies on abuse, neglect, and medication administration were reviewed, highlighting the failure to adhere to procedures designed to prevent neglect and ensure proper medication administration.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered for a resident, resulting in the resident experiencing unrelieved pain, frustration, and helplessness. The resident, who had a history of chronic pain and other medical conditions, was observed rubbing his legs and expressing significant pain. Despite having a physician's order for Hydrocodone-Acetaminophen to be administered every four hours, the resident did not receive his scheduled doses at 8:00 AM and 12:00 PM. During an observation, Nurse K was found with the resident's medications, including Norco, in a medication cup in the cart, which had not been administered. The narcotics log indicated that the medication was signed out, but the resident had not received it. Nurse K eventually administered the medications after being questioned by the surveyor. The Medication Administration Record inaccurately documented the administration times, and the nurse failed to notify the physician about the missed doses. The Director of Nursing was unaware of the situation until informed by the surveyor. Nurse K, who was a Nurse Manager, had picked up an extra shift and later quit in the middle of her shift. The facility's policy on resident rights emphasizes the importance of providing services as per the care plan, which was not adhered to in this case.
Inadequate Staffing and Delayed Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient staffing levels, including days with less than eight hours of Registered Nurse (RN) coverage, which affected the care of residents. On multiple occasions, the facility did not meet the required RN coverage, specifically on 01/01/24 and 01/15/24, where there were less than eight hours of RN presence. The Nursing Home Administrator was unaware of the reasons for this shortfall, and the scheduler confirmed the lack of adequate RN coverage on these days. Several residents reported issues related to insufficient staffing, such as delayed response times to call lights and unmet care needs. A resident with asthma, obstructive sleep apnea, and hypertension reported slow call light responses and a lack of water provision by aides, suggesting a shortage of staff. Another resident with quadriplegia and pressure ulcers stated that call lights often took 30 minutes to be answered. During a resident group meeting, several residents expressed concerns about inadequate staffing, particularly during the third shift, leading to late medication administration and prolonged call light response times. Individual interviews with residents revealed further issues. One resident with a history of stroke and dementia reported waiting over an hour for call light responses. Another resident with acute respiratory failure and dementia mentioned similar delays. A resident with Parkinson's disease and a tracheostomy indicated waiting times exceeding an hour. Additionally, a resident with heart disease and COPD noted that call light response times varied, with significant delays during early morning hours. These observations highlight the facility's failure to maintain adequate staffing levels to meet the residents' needs effectively.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, as observed during an inspection. Dirty plastic food storage containers were stacked and ready for use, and large drink dispensers and a crock pot were stored wet, with lids on, preventing proper air drying. The hot plate dispenser had debris, and many plates were chipped, posing a risk of injury. Additionally, metal tops to steam table food containers were found with food debris, and bowls of ice cream in the walk-in freezer were uncovered, exposing them to potential contamination. Plastic cereal storage containers were cracked, allowing air gaps and the risk of plastic falling into the cereal. In the dry storage area, sub buns were found with mold, and fourteen bags were removed due to visible mold. These packages lacked dates indicating when they were received or their expiration. The facility's policy required food items not in their original delivery box to be dated upon receiving, but this was not followed. The dish machine sanitizer concentration was also inadequate, with test strips showing less than 25 parts per million of chlorine sanitizer after two wash cycles, prompting the use of a three-compartment sink as an alternative. Further inspection revealed a large dried spill and food debris accumulation on the floor of the walk-in cooler, along with a white mold-like substance on the wire racks. The ice machine drain line had a small leak, causing water to accumulate on the floor. These conditions violated the 2017 FDA Food Code, which mandates that physical facilities be cleaned as often as necessary to maintain cleanliness and that plumbing systems be maintained in good repair.
