Willowbrook Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Flint, Michigan.
- Location
- G-4436 Beecher Road, Flint, Michigan 48532
- CMS Provider Number
- 235550
- Inspections on file
- 34
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Willowbrook Manor during CMS and state inspections, most recent first.
A resident admitted with a UTI and multiple comorbidities was ordered to receive only two doses of Nitrofurantoin 100 mg q12h to complete antibiotic therapy, but review of the EMR and MAR showed that staff entered and followed orders resulting in administration of a total of ten doses over several days, with some scheduled doses also missed. After this extended antibiotic administration, the resident reported vaginal itching, burning, and white discharge, and providers documented candidiasis and a vaginal yeast infection, ordering Diflucan and miconazole suppositories. During interviews, the ADON confirmed the original intent was for only two doses and could not explain why so many doses were given, and the DON reported no additional information to account for the excess dosing, despite care plans directing that medications be administered as ordered and residents monitored for side effects.
Multiple residents with complex medical needs, including dependence on supplemental O2, impaired mobility, and need for assistance with toileting and hygiene, experienced prolonged and inconsistent responses to call lights. In one case, a resident on O2 developed headache, dizziness, and lightheadedness after an O2 tank ran empty and waited about 25 minutes after activating the call light before staff responded and then left to find a full tank. Another resident with a prior hip fracture and moderate cognitive impairment was found on the floor with pants down after not receiving timely toileting assistance, and family reported waiting over 30 minutes for call light response, leading them to toilet and clean the resident themselves. Other cognitively intact residents reported and demonstrated call light waits of 30 minutes to an hour, malfunctioning or improperly connected call lights, and staff turning off call lights without completing requested care, such as incontinence care, even when the activated lights were visible from the nurse’s station. Resident council minutes documented repeated complaints over several months about long call light response times, despite facility policy and leadership statements that call lights should be answered promptly and remain on until needs are met.
Surveyors identified that respiratory care orders and procedures were not consistently followed for three residents. A resident receiving nebulizer treatments for COPD had the nebulizer mask, tubing, and medicine chamber stored wet inside a plastic bag, despite facility policy requiring rinsing and air-drying. Another resident, cognitively intact and dependent on staff for several ADLs, was left without prescribed continuous O2 after a CNA-assisted clothing change, with the nasal cannula left out of reach and an SpO2 of 87–88% when staff were notified. A third resident on supplemental O2 was observed receiving 4 L/min via concentrator, while the physician’s order specified 2 L/min, and the facility’s oxygen policy lacked direction on adhering to provider-ordered O2 flow rates.
A resident with multiple complex diagnoses experienced an acute change in condition, including unresponsiveness, high fever, and labored breathing. Facility staff failed to promptly recognize and respond to these changes, with delayed transfer to the hospital and insufficient monitoring and documentation of vital signs and Foley catheter status. Communication lapses and lack of clear care plan interventions contributed to the deficiency.
Surveyors found that multiple residents experienced prolonged call light response times, lack of follow-up on grievances, and dissatisfaction with food quality and snack distribution. Residents reported being left soiled for extended periods, staff ignoring call lights, and call lights being inaccessible. Documentation of Resident Council meetings showed persistent unresolved issues and lack of administrative follow-up.
A group of residents reported unresolved grievances regarding prolonged call light response times, poor food quality, lack of bedtime snack distribution, limited group activities, and staff availability and attitude. Residents were unaware of the grievance process or forms, and review of meeting minutes showed a lack of documentation and follow-up on concerns. The Administrator was not aware of her role in addressing council issues, and specific complaints included unaddressed dietary needs and inadequate staff response.
A group of residents reported that HS snacks were not consistently provided or distributed, with some only receiving them if they went to the nurse's station. One resident with diabetes was unaware of the availability of HS snacks and never received them. Resident Council meeting minutes showed missing documentation and no follow-up on concerns, and the Administrator was unaware of the issues and had not documented meeting postponements or resolutions.
Surveyors identified several deficiencies in kitchen sanitation and food safety, including outdated and unlabeled food items, improper refrigerator and freezer temperatures, incomplete temperature logs, dented cans stored with other food, and improper storage of ice scoopers. Additionally, a spider and web were found on the grill, highlighting lapses in cleanliness. These issues were acknowledged by the dietary manager and discussed with the Administrator.
The facility did not ensure that advance directives and code status were properly assessed, documented, and signed for two residents. One resident's code status assessment was missing from the care plan and not signed by the resident, while another resident's DNR order was not signed by a physician and the previous order had expired. Facility policy requiring timely and complete documentation was not followed, resulting in incomplete records for both residents.
Two residents did not receive care as ordered: one did not receive the prescribed collagen/silver dressing for a facility-acquired pressure ulcer due to supply issues, and another did not receive her ordered antihypertensive medication for several days because it was unavailable from the pharmacy. Nursing staff were aware of the issues but did not ensure the correct treatments were provided as recommended by the wound clinic and physician.
Two residents experienced deficiencies in nutrition management when the facility failed to update care plans for actual weight loss and did not consistently follow dietary orders for increased protein portions. One resident lost significant weight without a care plan addressing the loss, while another did not receive prescribed double protein portions and had declining albumin levels, with care plans and documentation not reflecting these needs.
A resident with dementia and hemiplegia was unable to use an ill-fitting lower partial denture for an extended period, resulting in ongoing difficulty chewing certain foods. Despite repeated documentation of the issue in dental records and staff awareness, no timely dental adjustment or dietary modification was made, and the resident remained on a regular diet. This failure to provide prompt dental services and ensure adequate nutrition was not in accordance with facility policy.
The facility did not ensure that emergency preparedness policies and procedures matched actual resources and practices. Staff were directed to use an emergency kit cart in a location where it was not present, and the severe weather policy referenced a weather radio at the main nurse station that did not exist. These discrepancies were confirmed during record review and interview with the maintenance director.
Surveyors found that battery back-up emergency lighting over transfer switches and in the activities area did not illuminate when tested, leaving critical areas without emergency lighting during a power outage. The maintenance director confirmed these findings during the inspection.
A deficiency was identified when the sprinkler escutcheon ring in the main office paper supply closet was found to have slid down around the sprinkler head, preventing proper sprinkler function. This issue was confirmed by the maintenance director and indicated a failure to maintain the sprinkler system according to NFPA 25 requirements.
The facility did not perform a full annual inspection and testing of all rated swinging fire doors, as only the cross corridor fire doors were included while other rated doors, such as those for storage and utility rooms, were omitted. This was confirmed by the maintenance director during record review.
Surveyors identified that the facility's automatic transfer switch for the equipment branch was not functioning and had been out of service for several months, as confirmed by the maintenance director. Additionally, the facility could not provide documentation of annual servicing or load bank testing for the back-up emergency generator, with the maintenance director stating that paperwork from a recent generator company visit was not yet available.
Surveyors found that multiple emergency exits were inaccessible or obstructed, including a sealed exterior door, a corridor blocked by dialysis transport chairs, and a stuck exit door from the main dining room. These issues were confirmed by the maintenance director during the inspection.
Exit signs in the older section of the facility failed to illuminate when tested for battery back-up, indicating they were not transferring to emergency power as required. The maintenance director believed the signs were working, but testing and observation confirmed the deficiency, which could affect 50 occupants during a power outage.
