Briarwood Nursing And Rehabilitation

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement and operationalize its policies and procedures for advance care planning, determination of decision‑making capacity, and verification of legal representation for three cognitively impaired residents. For one resident with dementia, psychosis, and anxiety, the MDS and multiple clinical notes over several months documented that the resident was rarely/never understood, alert only to self, highly cognitively impaired, and unable to make needs known. Psychiatric evaluations repeatedly described advanced dementia, profound cognitive impairment, and limited capacity for engagement, and a physician note explicitly stated the resident was cognitively impaired, unable to make decisions, and would need guardianship. Despite this, there was no documented competency assessment, no identification or activation of a legal decision maker, and no social services documentation addressing designation of a legal representative. The resident’s face sheet listed the resident as their own responsible party, and the granddaughter and daughters only as emergency contacts. During this same period, the facility obtained signatures on advance directive and psychotropic medication consent forms that were attributed to the resident, even though staff interviews confirmed the resident was not cognitively intact and did not have a DPOA or guardian. The advance directive form documented that the resident did not choose to formulate any advance directives, and psychotropic consents for Zyprexa and Remeron were signed and witnessed by staff, with illegible or inconsistent resident signatures/initials that appeared dissimilar from each other. Social services documented that the resident remained their own person and that the patient was their own decision maker, while other clinical notes described the resident as non‑verbal, unable to verbalize needs, unable to retain education, and exhibiting aggressive behaviors. Discussion with family about pursuing guardianship was not documented until approximately four months after admission, and social services acknowledged that no competency assessment was completed and that they did not address the lack of a legal decision maker because the resident was initially expected to be short‑term. For a second resident with a BIMS score of 0, severe cognitive impairment, aphasia, dysarthria, and dependence in ADLs, the MDS indicated the resident was rarely/never understood. The face sheet listed the resident’s mother as responsible party, but there was no documentation of competency assessment, guardianship, or DPOA in the EMR. Social services documented that the resident remained their own person and had no wishes to issue further advance directives, while also recording that the resident was nonverbal and that the mother refused psychiatric services on the resident’s behalf, even though she was not documented as a legal representative. When surveyors attempted to interview the resident, verbalizations were not understandable, and a CNA reported it was hard to know what the resident wanted and that they normally could not understand the resident. Despite this, an advance directive form in the EMR showed a clearly written resident signature that closely resembled the LPN witness’s signature; the LPN later denied that the signature was theirs or the resident’s and stated they did not know who signed the resident’s name. The LPN also reported the resident was admitted alone and was unsure who was making the resident’s medical decisions. For a third resident with heart disease and dementia, the MDS showed severe cognitive impairment and need for supervision to total assistance with ADLs. Two HCPs had deemed this resident incompetent to make medical decisions, and probate court documentation granted a named individual temporary guardianship for a defined period. However, no permanent or current guardianship documentation was present in the EMR after the temporary order expired, even though the face sheet continued to list this individual as the resident’s legal guardian. The Social Services Director stated that the resident had an active legal guardian and that guardianship documentation was maintained in the EMR, but when reviewed, only the expired temporary guardianship order could be produced. The director acknowledged they did not have current guardianship documentation and did not explain how they knew the individual was legally able to make decisions without proof. The facility’s own policies required ongoing assessment of decision‑making capacity, determination of when residents could no longer make their own health care decisions, and maintenance of documentation for guardianship or surrogate decision makers, but these processes were not carried out or documented for the three residents. The Administrator confirmed that social services was responsible for addressing competency and legal representation but was unable to explain why these issues were not addressed for the residents in question. The Administrator also acknowledged that the signatures on one resident’s advance directive form appeared similar and that it did not appear to be the resident’s signature, and agreed that no one else should sign for a resident unless requested and documented. The Administrator further confirmed that guardianship documentation should be scanned into the EMR and was informed that one resident’s guardianship documentation was not current, without providing further explanation. Overall, the facility did not follow its policies on advance directives, determination of advocates’ authority, and ongoing review of residents’ decision‑making capacity, resulting in the absence of timely competency determinations, lack of appropriate and legal representation for two residents, and lack of current guardianship documentation for the third resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement and operationalize its pressure ulcer care policies for two residents, resulting in inaccurate documentation and failure to carry out ordered interventions. For one resident with a right heel pressure ulcer present on admission, surveyors repeatedly observed the resident lying in bed on their back with both heels directly on the mattress. Heel boots ordered for off‑loading were seen unused on a table, and there were no pillows or other positioning devices in the room to float the heels. The resident reported having a pressure ulcer on the right heel and stated staff did not assist with positioning the heels off the mattress. Despite this, electronic documentation over the prior 30 days showed the task “Float heels (as tolerated) while in bed” marked as completed (“Yes”) 77 times, including multiple entries on the days when surveyors directly observed the heels not floated. Record review for this resident showed inconsistent and evolving documentation of the right heel wound, including