Aria Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansing, Michigan.
- Location
- 707 Armstrong, Lansing, Michigan 48911
- CMS Provider Number
- 235561
- Inspections on file
- 30
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Aria Nursing And Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident with multiple sclerosis and epilepsy reported that another resident, who appeared intoxicated and had an open can of beer, struck her left arm in a day room, with a RN and CNA hearing a slap-like sound and the resident cry out, and the aggressor later admitting he had "smacked" her arm after drinking. In a separate incident, a resident with dementia and cardiac and diabetic conditions became upset over a wallet he insisted was his, and multiple staff witnesses reported that the former NHA raised his voice, got close to the resident, pointed at him, and called him a profane name while the resident was hollering and swearing, with the resident later recalling that cussing words were used toward him.
A resident with morbid obesity, multiple comorbidities, moderately impaired decision-making, and documented dependence for bed mobility had a care plan requiring a two-person assist for rolling in bed. During early-morning incontinence care, a CNA, believing the resident was an assist of one based on the Kardex, rolled the resident away from herself while the bed was elevated, causing the resident to fall to the floor. Staff found the resident face down next to the elevated bed with a large right lower-leg laceration and pain, and EMS transported the resident to the hospital, where the wound required 24 sutures and internal drains. The facility’s investigation materials lacked the CNA’s reported written witness statement, and the DON acknowledged that staff failed to follow the care-planned two-person assist for bed mobility, resulting in the fall with injury.
A cognitively intact resident with insulin‑dependent DM and other chronic conditions experienced a significant medication error when an RN administered 52 units of short‑acting Novolog instead of the ordered long‑acting insulin, resulting in wrong medication and wrong strength/quantity. Family members reported that the resident was transferred to the hospital after this large dose of fast‑acting insulin, and facility documentation, including a medication error form, nurse progress note, and physician note, confirmed the mis‑administration. The DON acknowledged that a medication error had occurred, and later observation found the resident non‑verbal and non‑responsive with hospice services in place.
A resident with multiple diagnoses and a care plan requiring calm communication was subjected to profane and inappropriate language by a CNA, as confirmed by both the resident and a housekeeper. The CNA admitted to using inappropriate language in response to the resident, and the facility's investigation substantiated the verbal misconduct, resulting in a failure to honor the resident's right to dignity and respectful treatment.
A resident with multiple diagnoses, including Parkinson's Disease and mental health conditions, was present when a CNA was overheard using profane language in their room. The incident was reported internally but not reported to the State Agency within the required two-hour timeframe, with the delay confirmed by the NHA, who could not explain the late reporting.
Surveyors identified widespread failures in cleaning and maintenance throughout the facility, including soiled ventilation grills, damaged flooring, stained ceiling tiles, loose plumbing fixtures, and unaddressed work orders. These deficiencies affected 83 residents and were not documented in the facility's maintenance system, despite policies requiring daily cleaning and prompt repairs.
Surveyors found that medications were not consistently labeled or stored according to professional standards. A resident was found with a cup of pills left on the bedside table without assessment for self-administration, and a multi-dose inhaler was discovered on a medication cart without the required date of opening. Both the RN and DON confirmed these actions were not in line with facility policy.
Surveyors identified deficiencies in the cleaning and maintenance of food service equipment, as well as failures to properly date mark ready-to-eat food items. Multiple kitchen appliances and surfaces were found soiled with dust, dirt, and food residue, and some food products lacked required open or discard dates. These issues were observed during a kitchen tour and confirmed through interviews and policy reviews.
Surveyors found that two outdoor waste receptacles were not properly maintained and the surrounding concrete pad was not cleaned, with accumulated debris and damaged receptacle components observed. Facility policy required regular trash removal and cleanliness, but no related work orders were found. These deficiencies affected 83 residents.
A resident with multiple medical conditions and moderate cognitive impairment was prescribed Olanzapine, an antipsychotic, without being informed of the medication's benefits, risks, or alternatives. The social worker and DON confirmed that no consent documentation was present, and the resident was unable to state the reason for receiving the medication, despite facility policy requiring such information be provided before starting psychotropic drugs.
The facility did not promptly address or resolve multiple resident grievances, including missing clothing, inappropriate food options, and removal of privacy amenities. Grievance forms were incomplete and lacked resident signatures, and staff interviews confirmed ongoing issues with the grievance process and laundry procedures, resulting in unresolved concerns and resident frustration.
