Vista Grande Villa
Inspection history, citations, penalties and survey trends for this long-term care facility in Jackson, Michigan.
- Location
- 2251 Springport Road, Jackson, Michigan 49202
- CMS Provider Number
- 235254
- Inspections on file
- 21
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Vista Grande Villa during CMS and state inspections, most recent first.
Food service equipment, storage areas, and prep surfaces were found soiled and not maintained in clean condition. Surveyors observed residue on the walk-in cooler thermometer and shelving, clean equipment racks, a can opener, meat slicer, food processor, blender, ice scoop holder, char broiler, fryer, and paper towel dispenser, along with black buildup in the dish room and mop area. They also found an unmarked pan of liquid, a date-marked dressing bottle, damaged walls and flooring in storage and mop areas, worn pans, a torn hot box gasket, and missing lightbulbs in the pass-through heating assembly.
Unjustified Increase in Antipsychotic Medication: A resident with anxiety disorder, delusional disorders, and vascular dementia received an increased Seroquel dose despite no recent documented behaviors, hallucinations, or delusions in the chart. Psychiatry noted the resident had been stable, but hospice and nursing notes later referenced yelling out and anxiety at lunch, leading to an added afternoon Seroquel dose on top of the existing BID order. Staff interviews confirmed behavior documentation was limited.
Failure to report suspected misappropriation of a resident’s funds. A cognitively intact resident with cardiac dx and anxiety had bank statements reviewed during a Medicaid application, and staff identified withdrawals and charges that the resident could not have made. APS and the Ombudsman were notified, but staff did not call police or report the incident to the Administrator/State Agency because the resident did not want the family member in trouble and the former SW did not want to bother leadership while they were on vacation.
Failure to investigate resident fund misappropriation: A cognitively intact resident’s bank records showed unauthorized withdrawals and charges from checking and savings accounts, and staff learned a family member had been taking the resident’s money. APS and the Ombudsman were notified, but no facility incident report or investigation was found, the DON and Interim NHA were unaware of the event, and the former NHA’s response to the stolen funds was not documented.
Failure to complete required PASARR Level II screening for a resident with anxiety disorder, delusional disorders, and vascular dementia. The resident had severe cognitive impairment on BIMS, and the record showed a Level I review with Yes responses in Section II, but no DCH-3878/Level II screening was found. The SW said PASARR was handled by a third-party MDS group, and the MDS nurse could not locate the Level II form.
A facility failed to update care plans for two residents. One resident tested positive for COVID-19 and had symptoms, but the care plan did not reflect the diagnosis or TBP, and signage/PPE were not present at the door during observations. Another resident’s chart showed full code status, but the care plan still listed DNR, and the DON acknowledged the care plan was not updated.
Failure to Complete Ordered Daily Weights for Edema Monitoring: A resident with HTN and spinal stenosis had a physician order for daily weights to monitor edema, but weights were repeatedly not completed or documented as refused. The resident was observed with bilateral leg edema and reported worsening swelling, while notes showed multiple refusals and delays related to the early morning weigh time, with no documentation of completed weights or reattempts on those days.
A resident with anxiety disorder, delusional disorders, vascular dementia, and severe cognitive impairment had Seroquel ordered for anxiety, with an added afternoon dose later. Pharmacy asked to clarify the diagnosis to support antipsychotic use, and the prescriber agreed with delusional disorder/delirium, but the chart was not updated and still listed anxiety as the indication. The SW and DON both confirmed the record continued to reflect anxiety.
Failure to Maintain COVID-19 TBP for a Resident with COVID-19: A resident who tested positive for COVID-19 and had symptoms including cough, runny nose, headache, nausea, and fatigue was observed without TBP signage or PPE at the door. The DON and UM stated the resident should still have been on Droplet/Contact precautions, but the precautions were mistakenly discontinued early, and the record did not show use of the CDC test-based strategy to stop precautions.
The facility failed to send the Ombudsman a copy of the notice of transfer or discharge for two residents. One resident with heart failure was transferred to a hospital, and another resident with weakness was admitted and discharged home the same day. Staff interviews showed confusion about who was responsible for sending the monthly transfer/discharge list to the Ombudsman.