descriptions as a stage I pressure injury, a blister, and later an unstageable pressure injury with 100% slough and serous drainage. An external wound care provider documented an open right posterior heel wound likely related to pressure and recommended Q2H turning/repositioning and heel off‑loading with boots or floating. During a wound care observation, the nurse removed a dressing from the right heel and a wound with black necrotic tissue over a bony prominence, surrounded by red/purple tissue approximately the size of a half dollar, was observed. After the dressing change, the resident was again left with heels directly on the mattress, and no pillows were present for off‑loading. When questioned, the assigned RN acknowledged that the resident’s heels had not been floated and that attempts to float the heels had not been made when no positioning device was available, despite documentation indicating otherwise. For a second resident with an unstageable pressure ulcer on the left gluteal area being treated with Santyl, the facility also failed to follow care plan interventions for turning and repositioning. This resident was non‑ambulatory, required assistance with ADLs, and had care plan interventions including encouragement to turn and reposition every two hours and assistance by two staff for bed mobility. The resident reported having a wound on the buttocks and pain in the “backside,” rating the pain as four out of ten, and stated they could not reposition themselves. The resident indicated staff turned and repositioned them only when they needed to be changed, which they described as a couple of times a day. A family member present stated the resident had not moved since their arrival several hours earlier. Subsequent observations found the resident in bed on their back and later slightly on their right side, with the resident unable to recall how long they had been in that position and reporting ongoing pain and that morning care had not yet been provided. During a wound care observation for this second resident, staff removed the dressing from the left buttocks and revealed an area of black necrotic tissue approximately the size of a nickel with bright red surrounding tissue, and a separate nearby area about the size of a dime with a white wound bed. Immediately after the dressing change, the resident was transferred by mechanical lift to a wheelchair. Hours later, the resident remained in the wheelchair, reporting feeling sore and tired, stating they had not returned to bed, had not been repositioned in the wheelchair, and that their brief had not been checked or changed since being placed in the chair. The LPN confirmed the resident had been up in the wheelchair continuously since the wound care. The facility’s own skin management policy required skin assessments, weekly wound rounds, and interventions such as turning/repositioning, heel off‑loading, and scheduled time out of bed, but the observations and interviews showed these interventions were not consistently implemented for the two residents with pressure ulcers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper food safety practices in two key areas within the kitchen. First, the handwashing sink used by dietary staff near the kitchen entrance did not provide hot water at the required minimum temperature of 85 degrees Fahrenheit. Observations revealed that the water remained cold even after running for an extended period, and the temperature was measured at 67 degrees Fahrenheit. Neither the dietary supervisor nor the maintenance staff were monitoring the temperature of this sink, and there was no documentation of regular checks for this critical hand hygiene point. Second, the facility did not ensure that chemical test strips used to verify dish machine sanitizer levels were within their expiration date. The dietary supervisor provided test strips that had expired several months prior and was unaware of the need to check expiration dates. There were no additional strips available at the time, and dishwashing staff were preparing to use the dish machine without a valid means to confirm proper sanitization. The dish machine log did not include information about the lot number or expiration date of the test strips, and staff had not been trained to monitor this aspect. These failures created the potential for improper hand hygiene and dish sanitization for all residents receiving meal service.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically omitting care instructions for a right leg brace and a right foot PRAFO boot. The resident, who had a history of right knee replacement, post-surgical infection, reduced circulation in the right leg, heart disease, and arthritis, was observed with a dressing and a brace on her right lower leg. She reported previous knee surgery with subsequent infection and additional wounds on her right leg. Record review showed the resident had nine wounds on her right foot and lower leg, including wounds attributed to a medical device. The care plans in place addressed pressure ulcers but did not include interventions or instructions related to the right leg brace or the right foot PRAFO boot. Interviews with the wound nurse confirmed that while physician orders existed for the use and monitoring of the PRAFO boot, these were not reflected in the resident's care plan or Kardex. Additionally, progress notes did not mention the right knee brace or PRAFO boot. Facility policy required that recommendations for assistive devices be based on comprehensive assessment and documented in the care plan, but this was not done for the resident's leg brace or foot boot, resulting in a lack of documented guidance for staff on their application and monitoring.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that daily nurse staffing information was properly posted and maintained as required by federal regulations. During an observation, the Administrator indicated that the nurse staffing document was posted near the facility entry, but upon review, the posted document contained an incorrect day of the week. The Administrator acknowledged the error and stated that the staff member responsible would correct it. When asked to review the prior year's posted staffing records, the Administrator provided a binder containing the documents, which were used to track the number of RNs, LPNs, and CNAs on each shift, their hours worked, the date, and the resident census. Upon further review of the binder, it was discovered that approximately 60 days of posted staffing sheets were missing for the period from October 2024 to April 2025. The Administrator confirmed that the staff member previously responsible for completing the daily posted staffing documents was no longer in that role. As a result, the facility did not have the required nurse staffing information available for multiple days, preventing residents and visitors from knowing which clinical staff were working on those days.