Inadequate Infection Control and Legionella Monitoring
Penalty
Summary
The facility failed to adhere to infection control standards by not collecting, analyzing, and reporting infection surveillance data effectively. The Director of Nursing (DON) and the new Infection Prevention and Control (IPC) Nurse were unable to provide monthly summary reports of infection data, including types of infections, infectious organisms, trends, or resistance patterns. The facility's infection surveillance line listings were incomplete, lacking crucial information such as culture results, signs or symptoms of illness, and specific details about infections. This lack of comprehensive data hindered the facility's ability to identify trends and prevent the spread of infections. Additionally, the facility did not adequately monitor and remediate the presence of Legionella in its water system. Despite positive Legionella results in multiple water samples, the facility did not re-sample the positive locations or test additional resident rooms. The Maintenance Director and Administrator acknowledged the presence of Legionella but did not implement sufficient control measures, such as re-sampling or comprehensive testing. The facility's water management plan was not effectively integrated with the infection prevention and control program, leading to potential risks for residents. Several residents experienced respiratory issues and were transferred to the hospital, but their rooms were not tested for Legionella. The facility relied on urine antigen tests, which were not diagnostic for Legionellosis, and did not perform sputum cultures to detect other Legionella species. The Medical Director was unaware of the Legionella presence in the water system and stated that he would have taken different actions had he been informed. This lack of communication and inadequate testing contributed to the facility's failure to address the potential health risks associated with Legionella.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to maintain the dignity and rights of several residents, as evidenced by multiple observations and interviews. Residents were found wearing threadbare gowns and lacking adequate linen, which compromised their dignity. Additionally, residents reported long wait times for call light responses, with some call lights not being within reach, leading to unmet care needs. The facility's staff was observed using personal phones during work hours, which detracted from their attention to residents and was against facility policy. Residents expressed frustration over the lack of available snacks, particularly for those with diabetes, as snacks were often raided by other residents. This issue was compounded by the long interval between the evening meal and breakfast, leaving residents hungry. The facility's refrigerator lock was broken, and there was no proper record of snack distribution, indicating a lack of oversight in ensuring residents' nutritional needs were met. Specific incidents highlighted further deficiencies, such as a resident found on the floor without proper clothing and another resident left without pants, leading to embarrassment. These incidents, along with the lack of timely response to call lights and inadequate communication about appointments, demonstrate a failure to provide care with dignity and respect. The facility's policies on cell phone use and resident dignity were not adhered to, contributing to the overall deficiency in care.
Facility Fails to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by observations of cluttered and unclean rooms. During a facility tour, one room was found cluttered with garbage on the floor and under the bed, with items piled in chairs and boxes around the room. Another room, listed as empty, had partially empty drink containers on the floor and bedside table. A third room had an unmade bed with a mattress that had a large brown stain and was torn. Additionally, another room was observed to be very dirty, with silverware, papers, and debris on the floor, and sticky dirt smeared on the floor. Resident #33's room was observed to have a strong odor of urine, a full garbage can with old briefs and trash, and a sticky floor. The bathroom garbage was also full with trash and wipes with bowel movement on them. The resident's bed was unmade, with no sheets or blankets present, and the resident reported that the facility often runs out of garbage bags, leading to full garbage cans. The resident also stated that their bed is often not made, requiring them to lay on a bare mattress. Subsequent observations confirmed the bed remained unmade over several days, and a CNA indicated that linens are changed when residents get up for a shower or if the bed is visibly dirty, but could not explain why the bed was not made.
Failure to Update Care Plans Leads to Unmet Needs
Penalty
Summary
The facility failed to review and revise care plans for several residents, leading to potential unmet care needs. For Resident #31, the care plan did not address the impaired function of his left hand, despite the resident expressing a desire for an exercise program. Additionally, the care plan did not include specific interventions for a new dark purple area on the resident's left great toe, which was not previously identified by the wound physician. Resident #46's care plan lacked interventions for personal hygiene, as the resident reported not receiving assistance with shaving and hair washing. The resident was observed to be unkempt and had a strong smell of urine, indicating a lack of adequate care. Similarly, Resident #55's care plan did not address the proper positioning of the urinary catheter, which was observed lying flat on its side, and there was no mention of monitoring urine discoloration. Other residents, such as Resident #12, had outdated smoking assessments and care plans that were not revised to reflect current needs. Resident #30 experienced significant weight loss, but the care plan was not updated to address this issue, and the medical director was not informed. Resident #70 also had significant weight loss, but no interventions were in place to address it. Lastly, Resident #62's care plan incorrectly included a urinary catheter, which had been removed, indicating a failure to update the care plan to reflect the resident's current condition.
