Wellbridge Of Rochester Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Rochester Hills, Michigan.
- Location
- 252 Meadowfield Drive, Rochester Hills, Michigan 48307
- CMS Provider Number
- 235716
- Inspections on file
- 29
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Wellbridge Of Rochester Hills during CMS and state inspections, most recent first.
A resident with dementia, sarcopenia, a Stage II coccyx pressure ulcer, a right elbow abrasion, and a ruptured blister on the heel received wound treatments ordered by the attending physician, but there was no documentation that any physician ever assessed or evaluated these wounds. Nursing staff documented wound findings, took photos, and implemented treatment orders, while the DON described a process in which nurses and the IDT, but not the physician, routinely reviewed wound progress. The facility’s pressure ulcer policy required physician participation in defining ulcer characteristics, identifying contributing factors and medical interventions, and documenting wound healing during visits, yet physician progress notes on multiple visits omitted any wound assessment, and the attending physician later confirmed being unable to locate any such documentation in the record.
A resident with severe cognitive impairment, on hospice and dependent for all ADLs, reported that someone entered the room with their face covered, turned off the lights, and removed a wedding ring from her finger. An activities assistant relayed this allegation to an LPN, who searched the room and contacted the resident’s daughter to ask about the ring but did not disclose the resident’s report of theft or immediately notify the Abuse Coordinator. When the daughter arrived, the resident again reported that someone had stolen the ring, which the nurse overheard, but no prompt follow-up occurred, leading the daughter to call police. Law enforcement later advised that the ring had been pawned and that the ID used matched a CNA who had worked that day, while clinical notes documented bruising to the resident’s left ring finger and hospice records referenced an incident causing bruising and swelling. The facility had a policy prohibiting misappropriation of resident property and defining misappropriation as the deliberate wrongful use of a resident’s belongings without consent.
A cognitively impaired hospice resident reported that someone with a covered face entered her dark room, turned off the lights, removed her wedding ring from her finger while she yelled for help, and left. An activity assistant immediately told an LPN, but the LPN searched the room and called the resident’s daughter to ask if she had the ring instead of promptly reporting the allegation of abuse and misappropriation to the Administrator/Abuse Coordinator and authorities as required by facility policy and Section 1150B. The DON, after being informed of the allegation, instructed the LPN to continue searching the room due to the resident’s cognitive status, and the Administrator later stated they initially believed the ring was simply lost and did not timely notify the State Agency or law enforcement. Documentation submitted to the State omitted key details of the resident’s allegation and the bruising later documented on the resident’s ring finger, and no psychosocial or social work assessment was completed despite the Administrator’s report that one had been done, resulting in a failure to implement abuse/misappropriation policies and to accurately and timely report the incident and investigation findings.
A resident dependent on two-person assist for bed mobility fell from bed during care when one CNA stepped away, leaving the resident on their side, resulting in a fall and reported pain. In a separate incident, another resident with cognitive impairment and exit-seeking behavior eloped from the facility after staff failed to respond to a wander guard alarm, allowing the resident to leave unsupervised with a visitor. Both deficiencies were due to lapses in supervision and failure to follow safety protocols.
A resident with severe cognitive impairment and complex medical needs did not receive full showers as requested by her legal decision maker, who had clearly communicated that bed baths were not to be substituted. Despite these instructions, the resident received a bed bath instead of a scheduled shower, and the care plan did not specify the requirement for showers only, resulting in care not aligned with the expressed preferences.
A resident with diabetes experienced a prolonged delay in receiving insulin after reporting a high blood sugar level. Despite repeated requests and elevated glucose readings, the LPN and supervisor waited several hours for a provider response before administering additional insulin, contrary to facility protocols and expectations for timely intervention.
The facility did not adequately supervise or implement individualized fall prevention interventions for two residents with severe cognitive impairment and high fall risk, resulting in repeated falls, injury, and hospitalization. Required safety devices were missing from a resident's wheelchair, and a hot liquid spill incident involving another resident was not investigated or documented. Staff relied on generic interventions for all new admissions, and the facility's accident policy was outdated and incomplete.
