Autumnwood Of Mcbain
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcbain, Michigan.
- Location
- 220 South Hughston Street, Mcbain, Michigan 49657
- CMS Provider Number
- 235438
- Inspections on file
- 20
- Latest survey
- May 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumnwood Of Mcbain during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was admitted for respite care and experienced a significant medication error when their Carbidopa/Levodopa and Levothyroxine orders were transposed, leading to multiple overdoses of Levothyroxine. The error was not identified or corrected by nursing or medical staff, resulting in the resident's rapid decline, severe adverse effects, and eventual death.
A resident with multiple chronic conditions was admitted for respite care and experienced a significant medication error when Carbidopa/Levodopa and Levothyroxine orders were transposed during admission. The resident received excessive Levothyroxine doses and insufficient Carbidopa/Levodopa due to improper transcription and lack of a documented double-check by nursing staff. The error persisted for several days, leading to severe adverse effects and a marked decline in the resident's condition, ultimately resulting in death after discharge.
A resident with multiple chronic conditions was admitted and received an incorrect, excessive dose of Levothyroxine due to a transcription error and lack of verification by nursing staff. Despite abnormal symptoms and vital signs, staff did not question the unusual dosing frequency or check the original orders, resulting in the resident receiving five times the intended dose for several days and a significant decline in their condition.
Inadequate staffing at the facility resulted in residents being left in soiled conditions and experiencing long wait times for assistance. One resident with a leaking colostomy bag was not attended to promptly, while another waited 30 minutes for repositioning. Staff shortages, particularly during weekends and evening shifts, contributed to these deficiencies, as confirmed by staff and resident interviews.
The facility failed to store food according to professional standards, with expired and undated items found during a kitchen tour. Issues included wilted cabbage, rotten potatoes, a broken egg, moldy tomatoes, and exposed vegetarian patties. Additionally, hot dogs had an unclear use-by date. Damaged cabinetry near an ice machine was also noted, with past leakage issues confirmed. These deficiencies risked foodborne illness among 89 residents.
The facility failed to maintain functioning exhaust ventilation in resident bathrooms on the 300 Hall, affecting 19 residents. Noxious odors were noted, and an investigation revealed non-functioning exhaust systems in several rooms due to a broken belt on the motors. Maintenance checks were not conducted as required by facility policy.
The facility failed to provide dignified care to five residents, leading to feelings of frustration and low self-worth. A resident with a leaking ostomy bag was left soiled, another waited 30 minutes for repositioning assistance, and a third waited 27 minutes for bathroom help. Two residents with severe cognitive impairments faced undignified dining conditions, with one left out of reach of their meal. The DON acknowledged these issues, attributing them to staff behavior during the survey.
The facility failed to provide adequate ADL care for six residents, including assistance with personal hygiene and incontinence care. Residents were found soiled, unkempt, and without necessary grooming, with staff expressing being overwhelmed due to inadequate staffing. The facility's policy on regular checks and changes was not followed, leading to deficiencies in resident care.
The facility failed to provide appropriate respiratory care, including incorrect oxygen flow rates and lack of physician orders for some residents. Respiratory equipment was not properly maintained or stored, with nebulizers left uncleaned and undated. Some residents received oxygen therapy without documented physician orders, indicating systemic issues in respiratory care management.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.4% error rate. An LPN improperly broke an extended-release tablet for a resident with osteoarthritis, and an RN administered eye drops to a cognitively impaired resident without proper instruction. The DON confirmed the errors, which violated the facility's medication administration policy.
The facility failed to manage medication storage and labeling, resulting in expired and improperly dated medications on two medication carts. On the Maple Lane cart, a Novolin R FlexPen with an illegible date and expired Ibuprofen were found, while the Ivy Lane cart contained expired acetaminophen, nitroglycerin tablets, and undated Albuterol inhalers. The DON admitted the lack of a specific policy for medication dating and labeling, relying on a general policy and an undated document for guidance.
The facility failed to serve meals at appropriate temperatures, affecting two residents and the majority of a group meeting. Meals were delivered from the kitchen in an insulated cart, but food temperatures were below standard, with pancakes and scrambled eggs served at 98 to 106 degrees Fahrenheit. Residents reported dissatisfaction, with some resorting to ordering takeout. Despite attempts to address the issue, such as sending meals in waves, the problem persisted due to staffing challenges.