During a survey, it was observed that the soiled utility room door in the 600 hall did not latch when closed, failing to meet requirements for hazardous area fire barrier protection. This deficiency was confirmed with the maintenance director and could allow smoke or fire to escape into the emergency egress corridor.
Double rated fire corridor doors outside a resident room were found unable to fully close because of a failing door arranger, compromising their ability to resist smoke passage as required by NFPA standards. This deficiency was confirmed by the maintenance director and could affect 50 occupants by allowing smoke and fire to transfer between compartments.
A resident who required a Fentanyl patch for pain management went without the medication for three days after the patch fell off and the facility failed to obtain a new prescription in a timely manner. The resident experienced increased pain and frustration due to the lack of communication and delay in reordering the controlled substance, with documentation showing missed doses and unsuccessful attempts to secure a new script.
The facility failed to properly manage IV Vancomycin therapy for two residents, resulting in subtherapeutic levels for one and overdosing for another. Miscommunication with the pharmacy and lack of documentation led to these deficiencies, as the facility did not have a clear policy for managing IV medications.
A facility failed to assess, monitor, and document wounds for a resident with diabetes and other health issues, leading to the development of necrotic and abraded areas on the resident's toes. Despite an orthopedic consult identifying a wound, there was no documentation or physician orders in the medical records. The facility's care plans and policies for regular skin assessments were not followed, and the Director of Nursing acknowledged the oversight.
A facility failed to update the catheter status and documentation for a resident, leading to staff being unaware of the resident's actual catheter status. Despite the removal of the catheter, orders were not discontinued, and staff continued to document catheter care. The care plans did not reflect the removal, and the facility's policy lacked guidance on discontinuation. Interviews confirmed the discrepancy between the resident's actual status and the documentation.
The facility's kitchen was found to have multiple deficiencies, including mold-like accumulation on wire racks, a leaking steamer, and improper maintenance of a backflow prevention device. An opened soy sauce jug was improperly stored, and the walk-in freezer door gasket was damaged with excessive ice build-up. Additionally, a spray bottle was not labeled, posing a risk of contamination.
The facility failed to ensure accurate advance directive information for two residents, leading to potential non-compliance with their medical care preferences. One resident had a DNR order without a required declaration of incompetence, while another's advance directive lacked necessary witness signatures. These deficiencies highlight the facility's failure to adhere to policies and state requirements.
A resident was observed with a half lap tray attached to their wheelchair without a prior assessment to determine if it was a restraint or enabler. The facility's policy required an evaluation, a signed consent, and a current order specifying the restraint's use, none of which were met. The care plan was not updated to reflect the assessment findings.
Two residents in the facility had deficiencies in their care plans. One resident's care plan lacked specific side effects for Seroquel and Zoloft, while another resident's care plan was not updated for a new Zoloft order and did not specify the medical reason for a half lap tray on their wheelchair. A physical restraint assessment was missing until completed during the survey.
The facility failed to provide adequate ADL care for three residents, resulting in unmet hygiene needs. A resident with severe cognitive impairment had long, dirty nails and dry skin, while another resident, cognitively intact, reported not receiving preferred showers and was observed with greasy hair. A third resident, also cognitively intact, had long, dirty fingernails and reported not receiving oral care or scheduled showers. Documentation inconsistencies were noted in all cases.
A facility failed to perform dressing changes and remove a PICC line as ordered for a resident with neurogenic bladder and sepsis. The resident's PICC line dressing was dirty and peeling, and the line was not removed despite a physician's order. Staff were unaware of the resident's PICC line status, leading to a lapse in care.
The facility failed to implement proper interventions for pressure ulcer care for two residents. One resident's feet were pressed against a bed obstruction, leading to a pressure ulcer, while another resident's wound care was not performed as scheduled. Care plans for floating heels and using pressure reduction mattresses were not consistently followed, and documentation was incomplete.
A resident with a history of depression and anxiety did not receive necessary behavioral health interventions. Despite recommendations for socialization and meaningful activities, the resident was isolated, with no 1:1 visits in the past 30 days. The Activities Director confirmed the resident was not on the 1:1 visit list, leading to a lack of necessary care.
Two residents experienced medication administration errors, leading to a 20.69% error rate. A resident received insulin after eating, contrary to orders, and another resident's medication was delayed without notifying the physician. Additionally, an LPN left medications unattended on a sleeping resident's table.
A resident with osteomyelitis did not receive prescribed Vancomycin doses due to documentation errors and delays in receiving necessary lab results. The ADON acknowledged the issue and noted that staff education on proper charting was conducted.
A resident expressed dissatisfaction with the temperature of meals served at the facility. During an observation, the Certified Dietary Manager found that the fish, cauliflower, and potatoes on the resident's tray were below the required temperature of 140°F, while the apple pie was at an appropriate temperature. The resident, who was cognitively intact and had multiple diagnoses, reported that the food was frequently cold.
A facility failed to coordinate hospice services for a resident with multiple diagnoses, including COPD and prostate cancer. The resident was unable to explain the hospice service schedule, and no hospice calendar was present in the room. The plan of care lacked details on hospice disciplines and frequency, and the Kardex did not indicate hospice services. Staff interviews revealed confusion about the hospice schedule, with two undated calendars in a notebook and no clear indication of which was accurate. The resident had not received a hospice calendar, contrary to facility policy.
The facility failed to implement effective pressure ulcer prevention and management for two residents, leading to the development and worsening of facility-acquired pressure ulcers. One resident developed a Stage III ulcer on their left buttocks due to inadequate interventions and documentation, while another developed a Stage III ulcer on their left heel, with staff unaware of the ulcer and necessary preventive measures. The facility's policies were not effectively implemented, resulting in unnecessary pain and health decline.
The facility failed to properly monitor and maintain emergency medical equipment, resulting in expired and unsanitary items in two emergency carts. The central crash cart had mismatched lock numbers and contained expired medications, while the 600-hall cart had expired supplies and lacked essential items. The AED was soiled, and the facility's policy did not ensure consistent stocking of necessary supplies, potentially delaying emergency care.
A facility failed to prevent and investigate abuse allegations involving a CNA and three residents. One resident reported sexual abuse and neglect, while two others experienced physical abuse and intimidation. The facility's investigation was inadequate, with no suspension of the accused CNA and insufficient documentation of the incidents.
Excess Nitrofurantoin Dosing and Subsequent Yeast Infection
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered for a resident admitted with multiple diagnoses including diabetes, hypothyroidism, arthritis, dementia, history of falls, low back pain, hypertension, history of stroke, and a UTI. Hospital discharge instructions and a nurse practitioner note specified that the resident was to receive Nitrofurantoin 100 mg every 12 hours for a total of two doses to complete treatment for a UTI after admission. The physician orders in the facility’s EMR reflected Nitrofurantoin 100 mg twice daily for UTI for two administrations with a start date of 1/7/2026, and a second, similar order with a start date of 1/12/2026. Review of the January MAR showed the resident actually received 7 doses of Nitrofurantoin from 1/7/2026–1/11/2026, with missed doses on the morning of 1/9/2026 and the evening of 1/11/2026, and then 3 additional doses from 1/12/2026–1/13/2026 under the new order, for a total of 10 doses instead of the 2 doses ordered. Subsequently, provider encounter notes documented that the resident reported symptoms consistent with a yeast infection, including vaginal itching, burning, and white discharge. On 1/13/2026, a physician documented candidiasis and ordered Diflucan, and on 1/15/2026 an NP documented a vaginal yeast infection with intense itching and white discharge and ordered Diflucan and miconazole vaginal suppositories, which were initiated on 1/16/2026. The ADON, when interviewed, confirmed she had entered the Nitrofurantoin order for two doses and stated she did not know why the resident received so many doses, acknowledging that the resident developed a yeast infection and was very uncomfortable after receiving extra antibiotic doses. The DON reported there was no additional information explaining why more Nitrofurantoin doses were given than ordered. The resident’s care plans included interventions to administer medications as ordered and observe for side effects and effectiveness for both the UTI and subsequent vaginal yeast infection.