A resident with severe cognitive impairment was subjected to verbal and physical abuse by a CNA, who was caught on camera hitting the resident's hand and calling them 'Grumpy.' The incident was reported after a family member placed a camera in the room due to suspicions of abuse. The facility's Administrator confirmed viewing the footage and reeducating the CNA on communication and abuse policies.
The facility failed to ensure safe transfer practices, resulting in multiple resident injuries. One resident fell during a toilet transfer, fracturing their tibia, while another experienced repeated Hoyer lift incidents leading to hospital visits. Additionally, a cognitively impaired resident was improperly transported, causing leg pain. The facility's inadequate investigations and lack of proper transfer techniques contributed to these deficiencies.
A long-term care facility failed to ensure proper medication administration, resulting in errors for three residents. A nurse mistakenly gave Xanax to a resident without an order for it after preparing medications for two residents at once. The facility lacked complete documentation for the incidents, and the Director of Nursing confirmed awareness of the errors. The facility's policy on medication-related problems was not followed, leading to these deficiencies.
Two residents in the facility experienced untreated skin conditions due to a lack of proper assessment and documentation. One resident had visible venous ulcers on the feet, with no treatment provided despite physician orders. Another resident reported persistent itching and irritation, requesting Nystatin powder, but received no care. The DON and nursing staff failed to follow skin management policies, resulting in untreated conditions.
The facility failed to secure controlled substances in the 400-Hall due to a broken lock on the medication box, affecting all residents with prescribed controlled substances. A discrepancy in the count of Klonopin was noted, and staff interviews revealed awareness of the issue, but medications were not moved to a secure box. The facility's policy requires double-locked storage for controlled substances.
A resident's clonazepam medication count was found to be incorrect, with two tablets unaccounted for, indicating a failure to prevent misappropriation. The discrepancy was discovered during routine medication counts by LPNs and an RN, but the facility's investigation was inconclusive. The resident had a history of anxiety, dementia, and bipolar disorder.
A resident experienced multiple falls and made an allegation of abuse, resulting in a wrist fracture that was not identified and treated in a timely manner. Despite complaints of pain and visible swelling, the facility did not seek diagnostic tests until weeks later, leading to delayed treatment.
The facility failed to ensure a physician or physician extender evaluated and assessed pressure ulcers for a resident admitted with a right femur fracture and hypertension. Despite initial documentation of red, slow-to-blanch, boggy heels and a red, blanching sacrum and coccyx, there was no documentation of a Deep Tissue Injury (DTI) or orders for treatments until 10 days later. Interviews revealed that medical professionals relied on nursing staff to notify them of wound issues, contrary to the facility's policy on physician services.
Failure to Ensure Physician Assessment and Documentation of Pressure Ulcers
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of pressure ulcers and wound care for one resident when the facility failed to ensure physician evaluation and assessment of wounds as required by its own policy. The resident was readmitted with dementia, sarcopenia, a Stage II pressure ulcer to the coccyx, and a right elbow abrasion, and required staff assistance for all ADLs. Progress notes documented these wounds, and a subsequent nursing note described the resident verbalizing discomfort in the right heel, with assessment revealing a pre-existing ruptured blister; wound pictures were taken and treatment orders were implemented per protocol under the direction of the attending physician. However, physician examinations documented on multiple dates did not include any evaluation or assessment of these wounds. Further record review showed that, despite multiple wound treatments being ordered under the attending physician’s directive, there was no documentation that any physician examined or assessed the wounds or evaluated the effectiveness of the ordered treatments. The facility’s written policy on Pressure Ulcers/Skin Breakdown required that the physician and staff examine the skin of new admissions for ulcerations, that the physician help define the type and characteristics of ulcers, identify contributing factors and medical interventions, and evaluate and document wound healing progress during resident visits. In interviews, the DON stated that nursing staff assess wounds, take pictures, notify the physician for treatment orders, and that the interdisciplinary team, excluding the physician, reviews wound progress and contacts physicians if treatments are not effective, and also stated they had no control over what physicians document. The attending physician reported that they usually assess wounds when notified but, upon reviewing the resident’s record, could not find any documentation of wound assessment or evaluation, and no further documentation was provided by the end of the survey.