The facility failed to properly document and monitor the use of psychotropic medications for three residents, including missing or inconsistent diagnoses to support antipsychotic use, incomplete behavioral and side effect monitoring, unacknowledged pharmacy recommendations for dose reduction, and PRN antianxiety medication orders that exceeded regulatory time limits.
A resident with a history of repeated falls and multiple diagnoses experienced several falls over six months, some resulting in injury. Despite these incidents, the care plan was not consistently updated with new interventions, and staff discussions about the resident's needs were not reflected in the care plan documentation. This failure to revise the care plan led to the potential for further falls and unmet care needs.
The facility failed to provide adequate care for pressure ulcers, leading to the deterioration of wounds in two residents. One resident developed a Stage 2 pressure ulcer that worsened to an unstageable ulcer, resulting in hospitalization and surgery for osteomyelitis. The facility did not consistently follow the wound care plan, and incorrect treatments were administered. Another resident developed pressure sores, but the facility failed to document a wound assessment, notify the guardian, or order appropriate treatment. The care plans were not updated, and staff were unaware of the pressure injuries, leading to a lack of treatment.
The facility failed to administer medications according to physician-ordered parameters for three residents, leading to medication errors. A resident with heart disease received Metoprolol despite low blood pressure readings, another with atrial fibrillation was given Entresto without proper blood pressure checks, and a third with hypertension received Lisinopril without any blood pressure assessments. The DON confirmed these errors, which violated the facility's medication administration policy.
A resident reported being hit by a mechanical lift sling, resulting in welts, but the incident was not documented or investigated by the facility. The NHA considered it an accident and took no action against the CNA involved, despite the resident's report and photographic evidence of the injury.
A resident reported being hit by a mechanical lift sling, resulting in welts. The incident was not documented or reported by the NHA, who deemed it accidental. The CNA admitted to "goofing off" with the sling. The facility failed to prevent abuse and did not investigate or report the incident, leading to a deficiency citation.
Failure to Prevent Resident-to-Resident Physical Abuse and Administrator Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect one resident from physical abuse by another resident and another resident from verbal abuse by a staff member. One resident with multiple sclerosis and epilepsy, cognitively intact per a recent MDS, reported that approximately three weeks prior she was in the day room when another resident, who appeared intoxicated and had an open can of beer, choked her and then slapped her left arm hard enough to leave red marks. On the date of the incident, a RN passing medications just outside the day room heard a slap-like sound and the resident say “ouch,” then found the alleged aggressor in a wheelchair next to the resident and observed mild redness on the resident’s left upper arm. A CNA in the day room also heard a slapping noise and the resident call out, then turned and saw the alleged aggressor sitting next to her. The facility’s investigation substantiated resident-to-resident physical abuse based on the aggressor striking the resident’s left upper arm, though the choking allegation could not be substantiated. The resident alleged that the aggressor had been intoxicated and that he grabbed the front of her neck with one hand, making her unable to breathe, and then slapped her arm. The aggressor’s medical record showed moderate cognitive impairment on the BIMS, and he later acknowledged that he “smacked” the resident’s arm, stating he had been drinking beer at a family member’s house before being dropped off at the facility and did not remember the incident, but understood from others that it was an open-hand smack. The facility’s investigation documented that he appeared intoxicated at the time, had an open can of beer in his wheelchair, and had been watching the resident talk to another male resident, which he reportedly did not like, before approaching her. Staff present in or near the day room did not prevent the physical contact, and the abuse occurred in a common area while the aggressor was in possession of alcohol and visibly intoxicated. The deficiency also includes an incident of verbal abuse toward another resident by the former Nursing Home Administrator (NHA). This resident, with chronic diastolic heart failure, diabetes, and unspecified dementia and severe cognitive impairment per a recent MDS, was in his room with a wallet that staff believed belonged to another resident. During an attempt by staff, including the former NHA, Social Services Assistant, and Scheduler, to address the wallet issue, the resident became upset, hollering, swearing, and insisting the wallet and money were his. Multiple staff witnesses reported that the former NHA raised his voice, got in the resident’s face, pointed at him, and called him a “mother f**ker” after the resident swore at him, while the resident later recalled that the man involved swore and used “cussing words” toward him. The facility’s investigation determined that the wallet was in fact the resident’s, and staff accounts consistently described the former NHA’s use of profanity and raised voice toward the resident during the interaction.