Deficiencies in ADL Care and Assistance
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADLs) for several residents, leading to feelings of frustration, discouragement, and embarrassment among them. Resident #35, who has full cognitive abilities, reported receiving only one shower in 30 days despite being scheduled for twice-weekly showers. The resident expressed a preference for showers in the shower room rather than in their bathroom due to water spillage issues, which was not documented in their care plan. Additionally, the resident experienced a fall during a transfer attempt, indicating inadequate assistance during transfers. Resident #40, with moderate cognitive loss, reported long delays in response to call lights and inadequate assistance with changing briefs and providing fresh water. Documentation showed only one shower and four bed baths in 30 days, with no care provided during the first week of May. Similarly, Resident #46, who also has moderate cognitive loss, was observed unkempt and with a strong smell of urine in their room. The resident reported not receiving showers or assistance with shaving, and documentation confirmed only two showers in 30 days. Other residents, such as Resident #16, #27, #49, #22, and #101, also experienced deficiencies in ADL care. Resident #16 had long, unclean nails with no documentation of nail care provided. Resident #27 expressed dissatisfaction with the lack of showers and assistance with shaving, while Resident #49 reported missed showers and inadequate documentation of refusals. Residents #22 and #101, both requiring mechanical lifts for transfers, reported being left in bed for extended periods without assistance, despite expressing a desire to get out of bed. These deficiencies highlight a systemic issue in the facility's ability to provide necessary ADL care to its residents.
Deficiencies in Fall Documentation, Smoking Supervision, and Water Temperature Management
Penalty
Summary
The facility failed to correctly document a fall and complete neurological monitoring for a resident who had a fall with a head injury. The resident, who had moderately impaired cognition and required maximal assistance, reported multiple falls, including one where it took hours for staff to respond. Documentation discrepancies were noted, with a fall recorded two days late and neurological checks not completed as required, leaving a significant gap in monitoring. Another resident, identified as an unsafe smoker, was observed smoking without the required safety apron and adequate supervision. Staff members present were unaware of the resident's smoking status and did not have the list of unsafe smokers. The resident had severe cognitive impairment and required supervision while smoking, as per their care plan, which was not adhered to during the observation. Additionally, a resident was found on the floor, soiled and without supervision, after their assigned CNA left for lunch without arranging coverage. The resident, who had severe cognitive impairment and required assistance, was not checked or changed for an extended period. The facility's fall reduction policy was not followed, as the resident's care plan was not updated after the fall. Furthermore, unsafe water temperatures were recorded, with the facility's hot water temperature log showing inconsistencies and a lack of corrective action for temperatures exceeding safe limits.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice across multiple floors. On the 4th floor, the medication storage room's refrigerator was found with a temperature reading of 40 degrees Fahrenheit, and expired medications such as insulin ampules with an expiration date of 4/2024 were discovered. Additionally, the freezer compartment was covered with ice build-up, obscuring its contents. Expired medications and supplies, including hypodermic needles and various supplements, were also found in the storage room and medication cart. The Director of Nursing and floor nurses verified these findings. On the 2nd floor, the medication storage room's refrigerator was at 44 degrees Fahrenheit, exceeding the acceptable range of 31-41 degrees. The temperature log was missing, and expired medications were found, including a Paliperidone ER 6 mg with a discard date of 3/31/24. An unlocked medication cart was left unattended by an agency nurse, posing a risk of unauthorized access. The Director of Nursing was informed of these issues, and expired items were removed from storage. On the 3rd floor, the medication storage room's refrigerator was at 50 degrees Fahrenheit, and the temperature log showed consistent readings above the acceptable limit. Nurses were unsure of the correct temperature range and had not reported the issue. Expired medications were found in the medication cart, and a treatment cart was left unlocked and unattended. The Director of Nursing was notified, and expired items were collected for disposal. The facility's policies on refrigerator temperature logs and medication labeling and storage were requested for review.