Failure to Protect Resident From Misappropriation of Property and to Properly Respond to Theft Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of personal property and to respond appropriately to an allegation that a staff member stole the resident’s ring. The resident, who was readmitted with senile degeneration of the brain, chronic atrial fibrillation, was on hospice care, bedbound, dependent for all ADLs, hard of hearing, and had a BIMS score of 5 indicating severely impaired cognition, reported that someone entered the room with their face covered, turned off the lights, and removed the ring from her finger. An activities assistant reported this allegation to an LPN after lunch and before 4 PM. The LPN acknowledged being told that the resident said someone took the ring off her finger and that the person had something dark over their face. Instead of immediately reporting the allegation of theft and potential abuse/misappropriation to the facility’s Abuse Coordinator as required by policy, the LPN first searched the resident, the bed, and the room for the ring and then called the resident’s daughter to ask if she had taken it, without informing the daughter of the resident’s allegation that someone had stolen the ring. The LPN stated they wanted to “go through all of my options” before reporting the allegation. The daughter later arrived at the facility and, upon entering the room, the resident told her that someone had stolen the ring under the circumstances described above. The nurse was present in the doorway and heard this report but there was no documented immediate follow-up with the family in the room regarding the allegation. The daughter, after waiting without further follow-up from facility staff, contacted the police, who initiated an investigation. Law enforcement later informed the daughter and the Administrator that the ring had been taken from the resident and pawned, and that the identification used at the pawn shop matched that of a CNA who had worked at the facility on the date of the incident. The resident’s finger was later noted by a physician to have bruising on the left ring finger, and hospice documentation referenced an incident resulting in bruising and swelling of the left fourth digit, with an x-ray ordered to rule out fracture. Facility investigation statements confirmed that the activities assistant and LPN were aware of the resident’s report that someone with a covered face had taken the ring from her finger, and that the facility had a written policy prohibiting misappropriation of resident property and defining misappropriation as the deliberate wrongful use of a resident’s belongings without consent.
Failure to Timely Report and Accurately Investigate Alleged Theft and Abuse Involving a Resident’s Ring
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and misappropriation policies and to timely and accurately report a reasonable suspicion of a crime and the findings of its investigation to the State Agency (SA) and law enforcement, as required by Section 1150B of the Act. A cognitively impaired resident (BIMS 5/15), dependent on staff for all ADLs and under hospice care, reported that someone entered her darkened room with their face covered, turned off the lights, and removed her wedding ring from her finger while she yelled for help. The activity assistant who first heard the allegation immediately informed the LPN, but did not notify the Administrator/Abuse Coordinator directly, despite facility policy requiring staff to report any incident or suspicion of abuse, neglect, or misappropriation of property to the Executive Director (Administrator) or, in their absence, the DON immediately. After being informed by the activity assistant, the LPN chose to search the resident’s room and contact the resident’s daughter to ask if she had the ring, instead of immediately reporting the allegation of theft and possible abuse to the Abuse Coordinator and authorities. The LPN did not inform the daughter of the resident’s allegation that someone had stolen the ring off her finger. The LPN later notified the DON and Administrator of the resident’s report that someone with a covered face took the ring in the dark room, but the DON directed the nurse to continue searching the room because of the resident’s cognitive state, to make sure the resident was not hallucinating or dreaming. The Administrator stated that, even after being informed that the resident said someone took the ring off her hand, they initially thought the ring was lost and therefore did not promptly notify the SA or law enforcement as required. The Administrator also acknowledged that the daughter, not the facility, contacted the police, and that they did not consider the situation to be of much concern initially. The facility’s internal documentation and reporting to the SA were incomplete and inaccurate. The initial report to the SA noted a missing ring and that authorities were notified, but omitted the resident’s detailed allegation that someone entered her dark room with their face covered and removed the ring from her finger while she yelled for help. A skin assessment completed on the date of the incident documented no abnormal findings and contained no photos of the resident’s hand, despite the daughter later providing photos to the SA showing a dark maroon/purple bruise on the dorsal aspect of the resident’s left ring finger, and a physician note a few days later documenting bruising of that finger. The Administrator’s investigation summary submitted to the SA did not include the allegation details or the bruising, and the