The facility failed to follow proper infection control practices during meal service and medication administration. A CNA delivered meal trays without hand hygiene or changing gloves, and contaminated ice was used. A resident with respiratory issues received medication via a nebulizer that was not properly cleaned. The medication cart was unsanitary, with personal items and uncovered food. Infection control policies were outdated, and corporate is responsible for updates.
A resident with a below-knee amputation and cerebral palsy was discharged from a facility to a hotel for three nights without a long-term plan, resulting in unsafe living conditions. The resident required wound care and one-person assistance but was discharged without necessary support or supplies. Facility staff were unaware of the resident's situation post-discharge, failing to follow the policy for a safe and orderly discharge.
The facility failed to provide written notification to two residents and/or their representatives regarding their transfer to an acute care facility. One resident with vascular dementia and acute kidney failure was hospitalized due to low blood pressure, while another with coronary artery disease, heart failure, and COPD was transferred due to septic shock and respiratory failure. The facility's policy requires written notice, but the DON stated that notification was done verbally unless an appeal was requested.
The facility failed to provide written bed hold notifications to two residents during hospital transfers. One resident with vascular dementia and acute kidney failure was hospitalized, and a blank Bed Hold Authorization form was uploaded to their EMR. Another resident with coronary artery disease and COPD was transferred due to septic shock, but there was no evidence of receipt of the bed hold policy. The facility's policy required written notification, but lacked a procedure to ensure compliance.
The facility failed to develop and implement comprehensive care plans for two residents with ostomy care needs, leading to potential unmet care needs. One resident was observed with a leaking ostomy bag due to a lack of specific care plan directives, while another resident experienced frequent leaks from an ileostomy bag without proper staff guidance on care frequency. The facility's policy on individualized interventions was not adequately followed.
A resident with COPD, Parkinson's, and an amputation was observed eating in a wheelchair angled away from the table, causing discomfort and difficulty in eating. The wheelchair was purposely dumped as a fall intervention, despite the resident's complaints and the risk of aspiration noted by the SLP. The facility's policy on resident rights was not upheld as the resident's preferences and comfort were not addressed.
A resident with a history of diabetes and amputation developed a stage three pressure ulcer due to inadequate interventions and care. Despite being at high risk, the facility failed to update wound care orders or provide sufficient incontinence care and repositioning. Observations revealed improper wound cleaning and reuse of a dirty sock, contrary to the facility's skin management policy.
A resident with COPD and nicotine dependence was found with cigarettes and a lighter, despite the facility's non-smoking policy. The resident, who used oxygen at night, was observed smoking outside the facility. Staff interviews revealed no smoking safety assessment was conducted due to the facility's non-smoking status, and the resident frequently signed out to smoke. This failure to enforce the policy and secure smoking materials led to the deficiency.
The facility failed to administer pneumococcal vaccinations to three residents despite having signed consents from their guardians. An interview with the Infection Preventionist/RN revealed a recent change in the vaccination offering process, now conducted quarterly. However, the facility's policy required vaccinations for residents over 65, and the oversight was identified during a record review.
A facility failed to train a non-licensed employee, Activities Aide B, with the State-approved course for feeding assistance. During a breakfast observation, the aide was seen feeding a resident requiring a mechanical soft diet, despite not being certified or trained. The DON confirmed only CNAs should provide such assistance, and the facility lacked paid feeding assistants. The aide's file showed no certification or training, and the job description did not include feeding duties, increasing the risk of feeding complications.
The facility failed to employ sufficient staff with the appropriate competencies in food and nutrition services. Observations revealed improper food temperature checks and incorrect portion sizes. Resident interviews highlighted complaints about small portions and poor food quality, indicating a lack of proper training and oversight.
The facility failed to provide written bed hold notices to five residents or their representatives during hospital transfers, as required by policy. The deficiency was confirmed through interviews and record reviews, revealing that notifications were made verbally over the phone without obtaining necessary signatures.
A resident with multiple diagnoses was discharged without a recapitulation of stay or discharge plan documented in their EMR. The Social Service Director and DON confirmed the omission, mistakenly believing it was unnecessary for transfers to another skilled nursing facility, contrary to the facility's discharge planning policy.