Inconsistent Provision of Nighttime Snacks for Residents
Penalty
Summary
The facility failed to consistently offer a substantial evening snack to residents, including those with diabetes, leading to dissatisfaction and potential health risks. During a resident group meeting, it was revealed that snacks were not consistently available, and some residents would take multiple snacks, leaving others without. This issue was particularly concerning for diabetic residents who required a substantial snack to manage their blood sugar levels. The residents expressed frustration over the long period between the evening meal and breakfast, which could be up to 15 hours, and the inadequacy of the snacks provided. Interviews with staff, including the Unit Manager and Dietary Manager, highlighted procedural lapses in snack distribution. The Unit Manager acknowledged issues with the refrigerator lock and the lack of specific snacks for diabetic residents. The Dietary Manager claimed that enough snacks were sent to the floors but admitted that monitoring the distribution was the responsibility of CNAs and nurses. The facility's policy required that diabetic residents be offered a protein source with their nighttime snack, but this was not being consistently implemented. Resident #55, who had multiple health issues including diabetes and severe malnutrition, was not consistently offered a nighttime snack. A review of the resident's records showed that snacks were documented as received only 14 out of 27 days. The resident's care plan identified a potential nutritional problem, and interventions included monitoring for signs of poor hydration and documenting food acceptance. Despite these measures, the resident's nutritional needs were not adequately met, as evidenced by the inconsistent provision of nighttime snacks.
Failure in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to ensure that resistance patterns of infectious organisms were identified, analyzed, and reviewed in their Antibiotic Stewardship Program, potentially affecting all residents. The Director of Nursing (DON) and the new Infection Prevention and Control (IPC) Nurse I revealed that the facility had not been providing monthly summary reports analyzing antibiotic use, resident infections, and antibiotic culture reports. Additionally, the facility did not utilize an antibiogram to identify resistance patterns. The DON, who had been in the role for one month, acknowledged the absence of written reports and incomplete monthly infection surveillance data, which hindered the facility's ability to analyze data for trends. The facility's infection surveillance from June 2023 to May 2024 lacked comprehensive documentation, with missing line listings for several months and incomplete resident infection reports. There was no documentation of monitoring for multi-drug resistant organisms, and the antibiotics listed did not match with resident infection reports or line lists. The facility's policy on Infection Prevention and Control, which included an antibiotic stewardship program, was not effectively implemented, as evidenced by the lack of adherence to the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment across multiple floors, as evidenced by numerous observations during a survey. On the 2nd floor, a large wet area was found near air conditioners in the common area, posing a risk to residents who were observed moving through the space. Additionally, a round table in the room was unstable due to a loose pedestal. Several rooms had strong odors of urine, with discarded briefs contributing to the smell. In one instance, an unsecured oxygen tank was found in a resident's room, which the resident did not use or recognize. The tank was partially full and not in a holder, posing a potential hazard. Further observations revealed various maintenance issues, such as broken flooring, unsecured fixtures, and missing or damaged furniture. In room 307, the bathroom floor was broken, and a used bedpan was improperly stored. Other rooms had unsecured sinks, broken closet doors, and wobbly bed footboards. The facility's ventilation system was also neglected, with thick dust and debris covering vents near elevators on the 2nd and 3rd floors. The 2nd floor shower room lacked essential supplies like toilet paper and paper towels, and the clean linen room had dust and lint accumulation. Additional deficiencies included stained window valances, soiled bathroom floors, and improperly stored items in utility rooms. Ceiling tiles in several areas were stained, and an oxygen canister was improperly secured in the 4th floor clean utility room. Maintenance issues extended to broken bed frames, dripping faucets, and biofilm accumulation in bathrooms. A handrail near the 3rd floor clean linen room was detached from the wall, and a resident reported a non-functional over-bed light. Housekeeping was inadequate, with uncleaned spills and food debris in rooms that were supposedly cleaned. A spray bottle in the laundry room lacked proper labeling, and several areas had strong odors of urine, with attempts to mask the smell using air fresheners.