Administrator could not explain the omission. Additionally, although the Administrator reported to the SA that a psychosocial assessment had been completed, the medical record contained no psychosocial or social work assessments for the resident in the month of the incident or the following month, and the social worker confirmed that no formal psychosocial assessment (such as PHQ-9) was performed. These actions and omissions demonstrate the facility’s failure to follow its abuse/misappropriation policy and to report the allegation and investigation findings accurately and within the required time frames. The resident’s daughter reported that she was first contacted by a nurse asking if she had the ring and that she was not informed by staff that her mother had alleged someone stole the ring off her finger; she only learned of the allegation directly from the resident upon arriving at the facility. The daughter stated that the LPN heard the resident’s allegation in the doorway and said they were going to report it to the nurse manager, but no one returned to follow up, leading the daughter to call the police herself. The police later informed the daughter that the ring had been found at a pawn shop and that the identification used to pawn the ring matched that of a CNA who had worked at the facility on the date of the incident. The Administrator acknowledged that the case remained under police investigation. Throughout this sequence of events, the facility did not adhere to its policy requiring immediate reporting of suspected abuse or misappropriation to the Executive Director or DON, nor did it ensure timely, complete, and accurate reporting to the SA and law enforcement as required by regulation and facility policy.
Failure to Prevent Resident Fall and Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident, who was dependent for bed mobility and required a two-person assist, fell from their bed during routine care. The incident happened while two CNAs were providing in-bed care after the resident had a bowel movement. One CNA stepped away from the bedside to retrieve gloves, leaving the resident positioned on their side facing the door. During this moment, the resident rolled off the bed and was guided to the floor by staff. The resident, who had cognitive impairment, end-stage renal disease, and an above-knee amputation, reported pain in the head and shoulder and was sent to the hospital for evaluation due to being on blood thinners. The root cause was identified as a failure to maintain safe bed mobility during care, specifically not ensuring the resident was safely positioned before a staff member left the bedside. Another deficiency was identified when a resident with moderate cognitive impairment and a history of exit-seeking behavior eloped from the facility without staff knowledge. The resident was able to leave the premises with a visitor, who pushed the resident in a wheelchair out the front door. Although the resident's wander guard security alert activated the door alarm, staff did not respond in a timely manner. Witness statements revealed that staff assumed the resident was with a family member and turned off the alarm without verifying the resident's whereabouts. The resident was later found outside the facility at a nearby apartment complex by police and emergency services, unharmed. In both cases, the deficiencies were directly related to lapses in supervision and failure to follow established safety protocols. In the first incident, staff did not maintain appropriate supervision and positioning during care for a dependent resident. In the second incident, staff failed to respond appropriately to a wander guard alarm and did not follow the facility's elopement policy, resulting in a resident leaving the facility unsupervised.
Failure to Honor Resident's Bathing Preferences as Directed by Legal Decision Maker
Penalty
Summary
The facility failed to provide care in accordance with the expressed preferences of a resident's legal decision maker regarding bathing routines. The legal decision maker had clearly communicated, both verbally and in writing, that the resident was to receive full showers at least twice a week and that bed baths were not to be substituted for showers under any circumstances. Despite these instructions, documentation and interviews revealed that the resident received a bed bath instead of a scheduled shower, and there was no evidence that a shower was provided on the next scheduled day. The resident's care plan did not specify the requirement for full showers only, and the CNA documentation did not reflect that showers were consistently provided as requested. The resident in question had a history of End Stage Renal Disease and Parkinson's Disease, with severely impaired cognition, and was dependent on staff for all bathing activities. The resident was unable to clearly communicate her preferences regarding showers due to a language barrier and cognitive impairment. The legal decision maker had offered to assist with communication if the resident appeared to refuse showers, but staff did not consistently contact the family as requested. Records showed that the last documented shower occurred several days prior to the incident, and subsequent documentation indicated a refusal but did not show that the family was contacted or that further attempts were made to provide a shower as per the care plan. The facility's documentation practices and care planning failed to reflect the specific bathing preferences, leading to the resident not receiving care in accordance with the legal decision maker's wishes.