Failure to Follow Bed-Mobility Care Plan Leads to Fall and Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety and to implement care-planned interventions during staff-assisted care, resulting in a resident falling from an elevated bed and sustaining a serious leg laceration. The resident was an older female with chronic heart failure, diabetes, morbid obesity, major depression, and anxiety disorder. Her MDS showed a BIM score of 11, indicating moderately impaired decision-making, and documented that she was dependent on staff for toileting, dressing, bathing, and rolling in bed. Her care plan, dated 1/2/26, specified that she had a functional ability deficit related to morbid obesity and weakness, and required a two-person assist for all aspects of bed mobility, including rolling side to side. On the morning of the fall, a CNA was providing incontinence care to the resident and rolled her away from herself while the bed was elevated to between knee and hip height. During this maneuver, the resident fell out of the bed to the floor and began screaming in pain. Another CNA and a nurse responded and observed the resident lying face down on the floor next to the elevated bed, with blood pooling under her right knee and a large open wound on her right lower leg. The resident complained of back and leg pain. Emergency services were called, and the resident was transported to the hospital, where she was treated for a significant laceration of the right lower leg requiring 24 sutures and placement of internal drains. Record review showed that the resident’s care plan required a two-person assist for bed mobility, but the CNA who provided care at the time of the fall believed the resident was an assist of one based on the Kardex and did not verify this information. The CNA reported that she had completed a written witness statement and was later educated to follow the Kardex and to roll residents toward, not away from, herself during care. However, the administrator and DON were unable to produce any written witness statements as part of the facility’s investigation, and the investigation materials provided did not include such documentation. The DON acknowledged that the facility failed to follow the care-planned interventions for two-person assist with bed mobility, which led to the resident’s fall with injury, and stated that staff were expected to follow care plans and Kardex and to roll residents toward themselves during in-bed care.
Significant Insulin Administration Error Involving Wrong Insulin Type and Dose
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for one cognitively intact resident with insulin‑dependent diabetes, anxiety, and depression. The resident’s daughter had submitted a complaint to the state alleging that insulin was not administered according to physician orders. Review of the resident’s records showed that the resident was hospitalized and not present in the facility at the time of survey. During interviews, the resident’s daughter and son both reported that the resident had been transferred to the hospital after receiving a large dose of fast‑acting insulin instead of the prescribed long‑acting insulin. The DON acknowledged that the resident had a medication error. Further review of the medical record and facility documentation confirmed that the resident was administered 52 units of Novolog (short‑acting insulin) instead of the ordered long‑acting insulin, constituting wrong medication and wrong strength/quantity. A nurse involved in the incident reported that the fast‑acting insulin was given in error in place of the long‑acting insulin and that this was reported to the DON. A nurse progress note documented that the resident returned from the emergency department with EMS, with EMS reporting that the resident’s blood glucose never dropped below 100 and the event was uneventful. A physician note documented that staff reported the resident had been transferred to the emergency department after mis‑administration of 52 units of short‑acting insulin. During a later observation, the resident was seen in bed, non‑verbal and non‑responsive to questions, with her son at the bedside and hospice services in place.
Failure to Treat Resident with Dignity and Respect Due to Staff Use of Inappropriate Language
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, who was cognitively intact and required two-person assistance with activities of daily living, was not treated with dignity and respect. The resident's care plan and Kardex specified that staff should approach and speak to the resident in a calm, quiet manner. However, the resident reported that a Certified Nursing Assistant (CNA) used obscene and inappropriate language during an interaction, including profanities and derogatory remarks. This incident was corroborated by a housekeeper who overheard the CNA loudly using profane language inside the resident's room. Further interviews confirmed that the CNA admitted to responding to the resident with inappropriate language after being called names by the resident. The facility's investigation substantiated that the staff member was verbally inappropriate in the presence of the resident. The incident demonstrated a failure to honor the resident's right to a dignified existence and respectful communication, as required by the resident's care plan and facility policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the State Agency for one resident. The resident, who was cognitively intact and had diagnoses including Parkinson's Disease, anxiety disorder, major depressive disorder, and post-traumatic stress disorder, was present in their room when a CNA was overheard by a housekeeper repeatedly using profane language directed at the resident. The housekeeper reported the incident to the housekeeping supervisor and the administrator. Although the incident occurred and was discovered in the early afternoon, it was not reported to the State Agency until over seven hours later, exceeding the required two-hour reporting timeframe. The Nursing Home Administrator confirmed the delay and was unable to provide an explanation for the late reporting.