Plan Of Correction

Element 1: Posted Nurse Staffing document was updated with the corrected day of the week during survey. Element 2: Audit completed of Nurse Staffing binder to identify any missing postings. Element 3: Education completed with Staffing Coordinator to assure daily Nurse Staffing postings are completed accurately and available for review. The Administrator/Designee will verify daily, Monday through Friday, that Nurse Staffing is posted accurately. Weekend receptionist will verify, Saturday and Sunday, that Nurse Staffing is posted accurately and immediately notify the Administrator if not posted. Element 4: Administrator/Designee will complete random weekly audits, four weeks, of Nurse staffing posting to assure the document is posted accurately, with findings submitted to QAPI for review and recommendations. Element 5: Staffing Coordinator is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely and adequate assistance with activities of daily living (ADL) for two residents who required support. One resident, with a history of dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, and blindness in one eye, was observed multiple times over several days wearing the same dress and exhibiting signs of poor hygiene, such as scratching her face and emitting a strong odor. Documentation showed that she had not received a shower or bed bath for over ten days, despite her care plan indicating a need for staff oversight due to cognitive deficits and a tendency to refuse care. The care plan and progress notes did not reflect any updated or alternative interventions to address her refusals or preferences, and staff did not attempt different approaches as outlined in facility policy. Another resident, who was dependent on staff for all ADLs due to confusion, tube feeding, diabetes, dementia, stroke, and hemiplegia, was observed at a care conference and later in her room with uncombed hair and dirty fingernails. Despite being prepared for a care conference, her grooming needs were not met, as evidenced by her appearance and the presence of black debris under her nails. The facility's ADL policy required appropriate support and assistance with hygiene, including bathing, dressing, grooming, and oral care, for residents unable to perform these tasks independently. The observations and record reviews demonstrated that the facility did not consistently provide necessary ADL care, such as bathing, nail care, and hair care, for residents who were dependent or required oversight. The lack of timely and individualized interventions, as well as failure to update care plans and follow facility policy for residents who resist care, contributed to the deficiency in maintaining residents' hygiene and grooming.

Plan Of Correction

Element One: Resident #52 had her clothes changed and shower schedule was changed to 1st shift. Resident #139 had her fingernails cleaned and hair combed per her preference. Element Two: Audit completed of all Residents to ensure fingernails are clean and hair is combed per Resident preferences. Audit completed of Residents who refused showers to ensure alternative was offered and care planned. Element Three: Administrator/Designee completed education with the IDT members who conduct room rounds to ensure Residents fingernails are clean, hair is combed per resident preference and resident is not wearing the same clothing as previous day. Director of Nursing/Designee completed education with the nursing staff to ensure residents who refuse showers are offered an alternative and documented. Director of Nursing/Designee completed education with the nursing staff in regards to ensuring fingernails are clean, clothing has been changed daily and hair is combed per resident preference. Any staff not educated by May 20, 2025 will be educated on their next scheduled shift. Element Four: Nurse Manager/Designee will complete random weekly audits X4 weeks of residents to ensure Residents are dressed appropriately, fingernails are clean and hair is combed, with findings submitted to the Director of Nursing who will report findings to QAPI for review and recommendations. Element Five: The Director of Nursing is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to monitor weights in a timely manner for a resident who was readmitted after hospitalization with a significant change in nutritional status, specifically the initiation of a PEG tube for enteral feeding. The resident had a complex medical history, including intracerebral hemorrhage, gastrostomy, abdominal aortic aneurysm, dysarthria, aphasia, hemiplegia, Alzheimer's disease, and muscle wasting. Upon readmission, the resident had experienced a notable weight loss, dropping from 131.6 lbs prior to hospitalization to 118.4 lbs at readmission, and further to 114.2 lbs over the following 18 days. The resident's nutritional assessments indicated ongoing weight loss and recommended weekly weight monitoring for the first four weeks post-readmission, in accordance with facility policy and the dietitian's assessment. Despite these recommendations and the resident's continued weight loss, weekly weights were not consistently obtained after the increase in enteral feeding from four to five cartons daily. The dietitian and DON both acknowledged that the required weekly weights were missed during this critical period. Facility policy required weekly weights for residents within the first four weeks of admission or as determined by the interdisciplinary team, especially for those with significant nutritional changes. The failure to adhere to this policy resulted in a lack of timely monitoring of the resident's weight status, despite clear evidence of ongoing weight loss and changes in nutritional interventions.