Failure to Ensure Timely and Effective Call Light Response for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to timely response to call lights and basic care needs for multiple residents. One resident with heart failure, atrial fibrillation, COPD, and dependence on supplemental O2 experienced an oxygen concentrator malfunction and was placed on an oxygen tank that subsequently ran out. The resident developed a headache, dizziness, and lightheadedness, activated the call light, and waited approximately 25 minutes before staff responded. When staff did respond, they left the room to locate a full oxygen tank, placing the resident at serious risk of harm and demonstrating a failure to ensure basic medical safety and timely response. Another resident with a history of femur fracture, muscle disorders, falls, and moderately impaired cognition (BIMS 9/15) was dependent on staff for toileting and lower body dressing. Confidential persons reported that this resident needed to use the bathroom, was not attended to, and was later found on the floor of another resident’s room with pants down below the knees. A confidential person also reported activating the call light during a visit and waiting more than 30 minutes with no staff response, ultimately taking the resident to the bathroom themselves. They reported that staff became upset and stated visitors should wait for staff, but the resident could not hold it that long, would try to get up alone, and had multiple incontinence episodes while waiting for staff. The confidential person also reported finding the resident incontinent of bowel and changing the resident themselves due to long response times. A resident with stroke, diabetes, depression, and hemiplegia/hemiparesis, cognitively intact (BIMS 14/15) and dependent on staff for hygiene, toileting, bathing, dressing, mobility, and transfers, reported having a call light on for about 30 minutes with no staff entering the room. Observation showed the wall call light illuminated for the roommate, who denied activating it, while the resident’s own call light did not activate when pressed multiple times. Maintenance later adjusted the wall connection before the call light functioned. This resident reported that call light wait times could exceed 30 minutes and sometimes take up to an hour when calling for assistance after incontinence and for ice water. Another cognitively intact resident (BIMS 15/15) with peripheral vascular disease, depression, diabetes, and a left above-knee amputation, dependent on staff for toileting, bathing, lower body dressing, and transfers, was observed with the call light on and reported needing to be changed and wanting a drink. The resident stated that sometimes the call light worked and sometimes it did not, and that staff would turn off the light, say they would return, and then not come back, sometimes resulting in waits longer than 30 minutes. Surveyors observed the call light above this resident’s door visible from the nurse’s station, with staff present in and around the area and using a nearby breakroom, while the call light remained unanswered. Housekeeping entered a nearby room first, and later a staff member entered the resident’s room, turned off the light, then went into the breakroom. The resident subsequently received a drink but had not been changed. A further cognitively intact resident (BIMS 15/15) with anxiety disorder, heart failure, need for assistance with personal care, respiratory failure, and dependence on supplemental O2, dependent on staff for toileting, lower body dressing, mobility, and transfers, was observed with the call light on and reported that while it had not been on long at that moment, call light response times could be as long as an hour. Resident council minutes over several months documented repeated concerns that nursing call light response times were longer than normal or taking longer, with ongoing reports that call lights were not being answered timely. The ADON stated that call lights should be answered as soon as possible, within about 5 to 10 minutes, and that if a need was not met, the call light should remain on. Facility policy stated that call lights would be placed within residents’ reach and answered in a timely manner, and that staff should identify the location and answer promptly, turning off the light only if able to meet the resident’s request. Despite this, surveyor observations, resident interviews, and council notes showed ongoing delays, nonfunctioning or improperly connected call lights, and staff turning off call lights without meeting residents’ needs.
Failure to Follow Oxygen Orders and Proper Nebulizer Equipment Handling
Penalty
Summary
The deficiency involves failures in safe and appropriate respiratory care, including improper oxygen administration and nebulizer equipment handling for multiple residents. For one resident with COPD receiving scheduled Ipratropium-Albuterol nebulizer treatments four times daily, surveyors observed the nebulizer mask and tubing stored in a clear bag with the medicine chamber still wet and containing liquid drops, contrary to the facility’s nebulizer policy that requires rinsing and allowing the nebulizer to air-dry. The medication administration record showed a morning dose documented as given and an early afternoon dose documented as not given on the day of observation. Another resident, cognitively intact and dependent on staff for several ADLs, was found lying in bed without oxygen in place; the nasal cannula and tubing were positioned by the wall and out of reach. The resident stated she was supposed to use oxygen all the time and reported that a CNA had assisted with changing her shirt, during which the oxygen was removed and not replaced for about an hour. When staff were alerted, the resident’s oxygen saturation was measured at 87–88% before oxygen was reapplied. A third cognitively intact resident, dependent on supplemental oxygen, was observed receiving oxygen at 4 L/min via concentrator and nasal cannula. Review of the medical record with the ADON showed a physician’s order for oxygen at 2 L/min, indicating the oxygen flow being delivered did not match the provider’s order. The facility’s oxygen policy did not include directives on following provider orders or monitoring liters of oxygen to be used.
Failure to Timely Transfer and Monitor Resident with Acute Change in Condition
Penalty
Summary
A resident with a complex medical history, including gram-negative sepsis, heart failure, and dependence on supplemental oxygen, experienced an acute change in condition that was not promptly recognized or addressed by facility staff. The resident became unresponsive, diaphoretic, and exhibited labored breathing with a high fever and abnormal urine characteristics. Despite these significant changes, there was a delay in transferring the resident to the hospital, and staff failed to provide timely and thorough assessments or interventions during the acute episode. Documentation and interviews revealed that staff did not consistently monitor or document the resident's vital signs or Foley catheter status. The care plan and Kardex lacked specific interventions for ongoing assessment and monitoring of the Foley catheter, and staff were unclear on how to track urine output for residents with catheters. CNA and nursing documentation indicated that only one set of vital signs was recorded during the critical period, and there was no evidence of further nursing care or assessment until EMS arrived. Upon EMS arrival, the resident was found to be in severe distress, with a temperature of 104.1°F, unresponsiveness, and significant respiratory compromise, requiring intubation shortly after arrival at the emergency room. Interviews with facility leadership and staff highlighted gaps in communication, documentation, and escalation of care. Concerns raised by the resident's family regarding decreased mobility and responsiveness were not thoroughly assessed or communicated to the appropriate staff. The lack of clear protocols for monitoring residents with Foley catheters and the absence of timely nursing interventions contributed to the delay in recognizing the severity of the resident's condition and transferring him to the hospital.
