West Hickory Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Michigan.
- Location
- 3310 W Commerce Rd, Milford, Michigan 48380
- CMS Provider Number
- 235262
- Inspections on file
- 28
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at West Hickory Haven during CMS and state inspections, most recent first.
A resident with severe dementia, significant behavioral symptoms, and a known history of aggression and wandering was admitted after hospital evaluation, despite extensive pre-admission documentation of behavioral issues. Following multiple episodes of exit-seeking and physical aggression toward staff, the resident was transferred to the hospital, and when EMS later attempted to return the resident, nursing staff—under orders from the DON and Administrator—refused readmission, stating the facility could not meet the resident’s needs and issuing a verbal "do not return" directive. The resident’s representative was informed only verbally that the resident would not be accepted back, and the ombudsman was contacted by phone without written notice. Review of records showed incomplete transfer documentation, lack of required written involuntary discharge notices and appeal information, and outdated policies referencing obsolete regulations, despite a bed-hold/readmission policy that called for holding a bed and readmitting residents with an expectation of return unless specific criteria were met.
A resident with severe cognitive impairment, dementia, and significant behavioral symptoms was transferred emergently to a hospital after assaultive behavior toward staff, and when EMS later attempted to return the resident, nursing staff informed EMS and the hospital that the resident would not be accepted back due to aggressive and combative behavior. The resident’s spouse, identified as the responsible party and POA, was verbally told by a nurse that the resident would not be readmitted, but there was no evidence that a written transfer/discharge notice, bed-hold information, or appeal rights (FIT-100/ITD-100) were provided to the representative, nor that a written copy was sent to the Ombudsman. Review of the transfer checklist showed the regulatory notice items and second nurse witness signature were not completed, the Ombudsman information on the form was outdated, and the facility’s bed-hold policy contained obsolete regulatory references.
A resident with Alzheimer’s disease, DM with neuropathy, and peripheral vascular disease, who required substantial assistance with bed mobility and lacked sensation in the lower extremities, sustained a burn to the plantar surface of the right great toe when the bed was positioned directly adjacent to a metal baseboard heater. An LPN observed the resident sleeping on the side without apparent distress during early rounds and did not identify the foot on or against the heater. Within a short time, a CNA entered to provide ADL care, found the resident’s right great toe resting on the heater, and, upon removing it, noted bleeding. Subsequent assessments by nursing, hospice, and medical providers documented a large blister and open areas on the bottom of the right great toe, consistent with a thermal burn, and the facility’s incident investigation concluded that the bed’s placement next to the wall-mounted heating register created the environmental hazard that led to the injury.
An unlocked medication cart allowed a resident with moderate cognitive impairment and a history of diabetes, urinary retention, and falls to obtain three pill packets and several loose pills belonging to another resident. The RN responsible for the cart reported being very busy, walked away to assist another resident with breakfast, and failed to lock the cart. A CNA later observed pill packets in the resident’s pocket, and upon confrontation, the resident claimed another resident had the medications and took them. All medications were reconciled except for one dose of Namenda, which was not recovered.
A resident with severe cognitive impairment and on hospice was found with her shirt sleeves tied together by a CNA, restricting her movement for staff convenience during care. The restraint was applied without proper documentation, notification, or individualized care planning, and the resident was left unattended until discovered by oncoming staff. Facility policy prohibits such use of restraints, and the incident resulted in psychosocial harm to the resident.
A resident with severe dementia and Alzheimer's Disease was found with her shirt sleeves tied together by two CNAs, leaving her unable to move her arms. The incident was not immediately reported to the Abuse Coordinator or State Survey Agency, resulting in a delay of approximately 22 hours before the incident was reported. The CNAs involved continued to work subsequent shifts, and the nurse who discovered the incident did not escalate the report as required by facility policy.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
Two residents with severe cognitive impairment exited the facility and were redirected back inside by staff, but their responsible parties were not notified of the elopement incidents as required by facility policy. Interviews and record review confirmed the lack of notification.
Surveyors found that the facility did not review and update its emergency preparedness plan on an annual basis, as required. This deficiency was confirmed through record review and interviews with the Facility Maintenance Director and Administrator, potentially affecting all occupants in the event of a disaster.
The facility did not provide documentation of the required 30-second test, inspection, and maintenance for its battery-powered emergency light, as confirmed by the Maintenance Director and Administrator. This deficiency could affect all occupants in the event of a fire emergency.
The facility did not conduct or document the required quarterly fire drill for the first shift during the fourth quarter, as confirmed by facility leadership during record review. This deficiency could affect all occupants in the event of a fire emergency.