Delayed Insulin Administration for High Blood Sugar
Penalty
Summary
A resident with type 2 diabetes, who was admitted to the facility and had intact cognition, experienced a significant delay in receiving appropriate treatment for a high blood sugar episode. On the evening in question, the resident's blood sugar was measured at 420 mg/dl at 9:00 PM. The resident requested insulin, but the nurse on duty stated she could not administer additional insulin without a physician's order. The nurse attempted to contact the on-call health care provider but did not receive a response for several hours. During this period, the resident continued to experience elevated blood sugar levels, with subsequent readings remaining high. The nurse and supervisor informed the resident that they were waiting for a response from the provider and could not administer more insulin due to the lack of specific orders and the risk of hypoglycemia. The resident did not receive the necessary insulin to address the high blood sugar until approximately 2:00 AM, about five hours after the initial report of the elevated level. Facility records and interviews confirmed that the process for escalating care in the event of a delayed provider response was not effectively followed. Both the DON and another RN indicated that a timely response from a provider should occur within 30 minutes to an hour, and that further steps could have been taken to contact another provider or escalate the situation. Facility policy also required timely provider response and escalation if needed, but these protocols were not adhered to, resulting in a prolonged period before the resident received appropriate treatment.
Failure to Prevent Accidents and Implement Resident-Specific Fall Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions to prevent accidents for residents at high risk for falls. One resident with severe cognitive impairment and a history of falls was admitted following a hospital stay for a fall-related injury. Despite being identified as high risk for falls, this resident was only provided with generic fall prevention interventions upon admission, which did not address their specific needs or cognitive limitations. The care plan did not include individualized interventions, and the facility did not incorporate information from the hospital indicating the need for a 24-hour sitter. The resident experienced multiple falls in common areas, including the dining room, resulting in a hip fracture and head injury. Family members reported a lack of staff supervision in the dining room, and staff interviews confirmed that only standard interventions were implemented for new admissions, regardless of risk level. Another resident with significant cognitive impairment and a high risk for falls was observed without required safety devices on their wheelchair, such as anti-tip bars and dycem, despite these being listed as care plan interventions. The resident's call light was also found to be inaccessible due to a broken clip. Staff interviews revealed a lack of knowledge about how to access or implement care plan interventions, and the regional nurse consultant confirmed that the required safety devices were not in place. Observations over multiple shifts showed that the resident remained without these interventions, and staff were unaware of the missing equipment until it was pointed out by surveyors. Additionally, the facility failed to investigate an incident in which a resident with cognitive deficits spilled hot coffee on themselves in the dining room. This event was witnessed by a family member and a staff member, but the Director of Nursing was unaware of the incident and no investigation or documentation was found. The facility's policy on accidents and incidents was outdated and did not address the process for fall risk assessment, implementation of resident-specific interventions, or monitoring of interventions. Interviews with unit managers and the DON confirmed that only generic interventions were implemented upon admission, with resident-specific interventions added only after an incident occurred.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident, identified as R402, from mental and physical abuse by a Certified Nursing Assistant (CNA B). The incident was reported to the State Agency following a complaint submitted on 11/27/24. The complaint alleged that CNA B had verbally and physically abused R402 by hitting the resident on the hand and calling them 'Grumpy' multiple times. The family member of R402 had placed a camera in the room due to suspicions of abuse, which captured the incident. The video footage showed CNA B entering R402's room, addressing them as 'Grumpy,' and making an intimidating gesture towards the resident, who was observed pulling away from the CNA. R402 was admitted to the facility with a diagnosis of dementia, major depressive disorder, and anxiety disorder, and was receiving hospice services. The resident's Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of three, signifying severe cognitive impairment. During an interview, the facility's Administrator acknowledged viewing the video footage and confirmed that CNA B was reeducated on communication, company policy for abuse, and quality of care. However, the report does not provide additional information on further actions taken by the facility by the exit of the survey.