Failure to Ensure Dignified Care and Timely Call Light Response
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and respect, specifically regarding timely call light response, food palatability, and accessibility of call lights. During a Resident Council meeting, nine residents unanimously reported prolonged call light response times, often averaging 30 minutes or more. Residents described instances where staff would turn off call lights and promise to return but failed to do so, leaving residents waiting for assistance with activities of daily living (ADLs). Staff were also observed talking loudly, using cell phones, and gathering at the nurse's station while residents waited for help. Some residents reported being left soiled and wet for extended periods, and staff sometimes gave false reasons for delays, such as claiming equipment was unavailable when it was not. Residents also expressed dissatisfaction with the quality and variety of food, noting repetitive menus and unappetizing meals. They reported that alternative meal options often consisted of leftovers from previous meals, and that bedtime snacks were either not provided or only available if residents went to the nurse's station themselves. These concerns were consistently raised in Resident Council meetings from December to May, but meeting minutes showed a lack of follow-up or resolution. The March meeting was not held due to a COVID-19 outbreak, and there was no documentation of attempts to address the issues or communicate with the Resident Council president. Specific resident observations further supported these findings. One resident, who was cognitively intact and had a history of chronic embolism, muscle weakness, and dysphagia, reported average wait times of over 30 minutes for call light response and noted that staff sometimes did not return after turning off the call light. Another resident was found unable to locate his call light, which was on the floor and out of reach, despite housekeeping staff entering and exiting the room without noticing. A nurse aide eventually found and repositioned the call light. These events demonstrate the facility's failure to maintain an environment that promotes dignity, timely care, and respect for residents' rights.
Failure to Resolve Resident Grievances and Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide prompt efforts to resolve multiple grievances raised by a group of nine residents, as required by federal regulations. During a Resident Council meeting, residents reported ongoing issues such as prolonged call light response times, dissatisfaction with food palatability and variety, lack of bedtime snack distribution, limited group activities due to transportation issues, and concerns about staff availability and attitude. Residents expressed that their complaints were not being addressed or followed up on, and that they were not informed about the grievance process or the existence of a grievance form. When the grievance form was presented during the meeting, several residents indicated it was their first time seeing it and were unaware of how to file grievances or to whom they should report their concerns. Review of Resident Council meeting minutes from December through May revealed a lack of documentation regarding the resolution or follow-up of previously raised concerns. Old business sections in the minutes were often left empty, and unresolved issues were not consistently carried over or addressed in subsequent meetings. The March meeting minutes were missing, and the Administrator explained that the meeting was not held due to a COVID-19 outbreak, but there was no documentation of postponement or attempts to resolve outstanding issues. The Administrator also indicated a lack of awareness regarding her ability to attend council meetings to address concerns directly. Specific grievances included the absence of field trips since the facility sold its bus, repetitive and unappealing food menus, staff failing to provide or distribute bedtime snacks, and staff not responding promptly to call lights or making excuses about unavailable equipment. Residents also reported that staff sometimes turned off call lights without fulfilling requests and were observed socializing or using cell phones instead of attending to residents' needs. One resident with diabetes was unaware of the availability of bedtime snacks and had not received them. The facility's failure to inform residents about the grievance process and to document or resolve ongoing concerns resulted in unresolved grievances and resident frustration.
Failure to Consistently Provide and Distribute Bedtime Snacks
Penalty
Summary
The facility failed to ensure that a substantial bedtime (HS) snack was consistently offered and appropriately distributed to residents, as required by federal regulations. During a Resident Council meeting, nine residents reported that HS snacks were not provided or were only available if residents went to the nurse's station themselves. This practice excluded residents who were unable to reach the nurse's station or advocate for themselves. One resident with diabetes reported never receiving an HS snack and was unaware that such snacks were available. The issue was raised during multiple Resident Council meetings, with concerns about snacks not being passed and lack of follow-up on these issues. A review of Resident Council meeting minutes from December to May revealed missing documentation for March and no evidence of follow-up or resolution of previously discussed concerns. The Administrator was unaware of the ongoing issues and had not attended council meetings or documented the postponement of the March meeting due to a COVID-19 outbreak. There was no indication that the facility addressed or resolved the concerns raised by residents regarding the distribution of HS snacks.
Multiple Lapses in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen to maintain sanitary conditions and adhere to food safety standards. Outdated food items were found in both the refrigerator and freezer, including pre-made sandwiches and cooked dishes that were past their use-by dates, some of which were unlabeled or not properly covered. The walk-in refrigerator was found at 40°F, and the freezer was observed at temperatures above the required 0°F, with the CDM unaware of the improper readings. Temperature logs for the refrigerator and freezer were incomplete, with some entries filled in before the shift began, and key identifying information left blank. Additionally, three dented cans were found mixed with undamaged cans, and two ice scoopers were not stored appropriately, with one left uncovered on top of the ice machine. A spider and web were discovered on top of the grill during a hot tray observation, further indicating lapses in kitchen sanitation. The CDM acknowledged these issues during the survey and confirmed that staff should be checking food dates daily. Policies for temperature monitoring, leftover food, and kitchen sanitation were reviewed, and all findings were discussed with the Administrator. The deficiencies identified have the potential to affect all residents consuming food prepared by the facility.
Failure to Properly Document and Maintain Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that code status was properly assessed, documented, and accessible in the medical record for two residents reviewed for advance directives. For one resident admitted with a history of stroke, right-sided weakness, hypertension, anxiety, aphasia, and dysphagia, the electronic medical record indicated "Full Code" status on the face sheet and medication records, but there was no care plan for code status and no documented assessment of code status preferences in the "Documents" tab. The code status assessment form was only completed and signed by the social worker after the deficiency was identified, and not by the resident. Interviews with staff revealed that the code status assessment was missed during the admission process and that there was confusion regarding responsibility for completing the assessment. For another resident with cerebral infarction, dysphagia, diabetes, hemiplegia, hemiparesis, and vascular dementia, who was enrolled in hospice and had a legal guardian, the care plan indicated DNR and hospice services. However, the DNR order form in the medical record was not signed by a physician as required, and the previous DNR order had expired. The social worker confirmed that the DNR order was not current and that it was their responsibility to ensure the form was accurately completed and signed. Facility policy required annual review and physician signature for DNR orders, which was not followed in this case. The facility's own policy specified that advance directives and code status forms should be obtained, signed, and placed in the medical record upon admission, with annual review and re-signing as necessary. In both cases, the required documentation and signatures were either missing or incomplete, resulting in a lack of clear, accessible, and current information regarding the residents' code status and advance directives.
Failure to Administer Ordered Medications and Wound Treatments
Penalty
Summary
The facility failed to ensure that prescribed treatments and medications were administered as ordered for two residents. One resident with multiple comorbidities, including osteomyelitis, pressure ulcers, and morbid obesity, developed a facility-acquired pressure ulcer on the left lateral malleolus. The wound care clinic recommended a collagen/silver combination dressing for this wound, with instructions to change the dressing daily and a supply provided for 30 days. However, the facility was unable to consistently apply the recommended dressing due to a reported shortage of the product, and instead used a different dressing (calcium alginate with silver) that was not in accordance with the wound clinic's orders. Interviews with nursing staff revealed uncertainty about whether alternative suppliers or other corporate facilities were contacted to obtain the correct dressing, and documentation showed ongoing use of the non-recommended product. Another resident, admitted with a history of stroke, hypertension, and other conditions, did not receive her prescribed blood pressure medication, Nifedipine, for multiple days following admission. The medication was not available in the facility or from the backup pharmacy, and repeated documentation indicated ongoing communication with the pharmacy and the nurse practitioner about the unavailability. The resident expressed distress about not receiving her medication, which was ordered to be given four times daily. Despite care plan interventions specifying the need to administer medications as ordered and monitor for complications related to hypertension and recent intracranial hemorrhage, the medication was not administered as prescribed for an extended period. In both cases, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and physician recommendations. The failure to provide the ordered wound care treatment and to administer essential blood pressure medication as prescribed constituted a deficiency in the quality of care provided to these residents.