Surveyors identified that the facility did not complete or document the required annual inspection, testing, and maintenance of fire door assemblies as per NFPA 80 standards. The most recent available inspection record was over a year old, and this lapse was confirmed by facility leadership during the survey.
The facility failed to return residents' personal clothing from the laundry, affecting multiple residents. During a Resident Council meeting, several residents reported missing items, including a special football shirt and sweaters. One resident's Durable Power of Attorney had to repeatedly buy clothing due to losses, despite items being labeled. The facility's policy on missing items was not effectively implemented, and staff struggled with labeling and returning clothes correctly.
The facility failed to ensure staff could promptly identify a resident's code status during an emergency, leading to a delay in CPR initiation. An agency LPN struggled to find the code status in the electronic medical record and had to call the DON for guidance. The facility's documentation system was unclear, and agency staff were not trained on the code status system, affecting multiple residents.
Two residents in an LTC facility experienced falls due to staff failing to follow transfer protocols. One resident, with hemiplegia, was transferred by a single CNA despite needing two-person assistance, while another resident, with severe cognitive impairment, fell due to lack of non-skid footwear and inadequate assistance. Both incidents highlight a failure to adhere to care plans and provide adequate supervision.
A resident receiving hospice care experienced inadequate care coordination at the facility. The resident, who had multiple diagnoses and was cognitively intact, reported frequent moderate pain and delays in receiving pain medication. The facility failed to maintain accessible hospice documentation, hindering effective care coordination. Additionally, there was a lack of communication between the facility and the hospice provider, resulting in unaddressed symptoms of agitation and anxiety for the resident.
A facility's kitchen was found to have multiple sanitation and food storage deficiencies, including undated and expired food items, unsanitary conditions, and improper labeling. The kitchen lacked a supervisor, and the Corporate Registered Dietician was overseeing operations remotely. Observations revealed food crumbs in utensil drawers, moldy and compromised food items, and a leak causing ice buildup in the freezer. These issues violated the facility's policy and FDA Food Code, potentially affecting all residents consuming meals from the kitchen.
A facility failed to document and monitor the use of PRN anti-anxiety medication for a resident with schizophrenia and bipolar disorder. The resident received 46 doses of lorazepam over three weeks without evidence of targeted symptoms or non-pharmacological interventions. Staff interviews revealed a lack of adherence to the facility's policy on psychotropic medication use.
A resident with dementia and aggressive behaviors physically assaulted two other residents, causing psychosocial harm. The facility failed to manage the resident's behaviors and protect other residents, despite known issues and previous incidents. Staff reported a general atmosphere of fighting and hyperactivity on the unit.
A resident with multiple sclerosis and a compromised immune system reported feeling unwell during a COVID-19 outbreak. Despite requesting physician contact, the nurse did not perform an assessment or notify the physician. The resident called 911 and was hospitalized for five days with COVID-19. Interviews revealed the nurse failed to document or assess the resident's condition, leading to a deficiency.
A resident with severe cognitive impairment fell between the bed and the wall during a brief change, resulting in bruising and a hospital transfer. The incident occurred because a CNA attempted the task alone, despite the resident requiring two-person assistance. The CNA rolled the resident incorrectly, leading to the fall. The facility failed to provide adequate supervision and assistance, contributing to the deficiency.
An incident occurred where a resident with moderately impaired cognition pushed another resident, leading to a right arm fracture for the victim. The altercation followed a verbal dispute, with a witness reporting loud arguing and the victim expressing distress before a loud crash was heard. Both residents involved had documented cognitive impairments, including encephalopathy, adjustment disorder with anxiety, stroke, dementia, anxiety, and insomnia.
The facility failed to maintain a system to account for the accurate usage and reconciliation of controlled medications for two residents, resulting in potential medication errors and drug diversion. Discrepancies were found in the administration records of Morphine, Lorazepam, and Oxycodone, with multiple instances where medications were removed but not signed off on the MARs. The DON was unable to explain these discrepancies and admitted that audits were only performed monthly.
The facility failed to promptly resolve grievances and provide adequate care for a resident with a history of frequent UTIs and meal assistance needs. Despite requests for follow-up care and meal assistance, the resident was hospitalized with sepsis and pneumonia and later placed on hospice. The facility's response to grievances was delayed, and there was no timely follow-up or resolution documented.