Failure to Review and Verify Medication Orders Results in Severe Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician properly reviewed and verified medication orders for a resident admitted with multiple complex diagnoses, including cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease. Upon admission, the resident's medication orders for Carbidopa/Levodopa and Levothyroxine were transposed, resulting in the resident receiving incorrect dosages and frequencies of both medications. The error was not identified or corrected by the admitting nurse, the physician assistant, or the physician, despite documentation indicating that the medication orders were outside the recommended dosing regimen and pending confirmation. The resident, who was ambulatory and able to care for themselves upon admission, experienced a significant decline during their stay. The medication administration record showed that the resident received multiple extra doses of Levothyroxine over several days, totaling 2800 mcg within a 96-hour period. Progress notes and interviews revealed that the resident became confused, disoriented, unable to ambulate, and exhibited signs consistent with thyroid storm, such as elevated temperature, tachycardia, and altered mental status. Family members and the medical examiner confirmed the resident's rapid deterioration and the facility's admission of the medication error. The review of the resident's records indicated that the transcription error was made by the RN/Unit Manager and confirmed by the same nurse. The physician assistant noted the need to confirm the dosing but did not discontinue or correct the erroneous orders. The medical director stated that the physician assistant should have changed the orders and that the pharmacist and nursing staff should have recognized the error, as Levothyroxine is typically administered once daily in the morning. The failure to properly review, verify, and correct the medication orders directly resulted in the resident's severe adverse effects and subsequent death.
Failure to Accurately Transcribe and Double-Check Admission Medications Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a newly admitted resident's medications were incorrectly transcribed and not properly double-checked according to facility procedures. The resident, who had a history of cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease, was admitted for respite care and was ambulatory and alert at the time of admission. The hospital discharge orders specified Carbidopa/Levodopa to be given five times daily and Levothyroxine once daily, but these frequencies were transposed during the admission process. As a result, the resident received Levothyroxine five times daily and Carbidopa/Levodopa only once daily. Multiple staff interviews and record reviews revealed that the medication orders were entered by a unit manager and were supposed to be double-checked by a second nurse, but there was no documentation or confirmation that this double-check occurred. Several nurses and the pharmacist involved in the process either assumed the orders were correct or did not verify the original admission paperwork. The error persisted for several days, with the resident receiving excessive doses of Levothyroxine, totaling 2800 mcg over a 96-hour period. The facility's process lacked a formal policy or checklist for verifying new admission medication orders, and staff relied on informal practices that failed to prevent the error. The resident's condition deteriorated during the stay, with documented confusion, fever, tachycardia, and lethargy. The error was eventually discovered after the resident exhibited significant changes in condition, including increased confusion and abnormal vital signs. The facility's medical staff and hospice personnel confirmed that the medication error led to a thyroid storm, and the resident was discharged in a significantly worsened state, ultimately passing away at home shortly after discharge. The facility's documentation and interviews confirmed that the medication transcription error was not identified or corrected in a timely manner, and the required verification steps were not properly followed.
Failure to Identify and Correct Harmful Medication Dosing Error
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in medication administration, resulting in a resident receiving harmful doses of thyroid medication. Upon admission, the resident had multiple diagnoses, including cirrhosis, diabetes mellitus, hypertension, hypothyroidism, and Parkinson's disease. The resident was ambulatory and able to care for themselves at the time of admission. However, due to a transcription error, the frequencies for Carbidopa/Levodopa and Levothyroxine were switched, leading to the resident receiving five times the prescribed dose of Levothyroxine for several consecutive days. Nursing staff did not identify the incorrect dosing parameters or recognize the resulting side effects. Progress notes indicated that the resident became confused, febrile, tachycardic, and lethargic, with abnormal vital signs and a need for oxygen. Despite these symptoms and the fact that the medication orders exceeded the usual dosing regimen, staff assumed the orders were correct, particularly because the resident was on hospice care. Interviews with nursing staff revealed that they did not verify the medication orders against the admission paperwork or question the unusual dosing frequency, instead relying on the assumption that the orders had been entered correctly. The facility's policy required nurses to verify medication labels against the medication administration record and to resolve any discrepancies before administering medication. However, this procedure was not followed, and the resident received a total of 2800 mcg of Levothyroxine within a 96-hour period. The resident's condition deteriorated significantly during their stay, and they expired at home the day after discharge from the facility.