A resident with multiple health conditions and recent functional decline was subjected to mental and verbal abuse by a CNA, who displayed impatience, made derogatory remarks, and failed to provide necessary assistance during toileting. The resident was left to perform personal care alone, resulting in emotional distress. Another resident reported similar treatment by the same CNA, and staff observed the affected resident to be tearful and fearful following the incident.
A resident admitted for short-term rehab with a pelvic fracture and a sacral deep tissue injury did not have a care plan addressing the wound, despite being at risk for skin breakdown. Although interventions such as a foam dressing, specialty bed, and frequent repositioning were reportedly provided, these were not documented in the care plan, resulting in a deficiency for lack of a comprehensive, measurable care plan.
A facility failed to create a care plan for a resident prescribed Apixaban, an anticoagulant, upon admission. The resident, admitted for rehabilitation and cognitively intact, lacked a care plan and physician orders to monitor for side effects like bleeding or bruising. The DON confirmed the absence of necessary monitoring protocols for this high-risk medication.
Two residents experienced deficiencies in care due to the facility's failure to update and coordinate care plans with hospice services. One resident, with severe cognitive impairment, had hygiene issues due to lack of coordination between facility and hospice CNAs. Another resident experienced pain during showers and preferred hospice CNAs, but care plans were not updated to reflect this preference. The facility's lack of documentation and understanding of hospice services led to inadequate care delivery.
A resident with severe cognitive impairment and dependent on all ADLs did not receive necessary nail care, despite family requests. Observations showed long, unclean nails, and interviews revealed a lack of coordination between facility and hospice CNAs. The care plan lacked updates to ensure comprehensive care, leading to the resident not maintaining their highest practicable well-being.
A facility failed to document the rationale for a PRN psychotropic medication order extending beyond 14 days for a resident with anxiety disorder and atrial fibrillation. The resident, cognitively intact, was prescribed Hydroxyzine Pamoate for anxiety without a stop date. The Electronic Medical Record lacked justification for the continued use of the medication, contrary to the facility's expectation of a 14-day limit.
A survey revealed improper storage and labeling of medications in a facility's medication room. A vial of Humalog insulin was found without proper labeling, and a box of Narcan nasal spray was stored in an unlocked drawer without a resident label. The facility lacked a specific policy for medication labeling, relying on education to convey expectations.
The facility failed to ensure proper communication, collaboration, and documentation of hospice services for two residents, leading to a lack of coordinated care. One resident, with severe cognitive impairment, had incomplete hospice documentation, while another, cognitively intact, experienced inconsistent care coordination between facility and hospice CNAs. Staff interviews revealed confusion and a lack of understanding of hospice care responsibilities, resulting in inadequate care.
Food Service Equipment and Storage Areas Not Kept Clean or Properly Maintained
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment and food preparation areas. During observations in the kitchen and related storage areas, surveyors found the ambient air thermometer in the walk-in cooler with accumulated moist black droplets, the cooler shelving soiled with encrusted food residue, clean equipment storage pans with encrusted residue on the rims, and the clean equipment drying rack covered with black residue that transferred to a paper towel when wiped. Additional food-contact and nonfood-contact surfaces were observed soiled, including the can opener blade area, meat slicer base and blade back, food processor and blender bases, ice scoop holder with pooling water and black particles, char broiler surfaces, deep fat fryer interior burner compartment, and the paper towel dispenser undersurface in the food product serving room. The report also documented food storage and labeling concerns. A bottle of red wine dressing was observed with a facility date mark of 2/1/2026 to 3/1/2026, and the Director of Dining Services stated it was made in house and date marked one month out. A metal holding pan containing a liquid substance was observed unmarked and covered with plastic wrap; when asked what was in the pan, the Director of Dining Services stated it must be soup from the prior night. The facility policy required foods to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross contamination, and the cited FDA Food Code section required refrigerated ready-to-eat TCS food held more than 24 hours to be clearly marked with a consume-or-discard date. Surveyors also found multiple sanitation and maintenance issues in the food service support areas. The chemical storage room had broken drywall creating a visible hole, missing baseboard tiles, and a soiled floor. The mop room had damaged drywall adjacent to the mop sink, and the dry storage room return air vent was soiled with dust, dirt, and black residue. The dish room floor had black buildup, the hand sink and trash receptacle had grey splash residue, and the mop sink closet contained a soiled wringer, debris in the basin, a broken glass container lid with black residue, black residue on the wall above the sink, and debris in the ceiling light with peeling paint. The report also noted worn and etched pans, a torn gasket on the Metro C5 hot box unit, and a service pass-through heating assembly with three lightbulbs out and one missing.