Failure to Readmit Hospitalized Resident and Provide Required Written Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return following a hospital transfer and failure to provide required written discharge notices. The resident had been admitted with multiple cognitive and behavioral diagnoses, including severe vascular dementia with behavioral disturbance, other dementia with behavioral disturbance, mild cognitive impairment, and age-related cognitive decline. The admission MDS documented severe cognitive impairment, behavioral symptoms directed toward others and not directed toward others that significantly interfered with care and activities, behaviors that put others at significant risk of physical injury and significantly disrupted the living environment, and wandering that placed the resident at significant risk or intruded on others. Hospital records available to the facility before admission described a long history of dementia, agitation, prolonged behavioral outbursts, aggression, wandering, incontinence, and prior placement difficulties, confirming that the facility had access to extensive information about the resident’s behavioral history when it accepted the admission. After admission, facility progress notes documented multiple incidents of exit-seeking and physical behaviors such as swinging, kicking, spitting, and swearing, for which staff obtained additional IM psychotropic medications. On the night of the transfer, the resident reportedly assaulted staff, including a one-to-one staff member, and was sent to the hospital. A nurse’s note from the early morning hours documented that EMS attempted to return the resident, but nursing staff informed EMS that the facility could not provide care due to the resident’s behavior and that there were orders for a “do not return” because the facility was unable to meet the resident’s needs related to aggressive and combative behavior. The same note indicated that hospital staff called to inquire why the resident was refused, and the nurse explained that the resident had again attacked a staff member and that the DON and Administrator had ordered that the resident not be accepted back. Interviews with staff confirmed that the decision not to readmit the resident was made by facility leadership and communicated verbally. The social services staff member stated they were not involved in the admission decision or the later decision not to allow the resident to return, but understood that the refusal was due to exit-seeking and aggression and that the facility had discussed more appropriate locked memory care placement with the family. The DON reported that when the hospital called to ask if the resident could return, the facility said no and that they had a phone conversation with the ombudsman about not accepting the resident back, but there was no written notification. A nurse reported telling the resident’s wife by phone that the facility would not accept the resident back because the abuse that night was very dangerous and that their orders from the DON and Administrator were to send the resident out with a “no return.” Record review showed that the facility completed a “Facility-Initiated Transfer for Nursing Homes” form citing that the resident’s behavioral needs could not be met and describing combative behavior with staff, but the transfer packet documentation was left incomplete, including missing sections that required a second nurse witness signature. The facility’s policies on bed hold, hospital and therapeutic leave, readmission, and notice of transfer or discharge were reviewed. The bed hold/readmission policy stated that the facility would hold a bed for 10 days for emergency medical treatment and would readmit a discharged resident with an expectation of return unless the discharge was necessary for the resident’s welfare or the safety of individuals in the facility was endangered due to the resident’s clinical or behavioral status; this policy referenced obsolete federal regulations and had not been updated since 2017. The notice of transfer or discharge policy described requirements for facility-initiated transfers and involuntary discharges, including use of specific forms (FIT-100 and ITD-100), provision of written notice to the resident or representative with appeal information, submission of notice to the state agency, and written approval of transfer or discharge plans, but the facility did not provide evidence that these written notices and processes were followed for this resident. The Administrator acknowledged that the ombudsman had only been notified by phone, that written notification was not provided, that the local ombudsman information in facility materials was outdated, and that the relevant policy had not been updated.
Failure to Provide Written Transfer/Discharge Notice and Ombudsman Copy After Refusal to Readmit Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a written notice of transfer/discharge to a resident’s legal representative and to send a copy of that notice to the Ombudsman when the facility refused to readmit the resident after a hospital transfer. The resident was admitted in mid-February and transferred to the hospital in early March, after which the facility did not allow the resident to return. The clinical record identified the resident’s wife as the responsible party, emergency contact, and power of attorney for care and financial decisions. The admission MDS documented severe cognitive impairment, multiple dementia-related diagnoses, behavioral symptoms directed and not directed toward others that interfered with care and activities, wandering behavior that placed the resident and others at risk, and frequent bowel and bladder incontinence. Progress notes showed that EMS attempted to return the resident to the facility, but nursing staff informed EMS that the facility could not provide care due to the resident’s behavior and that there were orders for a “do not return” because the facility was unable to meet the resident’s needs related to aggressive and combative behavior. The nurse documented that the hospital called to inquire why the resident was refused and was told the resident had again attacked a staff member and that there was a “do not return” order. Transfer documentation included an “Emergent Transfer Requirement” checklist, which showed that regulatory items requiring completion with the resident or responsible party at the time of transfer—specifically the prepared transfer notice form with signed or witnessed acknowledgment and the bed-hold policy, as well as the FIT-100 form with appeal information—were not checked off. The associated Admission, Transfer, Discharge Rights form was signed by only one nurse, with the witnessing nurse section left blank, and it listed an outdated local Ombudsman contact. Interviews with the DON and nursing staff confirmed that the facility decided not to accept the resident back after the hospital transfer because they believed the resident’s behavioral needs could not be met and that the resident had assaulted staff. The DON reported that the hospital called to ask if the resident could return and was told no, and that the DON had a phone conversation with the Ombudsman about not accepting the resident back, but there was no written notification. The DON and a nurse stated that the transfer packet, including bed-hold information and notice of transfer, was sent with the resident via EMS, and the nurse reported verbally informing the resident’s wife that the resident would not be accepted back. However, the family was not present at the time of transfer, and there was no evidence that the legal representative received a written notice of transfer/discharge or that a written copy was sent to the Ombudsman. The facility’s policies on bed hold and notice of transfer/discharge were provided, but the bed-hold policy contained outdated regulatory references, and the process described in the notice policy (including FIT-100 and ITD-100 forms and written notices with appeal information) was not documented as having been followed for this resident.