Failure to Maintain Clean and Safe Physical Environment
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, impacting 83 residents. During environmental tours of various facility areas, surveyors observed multiple instances of unaddressed soiling, damage, and maintenance issues. These included missing or damaged cabinet components, soiled ventilation grills, stained and warped ceiling tiles, loose or damaged commode seats and supports, leaking plumbing, and soiled or damaged flooring. Additionally, equipment such as microwaves and box fans were found to be corroded or heavily soiled, and air filters in PTAC units were observed with accumulated dust and dirt. In several resident rooms, commode base caulking was found to be etched, scored, stained, or particulate, and some hand sinks were draining slowly or not at all. Interviews with the Director of Maintenance and Housekeeping Director revealed that while a work order system (TELS) was in place, many of the observed deficiencies had not been entered into the system or addressed. For example, missing flooring tiles in a janitor closet had been unaddressed since June 2022, and no work orders were found in the TELS system for the specific maintenance concerns identified during the survey. Staff acknowledged the issues when pointed out and indicated intentions to submit work orders, but these actions had not occurred prior to the survey. A review of the facility's housekeeping policy indicated that cleaning of non-carpeted floors and other horizontal surfaces should occur daily and more frequently if visibly soiled. However, the observations made during the survey demonstrated that these procedures were not consistently followed, as evidenced by the widespread presence of dust, dirt, stains, and damaged surfaces throughout both common and resident areas. The lack of effective cleaning and maintenance increased the likelihood of cross-contamination, bacterial harborage, and decreased air quality for residents, staff, and the public.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not consistently labeled and stored according to accepted professional standards. In one instance, a resident was found with a medication cup containing four to five pills left unattended on the bedside table for approximately 30 minutes while the resident was sleeping. The resident had not been assessed for self-administration of medications, and the Director of Nursing confirmed that residents were not permitted to self-administer medications. This indicates that staff failed to ensure medications were administered directly to the resident and not left at the bedside. Additionally, during a review of a medication cart, a multi-dose inhaler (Fluticasone Propionate Inhalation Aerosol 220 MCG) was found open and not dated as required by facility policy and professional standards. The Registered Nurse acknowledged that all medications should be dated when opened and could not explain why this was not done. The Director of Nursing also confirmed that it was expected practice to date all multi-dose medications upon opening, but could not account for the lapse in this instance.
Deficiencies in Food Service Equipment Sanitation and Date Marking
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations, specifically related to the cleaning and maintenance of food service equipment and the date marking of potentially hazardous ready-to-eat food products. During an initial tour of the kitchen, several pieces of equipment, including the Avantco 2-Door Reach-In Cooler and Vulcan convection ovens, were found with non-functional interior light bulbs. Additionally, the interior and exterior surfaces of refrigerators and ovens, as well as the can opener assembly, were noted to be soiled with accumulated and encrusted dust, dirt, and food residue. Overhead light lens covers, ceiling-mounted return-air-exhaust ventilation grills, and the mechanical dish machine ventilation hood were also observed to be heavily soiled with dust and debris. Further inspection revealed that food items such as a gallon of milk and a container of cottage cheese stored in the reach-in cooler were not properly date marked to indicate when they should be consumed or discarded, despite being open and held for more than 24 hours. The manufacturer's use-by dates were visible, but there was no effective open or discard date as required by the FDA Model Food Code. These findings were confirmed through interviews with the Dietary Director, who acknowledged the issues and indicated intentions to address them. Record reviews of the facility's policies and procedures for dietary cleaning, sanitation, and food handling confirmed that the facility is required to maintain kitchen sanitation and comply with time and temperature requirements to prevent foodborne illness. However, the observed conditions did not align with these policies, as equipment and non-food contact surfaces were not kept clean, and proper food handling techniques, such as date marking, were not consistently followed.