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, resulting in significant deficiencies in care. Multiple residents were left in soiled conditions for extended periods due to insufficient staff availability. For instance, one resident with a leaking colostomy bag was not attended to promptly, leading to soiling of the bed and clothing. The resident reported that staff were unable to change the bag during the night and had to wait until after breakfast service for assistance. This situation was exacerbated by a staff shortage due to a call-in, as confirmed by a registered nurse. Another resident activated their call light for assistance with repositioning in bed, but the call went unanswered for 30 minutes. During this time, staff were observed attending to other duties, such as meal service, indicating a lack of available personnel to address immediate resident needs. Similarly, another resident waited 27 minutes for assistance to use the bathroom, during which time they expressed discomfort and urgency. The delay was attributed to staff being occupied with other residents and a lack of coverage during staff lunch breaks. The report also highlights systemic issues with staffing levels, particularly on weekends and during evening shifts. The facility's staffing data revealed instances where the number of CNAs on duty was insufficient to meet the needs of the resident population, leading to delays in care and unmet needs. Interviews with staff and residents further corroborated these findings, with reports of long wait times for assistance and inadequate response to call lights. The facility's policies on staffing and care were not effectively implemented, contributing to the observed deficiencies.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during an initial kitchen tour. Expired and undated food items were found, including wilted cabbage, rotten potatoes, a broken raw egg, moldy cherry tomatoes, and undated vegetarian burger patties exposed to the environment. Additionally, hot dogs were found with an unclear use-by date. Culinary Aide W acknowledged the need for proper labeling and sealing of food items, while Dietary Manager Y confirmed that all foods should be labeled with a use-by date and discarded accordingly. The presence of visibly spoiled food and broken eggs was also noted as requiring immediate disposal. Furthermore, the cabinetry surrounding an ice machine in the main dining room was observed to be damaged and rotted, with Maintenance Director I confirming past issues with the ice machine leaking. The damaged cabinetry was acknowledged as needing replacement. These deficiencies in food storage and equipment maintenance had the potential to result in foodborne illness among the 89 residents in the facility, as per the FDA 2022 Food Code requirements.
Exhaust Ventilation Failure in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the exhaust ventilation system was functioning in resident bathrooms on the 300 Hall, affecting 19 out of 89 residents. This deficiency was identified through observations of noxious odors permeating the hall on two consecutive days. An investigation revealed that the exhaust systems in several bathrooms were not creating adequate negative pressure, as evidenced by a paper towel test. The rooms affected included 302, 303/304, 305, 306, 307/308, and 309. Interviews with the Maintenance Director and Maintenance Assistant revealed that the exhaust system motors were checked monthly, but the last check was reportedly conducted earlier in the month. The Maintenance Assistant discovered a broken belt on the motors responsible for the 300 Hall's exhaust ventilation, which had not been addressed since November due to the winter season. The facility's policy on maintenance requires the Maintenance Department to ensure proper functioning of ventilation systems, but this was not adhered to, leading to the deficiency.
Failure to Provide Dignified Care
Penalty
Summary
The facility failed to provide dignified and respectful care to five residents, resulting in feelings of frustration, humiliation, and low self-worth. Resident #37, who was cognitively intact, experienced a leaking ostomy bag that was not changed overnight, leading to soiled bedding and clothing. Despite the resident's request for assistance, staff delayed cleaning until after breakfast, leaving the resident in an undignified state. The facility's records did not indicate any refusal of care by the resident, contradicting staff claims. Resident #51, with mild cognitive impairment, activated the call light for assistance to reposition in bed. Despite the call light being illuminated and audible at the nurse's station, staff did not respond for 30 minutes, during which the resident was unable to eat comfortably. Similarly, Resident #7, with moderate cognitive impairment, activated the call light for assistance to use the bathroom. The resident waited 27 minutes for assistance, during which time staff failed to communicate the resident's needs to others before leaving the unit. Residents #38 and #2, both with severe cognitive impairments, were subjected to undignified dining conditions. Resident #38 was seated at a table with soiled meal trays and cups, while Resident #2 was placed out of reach of their meal and left without assistance. Despite attempts to reach the meal, Resident #2 was not aided by staff, resulting in spilled food. The Director of Nursing acknowledged the issues, noting that staff were not acting as usual due to the presence of surveyors and that housing soiled items on dining tables was unacceptable.