Burn Injury from Bed Placement Next to Baseboard Heater
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident’s bed was positioned to avoid contact with a nearby metal baseboard heater, creating an accident hazard that resulted in a thermal burn to the resident’s right great toe. The resident had diagnoses including Alzheimer’s disease, type 2 diabetes mellitus with neuropathy, peripheral vascular disease, and cerebral atherosclerosis, and was on hospice services. An MDS assessment documented moderately impaired cognition and a need for substantial/maximal assistance with rolling in bed. Due to neuropathy, the resident did not have sensation in the feet or lower legs and was therefore unaware of the burn while the toe was in contact with the heater. On the morning of the incident, an LPN began the shift and conducted rounds at approximately 6:45 AM, observing the resident sleeping on their side with the right foot lying over the left foot. The LPN called the resident’s name, obtained a response, and noted no signs of distress, but did not identify that the resident’s foot was on or near the heater. Within approximately 10–30 minutes, a CNA entered the room to provide ADL care and discovered the resident’s right great toe had been resting on the baseboard heating unit next to the bed. When the CNA removed the foot from the heater, bleeding was observed from the right great toe. Subsequent assessments documented a significant injury to the plantar surface of the right great toe. The LPN’s alert note described the toe as bloody and newly injured, with the resident appearing confused. The DON’s examination identified an open blister on the bottom of the right great toe measuring 4 cm by 3 cm with serous fluid, and an adjacent open area measuring 0.5 cm by 0.3 cm by 0.2 cm, with no sensation in the feet or lower legs. Hospice documentation and provider notes confirmed the injury as a burn to the plantar surface of the right great toe, with erythema, swelling, warmth, a dry denuded blister, and underlying hematoma. The facility’s own incident report and investigation identified that the bed had been placed adjacent to the wall-mounted heating register, and that this bed placement created the environmental hazard that led to the resident’s thermal injury while positioned in bed.
Unlocked medication cart allowed resident access to another resident’s medications
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments when a medication cart (Sapphire Cart) was left unlocked, allowing a resident to access another resident's medications. A facility reported incident indicated that at 9:30 AM, the resident was observed with three pill packets and several loose pills in their left pant pocket. When the medications were reconciled, all were accounted for except one dose of Namenda, a medication used to treat moderate to severe dementia, which was never recovered. The resident involved had been admitted for long-term care with a medical history including diabetes, urinary retention, and falls related to muscle weakness. They were independent in a wheelchair for short distances, alert and oriented to person and place, their own responsible party, and had a BIMS score of 8/15 indicating moderate cognitive impairment. In a telephone interview, the RN assigned to the Sapphire Cart acknowledged and accepted full responsibility for leaving the cart unlocked, explaining they had been very busy, walked away from the cart to assist another resident with breakfast, and did not lock it. The RN reported being informed by a CNA that the resident had pill packets hanging from their pant pocket; when confronted, the resident stated another resident had the medications, took them from them, and that they were going to tell staff.
Improper Use of Physical Restraint for Staff Convenience
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with Alzheimer's Disease, who was dependent on staff for all activities of daily living and enrolled in hospice, was found with her shirt sleeves tied together, restricting her arm movement. This action was taken by a Certified Nursing Assistant (CNA) during care, reportedly to prevent the resident from scratching or pinching staff. The CNA, working without the required second staff member for assistance, tied the resident's sleeves together and then left the room to assist with another resident, forgetting to return and untie the sleeves. The resident was left unattended in this restrained state for an extended period. Interviews and record reviews revealed inconsistencies in staff accounts regarding who was present and involved in the incident. The CNAs involved provided conflicting statements about their roles and awareness of the restraint. There was no documentation of behaviors or incidents justifying the use of a restraint on the date in question, and the resident's care plan did not include individualized interventions for such behaviors prior to the incident. Additionally, the nurse on duty was not notified of any behavioral issues or the use of a restraint, and the restraint was only discovered by oncoming staff during shift change. Facility policy prohibits the use of physical restraints for staff convenience or discipline, defining a restraint as any method that restricts a resident's freedom of movement and cannot be easily removed by the resident. The investigation found that the restraint was used for staff convenience rather than as a last resort or with appropriate documentation and oversight. The resident, who was unable to communicate and was described as frail and contracted, experienced psychosocial harm as a result of being restrained in this manner.