Failure to Accurately Document and Communicate Code Status
Penalty
Summary
The facility failed to ensure that the code status of two residents was accurately assessed, documented, and accessible in their medical records, leading to potential miscommunication and inappropriate care interventions. Resident #35, who was admitted with conditions such as diabetes, COPD, and hypertension, had a Medical Treatment Decision Form indicating Full Code, but it was not signed by the resident. During an interview, the resident expressed disagreement with the Full Code status and stated that he had not been consulted about it. The social worker acknowledged the oversight and mentioned that the resident's code status was due for an update. Resident #55, with diagnoses including multiple sclerosis and severe protein-calorie malnutrition, had conflicting code status information in the medical record. Although the resident had signed a DNR form, the electronic medical record and physician orders incorrectly indicated Full Code. The social worker explained that the error occurred when the resident was readmitted from the hospital, and the nurse failed to reassess the code status. The social worker later provided an updated Medical Treatment Decision Form signed by the resident, indicating a preference for Full Code.
Late Submission of Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for one resident, resulting in a deficiency. The resident, who was admitted with chronic obstructive pulmonary disease, acute respiratory failure, depression, and hypoxemia, was discharged from the facility on December 4, 2023. However, the discharge MDS assessment was not completed until April 30, 2024, and was not transmitted to the Centers for Medicare and Medicaid Services (CMS) until May 21, 2024. This delay was discovered during a record review on May 21, 2024. An interview with the MDS Coordinator revealed that the assessment was not added to a batch for submission, leading to the oversight. According to the CMS Resident Assessment Instrument (RAI) Version 3.0 Manual, discharge assessments should be completed no later than 14 days after discharge and transmitted no later than 14 days after completion.
Failure to Complete Yearly PASARR Level II Screening
Penalty
Summary
The facility failed to complete the required yearly PASARR Level II Screening and/or exemption criteria certification for a resident diagnosed with schizophrenia, major depressive disorder, and unspecified severe dementia with behavioral disturbances. The resident's medical record showed PASARR forms dated over three consecutive years, each indicating the presence of mental illness and dementia, and the use of antipsychotic or antidepressant medications. Despite these indications, the necessary Level II Evaluation or exemption criteria certification (Form DCH-3878) was not completed for the years 2022, 2023, and 2024. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of the required forms. The Social Worker acknowledged the absence of the necessary documentation and indicated that the doctor was responsible for signing the forms. However, the Social Worker also admitted that the resident should have had the Form-3878 completed, but did not confirm if it had been done in previous years. The Director of Nursing was informed of the deficiency and indicated they would investigate the issue further. The facility later provided the required exemption criteria certification, signed by a Nurse Practitioner, but this was after the deficiency was identified.