Unjustified Increase in Antipsychotic Medication
Penalty
Summary
The facility failed to justify an increased dose of an antipsychotic medication for one resident with diagnoses including anxiety disorder, delusional disorders, and vascular dementia. The resident’s MDS with an ARD of 1/24/26 showed severe cognitive impairment with a BIMS score of 1 out of 15. On 2/19/26, the resident was observed sitting calmly in a gerichair in the room watching television with headphones and a super ear hearing device, and was very talkative. The medical record showed Seroquel 25 mg twice daily was ordered for vascular dementia until 12/15/25, then increased to 50 mg twice daily for anxiety. A psychiatry follow-up note dated 2/4/26 stated there had been no recent behaviors of note and that the resident continued on trazodone, Seroquel, and Ativan per hospice, with Seroquel continued because it appeared to be providing stability. However, progress notes and behavior monitoring contained no documented behaviors, hallucinations, or delusions after 2/4/26. A hospice communication note dated 2/16/26 stated the resident was yelling out after lunch again, and a resident progress note on 2/18/26 documented anxiety at lunch time and a one-time Seroquel dose. A physician order dated 2/18/26 added Seroquel 25 mg in the afternoon for anxiety, in addition to the already ordered Seroquel 50 mg twice daily. Staff interviews indicated the resident had been yelling out more, but documentation of behaviors, hallucinations, and delusions was lacking, and the additional Seroquel dose was administered on 2/19/26.
Failure to Report Suspected Misappropriation of Resident Funds
Penalty
Summary
The facility failed to develop and/or implement policies and procedures for reporting a reasonable suspicion of a crime under section 1150B of the Act for one resident. Resident 15 was admitted with cardiac diagnosis and anxiety, and the MDS showed the resident was cognitively intact with a BIMS score of 14 out of 15. Review of the clinical record showed that facility staff discovered the resident’s family member had been misappropriating funds from the resident’s checking and savings accounts after reviewing bank statements during the Medicaid application process. A progress note documented that the Social Worker and biller identified the misappropriation, and APS and the Ombudsman were notified. Another note stated the Social Worker offered to help the resident notify the bank and call the police, but the resident did not want the family member to get in trouble and requested that police not be called. During interviews, the Interim NHA and DON were unaware of the misappropriation and could not locate a facility-reported incident. The biller stated she and the former Social Worker did not call the police because of the resident’s request, and the former Social Worker stated she believed it was appropriate to notify APS and the Ombudsman and honor the resident’s wishes not to involve police; she also stated she did not want to bother the former NHA or DON while they were on vacation.
Failure to Investigate Resident Fund Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation that a resident’s family member had misappropriated funds from the resident’s checking and savings accounts, and it did not document an incident report or other investigation related to the event. Resident 15 was admitted with diagnoses including a cardiac condition and anxiety, and had a BIMS score of 14 out of 15, indicating cognitive intactness. A social worker and biller discovered on 01/22/25 that the resident’s bank statements showed withdrawals and charges the resident could not have made, including charges to liquor stores, general stores, television streaming services, and other large withdrawals. The social worker documented that APS and the Ombudsman were notified and that the resident was offered help to notify the bank and call the police, but the resident did not want the family member to get in trouble and requested that police not be called. During later interviews, the Interim NHA and DON were unaware of the misappropriation and could not locate any facility-reported incident or investigation. The biller stated she and the former social worker met with the resident, who was upset and called the family member in their presence, but she was unsure how the former NHA handled the matter. The former social worker stated she emailed the former NHA about the concerns but did not call the DON or former NHA because they were on vacation, and no explanation was provided for why the former NHA failed to investigate the stolen money.
Failure to Complete Required PASARR Level II Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident. The resident was admitted with diagnoses including anxiety disorder, delusional disorders, and vascular dementia, and the MDS with an ARD of 1/24/26 showed a BIMS score of 1 out of 15, indicating severe cognitive impairment. The resident was observed sitting in a gerichair in the room watching television with headphones and a super ear hearing device, and appeared calm and very talkative. The medical record showed an Annual Resident Review Level I screening completed on 9/22/25 with Yes responses in Section II, which indicated that a Level II screening should be sent if required, but the record did not contain a DCH-3878/Level II screening. The Social Worker stated PASARR assessments were completed by a third-party MDS group and agreed the record lacked a Level II screening, and the MDS Nurse reported they could not locate a Level II screening/3878 for the resident.