Failure to Timely Report Alleged Abuse and Delay in Investigation
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving a resident with severe dementia and Alzheimer's Disease, who was non-communicative and dependent on staff for all activities of daily living. The incident involved two CNAs who tied the resident's shirt sleeves together to prevent her from scratching and pinching during care. The resident was left unattended with her sleeves tied for approximately an hour, and the incident was not immediately reported to the Abuse Coordinator or the State Survey Agency as required by regulation. The incident was discovered by oncoming CNAs at the start of their shift, who found the resident unable to move her arms due to her sleeves being tied together. The nurse on duty was notified, and the sleeves were untied. However, the nurse did not report the incident to the Director of Nursing or the Abuse Coordinator, citing being busy with other duties. The CNAs who discovered the incident also did not immediately escalate the report beyond notifying the nurse, assuming the nurse would handle the reporting process. It was only after several hours that one of the CNAs contacted the Director of Nursing directly. A review of time records showed that the CNAs involved in restraining the resident continued to work subsequent shifts after the incident, as the delay in reporting prevented immediate administrative action. The facility's policy required immediate reporting of abuse allegations, but the actual reporting to the State Agency occurred approximately 22 hours after the incident. The failure to promptly report the incident resulted in a delay in investigation and allowed the alleged perpetrators to continue working with the resident.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Responsible Parties of Resident Elopement
Penalty
Summary
The facility failed to notify the responsible parties of two residents who eloped from the facility. Both residents had severely impaired cognition, with one diagnosed with Alzheimer's disease, adjustment disorder, mood disorder, and delirium, and the other with dementia, traumatic brain injury, falls, and muscle weakness. On two separate occasions, each resident exited the facility through the front doors and was observed and redirected back inside by staff. However, there was no documentation in either resident's clinical record indicating that their responsible parties had been informed of these elopement incidents. Interviews confirmed that at least one family member was not made aware of the elopement. The facility's own policy required that the family or legal representative be notified upon the return of an eloped resident, but this was not followed. The deficiency was identified through a complaint received by the State Agency and confirmed by record review and interviews.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually, as required by federal regulations. During a record review conducted on March 13, 2025, it was found that the emergency preparedness plans and policies had not been updated on an annual basis. This deficiency was identified through documentation review and confirmed in interviews with the Facility Maintenance Director and the Administrator at the time of the record review. This lapse in compliance could potentially affect all 70 occupants in the event of a facility-wide disaster. The report does not mention any specific residents or their medical conditions, nor does it describe any adverse events that occurred as a result of this deficiency. The findings are based solely on the lack of timely review and update of the emergency preparedness plan as observed by surveyors.
Failure to Document Emergency Lighting Inspection and Maintenance
Penalty
Summary
The facility failed to provide documentation of the required 30-second test, inspection, and maintenance for the battery-powered emergency light located in the building. This deficiency was identified during a record review conducted on March 13, 2025, at approximately 10:00 AM. The absence of this documentation indicates that the facility did not ensure automatic emergency lighting was provided in accordance with the applicable code section 7.9. The Facility Maintenance Director and Administrator confirmed the lack of documentation during the exit interview and at the time of record review. This deficiency could potentially affect all 70 occupants in the event of a fire emergency, as noted in the findings.
Failure to Conduct and Document Required Quarterly Fire Drill
Penalty
Summary
The facility failed to conduct and document the required quarterly fire drill for the first shift during the fourth quarter of 2024, as identified during a record review on March 13, 2025. According to the report, fire drills are mandated to be held at least quarterly on each shift, including the transmission of a fire alarm signal and simulation of emergency fire conditions. The absence of documentation for the required fire drill was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of record review. This deficiency could potentially affect all 70 occupants in the event of a fire emergency, as the required procedures for fire safety preparedness were not followed for the specified period.
Failure to Complete Annual Fire Door Inspections and Documentation
Penalty
Summary
The facility failed to conduct and document the required annual inspection, testing, and maintenance of fire door assemblies in accordance with NFPA 80, 2010 edition. During a record review, surveyors found that the most recent fire door inspection record available was dated over a year prior to the survey, indicating that the annual requirement had not been met. This deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of record review. The lack of current documentation for fire door inspections and testing could potentially affect all 70 occupants in the event of a fire emergency, as stated in the findings. No specific residents or their medical conditions were mentioned in the report.