Inadequate ADL Care and Staffing Issues
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for six residents who required assistance with personal hygiene and incontinence care. Resident #35, who had severe cognitive impairment and required substantial assistance, was found soiled in urine and had not been checked on since 8:00 AM, despite being observed needing help at 11:56 AM. Similarly, Resident #36, also with severe cognitive impairment, was observed with unkempt hair, indicating a lack of assistance with personal grooming. Resident #42, who required total assistance for toileting and was frequently incontinent, was found lying in a urine-saturated soaker pad, causing skin irritation. The CNA responsible for their care had not checked on them since 3:00 AM, and the resident was left in this state until after breakfast. The CNA expressed being overwhelmed due to inadequate staffing, as they were the only CNA on duty with no additional help available. Resident #48, who required total assistance and was always incontinent, was also found in a similar state with a soiled soaker pad and bed sheets, and had not received care since the CNA's shift began at 7:00 AM. Resident #65, who required moderate assistance with personal hygiene, was observed with visible whiskers on her chin, indicating a lack of grooming. Resident #81, with severe cognitive impairment, was seen with disheveled and greasy hair, further highlighting the facility's failure to provide necessary ADL care. The facility's policy on ADL care, which includes regular checks and changes every two hours, was not adhered to, contributing to the deficiencies observed in the care of these residents.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by the lack of physician orders and improper administration of oxygen at prescribed flow rates. For instance, Resident #243 was observed with oxygen set at incorrect flow rates on multiple occasions, contrary to the physician's order of 2 LPM. Additionally, the portable oxygen tank was found empty, failing to provide the necessary supplemental oxygen. The facility's records inaccurately documented the administration of oxygen at the prescribed rate, and there were no orders allowing for adjustments in the flow rate. The facility also failed to ensure proper maintenance and storage of respiratory equipment. Several residents, including Resident #43 and Resident #88, had nebulizer equipment that was not stored with a barrier, was not dated, and was not cleaned appropriately after use. The nebulizer equipment was left assembled and exposed, increasing the risk of contamination. The Director of Nursing confirmed that nebulizers should be disassembled, rinsed, and stored in a bag, which was not adhered to in these cases. Furthermore, some residents were receiving oxygen therapy without a physician's order, such as Resident #3 and Resident #245. The facility did not have documented orders for these residents to receive supplemental oxygen, yet they were observed using oxygen concentrators. This lack of proper documentation and adherence to physician orders indicates a systemic issue in the facility's management of respiratory care, potentially compromising resident safety and care quality.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.4% error rate. This deficiency involved two residents. Resident #11, who was admitted with a primary diagnosis of osteoarthritis, had a physician's order for Tylenol 8 Hour Arthritis Pain Extended Release tablets. On a specific date, an LPN was observed breaking the extended-release tablet in half before administering it to the resident, contrary to the instructions that the tablet should be swallowed whole. The LPN justified the action by stating that the resident could not take a whole tablet. Resident #26, residing in a secured unit for cognitively impaired individuals and diagnosed with glaucoma, had a physician's order for Timolol Maleate Ophthalmic Solution. During medication administration, an RN was observed administering the eye drops in a dining room with other residents present, without instructing or assisting the resident to hold the lacrimal ducts to ensure proper absorption. The Director of Nursing confirmed that extended-release tablets should not be broken and did not provide a response regarding the proper administration of eye drops. The facility's policy on medication administration emphasizes accurate, safe, and sanitary practices, which were not adhered to in these instances.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage and labeling, leading to the presence of expired and improperly dated medications on two of the three medication carts reviewed. On the Maple Lane medication cart, a Novolin R FlexPen was found with an illegible date, and it was confirmed by an LPN that it was expired and needed disposal. Additionally, a bottle of ciprofloxacin eye drops was found with conflicting dates, raising concerns about its validity. An expired bottle of Ibuprofen was also discovered, and the LPN acknowledged the need for replacement. The LPN indicated that only certain medications, such as eye drops, insulins, and inhalers, were expected to be dated when opened. On the Ivy Lane medication cart, expired liquid acetaminophen and nitroglycerin sublingual tablets were found, along with three undated inhalers of Albuterol. The RN responsible for this cart confirmed the need to reorder these medications. The Director of Nursing admitted the absence of a specific policy for dating and labeling medications, relying instead on a general medication management policy and a document listing medications with shortened expiration dates. This document was used by nurses to determine the timeframe for using opened medications, but it was undated and not formally integrated into the facility's procedures.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable and appetizing temperature, affecting two specific residents and the majority of residents in a confidential group meeting. Observations revealed that meal trays were delivered from the main kitchen in an insulated cart, but the food temperatures were below the desired levels. For instance, pancakes and scrambled eggs were served at temperatures ranging from 98 to 106 degrees Fahrenheit, which is below the standard for hot foods. An Activities Aide reported that residents often complained about receiving cold meals, and the facility attempted to mitigate this by sending meals in waves, but staffing issues hindered timely delivery. Interviews with residents highlighted ongoing dissatisfaction with meal temperatures. One resident reported consistently receiving unappetizing meals due to cool temperatures and resorted to ordering takeout. Another resident confirmed the issue, stating that food temperatures were a frequent topic of concern in group meetings. Despite improvements in meal variety, the temperature issue persisted. During a confidential group meeting, eight out of nine residents expressed that meals were consistently served at unpalatable temperatures, with hot foods often arriving cool or cold. These concerns had been previously communicated to the Dietary Manager, but the problem remained unresolved.