Failure to Update Care Plans for COVID-19 Precautions and Code Status
Penalty
Summary
The facility failed to revise care plans for two residents. One resident was diagnosed with COVID-19 after testing positive and had symptoms including an unproductive cough, runny nose, headache, nausea, and fatigue. The resident was observed in bed and reported the recent COVID-19 diagnosis, but there was no signage or PPE available at the door during observations. Review of the resident’s care plans showed they were not updated to reflect the COVID-19 diagnosis or the use of transmission-based precautions, and the DON and UM reported the precautions had been mistakenly discontinued before the resident was still supposed to be on Droplet/Contact precautions. Another resident’s record showed conflicting code status information. The medical record profile identified the resident as full code, while the care plan dated earlier indicated the resident had chosen DNR status. The DON acknowledged that the record showed full code status but the care plan still reflected DNR, and reported the care plan was not updated to match the resident’s actual code status.
Failure to Complete Ordered Daily Weights for Edema Monitoring
Penalty
Summary
The facility failed to implement a physician’s order for daily weights for edema monitoring for one resident who was admitted with diagnoses including hypertension and spinal stenosis. The resident’s MDS showed the resident was cognitively intact with a BIMS score of 15 out of 15. On observation, the resident was sitting in a recliner with both legs edematous, and the resident reported worsening edema in the legs, especially the left leg. Compression stockings were observed on the resident’s bed and later on the resident’s legs while the resident sat with legs elevated. Review of the physician’s order dated 1/8/26 showed daily weights were ordered for monitoring of edema interventions, with a scheduled time of 7:00 AM. Review of the MAR and weight summary showed multiple dates when daily weights were not completed or documented as refused. Progress notes documented several refusals, and additional notes showed the resident wanted to wait until later in the morning, until breakfast, or until before breakfast. There was no documentation that weights were completed or that reattempts were made on those days. In interview, the Unit Manager stated the resident was supposed to be weighed daily and that staff had changed the weight time to 7:00 AM because the resident did not like to get up early.
Pharmacy Recommendation Not Implemented for Antipsychotic Diagnosis
Penalty
Summary
The facility failed to implement pharmacy recommendations for one resident reviewed. The resident was admitted with diagnoses including anxiety disorder, delusional disorders, and vascular dementia, and the MDS with an ARD of 1/24/26 showed a BIMS score of 1 out of 15, indicating severe cognitive impairment. On 02/19/2026, the resident was observed sitting in a gerichair in his room watching television with headphones and a super ear hearing device, and he appeared calm and very talkative. The physician order dated 12/15/25 showed Seroquel 50 mg twice daily for anxiety, and a later order dated 2/18/26 added Seroquel 25 mg in the afternoon for anxiety. A pharmacy note dated 12/26/25 asked to clarify the Seroquel diagnosis to support antipsychotic use, and the prescriber response agreed with delusional disorder/delirium; however, the diagnosis was not updated and continued to reflect anxiety. The SW reported the medical record still showed Seroquel as prescribed for anxiety, and the DON stated pharmacy recommendations were printed for physicians to review, but agreed the diagnosis change was recommended and accepted while the indication remained anxiety.
Failure to Maintain COVID-19 Transmission-Based Precautions
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident diagnosed with COVID-19. The resident was admitted to the facility and had a diagnosis of COVID-19 on 2/10/26. The MDS with an ARD of 2/1/26 showed the resident scored 15 out of 15 on the BIMS, indicating cognitive intactness. On 02/18/2026 at 9:15 AM, the resident was observed lying in bed and reported she had recently been diagnosed with COVID-19. At that time, there was no transmission-based precautions signage or PPE on the door. On 02/19/26 at 9:40 AM, the resident still did not have signage or PPE available at the door. The progress notes dated 2/10/26 documented that the resident tested positive for COVID-19 at 11:35 AM and had symptoms including unproductive cough, runny nose, headache, nausea, and fatigue for one day. During an interview on 02/19/2026 at 12:48 PM, the DON and UM reported COVID-19 transmission-based precautions should be implemented for 10 days and that the resident should still have been on Droplet/Contact precautions, but the precautions were mistakenly discontinued on 2/17/26. The record did not show that the CDC test-based strategy was used to discontinue the precautions.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for two residents reviewed. One resident had diagnoses including heart failure and was transferred out to a local hospital on 12/7/25. The other resident had diagnoses including weakness, arrived at the facility on 12/3/25, and was discharged home the same day. During interviews, the Social Worker stated she does not send the monthly list of transfers or discharges to the Ombudsman, while the Interim Nursing Home Administrator stated it was Social Work’s responsibility to send the monthly list. The DON and Executive Director stated they were not sure who was sending the list to the Ombudsman.