Plan Of Correction

Element 1 Resident #62's weight was obtained. Physician was notified. She was assessed by Dietitian for nutritional needs and nutrition plan of care was reviewed. Weight obtained showed weight gain and that interventions were successful. Resident will continue to be followed by Dietitian. Element 2 An audit was completed for Residents who returned from the hospital to ensure weekly weights were completed x4 weeks and all Residents with significant weight loss had interventions in place. An audit was completed for Resident on enteral feeding to ensure any weight loss or changes in orders were addressed with weekly weight monitoring in place. Any concerns identified were corrected. Element 3 Director of Nurses/Designee completed re-education to Nursing staff in obtaining weekly weights x4 weeks for any new admits or any Residents who were recently admitted to the hospital and re-admitted to the facility. Director of Nursing/Designee completed education to Registered Dietitian on tracking and requesting weekly weights for new admits as well as for any Resident showing weight loss or had changes in enteral feeding. Any staff members not educated by May 20, 2025 will be educated on their next scheduled shift. Unit Managers/Designee will verify that there are no missing weekly weights for new admits x4 weeks. Registered Dietician will provide a list to nursing for Residents with weight changes or enteral feeding changes. Nurse Managers will review medical record for new admits as well as re-admits during morning meeting to ensure all weights are obtained. Nurse Managers will review medical record for Residents with weight changes or enteral feeding changes during morning meeting to ensure all weights are obtained. Element 4 Unit Manager/Designee will complete random weekly audits X4 weeks of weights to ensure no weekly weights are missed with results of findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5 Director of Nursing is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified regarding the administration and monitoring of parenteral/IV fluids for several residents. For one resident with osteomyelitis, there was an increase in the Vancomycin dosage from 1500 mg to 2000 mg intravenously daily, but there was no documentation in the medical record providing the clinical rationale for this change. Although a pharmacy document indicated a low trough level as the reason for the dosage increase, this information was not accessible in the resident's medical record, and no progress note was completed by the nurse to explain the adjustment. Another resident, admitted for IV antibiotics following pneumonia and a secondary joint infection, missed three antibiotic doses (one Vancomycin and two Cefepime) while on a leave of absence (LOA) with family. The medical record did not contain documentation that the resident’s physician or infection preventionist was notified about the missed doses, nor were there progress notes outlining the next steps or physician instructions following the missed medications. A third resident, who had a PICC line for IV antibiotics, did not have documented monitoring of the external catheter length during dressing changes, as required by the facility’s standard operating procedure. Additionally, there was no documentation of arm circumference measurements or assessment of the external catheter in the treatment administration record, progress notes, care plan, or admission assessment. The facility’s policy required measurement of the external catheter length at each dressing change, but this was not completed or documented for the resident.