Improper Maintenance and Cleaning of Outdoor Waste Receptacles
Penalty
Summary
Surveyors observed that the facility failed to properly maintain two out of three outdoor waste receptacles and did not clean the concrete pad surface where the receptacles were located. Specifically, accumulated dirt and debris, including paper products, plastic bottles, a plastic milk crate, and a wooden pallet, were present on the concrete pad. Additionally, one of four receptacle plastic lids was missing, and one of four receptacle slider panels was broken, with a hole measuring approximately 6 inches by 6 inches. Review of facility policy indicated that trash should be removed on a specific schedule and the area surrounding the dumpster kept free of debris. However, a review of work orders for the past 180 days showed no entries related to maintenance or cleaning of the outdoor waste receptacles or the concrete pad surface. These deficiencies affected 83 residents.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including chronic kidney disease, bipolar disorder, and depression, was prescribed Olanzapine, an antipsychotic medication, without being informed of the associated benefits, risks, or alternatives. The resident had a moderate cognitive impairment, as indicated by a BIMS score of 12 out of 15. Review of the medical record showed no documentation of consent or evidence that the resident or their responsible party had been provided with information regarding the use of Olanzapine. Interviews with facility staff revealed that the social worker was responsible for ensuring that residents or their representatives received and signed consent forms for psychotropic medications. However, the social worker was unable to provide any documentation of consent for this resident, and the DON confirmed that no such consent was present in the medical record. The resident was also unable to explain why they were receiving the antipsychotic medication. Facility policy required that residents and/or their representatives be informed of the benefits, risks, and alternatives before initiating or increasing psychotropic medications, but this procedure was not followed in this case.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to act promptly on grievances reported during resident council meetings and did not provide adequate responses to grievances for six of nine residents, as evidenced by a review of resident council meeting minutes and grievance forms. Concerns and complaints, such as missing clothing, inappropriate food options, and removal of a phone that provided privacy, were repeatedly documented over several months without resolution or proper documentation indicating that the issues had been addressed. Grievance forms were found to be incomplete, lacking documentation of resolution and resident signatures to confirm satisfaction with outcomes. Residents expressed ongoing frustration during council meetings, reporting that missing clothing issues persisted for weeks or months, with some residents observing others wearing their clothes and staff failing to act when notified. Additional concerns included being served food that did not meet dietary needs or preferences, repeated offering of undesirable alternatives, and the removal of a phone that previously allowed for private conversations. Multiple residents reported receiving cold food, sour milk, and food they were allergic to, with all nine residents at the meeting sharing that their grievances remained unresolved. Interviews with facility staff revealed a lack of consistent follow-through in the grievance process. The Activity Director and other staff described the process for handling grievances but acknowledged that forms were not always completed fully or signed by residents to indicate satisfaction. The Housekeeping Director detailed ongoing issues with the laundry process, including improper labeling of clothing and incomplete personal item lists, which contributed to the unresolved complaints about missing clothing. Despite these issues being discussed in daily meetings, no changes had been made to address the underlying problems.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper documentation and monitoring for the use of psychotropic medications for three out of five residents reviewed. For one resident with dementia and depression, Risperidone was prescribed without a documented allowable diagnosis to support its use, and the diagnosis of 'depression with psychotic features' was not consistently reflected in the medical record or on the active diagnoses list. The resident's care plan and behavioral documentation were incomplete, and not all possible side effects listed in the informed consent were included on the treatment administration record for staff monitoring. Additionally, a pharmacy recommendation for a gradual dose reduction (GDR) of Risperidone was not acknowledged or acted upon by the physician, and there was a lack of clear process ownership for monitoring psychotropic medications among staff. Another resident received multiple PRN (as needed) orders for Ativan, an antianxiety medication, with durations exceeding the regulatory 14-day limit for PRN antianxiety medications. These orders were not appropriately limited or reviewed within the required timeframe, indicating a failure to comply with federal regulations regarding the use of PRN psychotropic medications. A third resident was prescribed both an antipsychotic (Olanzapine) and an antidepressant (Trazodone) without corresponding physician orders for monitoring side effects. The Director of Nursing confirmed that monitoring for side effects should have been ordered and documented, but could not provide evidence that this was done. The facility's policy required monitoring for efficacy, side effects, and adverse consequences of psychoactive medications, but this was not followed for the resident in question.