Failure to Revise Care Plans and Follow Dietary Orders for Nutrition and Hydration
Penalty
Summary
The facility failed to ensure that dietary care plans were revised for actual weight loss and did not follow dietary orders for two residents, resulting in the potential for continued weight loss. One resident, a 91-year-old with multiple diagnoses including major depressive disorder, congestive heart failure, and anxiety, experienced a 10.1% weight loss over six months. Despite a significant weight loss being identified, there was no care plan addressing actual weight loss, only a care plan for potential alterations in nutritional status, which had not been updated. The Registered Dietitian confirmed that a care plan for actual weight loss should have been in place and acknowledged that no additional interventions were implemented beyond updating preferences and adding the resident to weekly weights. Another resident, admitted with diagnoses including heart failure, COPD, and mild protein-calorie malnutrition, had physician orders for a regular diet with large or double protein portions. The resident reported not consistently receiving the ordered double portions of protein and expressed concern about the lack of protein options and the quality of alternatives provided. The care plan did not mention the need for additional protein, and the nutritional evaluation failed to address the extra protein requirement. The resident's albumin levels were low and declining, and there was a lack of documentation and follow-up regarding the resident's dietary concerns and lab results. Both cases demonstrate failures in care planning and implementation of dietary orders. The facility did not update care plans to reflect actual weight loss or ensure that dietary interventions matched physician orders and resident needs. There was also insufficient monitoring and documentation of residents' nutritional status and preferences, as well as a lack of communication between dietary staff and other care team members regarding residents' changing conditions and concerns.
Failure to Provide Timely Dental Services and Dietary Adjustments
Penalty
Summary
A deficiency was identified when a resident with a history of dementia, contracture, and hemiplegia was not provided timely dental services for an ill-fitting lower partial denture. The resident reported being unable to wear the denture due to poor fit and discomfort since receiving it, which affected his ability to chew certain foods such as chicken and hamburgers. Despite repeated documentation in dental visit notes over several months that the denture did not fit and the resident was not wearing it, no effective adjustment or replacement was made for an extended period of approximately ten months. The resident remained on a regular diet despite his inability to chew certain foods, and staff were aware of his difficulties. The registered dietitian was not directly informed of the resident's issues with the denture or eating, and only considered a diet change after being specifically asked. Dental records indicated ongoing problems with the denture, requests for adjustments, and pending x-rays, but there was no evidence of follow-up or resolution after the x-rays were completed. The unit manager confirmed that the resident should have been referred for further dental evaluation and dietary review much earlier. Facility policy required prompt referral for dental services within three days of lost or damaged dentures and documentation to ensure adequate nutrition if delays occurred. However, the resident's ongoing inability to use the denture and lack of timely intervention or dietary adjustment demonstrated a failure to meet these requirements. The deficiency was substantiated by interviews, record reviews, and direct observations of the resident's continued difficulty eating and lack of appropriate dental or dietary support.
Deficient Emergency Preparedness Policies and Procedures
Penalty
Summary
The facility failed to develop and implement emergency preparedness policies and procedures in accordance with regulatory requirements. Specifically, the emergency plan, risk assessment, and communication plan were not fully integrated into the facility's policies and procedures, and the required annual review and update of these documents was not completed. During record review, it was found that the policy for emergency situations involving electrical power outages directed staff to use an 'emergency kit' cart located in the 500 Hall. However, field verification revealed that there was no emergency kit cart in the 500 wing, as it had been moved to the 600 service hall without updating the policy or informing staff of the new location. Additionally, the facility's severe weather policy stated that staff would monitor a weather radio located at the main nurse station. Upon field verification, it was discovered that there was no weather radio at the main nurse station, contrary to what the policy indicated. These discrepancies were confirmed through an interview with the maintenance director at the time of record review. The lack of alignment between the facility's written policies and the actual resources and equipment available could affect all occupants in the event of an emergency.
Failure to Provide Functional Emergency Lighting
Penalty
Summary
On June 24, 2025, observations revealed that the facility failed to provide automatic emergency lighting in accordance with regulatory requirements. Specifically, the battery back-up emergency lighting over the transfer switches did not illuminate when tested, which would result in the area being left in darkness if the transfer switches failed to transfer power during a power loss. Additionally, the battery back-up light in the activities area above the doors did not illuminate when the test button was pressed, indicating that this area would also be left without emergency lighting during a power outage. These deficiencies were confirmed through interviews with the maintenance director at the time of observation.
Sprinkler System Maintenance Deficiency
Penalty
Summary
During an inspection, it was observed that the sprinkler escutcheon ring in the main office paper supply closet had slid down around the sprinkler head. This condition prevents the sprinkler from functioning as designed in the event of a fire. The issue was identified through direct observation and confirmed in an interview with the maintenance director at the time of the inspection. The facility failed to provide proper maintenance and testing of the sprinkler system as required by NFPA 25, resulting in a deficiency that could affect all occupants in the event of a fire.
Incomplete Annual Fire Door Inspections
Penalty
Summary
The facility failed to conduct a complete annual inspection and testing of all rated swinging fire doors as required by NFPA 101 and NFPA 80 standards. Record review on June 24, 2025, revealed that the inspection only included the seven sets of cross corridor rated fire doors and did not encompass all other rated doors, such as those for storage rooms, soiled utility rooms, and other tagged rated fire doors. This incomplete inspection was confirmed during an interview with the maintenance director at the time of record review.
Deficient Emergency Power System Maintenance and Documentation
Penalty
Summary
The facility failed to ensure that its generators and associated emergency power systems were maintained and tested in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. During an observation, it was found that the automatic transfer switch number 2 for the equipment branch was not functioning, as indicated by the absence of display and indicator lights. The maintenance director confirmed that this issue had persisted since February or March, and that the generator company had not yet responded to address the malfunction. Despite the malfunction, the facility continued to have lights and power during outages, but the non-functioning transfer switch could limit available resources during a power loss. Additionally, a review of facility records revealed that there was no documentation available to verify that the back-up emergency generator had been serviced annually or that the required annual load bank test had been conducted. The maintenance director stated that the generator company had recently visited but had not yet provided any paperwork. The lack of documentation means that the facility could be unaware of potential generator issues, which may result in generator failure during a power outage. These findings were confirmed through interviews with the maintenance director at the time of observation and record review.
Obstructed and Inaccessible Emergency Exits Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain clear and accessible means of egress as required by code. Specifically, the Human Resources office exterior door was found sealed shut and could not be opened, preventing its use in emergencies. Additionally, an excessive number of dialysis infusion transport chairs were stored in the emergency egress corridor outside the dialysis treatment room for several hours, with no dedicated space available to relocate them during an evacuation. Furthermore, the west emergency exit door from the main dining room was stuck closed and required excessive force to open, impeding emergency evacuation from that area. These deficiencies were confirmed through interviews with the maintenance director at the time of observation.