Deficiency in Returning Residents' Personal Clothing
Penalty
Summary
The facility failed to ensure that residents' personal clothing was routinely returned to them from the laundry, affecting multiple residents. During a Resident Council meeting, several residents expressed concerns about their clothing not being returned after being sent to an outside laundry service. One resident mentioned a special football shirt that was never returned, while another reported missing sweaters. The residents indicated that the facility was aware of the issue but had not resolved it. Specific cases included a resident who entered the facility in February 2025 and reported missing shirts with local football players' names. This resident's clothes were not labeled, and they lacked the means to label them themselves. Another resident, who had been at the facility for several years, reported missing shirts and pajamas provided by family. The facility's laundry staff acknowledged that clothing should be labeled, but it often wasn't, leading to difficulties in returning items to the correct residents. The Durable Power of Attorney for another resident reported having to repeatedly buy clothing and blankets for the resident due to losses in the laundry. This resident's clothing was labeled, yet items still went missing, and other residents' clothes were found in their closet. The facility's policy on missing items states that lost personal clothing should be investigated and returned or a written response provided, but this was not effectively implemented. The facility lacked a label machine, and staff sometimes struggled to read names on clothing, contributing to the issue.
Deficiency in Identifying Resident Code Status
Penalty
Summary
The facility failed to ensure that all staff, including agency staff, could promptly identify a resident's code status in the event of an emergency. This deficiency was highlighted by an incident involving a resident who was found unresponsive by a CNA. The agency LPN on duty was unable to locate the resident's code status in the electronic medical record and had to call the Director of Nursing at home for guidance. The LPN eventually found the code status in a binder, but the document was unclear, leading to a delay in initiating CPR. Further investigation revealed that the facility's system for documenting and accessing residents' code statuses was inadequate. The physician orders did not clearly reflect the residents' wishes regarding their code status, and the facility's orientation documentation for agency staff did not include training on the code status system. This lack of training and clarity in documentation affected multiple residents, as evidenced by the review of records for other residents, which also showed inconsistencies and lack of clear documentation of code statuses. The facility's policy on Cardiopulmonary Resuscitation did not provide clear directives for staff on where to locate and identify residents' CPR or DNR status. The surveyors found that the facility's electronic medical record system had a link for code status that did not function properly, further complicating the ability of staff to access critical information in a timely manner. The facility's failure to ensure immediate identification of residents' code status in emergencies posed a risk to all residents in the facility.
Failure to Follow Transfer Protocols Leads to Resident Falls
Penalty
Summary
The facility failed to appropriately transfer two residents, R51 and R64, according to their assessed needs, leading to falls. R51, who has hemiplegia affecting the left side and requires a two-person assist for transfers, was transferred by a single CNA, resulting in a fall. Despite the care plan clearly indicating the need for two-person assistance, the CNA proceeded with the transfer alone, reportedly because R51 did not want to wait for additional help. This incident highlights a lack of adherence to the care plan and inadequate supervision during the transfer process. R64, who has severe cognitive impairment and requires a two-person assist for transfers, experienced a fall when being transferred from the toilet to a wheelchair. The CNA involved in the incident did not ensure that R64 was wearing non-skid footwear, as required by the care plan, which contributed to the fall. The care plan specified the need for two-person assistance and non-skid footwear during transfers, but these precautions were not followed, leading to the resident's feet sliding and a subsequent fall. Both incidents demonstrate a failure to follow established care plans and provide adequate supervision to prevent accidents. The care plans for both residents were clearly documented, yet the staff did not adhere to these guidelines, resulting in falls. The facility's Director of Nursing acknowledged the need for two-person assistance in both cases, but the staff's actions did not reflect this requirement, indicating a lapse in communication and execution of care protocols.