Failure to Revise Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was revised to address the ongoing care needs of a resident with a history of repeated falls. The resident, who had diagnoses including repeated falls, diabetes, left hip pain, bipolar disorder, and dementia, experienced eight falls over a six-month period. Despite multiple incidents, including falls in the bathroom and bedroom, care plan interventions were either not updated or only minimally addressed, such as ensuring toileting after meals or applying anti-rollback bars to the wheelchair. Several falls resulted in injuries, including a 3 cm abrasion above the left eyebrow and a laceration with a knot, yet no new care plan interventions were implemented following these events. Interviews with staff revealed that the resident often attempted to self-transfer, leading to falls, and that while incidents were discussed in daily meetings, these discussions did not result in updates to the care plan. The care plan was not consistently revised to reflect the resident's changing needs or to implement new interventions after each fall. Documentation showed that recommendations, such as transferring the resident to the unit dayroom with nursing staff, were discussed but not added to the care plan or put into practice. This lack of timely and comprehensive care plan revision resulted in the potential for additional falls and unmet care needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure injuries, leading to the deterioration of wounds and subsequent hospitalization. Resident #1, a cognitively intact male with Type II Diabetes and other health issues, developed a Stage 2 pressure ulcer on his left heel during his stay. Despite initial improvement, the wound care plan was not consistently followed, and incorrect treatments were administered. The wound deteriorated to an unstageable pressure ulcer, and the resident was hospitalized with osteomyelitis, requiring surgical intervention. Resident #6, a cognitively intact female with muscle weakness and morbid obesity, was found to have a pressure sore on her left thigh and a new red spot on her right buttock. The facility failed to document a wound assessment, notify the guardian, or order appropriate treatment upon identification of the pressure injury. The resident's care plan was not updated with necessary interventions, and the staff was unaware of the pressure injuries, leading to a lack of treatment. The facility's failure to adhere to professional standards of practice for pressure ulcer care resulted in the worsening of residents' conditions. The care plans were not revised to reflect changes in the residents' skin conditions, and the necessary notifications and treatments were not completed. This lack of appropriate care and communication contributed to the deterioration of the residents' pressure injuries.
Medication Administration Errors Due to Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician-ordered parameters for three residents, resulting in medication errors. Resident #7, a male with heart disease and hypertension, received Metoprolol despite blood pressure readings that were below the prescribed parameters on multiple occasions. Additionally, there were instances where his blood pressure was not assessed prior to medication administration, relying instead on outdated readings. Resident #8, a male with atrial fibrillation, was administered Entresto even when his blood pressure readings were below the ordered parameters, and on some occasions, his blood pressure was not assessed before medication administration. Resident #10, a female with hypertension, received Lisinopril throughout June without any blood pressure assessments to ensure compliance with the ordered parameters. The Director of Nursing confirmed that medications for these residents were administered outside of parameters or without necessary vital sign assessments. The facility's policy on medication administration, last revised in April 2019, requires that medications be administered in accordance with prescriber orders, including any necessary vital sign checks. The failure to adhere to these protocols led to the administration of medications without verifying that the residents' vital signs were within the prescribed limits, contributing to the cited deficiencies.
Failure to Prevent and Investigate Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse and did not adequately protect residents or investigate allegations, leading to the potential for continued abuse. A resident, who was cognitively intact, reported being hit on the back by a mechanical lift sling, resulting in welts. The incident was witnessed by others, and the resident had photographic evidence of the injuries. Despite the resident reporting the incident to the Nursing Home Administrator (NHA), it was not documented or addressed in the medical record. The NHA did not report the incident, considering it an accident rather than abuse, and took no disciplinary action against the involved CNA. The CNA admitted to goofing off with the mechanical lift sling, which led to the resident being hit. The NHA acknowledged discussing the incident with the resident, who expressed that the hit was painful but did not want to get anyone in trouble. The lack of documentation and failure to report or investigate the incident contributed to the deficiency.
Failure to Report and Investigate Staff-to-Resident Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident abuse and did not properly investigate or report the incident to the state agency. A resident, who was cognitively intact, reported being hit on the back by a mechanical lift sling, which left welts. The incident occurred when a CNA was "goofing off" with the sling, and the resident reported it to the Nursing Home Administrator (NHA) two weeks later. Despite the resident showing photographic evidence of the injury, the incident was not documented in the medical record. The NHA did not report the incident, believing it was an accident and not intentional abuse. The NHA also did not take any disciplinary action against the CNA involved, nor did he educate staff on the incident. The CNA admitted to "goofing off" with the sling, which led to the resident being hit. The NHA acknowledged discussing the incident with the resident, who expressed that the hit was painful but did not want to get anyone in trouble. The lack of documentation and failure to report the incident resulted in a deficiency citation for the facility.
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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