Exit Signs Not Illuminated on Emergency Power
Penalty
Summary
During an inspection, it was observed that exit signs in the older section of the facility did not remain illuminated when the battery back-up test button was pressed. This indicated that the exit signs were not transferring from regular power to emergency battery power as required. The maintenance director, when interviewed, believed that the signs were functioning properly, but the test demonstrated otherwise. These findings were confirmed through direct observation and interview with the maintenance director at the time of the inspection. The deficiency was noted to potentially affect 50 occupants in the event of a power loss, as the exit signs would not be illuminated during an outage. No specific residents or their medical conditions were mentioned in the report.
Deficient Fire Barrier Protection in Hazardous Area
Penalty
Summary
A deficiency was identified when, during an observation on June 24, 2025, the door to the soiled utility rated room in the 600 hall was found not to latch when closed. This door is required to be self-closing or automatic-closing and to latch in order to maintain the integrity of the fire barrier, as specified by regulatory requirements for hazardous area enclosures. The failure of the door to latch could allow smoke, heat, fire, or biohazard to escape the rated space and enter the emergency egress corridor. The findings were confirmed through an interview with the maintenance director at the time of observation. No specific information about the medical history or condition of the affected occupants was provided in the report.
Failure of Corridor Fire Doors to Fully Close Due to Faulty Door Arranger
Penalty
Summary
Surveyors observed that the double rated fire corridor doors located outside of resident room 210 did not fully close due to a failing door arranger. This deficiency was identified during an inspection on June 24, 2025, at approximately 12:15 PM. The inability of the doors to close completely compromises their function to resist the passage of smoke, as required by NFPA 19.3.6.3. The observation was confirmed through an interview with the maintenance director at the time of the inspection. This issue affects the doors protecting corridor openings, which are critical for preventing the transfer of smoke, heat, and fire between compartments. The deficiency could potentially impact 50 occupants in the event of a fire, as the compromised doors would allow smoke and fire to move from one compartment to another. No specific details about individual residents' medical histories or conditions at the time of the deficiency were provided in the report.
Failure to Timely Reorder Pain Medication Results in Resident Missing Fentanyl Patch
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who required a Fentanyl transdermal patch for pain control. The resident, who was cognitively intact and able to communicate her needs, experienced a lapse in her pain management regimen when her Fentanyl patch fell off and there was no replacement available. Documentation shows that after the patch was applied, the resident was due for a new patch, but due to a lack of available patches and a delay in obtaining a new prescription, she went without her pain patch for three days. During this period, the resident reported increased pain and expressed frustration with the lack of communication from staff regarding the situation. The clinical record and medication administration records confirm that the facility did not have a valid prescription to refill the Fentanyl patches, and attempts by the pharmacy to contact the provider for a new script were unsuccessful. The facility's process for reordering controlled substances was not effectively followed, resulting in a gap in pain management. The resident's daughter also raised concerns about the potential for withdrawal due to the missed medication. There was no documentation of timely communication with the provider or pharmacy to resolve the issue before the resident missed multiple doses.
Deficiencies in IV Medication Management
Penalty
Summary
The facility failed to properly assess and monitor intravenous medication therapy for two residents, leading to deficiencies in the administration of Vancomycin. Resident #702 was admitted with several serious conditions, including necrotizing fasciitis and stage 3 kidney disease, and was prescribed Vancomycin to be dosed by the pharmacy. However, there was a lack of communication between the facility and the pharmacy, resulting in the pharmacy not receiving the order to dose until nearly four weeks after the initiation of the antibiotic. During this period, Resident #702's Vancomycin levels were consistently subtherapeutic, and there was no documentation that the facility contacted the pharmacy regarding these levels until the practitioner intervened. Resident #703, who had acute kidney failure and other serious conditions, was also prescribed Vancomycin. Despite elevated Vancomycin levels being reported, the facility failed to communicate these results to the pharmacy in a timely manner. As a result, Resident #703 received two additional doses of Vancomycin after the elevated levels were identified. The facility staff contacted the pharmacy 24 hours after receiving the lab results, at which point the pharmacy ordered the antibiotic to be held due to the elevated levels. Interviews with facility staff, including the DON and a nurse, revealed a lack of clarity and consistency in the procedures for managing Vancomycin dosing and communication with the pharmacy. The facility did not have a policy for intravenous medications or a specific procedure for when residents are prescribed Vancomycin. Additionally, there was no standard practice for documenting the communication of lab results to the pharmacy, contributing to the oversight in dosing management for both residents.
Failure to Assess and Document Wounds
Penalty
Summary
The facility failed to ensure proper wound assessment, monitoring, and intervention for a resident, resulting in the development of wounds on the resident's left foot great toe, left foot third toe, and right foot third toe. The resident, who had a history of chronic kidney disease, diabetes, and other health issues, was observed with necrotic and abraded areas on her toes. Despite an orthopedic consult identifying a wound on the left great toe on 8/29/2024, there was no corresponding documentation or physician orders in the resident's medical records. The facility's Wound Nurse acknowledged that the consult was missed, and an assessment was only initiated on 9/16/2024. The facility's care plans and policies required regular skin assessments and documentation of any abnormalities, but these were not followed. The resident's care plan included interventions for monitoring skin integrity and blood sugar levels, yet the wounds were not identified during routine assessments. The Director of Nursing confirmed that the wounds should have been documented and assessed, but they were not. The facility's policies emphasized the importance of identifying and documenting wounds and changes in resident status, which were not adhered to in this case.
Failure to Update Catheter Status and Documentation
Penalty
Summary
The facility failed to properly manage the indwelling urinary catheter for a resident, resulting in staff being unaware of the resident's catheter status. The resident, who had full cognitive abilities and required some assistance with care, was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder. The Minimum Data Set (MDS) assessment indicated the presence of an indwelling urinary catheter. Despite the catheter being removed on a specific date, the orders for the catheter were not discontinued, and staff continued to document the presence and care of the catheter. The facility's records showed that after the catheter was removed, there were multiple entries indicating the resident still had an indwelling catheter, and catheter care was documented as performed numerous times. The care plans did not reflect the removal of the catheter, and the facility's policy on catheter care did not address discontinuation or removal. Interviews with the Infection Preventionist and the Director of Nursing confirmed the resident no longer had a catheter, yet the orders and documentation inaccurately reflected otherwise.