Plan Of Correction

Element 1 Resident #8 PICC line was discontinued prior to entrance of survey team. Resident #84 medical record was updated with rationale for the increased Vancomycin. Resident #289 physician was contacted regarding missed doses due to resident being out on LOA. Element 2 An audit was completed for residents who have PICC lines to ensure measurements of the external catheter length are documented in the TAR/MAR or in a progress note. Any concerns identified were corrected. An audit was completed for residents who have had an increase in dosage of Vancomycin to ensure rationale was documented in the medical record. Any concerns identified were corrected. An audit was completed for residents who leave the facility on LOA to ensure dosage of medications were not missed. If any medications are missed due to the resident being out of the facility, documentation of physician notification in the patient's medical record. Element 3 Director of Nursing/Designee completed re-education to licensed nurses in measuring PICC line from the insertion site to the end of the PICC line on admission and weekly with dressing changes. Director of Nursing/Designee completed education to licensed nurses in the process for when pharmacy adjusts the dose of Vancomycin via phone call or fax; the staff will adjust the order and document. Director of Nursing/Designee completed education to licensed nurses in the procedure for missed doses: the nurse will contact the physician and document in the patient's medical record. Any staff members not educated by May 20, 2025, will be educated on their next scheduled shift. Unit Managers/Designee will verify that there are no missing PICC line weekly measurements during morning meetings. Nurse Managers will review medication orders during morning meetings to ensure all increases of Vancomycin dosage have documentation of physician rationale. Nurse Managers will review medical records for any missed dosage of medications while residents are out on leave to ensure physician notification is documented in the patient's medical record. Element 4 Unit Manager/Designee will complete random weekly audits for four weeks of PICC line measurements, change in Vancomycin dosage rationalization, and missed dosage documentation. The results of findings will be submitted to the DON, who will report findings to QAPI for review and recommendations. Element 5 The Director of Nursing is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to identify and address a medication order discrepancy for a resident with multiple cardiac diagnoses, including hypertension, atherosclerotic heart disease, atrial fibrillation, and a coronary angioplasty implant. Upon admission, the resident was prescribed Diltiazem 60 mg to be taken four times daily. Later, a physician's note indicated a switch to Cardizem CD 240 mg once daily, and a new order for Cardizem LA 240 mg once daily was entered. However, the original Diltiazem 60 mg order was not discontinued, resulting in both medications being administered concurrently. The Medication Administration Record (MAR) showed that both Cardizem LA 240 mg and Diltiazem 60 mg were scheduled and administered at overlapping times. The monthly medication regimen review (MRR) conducted in February did not address the duplicate therapy, and the March MRR only raised the issue in a written recommendation to verify the necessity of both medications. This recommendation was not signed or addressed by the attending physician, and the duplicate orders remained active. Interviews with the Director of Nursing confirmed that the pharmacy's recommendations had not been acted upon and that the duplicate medication orders constituted a medication error. Facility policy required timely review and resolution of such irregularities, including immediate physician notification if resident safety was at risk, but these steps were not followed. The failure to discontinue the previous order and to act on the pharmacist's recommendations led to the ongoing administration of duplicative therapy.

Plan Of Correction

Element 1: Resident #18 order for Diltiazem 60mg was discontinued. Physician was notified of medication error during survey. Element 2: An audit of Pharmacy Medication Reviews was completed for the last 30 days to ensure reviews were completed by Physician and had documented response from the Physician in Residents' medical record. Any concerns were corrected. Element 3: Physicians were reeducated on reviewing and completing documentation of Pharmacy Medication Reviews in the Residents' medical record. Element 4: Unit Manager/Designee will complete random monthly audits of Pharmacy Medication Reviews to ensure all reviews have been documented with findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5: Director of Nursing is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain a signed consent for treatment with an antipsychotic medication for a resident diagnosed with dementia, depression, anxiety, and other chronic conditions. The resident was prescribed Fluoxetine for depression, but a review of the medical record did not identify a consent form for this treatment. Additionally, the resident's care plan did not mention the use of medication for depression, despite the ongoing prescription and administration of Fluoxetine. The Director of Nursing confirmed that a consent form could not be found for this medication. Another deficiency was identified when a resident with a history of hypertension, heart disease, and atrial fibrillation was administered duplicate medications containing diltiazem. The resident's physician ordered a switch from Diltiazem 60 mg four times daily to Cardizem LA 240 mg once daily, but the original order for Diltiazem 60 mg was not discontinued. As a result, the resident received both medications concurrently, as documented in the Medication Administration Record. The Director of Nursing acknowledged this as a medication error, and facility policy requires monitoring to prevent such errors.