Incomplete Care Plans for Residents with Catheter and Tracheostomy
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in incomplete care plans and potential unmet care needs. For one resident, observations revealed an uncovered and full catheter bag, and there was no care plan in place for the catheter. An LPN confirmed the absence of an order, diagnosis, or care plan for the indwelling catheter, and stated that CNA's would only see the task on their point of care charting after a care plan is created. Despite an order for the catheter being entered later, the care plan remained absent, and the resident's minimum data assessment did not indicate the presence of an indwelling catheter. Another resident, who had a tracheostomy and PEG tube, was observed with improperly managed tracheostomy and feeding equipment. The care plan for this resident lacked specific interventions for tracheostomy care and did not include a comprehensive plan for the PEG tube. The resident's medical record indicated a history of Parkinson's disease, acute respiratory failure, and other conditions, and the resident was dependent on staff for self-care. The absence of a comprehensive care plan for the resident's tracheostomy and PEG tube care contributed to the deficiency.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to implement appropriate interventions to prevent and manage pressure ulcers for several residents, leading to the development and worsening of pressure ulcers. Resident #31, who had a history of diabetes, kidney disease, and a right leg amputation, developed a new pressure ulcer on his left great toe. Despite physician orders to ensure the resident's left lower limb was pressure off-loaded, there were inconsistencies in documentation regarding the use of heel boots, and no specific orders were in place for the new ulcer on the toe. Observations revealed that the resident's foot was often against the footboard, and the wound physician was unaware of the new ulcer until it was pointed out during the survey. Resident #55, who had multiple diagnoses including multiple sclerosis and severe malnutrition, was found to have multiple pressure ulcers, some of which were acquired in the facility. The resident's care plan was not updated to reflect the current condition and wounds. There were numerous instances where the nurses did not complete the physician-ordered wound care, as evidenced by the lack of documentation in the Medication Administration Record/Treatment Administration Record (MAR/TAR). This lack of adherence to wound care protocols contributed to the resident's deteriorating skin condition. Resident #101, who was admitted with quadriplegia and existing pressure ulcers, was not consistently provided with positioning devices to aid in pressure ulcer prevention. Despite having pressure-relieving boots, the wedge cushion intended for repositioning was often found unused, either on the window sill or under the bed. The resident reported that the staff did not frequently use the wedge cushion, which was confirmed by observations during the survey. This failure to utilize prescribed positioning devices likely contributed to the worsening of the resident's pressure injuries.
Failure to Address Range of Motion Decline in Resident
Penalty
Summary
The facility failed to identify and implement necessary interventions to address changes in the range of motion (ROM) for a resident, resulting in the resident developing limited movement in four fingers and the thumb on the right hand. The resident, who had a history of diabetes, kidney disease, and other medical conditions, was observed with fingers curled under and expressed that he did not receive any exercise program for his left hand, nor did he have a brace or splint to prevent finger contraction. Despite having orders for physical and occupational therapy, these interventions had expired, and there was no mention of the resident's impaired hand function in the care plans. Interviews with facility staff revealed that there was no Restorative Nursing program in place, although a Functional Maintenance program was mentioned. The Therapy Manager was unaware of the resident's hand contracture and confirmed that the resident had received therapy for a limited period. The resident reported that no exercises were provided by aides or therapists, and there was no plan to restore or prevent further decline in hand function. The facility's policy on Restorative Nursing Programs was not effectively implemented, as evidenced by the lack of services to maintain or improve the resident's abilities.
Deficiencies in Urinary Catheter Care
Penalty
Summary
The facility failed to properly assess and maintain indwelling urinary catheters for three residents, leading to unmet care needs and potential infection risks. Resident #41 had an indwelling catheter with no physician's order, care plan, or CNA tasks documented in the electronic health record (EHR). Observations revealed the catheter bag was uncovered and full of urine, and the resident had a history of urinary tract infections (UTIs). Licensed Practical Nurse (LPN) 'L' was unaware of the specific reasons for the catheter and could not locate necessary documentation in the EHR. Resident #55 was observed with a catheter lying flat in a basin, preventing proper urine flow, and the urine was discolored. The resident had no water at the bedside and expressed concern about not receiving water. The Director of Nursing acknowledged the improper positioning of the catheter. The resident's care plan did not include instructions to prevent the catheter from lying flat or to monitor urine discoloration, and there was no documentation of catheter monitoring until a later date. Resident #30 had a suprapubic catheter with cloudy sediments in the tubing, and the drainage bag was not secured in a dignity bag. The resident could not recall the frequency of catheter changes, and there were no recent updates in the care plan or progress notes regarding the catheter's condition. Additionally, no laboratory tests were ordered to check for potential UTIs, and the Director of Nursing did not provide requested records related to recent urinary or blood tests.