Sanitation and Equipment Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment and ensure that equipment and plumbing were in good repair, which increased the risk of foodborne illness for all residents consuming food from the kitchen. Observations revealed white mold-like accumulation on two wire racks in the walk-in cooler, indicating a lack of cleanliness in food storage areas. Additionally, the steamer on the cookline was leaking water onto clean pitchers stored below, and the chef was unaware that the steamer should not be leaking, suggesting a lack of awareness and maintenance of kitchen equipment. Further issues included a backflow prevention device at the dish machine that was covered with a cloth and leaking water, with scale build-up from hard water, indicating improper maintenance. An opened jug of soy sauce was found unrefrigerated in the dry storage room, contrary to the manufacturer's instructions, showing a lack of adherence to food storage guidelines. The walk-in freezer door gasket was damaged with excessive ice build-up, and staff attempts to remove the ice were damaging the gasket further. Additionally, a spray bottle near the kitchen entrance was not labeled to identify its contents, posing a risk of contamination from unidentified toxic materials.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure accurate advance directive information for two residents, leading to potential non-compliance with residents' medical care preferences. Resident #182 was admitted with multiple diagnoses, including severe cognitive impairment. Despite having a physician's order for Do Not Resuscitate (DNR), there was no declaration of incompetence in the medical record, which is required to activate a Durable Power of Attorney (DPOA). The Social Worker Supervisor confirmed the absence of the necessary documentation and acknowledged that the DNR order was incorrect without a proper declaration of incompetence. Resident #88, who was cognitively intact, had an advance directive indicating a DNR status that was not witnessed by two people as required. The social worker responsible for ensuring the documentation was complete could not explain why the necessary signatures were missing. During the survey, it was found that the advance directive was filled out and scanned into the medical record, but the timing of this action was unclear. The facility's policy requires a determination of a resident's cognitive level by two physicians or a physician and a psychologist before a DPOA can be activated. This process was not followed for Resident #182, and the advance directive for Resident #88 lacked the required witness signatures. These deficiencies highlight the facility's failure to adhere to its own policies and state requirements for advance directives, potentially compromising residents' rights to have their medical care preferences respected.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper assessment and documentation. A resident was observed with a half lap tray attached to their wheelchair on multiple occasions. However, there was no initial assessment found in the resident's electronic medical record to determine if the lap tray was a restraint or an enabler. An assessment was only completed during the survey, which indicated the tray was for positioning, support, and comfort. Despite this, the care plan was not updated to reflect the assessment findings. The facility's policy required a physical device evaluation before using any device, a current signed restraint consent, and a current order specifying the type of restraint, when to use it, the medical symptom for its use, and a release/exercise statement. None of these requirements were met for the resident in question. The Director of Nursing confirmed that an evaluation should have been performed prior to the use of the device and that the care plan should have been updated accordingly.
Deficiencies in Care Plan Implementation and Documentation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For one resident, the care plan did not specify the side effects of the medications Seroquel and Zoloft, which were prescribed for mood disorder and depression, respectively. The care plan only included generic side effects and did not mention the specific medications the resident was receiving. This lack of specificity in the care plan could hinder staff's ability to monitor and manage potential adverse reactions effectively. Another resident's care plan was not updated to reflect a new order for Zoloft, and it lacked specific interventions related to the medication's use and side effects. Additionally, this resident was observed with a half lap tray attached to their wheelchair, but there was no documentation specifying the medical reason for its use. A physical restraint assessment was not found in the resident's electronic medical record until it was completed during the survey. The care plan did not indicate why the lap tray was necessary, and the Director of Nursing stated that an evaluation should have been performed before using the device, with the care plan updated accordingly.
Deficiencies in ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate care for Activities of Daily Living (ADL) for three residents, resulting in not achieving and/or maintaining their highest practicable well-being. Resident #91, who is severely cognitively impaired and dependent on staff for personal care, was found with long, dirty nails and dry, flaking skin. Despite documentation indicating care was provided, interviews with the resident's daughter revealed that the resident was not receiving adequate hygiene care, such as proper foot cleaning and nail trimming. Resident #80, who is cognitively intact but dependent on staff for personal care, reported not receiving showers as preferred and was observed with greasy hair and uneven shaving. The resident expressed dissatisfaction with the care provided, stating that only partial bed baths were given instead of full showers. Documentation did not specify whether the resident received a shower or a bed bath, and the shower log did not reflect the resident's preferences or the care provided. Resident #32, who is cognitively intact and has multiple medical conditions, was observed with long, dirty fingernails and reported not receiving oral care or showers as scheduled. Despite being marked as having received a bed bath or shower, the resident stated otherwise, and a CNA confirmed that the resident did not receive the care documented. The resident expressed a desire for reminders of shower days and reported not receiving scheduled showers.
Failure to Maintain and Remove PICC Line as Ordered
Penalty
Summary
The facility failed to perform dressing changes as ordered and did not follow the physician's orders for the removal of a peripherally inserted central catheter (PICC) for a resident, resulting in potential risks. The resident, who was admitted with diagnoses including neurogenic bladder and sepsis, was observed with a PICC line in his left upper arm that had not been maintained according to the physician's orders. The dressing on the PICC line was dirty, stained, and peeling, with no date indicating when it was last changed. The resident, who was knowledgeable about PICC line maintenance, reported that it had been over a week since the dressing was changed and that his concerns were dismissed by the staff. The treatment administration record showed a physician's order to change the PICC line dressing every seven days, which was last marked as completed on 5/25/24. Additionally, there was an order for the removal of the PICC line, which was marked as completed, although the line was still in place. Interviews with the LPN and the ADON revealed a lack of awareness and oversight regarding the resident's PICC line status. The ADON confirmed that the PICC line should have been removed and acknowledged that the completion of the order led to the cessation of required dressing changes and flushes, indicating a breakdown in communication and adherence to care protocols.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement appropriate interventions to promote pressure ulcer healing and prevent the development of new pressure ulcers for Resident #37 and Resident #91. Resident #37 was observed with his feet pressed against a Medi-[NAME] case on his bed, which contributed to the development of a pressure ulcer on his left toe. Despite having a care plan that included floating heels and using soft heel lift boots, these interventions were not consistently implemented, as evidenced by observations of Resident #37's heels not being floated and the green foam boot not being used. Additionally, the maintenance team was not promptly informed about the need for a new bed frame to prevent further injury. Resident #91, who was severely cognitively impaired, was found with a dressing on his left heel that had not been changed according to the prescribed schedule. The care plan for Resident #91 included floating heels and using a pressure reduction mattress, but these measures were not observed during the survey. The dressing on the left heel was dated several days prior, indicating a lapse in wound care management. Furthermore, the sacral pressure ulcer care was not adequately documented, and the necessary repositioning and support to prevent further skin breakdown were not consistently provided. The facility's staff, including the wound care nurse and maintenance personnel, demonstrated a lack of coordination and timely response to the residents' needs. The wound care nurse was unaware of the purpose of the Medi-[NAME] and delayed notifying maintenance about the bed frame issue. Additionally, the documentation of wound care interventions and refusals was incomplete, contributing to the inadequate management of pressure ulcers for both residents. These deficiencies highlight a failure in the facility's processes to ensure proper pressure ulcer prevention and care.