Failure to Protect Resident from Mental and Verbal Abuse by CNA
Penalty
Summary
A resident admitted for short-term rehabilitation following a fall, with diagnoses including chronic obstructive pulmonary disease, repeated falls, and macular degeneration, was found to be cognitively intact according to the Brief Interview for Mental Status. On the date of the incident, the resident required assistance with toileting and was unable to lock her wheelchair or pull down her pants due to weakness. The assigned CNA displayed impatience, made a disparaging comment about residents needing to help themselves, threw a clean brief at the resident, and left her to complete peri care and brief application without assistance. The resident reported feeling scared, weak, and emotionally distressed, crying during and after the incident, and continued to be affected by the event during the surveyor's interview. A review of statements from the resident's former roommate indicated a similar experience with the same CNA, who was described as rude and unsupportive, making comments about the resident's inability to walk to the bathroom. Another CNA reported that the resident was tearful and reluctant to accept help the day after the incident, and upon inquiry, the resident disclosed the previous day's mistreatment. The facility's abuse policy defines mental, verbal, and physical abuse, and the actions of the CNA were consistent with mental and verbal abuse as described in the policy. The facility terminated the CNA's employment following the incident.
Failure to Develop and Implement Care Plan for Deep Tissue Injury
Penalty
Summary
The facility failed to develop and implement a care plan addressing a deep tissue injury (DTI) for a resident admitted for short-term rehabilitation following a pelvic fracture. Upon admission, the resident was found to have a DTI on the sacrum, as documented in the skin assessment, and was identified as being at risk for skin breakdown based on a Braden Scale score. The resident reported decreased mobility and pain with movement and repositioning, and stated that nursing staff applied a cream to the affected area daily. Despite these findings, a review of the resident's care plans revealed no interventions or strategies in place to address the DTI, prevent further skin breakdown, or promote healing. During interviews, the facility's wound nurse confirmed the presence of the DTI and described interventions such as a foam dressing, specialty bed, cushion, and frequent repositioning, noting that staff assistance was needed to prevent shearing. However, these interventions were not documented in the resident's care plan. The lack of a documented care plan meant that there were no measurable actions or timetables established to address the resident's skin integrity needs, resulting in a deficiency related to the development and implementation of a comprehensive care plan.
Failure to Develop Anticoagulant Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident who was prescribed an anticoagulant medication, Apixaban, upon admission. The resident, who was cognitively intact and admitted for rehabilitation, had no care plan in place to monitor for potential side effects such as bleeding or bruising, nor were there any physician orders for such monitoring. This oversight was confirmed by the Director of Nursing, who acknowledged the absence of both a care plan and physician orders for monitoring the high-risk medication.
Deficiencies in Care Plan Updates and Coordination
Penalty
Summary
The facility failed to revise and update comprehensive, individualized care plans for two residents, leading to potential deficiencies in care and psychosocial well-being. Resident #15, who was admitted with diagnoses including left-sided weakness from a stroke, dysphagia, vascular dementia, and Alzheimer's disease, required substantial assistance with daily activities. Despite being dependent on care, observations revealed that Resident #15's fingernails were long and dirty, indicating a lack of proper hygiene care. Interviews with family members and staff highlighted a lack of coordination between facility CNAs and hospice CNAs, with no updates made to the care plan to reflect this collaboration. Resident #26 also experienced deficiencies in care coordination. The hospice binder at the nurse's station lacked necessary documents for collaboration, such as a current calendar, plan of care, and visit notes. Interviews revealed that Resident #26 experienced pain during showers and preferred hospice CNAs for this task. However, there was no documentation of collaboration between facility and hospice CNAs in the care plan, and missed showers were not properly reported or documented. The facility's CNAs were unaware of the hospice's role, leading to inconsistencies in care delivery. The lack of updated care plans and coordination between facility and hospice staff resulted in inadequate care for both residents. The facility's failure to document and revise care plans to reflect hospice involvement and resident preferences contributed to the deficiencies observed. Interviews with staff indicated a lack of understanding of hospice services and the need for better communication and documentation practices to ensure residents receive the care they require.