Deficiencies in Nutrition and Hydration Monitoring
Penalty
Summary
The facility failed to ensure proper nutrition and hydration for three residents, leading to significant weight loss and lack of access to fresh water. Resident #55, who had multiple health issues including severe protein-calorie malnutrition and pressure ulcers, was observed without water at the bedside on multiple occasions. Despite having a care plan that included monitoring for hydration issues, the resident expressed concern about not receiving water, and the Director of Nursing confirmed that routine water passes were not being conducted as required by facility policy. Resident #30 experienced a 6.78% weight loss over a month, dropping from 118 lbs to 110 lbs. Despite being cognitively intact and aware of his weight loss, which he attributed to a recent infection, there was no evidence that the medical director was informed of this significant change. The care plan for Resident #30 included reporting significant weight changes, but no updates or revisions were made, and the regional dietician was not notified to assess the situation. Resident #70 also experienced a significant weight loss of 7.41% in less than four weeks, dropping from 281 lbs to 270 lbs. The resident complained about the food being served cold, which may have contributed to the weight loss. Despite the facility's policy to monitor significant weight changes, no updates were made to the nutritional care plan, and the regional dietician was not referred to assess the resident's condition. This lack of action and communication highlights deficiencies in the facility's adherence to its own policies regarding nutrition and hydration monitoring.
Deficiencies in Enteral Nutrition Management
Penalty
Summary
The facility failed to ensure proper administration and management of enteral nutrition for two residents, leading to deficiencies in care. Resident #46, who had a history of stroke, dysphagia, and other medical conditions, was observed receiving enteral feeding at an incorrect rate of 85 ml/hr instead of the ordered 70 ml/hr. This discrepancy was confirmed by the unit manager and nurse, who noted that the medication administration record was not documented as required. The registered dietitian was unaware of the incorrect administration rate, indicating a lack of communication and oversight in the facility's processes. Resident #62, who had Parkinson's disease, a tracheostomy, and a PEG tube, was found with unlabeled and undated enteral feeding equipment, which could lead to infection. The resident's room contained a dirty feeding pump and improperly stored supplies, such as an open suction device and undated syringes. The Director of Nursing confirmed that the equipment should have been dated and replaced daily, and there was no documentation of the resident's refusal of tube feeding or the amount administered, highlighting a failure in record-keeping and adherence to facility policy. The facility's policies on enteral tube medication administration and care and treatment of feeding tubes were not followed, resulting in improper care for both residents. The lack of documentation and adherence to prescribed feeding rates and equipment management standards contributed to the deficiencies observed by the surveyors. These findings indicate a need for improved communication, documentation, and compliance with established care protocols to ensure resident safety and proper nutrition management.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure that emergency tracheostomy equipment was readily available and properly maintained for a resident with a tracheostomy. During an observation, it was noted that the resident's tracheostomy tube and dressing were not properly in place, and the equipment cart lacked a readily accessible outer cannula for emergency use. The water for humidification on the oxygen machine was outdated, and the tracheostomy suction tubing was reused without proper dating. The Director of Nursing (DON) and a nurse were unable to locate the necessary emergency equipment initially, which was later found behind the equipment cart. Another deficiency was observed in the storage and maintenance of nebulizer equipment for a resident with respiratory conditions. The nebulizer was found on the bedside table without a barrier and with visible residue in the medication cup. The resident confirmed that staff often left the nebulizer in this manner. The nurse responsible for the resident acknowledged that nebulizers should be rinsed, dried, and stored properly, but this was not done in this instance. The facility's policies for tracheostomy care and nebulizer therapy were not followed, leading to potential risks of infection and respiratory distress for the residents involved. The tracheostomy care policy required sterile techniques and timely replacement of equipment, while the nebulizer therapy policy outlined proper disassembly, rinsing, and storage procedures, which were not adhered to in these cases.
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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