Deficiencies in Resident Transfer and Supervision
Penalty
Summary
The facility failed to ensure safe transfer practices for residents, leading to multiple accidents and injuries. One resident, who required maximum assistance for transfers, fell during a toilet transfer when their knee buckled, resulting in a tibia fracture that required surgery. The LPN assisting the resident did not use a gait belt, and the facility's investigation into the incident was inadequate, failing to identify the proper transfer technique or the necessity of using a gait belt. Another resident experienced multiple incidents involving a Hoyer lift, resulting in injuries that required hospital visits. The facility did not conduct thorough investigations into these incidents, and there was a lack of documentation regarding the staff involved and the specific circumstances of the accidents. The facility also failed to ensure that the appropriate Hoyer lift was used for the resident's weight, contributing to the accidents. Additionally, a resident with severe cognitive impairment was improperly transported in a reclining wheeled chair, causing leg pain and distress. The facility's staff did not follow proper procedures for moving the resident, and the incident was observed by the resident's family via Facetime, leading to a police report and emergency department visit. The facility's failure to provide adequate supervision and safe transfer techniques resulted in repeated falls and injuries for another resident with a history of falls and poor cognition.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff correctly administered physician-ordered medications to residents, resulting in medication errors for three residents. On one occasion, a nurse mistakenly gave a resident medication intended for another resident, specifically administering Xanax to a resident who did not have an order for it. This error occurred after the nurse had worked a long shift and was preparing medications for two residents simultaneously. The incident was not documented in the resident's clinical record, and the resident was not notified of the error. Additionally, the facility did not provide Incident and Accident reports for all involved residents, specifically lacking documentation for one resident. The Director of Nursing confirmed awareness of the medication errors, which included administering an incorrect medication and dose to another resident on a separate occasion. The facility's policy on medication-related problems emphasizes the importance of following clinical guidelines to prevent such errors, yet these guidelines were not adhered to, leading to the deficiencies observed.
Failure to Identify and Treat Skin Conditions
Penalty
Summary
The facility failed to identify and treat new venous ulcers, ensure physician oversight, and accurately assess a change in skin condition for two residents. Resident #21 was observed with swollen legs and feet, with visible drainage and open areas on the feet, indicating untreated venous ulcers. Despite having physician orders for wound care, there was no documentation of treatment for the feet, and the physician's progress notes did not mention any wounds. The nursing staff, including LPNs and the DON, were aware of the condition but failed to provide appropriate care or documentation, citing the resident's refusal of care as a reason. Resident #12 reported abdominal itching and groin irritation for three weeks, requesting Nystatin powder, which had been used previously for similar issues. Despite informing nursing staff and a doctor, no action was taken, and no orders for treatment were found in the resident's records. Upon assessment, the resident's skin showed signs of irritation, confirming the resident's complaints. The DON was unaware of the issue until informed by the surveyors, indicating a lack of communication and follow-up on the resident's concerns. The facility's policies on skin management and physician involvement were not followed, as evidenced by the lack of documentation and treatment for the residents' skin conditions. The DON admitted to not having a wound nurse or contracting with an outside provider, placing the responsibility on the attending physician and herself. The failure to assess, document, and treat the residents' skin conditions highlights significant deficiencies in the facility's care processes.
Controlled Substances Not Securely Stored Due to Broken Lock
Penalty
Summary
The facility failed to ensure that controlled substances were stored in locked compartments in the 400-Hall, which could potentially affect all residents with prescribed controlled substances in that area. A discrepancy was noted in the count of Klonopin, a Schedule IV anti-anxiety medication, where the count decreased from 25 to 22 without any signature accounting for its administration. Interviews revealed that the lock on the controlled substance box was broken, and although the Director of Nursing (DON) was aware and a work order was put in, the medications were not moved to a secure box. Interviews with staff members, including RN E, LPN A, LPN B, and RN G, indicated varying levels of awareness and communication about the broken lock. RN E was informed by the day shift nurse about the broken lock, and RN G confirmed receiving a report about it. The Maintenance Director confirmed replacing the lock after a work order was created by the DON. The facility's policy requires controlled substances to be stored in a double-locked compartment, which was not adhered to in this instance.