Inadequate Hospice Care Coordination for Resident
Penalty
Summary
The facility failed to provide adequate care coordination related to hospice services for a resident, identified as R52, who was receiving hospice care. R52 was admitted with diagnoses including lung disease, alcohol abuse, pressure ulcers, and dementia. Despite being cognitively intact, R52 experienced frequent moderate pain, which interfered with their sleep. The resident was observed to be thin, underweight, and expressed feelings of loneliness and discomfort. R52 reported delays in receiving pain medication, which was scheduled every four hours and as needed for breakthrough pain every two hours. The resident's pain management was not effectively coordinated, as evidenced by their frequent use of the call light and reports of high pain levels. The facility's failure to maintain and provide access to hospice documentation further contributed to the deficiency. During the survey, the hospice care book and communication notes for R52 were not readily available, and the facility staff, including the RN and unit managers, were unable to locate the current hospice plan of care. The Nursing Home Administrator (NHA) was also unable to provide the missing hospice documentation initially. The lack of accessible hospice records hindered the facility's ability to coordinate care effectively and address R52's ongoing pain and psychosocial needs. Additionally, there was a lack of communication and coordination between the facility and the hospice provider. The facility's physician, identified as Physician Q, was not made aware of R52's ongoing agitation, restlessness, and high anxiety, which could have been addressed with appropriate medication adjustments. The hospice nurse reported that they were not informed of R52's persistent symptoms and that there was a disconnect in communication regarding medication changes. The facility's hospice policy and contract with the hospice provider outlined the need for regular communication and documentation, which was not adhered to, leading to inadequate care coordination for R52.
Sanitation and Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment and properly manage food storage, which was observed during a survey following a complaint. The kitchen lacked a supervisor, and the Corporate Registered Dietician was overseeing operations remotely. During the inspection, several issues were noted, including a buildup of food crumbs in drawers containing clean utensils and scoops, undated food items in the reach-in cooler, and a soiled rag covering the coffee maker overflow tray. Further inspection revealed multiple food items in the reach-in refrigerator and freezer that were either undated or past their use-by dates, such as hard-boiled eggs, cheese slices, fruit cocktail, butter, banana pudding, and hash brown patties. The dry storage area contained items like chocolate chips, brownie mix, salad dressing packets, potatoes, marshmallows, imitation vanilla, chili sauce, hamburger buns, and white bread without proper labeling. Additionally, thickened orange juice cartons were found with compromised packaging and mold growth. The walk-in refrigerator and freezer also had issues, including cracked eggs with spillage, moldy grapes, undated bacon, and a leak from the cooling unit causing ice buildup. The facility's policy required food to be labeled with open and use-by dates, which was not adhered to, and the FDA Food Code mandates for cleanliness and food safety were not met. These deficiencies had the potential to affect all residents consuming meals from the kitchen.
Failure to Document and Monitor PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of specific targeted symptoms and behaviors, as well as attempts at non-pharmacological interventions, before administering PRN anti-anxiety medications to a resident. The resident, who had diagnoses including schizophrenia, bipolar disorder, and severely impaired cognition, was observed to have received 46 doses of lorazepam over a period of approximately three weeks. Despite the frequent administration of this medication, there was no evidence in the clinical record of identified target symptoms or behaviors, nor documentation of non-pharmacological interventions attempted prior to the medication's use. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed a lack of awareness and adherence to the facility's policy on psychotropic medication use. The policy required that psychotropic medications should not be used without first determining the underlying causes of behaviors and attempting non-pharmacological interventions. The Director of Nursing acknowledged that there should be documentation of the behavior being treated, evidence of non-pharmacological interventions, and a follow-up assessment, none of which were present in the resident's records.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving a resident, R806, who physically assaulted two other residents, R805 and R808. R806, who had diagnoses including dementia with anxiety and Alzheimer's disease, exhibited aggressive behaviors that were not adequately addressed by the facility. On one occasion, R806 ran over R805's foot with a walker and then punched R805 in the face, neck, and chest. This incident was witnessed by two staff members, and it was noted that R806 had a history of aggression towards staff and other residents. In another incident, R806 entered R808's room through a shared bathroom and punched R808 in the face. Although there were no direct witnesses to this event, R808, who had intact cognition, reported the incident, and staff confirmed R806's presence in the room. The facility's investigation into these incidents did not adequately address R806's prior aggressive behaviors, which included wandering into other residents' rooms, becoming combative, and exhibiting inappropriate behaviors such as throwing bowel movements. Interviews with staff revealed that R806 was known for aggressive interactions, and there was a general atmosphere of fighting and hyperactivity on the unit where R806 resided. Despite these known issues, the facility did not implement effective interventions to prevent repeated resident-to-resident abuse, as evidenced by the recurrence of such incidents. The facility's failure to manage R806's behaviors and protect other residents from harm resulted in psychosocial harm to R805 and R808.