Infection Control Deficiencies in Meal Service and Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during meal service and medication administration. Certified Nurse Aide (CNA) FF was observed delivering meal trays without performing hand hygiene or changing gloves between residents. Additionally, CNA FF handled a can of soda pop that had fallen into an ice chest with an ungloved, unwashed hand, and the contaminated ice was subsequently used by an Activities Aide. The facility's hand hygiene policy, effective 10/11/23, mandates hand hygiene before and after resident contact, which was not followed in these instances. Resident #88, who was admitted with acute respiratory failure and pneumonia, received medication via a nebulizer that was not properly cleaned or stored. Licensed Practical Nurse (LPN) O administered medication without assisting the resident with oral care or cleaning the nebulizer mouthpiece, which had been left on a bedside stand without a barrier. The nebulizer was not disassembled or rinsed as per the facility's procedure, which requires rinsing with sterile or distilled water and air drying. The facility's medication cart was also found to be unsanitary, with personal items and uncovered food containers placed on it. Registered Nurse (RN) A was observed drinking from a mug and placing it on the cart, alongside a cellular phone and an uncovered pudding container. The Director of Nursing confirmed that personal items should not be on medication carts and that hand hygiene is expected between resident interactions. Additionally, several infection control policies were outdated, with the Nursing Home Administrator and Infection Preventionist confirming that corporate is responsible for updating these policies annually.
Inadequate Discharge Planning for Resident with Amputation and Cerebral Palsy
Penalty
Summary
The facility failed to ensure a safe community discharge for a resident with a below-knee amputation and cerebral palsy, resulting in fear, distress, and feelings of helplessness. The resident was discharged to a hotel for three nights, paid by the facility, without a long-term discharge plan. The resident's insurance was supposed to cover his stay through October 2025, but the facility stated he no longer met the criteria for an insured stay. After the hotel stay, the resident had no place to go and ended up in a family member's travel trailer, which was not accessible for his wheelchair, leading to falls and further complications. The resident's medical record indicated he required wound care for his surgical site, but no formal wound care training or supplies were provided upon discharge. Interviews with facility staff revealed a lack of communication and planning for the resident's long-term accommodation needs. The Nursing Home Administrator and Director of Nursing were unaware of the resident's living situation after the hotel stay and did not provide adequate support or resources for his transition. The facility's policy on transfer and discharge requires sufficient preparation and orientation to ensure a safe and orderly discharge, which was not followed in this case. The resident's discharge plan indicated he needed one-person assistance for transfers, toileting, and bathing, yet he was discharged without the necessary support. The facility's actions and inactions led to the resident living in unsafe conditions without proper care or resources.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reason for their transfer to an acute care facility. This deficiency was identified for two residents. Resident #6, who was admitted with vascular dementia and acute kidney failure, was hospitalized due to low blood pressure. The facility's document titled 'Facility-Initiated Transfer for Nursing Homes' did not indicate a date of notification to the resident or guardian, nor did it have a signature. The Director of Nursing (DON) stated that the notification process involved verbal communication via telephone rather than written notice. Similarly, Resident #51, who had coronary artery disease, heart failure, and COPD, was transferred to the emergency room due to septic shock and acute hypoxic respiratory failure. The facility's transfer document noted the reason for transfer but lacked a signature from the resident or representative acknowledging receipt. The DON reported that written notice is only provided if an appeal is requested, and the reason for transfer and appeal rights are documented in the medical record. The facility's policy requires written notice of transfer or discharge, except in emergencies, where notice should be provided as soon as practicable.
Failure to Provide Written Bed Hold Notifications
Penalty
Summary
The facility failed to provide written notification of bed hold policies to two residents or their representatives during hospital transfers. Resident #6, who was initially admitted with vascular dementia and acute kidney failure, was hospitalized from November 19 to November 26, 2024. Although a blank Bed Hold Authorization form was uploaded to the resident's electronic medical record, the Business Office Manager confirmed that it was not the facility's practice to provide written notifications or obtain signatures, relying instead on verbal communication. Similarly, Resident #51, admitted with coronary artery disease, heart failure, and COPD, was transferred to the hospital on January 9, 2025, due to septic shock and acute hypoxic respiratory failure. The facility's transfer document indicated that the bed hold policy was included, but there was no evidence of the resident's or representative's receipt of this information. The facility's policy required written notification during admission and within 24 hours of hospital transfer, but it lacked a procedure to ensure this was done at the time of transfer.