Misappropriation of Controlled Substance in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of a controlled substance medication for one resident, identified as R401, who was prescribed clonazepam for conditions including generalized anxiety disorder, dementia with behavioral disturbance, and bipolar disorder. The discrepancy was noted when the controlled substance count sheet for R401's clonazepam showed a reduction from 25 to 22 tablets without proper documentation or signatures accounting for the administration of the medication. The facility's policy on abuse, neglect, and misappropriation of resident property defines misappropriation as the wrongful use of a resident's belongings or money without consent. Interviews with staff revealed that the discrepancy was discovered during routine medication counts conducted by LPN A and RN G. LPN A did not notice the discrepancy during her shift as R401's medication was only administered at night. When the count was off, LPN A and LPN B documented the actual count and notified the DON. RN G, who was involved in the medication count, did not notice the discrepancy until the count was conducted with LPN A. A urine drug test for RN G did not include testing for benzodiazepines, and the facility's investigation into the missing medication was inconclusive, with two clonazepam tablets unaccounted for.
Failure to Timely Identify and Treat Wrist Fracture
Penalty
Summary
The facility failed to identify and treat a wrist fracture in a timely manner for a resident (R701) who experienced multiple falls and made an allegation of abuse. The resident was observed with a cast on his left arm and reported pain when not taking pain medication. The clinical record revealed that the resident had a fracture of the left wrist and hand, and a displaced fracture of the left ulna, diagnosed on 4/10/24. Despite multiple falls and complaints of pain, the facility did not seek timely treatment or diagnostic tests to rule out a fracture until 4/1/24, when an X-ray was finally ordered and confirmed the fracture on 4/2/24. The resident's clinical record showed several instances where the resident fell, complained of pain, and exhibited swelling and bruising on the left wrist. On 2/24/24, the resident alleged abuse, stating he was hit and fell, hurting his wrist. Despite this, the physician did not order an X-ray, citing no palpable pain and normal range of motion. The resident continued to experience pain and swelling, with multiple progress notes documenting these symptoms, but no further diagnostic tests were ordered until the end of March. Interviews with staff and the resident's family member revealed that the resident's wrist was visibly deformed and swollen, and the family member expressed concerns about the lack of timely medical intervention. The Director of Nursing acknowledged awareness of the resident's condition and falls but stated that they followed the physician's orders, which did not include an X-ray. The facility's policy on acute condition changes emphasized the need for detailed observations and timely communication with the physician, which was not adequately followed in this case.
Failure to Evaluate and Assess Pressure Ulcers
Penalty
Summary
The facility failed to ensure a physician or physician extender evaluated and assessed pressure ulcers for a resident (R702). R702 was admitted with diagnoses including a right femur fracture and hypertension, and initially had no pressure ulcers. However, on 7/2/23, a wound progress note indicated red, slow-to-blanch, boggy heels bilaterally, and a red, blanching sacrum and coccyx. Despite this, there was no documentation of a Deep Tissue Injury (DTI) or orders for treatments or heel lift protectors until 7/12/23. By 7/9/23, R702 had developed a Stage 2 sacrum pressure ulcer and a DTI to the right heel. The physician progress notes from Dr. J and NP K did not mention these pressure ulcers or injuries, and both medical professionals indicated they focused on the resident's primary reason for admission rather than the pressure ulcers unless specifically notified by nursing staff. Interviews with Dr. J and NP K revealed that they relied on nursing staff to notify them of wound issues and typically did not assess or evaluate pressure ulcers unless there was a specific concern such as infection or the need for debridement. The facility's policy on physician services indicated that the attending physician should participate in the resident's assessment and care planning, including monitoring changes in the resident's medical status and providing consultation or treatment. However, this policy was not followed in the case of R702, leading to a lack of proper evaluation and treatment of the resident's pressure ulcers.
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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