Failure to Provide Necessary Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary care to a resident who was dependent on all activities of daily living (ADLs). The resident, who had severe cognitive impairment and required maximum assistance for tasks such as oral hygiene, toileting, and bathing, was observed with long fingernails and a brown substance under them. Despite the family's requests for regular nail care, the resident's nails were not trimmed or cleaned as needed. The resident's care plan indicated that showers were provided by both facility and hospice CNAs, but there was no evidence of collaboration between the two to ensure comprehensive care, including nail care. Interviews and observations revealed that the facility's unit manager was unaware of the resident's nail condition until it was pointed out. The care plan review showed that the resident received showers on specific dates, but nail care was neglected. Additionally, there was no hospice CNA care plan available to clarify responsibilities, leading to a lack of coordination in providing essential care for the resident. This oversight resulted in the resident not receiving the necessary care to maintain their highest practicable well-being.
Failure to Document Rationale for Extended PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to document the rationale for as-needed (PRN) psychotropic medication orders that extended beyond 14 days for a resident, resulting in the potential for an unnecessary medication regimen and adverse side effects. The resident was admitted with diagnoses including generalized anxiety disorder and atrial fibrillation and was cognitively intact, scoring 14 out of 15 on the Brief Interview for Mental Status. The resident was prescribed Hydroxyzine Pamoate capsules 25 milligrams for anxiety, to be taken every 12 hours as needed, with no stop date provided. The Electronic Medical Record lacked documentation justifying the continued use of the anti-anxiety medication beyond the 14-day period. During an interview, the Director of Nursing stated that the expectation for residents prescribed a PRN medication is to have a stop date that does not exceed 14 days.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in its medication room, as observed during a survey. A vial of Humalog insulin was found in the medication refrigerator without a label indicating the date it was opened or any resident information. The vial was inside its original box, which had been opened, and the box had the numbers '1102' handwritten on it. Additionally, a box containing Narcan nasal spray was discovered in an unlocked drawer, with the resident label removed and not stored with other resident-specific medications. The Licensed Practical Nurse (LPN) present during the observation acknowledged that the insulin would need to be destroyed due to improper labeling. The Director of Nursing (DON) later confirmed that both the insulin vial and the Narcan nasal spray would be discarded. The facility did not have a specific policy for medication labeling, as confirmed by the Nursing Home Administrator (NHA). The DON stated that the expectation for labeling multi-use insulin vials included the resident's name and room number, physician's name, and date opened, but this information was provided through education rather than a formal policy.
Lack of Coordination and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure proper communication, collaboration, and documentation of hospice services for two residents, resulting in a lack of coordination of care. Resident #15, who was admitted with severe cognitive impairment and multiple health issues, did not have a complete hospice binder or electronic medical record (EMR) documentation. The hospice binder lacked a Plan of Care, CNA care plan, current physician orders, and a medication list. Interviews revealed confusion among staff and hospice liaisons about the process for updating hospice information, leading to missing documentation and uncoordinated care. Resident #26, who was cognitively intact but required assistance with daily activities, also experienced a lack of coordination between facility and hospice services. The hospice binder for this resident was missing essential documents, and there was no evidence of collaboration in the EMR. The resident reported receiving showers from both facility and hospice CNAs, but documentation was inconsistent, and there was no clear plan for coordinating these services. Interviews with staff indicated a lack of understanding of hospice care responsibilities and documentation requirements. The deficiency was further highlighted by the absence of updated care plans and coordination of care between facility and hospice staff. Facility CNAs were unaware of hospice rules and did not consistently document or report missed showers or refusals. The Director of Nursing and Unit Manager acknowledged the issues but did not have a clear process for ensuring that hospice documentation was complete and accessible. This lack of coordination and documentation led to inadequate care for the residents involved.
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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