Failure to Assess Resident and Notify Physician
Penalty
Summary
The facility failed to thoroughly assess a resident with a change in condition and notify the physician, which led to a deficiency. The resident, who had multiple sclerosis and a compromised immune system, reported feeling unwell with a severe headache during a COVID-19 outbreak in the facility. Despite the resident's request, the nurse did not contact the physician, and the resident had to call 911 for assistance. The resident was diagnosed with COVID-19 and was hospitalized for five days, requiring intravenous fluids, medications, oxygen, and potassium supplementation. The facility's records showed that the resident had complained of a headache and was given pain medication, but no further assessment or vital signs were documented. The nurse on duty did not contact the physician despite the resident's request and the positive COVID-19 test. Interviews with the staff revealed that the nurse who was on duty when the resident went to the hospital did not perform the necessary assessments or document the situation. The Director of Nursing confirmed that the expectation was for the nurse to assess the resident, including taking vital signs, and to contact the medical provider, which was not done in this case.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a resident received proper care to prevent a fall, resulting in a deficiency. A complaint was filed alleging that a staff member attempted to conduct routine personal hygiene on a resident alone, leading to the resident falling between the bed and the wall. This incident caused bruising and required the resident to be transferred to the hospital. The resident, who was severely cognitively impaired and required assistance with personal care, was noted to need two persons for brief changes and activity in bed. However, the staff member involved attempted to perform the task alone, which led to the fall. The investigation revealed that the CNA involved in the incident rolled the resident incorrectly during a brief change, causing the resident to fall. The facility's documentation indicated that the CNA refused to participate in re-education following the incident. The interim DON, who was not employed at the time of the incident, reviewed the investigation and noted that the fall could have been prevented if the resident had been rolled correctly. The facility's failure to provide adequate supervision and assistance during personal care activities directly contributed to the resident's fall and subsequent injury.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, resulting in a right arm fracture for the resident who was pushed to the floor. The incident occurred following a verbal altercation between the two residents, with the resident with moderately impaired cognition pushing the other resident, who also had cognitive impairments. The resident who witnessed the altercation reported hearing loud arguing and the victim saying, 'Let go of me! You're hurting me!' before a loud crash was heard. The victim was subsequently found on the floor in pain, leading to a hospital evaluation and diagnosis of a fractured right humerus. Both residents involved had documented cognitive impairments, with one resident having encephalopathy, adjustment disorder with anxiety, and stroke, while the other had dementia with anxiety and insomnia.
Failure to Accurately Reconcile Controlled Medications
Penalty
Summary
The facility failed to maintain a system to account for the accurate usage and reconciliation of controlled medications for two residents, resulting in potential medication errors and drug diversion. For one resident, discrepancies were found in the administration records of Morphine Oral Concentrate and Lorazepam, with multiple instances where the medication was removed but not signed off on the Medication Administration Records (MARs). Additionally, there were instances where Lorazepam was administered outside of the physician's orders without proper documentation or notification to the physician. The Director of Nursing (DON) was unable to explain these discrepancies and admitted that audits were only performed monthly, which was insufficient to catch these errors in a timely manner. For another resident, discrepancies were found between the Controlled Drug Receipt/Record/Disposition Forms (CDR) and the MARs for Oxycodone. Several instances were noted where Oxycodone was signed out on the CDR but not documented on the MAR, indicating the medication was not given. The resident reported difficulty in receiving pain medication when requested, which was corroborated by the discrepancies found in the records. The DON was unaware of these discrepancies and admitted that audits were only performed monthly, which was insufficient to catch these errors in a timely manner. The facility's policy on controlled medication storage, security, and disposition was not followed, leading to these discrepancies. The DON admitted that the process for documenting both scheduled and as-needed medications on the same CDR form was a practice of their pharmacy and had been in place for about seven months. Despite being asked for additional documentation, the DON was unable to provide any further records to explain the discrepancies identified during the survey.
Failure to Promptly Resolve Grievances and Provide Adequate Care
Penalty
Summary
The facility failed to provide and document evidence of prompt resolution to grievances identified by a family member for a resident. The family member reported that the resident, who had a history of frequent urinary tract infections (UTIs) and required assistance with meals, was not receiving adequate care. Despite the family member's request for a follow-up urinalysis after the completion of antibiotics, the physician assistant declined to order it, stating the resident was fine. Subsequently, the resident was sent to the emergency room, admitted to the ICU with sepsis and pneumonia, and later placed on hospice care. Additionally, the family member reported that the resident's dentures were missing and that staff were not assisting with meals, leading to weight loss due to unopened and improperly set-up food. The facility received a grievance from the ombudsman on behalf of the resident, highlighting issues with meal assistance and the need for adaptive silverware. The facility's response to the grievance was delayed, with documented follow-up occurring more than a month later, after the resident had already been discharged. The Director of Nursing (DON) claimed that grievances are typically addressed immediately and documented in progress notes, but in this case, there was no evidence of timely follow-up or resolution. The DON was also unaware of the missing dentures and provided staff education on meal assistance only after the surveyor's inquiry.
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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