Deficiency in Comprehensive Care Planning for Ostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents with ostomy care needs, resulting in potential unmet care needs. Resident #37, who is cognitively intact and dependent on staff for activities of daily living, was observed with a leaking ostomy bag that was not being checked or emptied regularly as per any documented care plan directives. The resident's care plan lacked specific interventions regarding the frequency of checking and emptying the ostomy bag, as well as measures to address the frequent leakage issues. Similarly, Resident #12, who has moderate cognitive impairment and is dependent on staff for personal hygiene, reported frequent leaks from his ileostomy bag due to the facility using different supplies than he was accustomed to. The resident's care plan did not reflect the change in his ability to manage his ileostomy care, nor did it provide guidance on how often staff should check and empty the bag. The facility's policy on activities of daily living emphasized the need for individualized interventions and care plan updates, which were not adequately implemented for these residents.
Failure to Ensure Proper Positioning During Mealtimes
Penalty
Summary
The facility failed to ensure proper functional positioning during mealtimes for a resident with chronic obstructive pulmonary disease, Parkinson's disease, and an above-knee amputation. The resident was observed eating in a wheelchair that was angled away from the dining table, forcing him to balance his plate on his abdomen. This positioning was due to the wheelchair being purposely dumped as a fall intervention, which caused discomfort and difficulty in eating and swallowing. The resident expressed discomfort and difficulty reaching the table, and no assistance was provided to help him cut his food into manageable pieces. Interviews with the Director of Rehabilitation and the Director of Nursing confirmed that the wheelchair's positioning was intended as a fall prevention measure, despite the resident's complaints of discomfort and difficulty in maintaining an upright posture. The Speech Language Pathologist also noted that the reclined position could increase the risk of aspiration. The facility's policy on resident rights emphasizes the importance of self-determination and freedom of choice, which was not upheld in this case as the resident's preferences and comfort were not adequately addressed.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to implement appropriate interventions to prevent the development of a pressure ulcer for a resident with a history of hypertension, type two diabetes mellitus, and a below-the-knee amputation. The resident was admitted with a moderate risk for pressure sores, as indicated by a Braden scale score of 14, which later increased to a high risk with a score of 12. Despite this, the resident developed a facility-acquired, unstageable pressure sore on the left Achilles, which progressed to a stage three ulcer. The care plan for the resident included addressing skin integrity issues related to decreased mobility and diabetes with neuropathy. However, the physician's progress notes during the critical period lacked any mention of the pressure sore, and the wound care orders remained unchanged despite the worsening condition. Observations revealed that the resident was left in a saturated soaker pad, indicating inadequate incontinence care, and was not repositioned frequently enough, as confirmed by a CNA's statement. Further deficiencies were noted during wound care, where a nurse attempted to reuse a dirty sock after cleaning the wound, and the cleaning method was inadequate. The facility's policy on skin management emphasized the need for appropriate preventative measures and ongoing monitoring, which were not effectively implemented in this case. Interviews with staff confirmed these lapses in care, highlighting a failure to prevent the development and progression of the pressure ulcer.
Failure to Secure Smoking Paraphernalia for Resident
Penalty
Summary
The facility failed to ensure that smoking paraphernalia was stored securely for a resident with a history of chronic obstructive pulmonary disease (COPD), nicotine dependence, and chronic respiratory failure. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15/15, was observed with cigarettes and a lighter in his jacket pocket, despite the facility's non-smoking policy. The resident expressed frustration about having to leave the premises to smoke and was seen smoking in the roadway in front of the facility. The resident's electronic medical record included a physician's order for oxygen use at night, highlighting the potential risk associated with smoking. Interviews with facility staff revealed that a smoking safety assessment had not been conducted for the resident due to the facility's non-smoking status. The Licensed Practical Nurse (LPN) confirmed the resident's possession of smoking materials, and the Director of Nursing (DON) reiterated the facility's policy that residents should not have smoking paraphernalia. Despite the policy, the resident had signed out of the facility multiple times to smoke, as documented in the leave of absence binder. This oversight in enforcing the non-smoking policy and securing smoking materials contributed to the deficiency.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to maintain an effective vaccination program for three residents, as identified during a survey. The records for three residents revealed that although consents for pneumococcal vaccinations were signed by their guardians, the residents did not receive the vaccination boosters. This oversight was discovered during a record review, which showed discrepancies between the electronic medical records and the state immunization report. All three residents were noted to be over the age of 65, which places them in a high-risk category for serious complications from pneumococcal pneumonia. An interview with the Infection Preventionist/Registered Nurse (RN) D revealed that the facility had recently changed its vaccination offering process. Previously, vaccinations were offered yearly after a declination, but starting in January 2025, the facility began offering them quarterly. Despite this change, the facility's policy, dated November 2024, indicated that all residents over the age of 65 should receive the pneumococcal vaccine. The policy also required maintaining a log documenting the number of residents vaccinated, refused, or not vaccinated, and obtaining informed consent prior to vaccination. The failure to administer the vaccinations as per the signed consents and policy guidelines led to the deficiency.