Failure to Implement Behavioral Health Interventions for a Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care interventions for a resident with a history of depression and anxiety. The resident, who was cognitively intact and had multiple diagnoses including major depressive disorder and bipolar disorder, reported feelings of loneliness and depression. Despite previous psychology notes recommending encouragement of socialization and participation in meaningful activities, the resident was observed in a room with closed blinds, no reading materials, and without a displayed activities calendar. The resident expressed a desire to regain strength to use a power wheelchair and mentioned past suicidal remarks, although there was no current desire to act on them. The care plan for the resident included interventions such as offering materials for individual activities and encouraging participation in group activities. However, the resident had not received any 1:1 visits in the past 30 days, which was a part of the recommended interventions. The Activities Director confirmed that the resident was not on the 1:1 visit list, despite acknowledging that the resident would benefit from such activities. This oversight resulted in the resident not receiving the necessary behavioral health care and services, potentially exacerbating their mental health issues.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 20.69% due to six medication errors observed out of 29 opportunities. For Resident #186, a Registered Nurse (RN) administered insulin Lispro based on a blood glucometer reading taken after the resident had consumed breakfast, contrary to the physician's order to obtain the reading before meals. Additionally, the Fenofibrate Oral Tablet was not administered at the scheduled time of 09:00 a.m. due to its unavailability, and there was no documentation of physician notification for the delay. For Resident #64, a Licensed Practical Nurse (LPN) left a medication cup containing four pills unattended on the resident's over-bed table while the resident was asleep. The LPN acknowledged that leaving medications unattended was not standard practice. These actions and inactions contributed to the facility's failure to adhere to proper medication administration protocols, as observed during the survey.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to prevent a significant medication error for a resident who was not administered a prescribed medication, leading to the potential for a worsening infection. The resident, who had a history of cerebral infarction, gastrostomy status, and heart failure, was admitted with a diagnosis of osteomyelitis in the right heel. The resident was prescribed intravenous Vancomycin and Cefepime for the infection. However, the Medication Administration Summary for April and May showed several instances where Vancomycin doses were either held or not given without any explanation documented in the medical record. The Assistant Director of Nursing, who temporarily assumed the role of Infection Control Nurse, acknowledged the issue of missing Vancomycin doses. The ADON indicated that the nursing staff was educated on using the appropriate code when charting in the Medication Administration Record. Some missed doses were attributed to delays in receiving Vancomycin trough results, which were required by the pharmacy before sending additional doses. The medical provider was notified of the missed doses, and increased monitoring for infection was implemented.
Food Temperature Deficiency
Penalty
Summary
The facility failed to serve food at the preferred temperature for a resident, resulting in dissatisfaction during meals. The resident, who was admitted with multiple diagnoses including insomnia, depression, heart failure, and anxiety, was observed to be cognitively intact with a BIMS score of 15 out of 15. During an interview, the resident expressed dissatisfaction with the food, stating it was frequently cold. On a specific observation, the food cart arrived at the resident's unit, and the resident's meal was delivered. The Certified Dietary Manager (CDM) was present and took the temperatures of the food items on the resident's tray. The fish, cauliflower, and potatoes were found to be below the required temperature of 140 degrees Fahrenheit, while the apple pie was at an appropriate temperature. The CDM acknowledged the temperature issue and took the tray back to the kitchen for reheating.
Failure to Coordinate Hospice Services for Resident
Penalty
Summary
The facility failed to coordinate hospice services for a resident, resulting in the potential for care not being provided and residents not being fully informed of hospice services. The resident, who was admitted with multiple diagnoses including COPD, dysphagia, and prostate cancer, was receiving hospice services as indicated in the medical record. However, the resident was unable to explain the schedule or disciplines of the hospice services, and no hospice calendar was observed in the resident's room. The plan of care did not specify the hospice disciplines or the frequency of care, and the Kardex used by CNAs did not indicate that the resident was on hospice services. Interviews with facility staff revealed confusion and lack of clarity regarding the hospice services provided. A CNA referred to a notebook at the nurse's station, which contained two different weekly calendars without dates, and was unable to determine which was accurate. Another CNA could not find hospice information in the resident's Kardex. The Director of Nursing and Social Work Technician also could not confirm the correct hospice calendar, and it was revealed that the resident had not received a copy of the hospice calendar. The facility's policy required a plan of care reflecting hospice participation and ensuring staff awareness of their responsibilities, which was not adhered to in this case.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to implement and operationalize policies and procedures for pressure ulcer prevention and management for two residents, resulting in the development and worsening of facility-acquired pressure ulcers. Resident #704, who was admitted with multiple diagnoses including diabetes, heart disease, and hemiplegia, developed a Stage II pressure ulcer on their left buttocks, which worsened to a Stage III ulcer. The facility's records indicated a lack of consistent and appropriate interventions, such as the absence of a specialty mattress and inadequate documentation of turning and repositioning, which contributed to the deterioration of the resident's condition. Resident #710, admitted with heart failure and decreased mobility, developed a Stage III pressure ulcer on their left heel. Despite being at risk for pressure ulcer development, the resident's care plan lacked specific interventions to prevent such injuries. The facility staff, including a CNA and a wound care RN, were unaware of the resident's pressure ulcer and the necessary preventive measures, such as floating heels or using heel boots. The resident's care plan and Visual/Bedside Kardex did not reflect the resident's actual needs, leading to inadequate care and the development of the pressure ulcer. The facility's policy on skin management was not effectively implemented, as evidenced by the lack of appropriate preventative measures and documentation for residents at risk of skin compromise. The facility's failure to provide adequate care and monitoring for residents with pressure ulcers or those at risk resulted in unnecessary pain and a decline in the residents' overall health status. The report highlights significant deficiencies in the facility's pressure ulcer prevention and management practices, as observed by surveyors.
Deficiency in Emergency Medical Equipment Management
Penalty
Summary
The facility failed to ensure the proper monitoring and accessibility of emergency medical equipment and supplies, leading to expired and unsanitary items in two emergency medical response carts. During an observation, it was found that the crash cart in the central area of the facility had a lock number that did not match the documented log, indicating it had been opened and not properly restocked. Expired medications and supplies, such as an Epinephrine Auto Injector and various IV catheters, were found in the cart. Additionally, the Automated External Defibrillator (AED) was visibly soiled, and the Director of Nursing (DON) confirmed it needed cleaning. A second emergency cart on the 600-hall was also inspected and found to contain expired items, including oral glucose gel and sterile water containers. The suction tubing was improperly connected and uncovered. The cart lacked essential items like an Epinephrine pen and glucometer control/testing solution. The DON acknowledged the discrepancies and the difficulty in ordering AED pads, which resulted in only one set being available. The facility's policy on medical emergency management was reviewed, revealing that supplies should be regularly checked and maintained. However, the DON was unable to provide a consistent list of required items for the carts, and the facility's policy on glucometer testing did not include information on running controls. This lack of consistency and oversight in maintaining emergency supplies could lead to delays in care during medical emergencies.
Failure to Prevent and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure an environment free of abuse by a staff member for three residents, resulting in a lack of administrative oversight to identify and monitor for increased risk of abuse by staff, and prevent abuse. Resident #709 experienced verbal abuse and neglect, while Resident #702 and Resident #711 experienced physical abuse, including intimidation. The facility did not adequately investigate or document the allegations, nor did they suspend the accused staff member, CNA G, following the allegations. Resident #709 reported to a Hospice RN that CNA G had attempted to touch them sexually, and they did not want CNA G to care for them. The resident also reported being neglected, as they were left covered in stool despite asking for help. The Hospice RN confirmed the resident's cognitive status as occasionally confused but able to verbalize needs. The facility's investigation did not include interviews with other staff or residents, and CNA G continued to work without suspension. Resident #702 reported being pushed down on their bed and having their shirt grabbed by CNA G, which brought back traumatic memories of past abuse. Resident #711 reported being grabbed by the neck by CNA G, which they perceived as intimidation. Both residents indicated that CNA G was moved to a different hall but continued to work in the facility. The facility's documentation and investigation into these incidents were inadequate, with no evidence of a thorough investigation or reporting to the state agency.
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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