Untrained Staff Providing Feeding Assistance
Penalty
Summary
The facility failed to ensure that a non-licensed employee, Activities Aide B, received the State-approved training course for feeding assistance to residents. During a breakfast observation, Activities Aide B was seen feeding a resident who required assistance with a level 3 advanced mechanical soft diet. When questioned, Activities Aide B stated that she was providing assistance because other staff were unavailable. The Director of Nursing confirmed that only Certified Nurse Aides are allowed to provide feeding assistance, and the Nursing Home Administrator verified that the facility does not employ any paid feeding assistants. A review of Activities Aide B's employee file revealed that she was not certified and had not completed the required State-approved training course for feeding assistance. This training includes essential skills such as feeding techniques, communication, safety procedures, and recognizing changes in residents' behavior. Additionally, the facility's job description for the Activity Aide position did not include feeding assistance as part of the essential functions and responsibilities. This oversight resulted in an increased risk of feeding complications for the residents requiring assistance during mealtimes.
Deficiency in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition services. During an interview, Dietary Cook (Staff) H admitted she had not completed the Certified Dietary Manager's (CDM) course work and relied on a CDM from another facility to help with tracking residents' weights. Observations revealed that Staff I was unable to bring tacos up to the required temperature of 135 degrees Fahrenheit and used improper methods to check the temperature. Additionally, Staff I incorrectly measured serving sizes, using a 4-ounce scoop for ham and potato casserole instead of the required 6-ounce serving size. The Nursing Home Administrator confirmed the absence of a full-time CDM at the facility. Further observations showed that Dietary Aide (Staff) J also failed to serve the correct portion sizes, using a 2-ounce scoop for collard greens instead of the required 4-ounce serving size. Resident interviews revealed complaints about small portion sizes and poor food quality, with one resident representative describing the food as often over or undercooked and portions varying significantly. These deficiencies indicate a lack of proper training and oversight in the facility's food and nutrition services, leading to inadequate meal preparation and serving practices.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to ensure written information was provided to five residents or their representatives regarding bed hold policies during hospital transfers. Specifically, the facility did not obtain signatures from the residents or their representatives on the Bed Hold Authorization forms for residents who were transferred to the hospital. This deficiency was identified through a review of progress notes, clinical census reports, and Bed Hold Authorization forms for five residents. In each case, the forms indicated that the resident or their representative was informed via telephone, but no written notice or signatures were obtained as required by the facility's policy. During an interview, the Accounts Receivable Manager confirmed that written notices were not issued and acknowledged that the bed hold policies were communicated verbally over the phone. The Nursing Home Administrator also acknowledged a system failure regarding the bed hold notifications. The facility's policy, revised on 2/14/22, mandates that residents or their responsible parties must sign the bed hold agreement, and these signed agreements should be part of the resident's business file. The failure to provide written notices and obtain signatures represents a clear deviation from this policy.
Failure to Complete Recapitulation of Stay for Discharged Resident
Penalty
Summary
The facility failed to ensure a recapitulation of stay was completed for a resident at the time of a planned discharge. The resident, who had diagnoses including bipolar disorder, major depressive disorder, suicidal ideations, and post-polio syndrome, was discharged from the facility without a discharge plan or recapitulation of stay documented in their electronic medical record (EMR). The Social Service Director and the Director of Nursing confirmed that no post-discharge summary was completed because the resident was transferred to another skilled nursing facility, under the mistaken belief that a recapitulation of stay was not needed for such transfers. The facility's policy on discharge planning, revised on 9/7/23, mandates that all planned discharges must include a completed post-discharge plan and summary by the interdisciplinary team. This includes a recapitulation of the resident's stay, a final summary of the resident's status at discharge, medication reconciliation, and a post-discharge plan developed with the resident's participation. The failure to follow this policy resulted in the deficiency noted in the report.
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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