Plan Of Correction

Element 1 Resident #52 was not on an Antipsychotic medication at the time of the survey. Consent was obtained for Antidepressant Fluoxetine. Resident #18 order for Diltiazem 60mg was discontinued, Physician was notified of medication error during survey. Element 2 An audit of Antidepressant medication orders was completed to ensure consents were present for all Antidepressant medications. Any concerns were corrected. An audit of Pharmacy Medication Reviews were completed for the last 30 days to ensure reviews were completed by Physician and had documented response from the Physician in Residents medical record. Any concerns were corrected. Element 3 Director of Nurses/Designee completed re-education to Licensed nurses on documentation of obtaining consents for Antidepressant medications and discontinuing orders per Physician order. Any licensed nurse not educated by May 20, 2025 will be educated on their next scheduled shift. Licensed Nurse will verify that there is a consent signed for any new Antidepressant Medications as part of the report during shift change. Nurse managers will review during morning meeting to ensure medication orders were discontinued per Physician changes of medications and all consent have been obtained for Antidepressant medications. Element 4 Unit Manager/Designee will complete random weekly audits X4 weeks of medication changes to ensure orders were discontinued and any resident with new Antidepressant medications has a signed consent. Results of findings submitted to DON who will report findings to QAPI for review and recommendations. Element 5 Director of Nursing is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that three out of four medication carts (located on Halls 300, 400, and 500) were not maintained in a clean and sanitary condition. The drawers of these carts contained crushed pills, loose pieces of paper, dust, and in some cases, whole or partial pills. These observations were made during walkthroughs with nursing staff, who acknowledged that the carts could have been cleaned better and stated that cleaning was typically assigned to the third shift, but any nurse could perform the task. Interviews with multiple nurses and the Director of Nursing confirmed that the responsibility for cleaning the medication carts was assigned to the third shift nursing staff, and this was consistent with the facility's Medication Storage policy. The failure to keep the medication carts clean and free of medication debris and other contaminants was directly observed and confirmed by staff, indicating non-compliance with requirements for proper storage and maintenance of drugs and biologicals.

Plan Of Correction

Element 1: Medication carts on 300, 400, and 500 halls were cleaned during survey. Element 2: Audit of medication carts was completed to ensure all medication carts are clean and sanitized, free of crushed pills, pieces of loose papers, and dust in the drawers. Any identified areas were addressed. Element 3: The Director of Nursing/Designee reeducated Licensed Nurses on cleaning of medication carts, which included making sure cart drawers are free of dust, paper particles, and crushed pill residue. Any Licensed Nurses not educated by May 20, 2025, will be educated on their next scheduled shift. Nurse managers/designee will complete random weekly audits of medication carts to ensure they are clean and sanitized. Element 4: Unit Manager/Designee will complete random weekly audits, for four weeks, of medication carts to ensure they are clean and sanitized. They will also query Nurses if they are able to verbalize the appropriate way to clean medication carts, with results reported to the Director of Nursing who will be present to QAPI for further follow-up and recommendations. Element 5: The Director of Nursing will be responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed multiple instances of unsanitary conditions and improper cleaning of kitchen equipment and utensils during a kitchen tour. Specifically, a large can opener had a dark, sticky substance behind the blade, and a large counter mixer that was considered clean had dried batter-like residue on its attachment. Additionally, a carving knife and a bread knife, both labeled as clean and ready for use, were found with dried food on their blades. The meat slicer, also marked as clean, had an oily substance and dried food on its blade. These findings were confirmed by the Dietary Director during the inspection. Further observations included six plate covers stacked together with water inside, and three coffee cups ready for serving that also contained water, both of which can promote bacterial growth. The facility's Dietary Manager job description requires providing training, direction, and guidance for dietary staff, but the observed conditions indicate a failure to maintain food preparation and kitchen equipment in a sanitary and good working condition. These deficiencies affected 82 residents who consumed food and beverages prepared in the facility's kitchen and ice machine.

Plan Of Correction

Element 1: Plate covers and coffee cups that were on the rack with water were re-washed and dried properly before returning to the rack for use. Can opener, meat slicer, mixer, and knife were cleaned during survey. Element 2: Audit completed of kitchen to assure equipment cleanliness as well as plate covers and coffee cups are completely dry on the clean rack. Element 3: Education completed with Dietary staff to assure kitchen equipment cleanliness, plate covers, and coffee cups are completely dry before putting away on the clean rack. Any staff not educated by May 20, 2025, will be educated on their next scheduled shift. Dietary Manager/Designee will complete weekly kitchen audits to ensure appropriate processes are being followed. Element 4: Dietary Manager/Designee will complete random weekly audits X4 weeks of kitchen to assure kitchen cleanliness and all items dried and stored properly, with findings submitted to QAPI for review and recommendations. Element 5: Dietary Manager is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean and comfortable environment for residents, as evidenced by multiple deficiencies in cleaning and organization. In the therapy gym, equipment such as Nu Step machines and Omni Cycles were observed to have debris, sand-like buildup, hair, and deteriorating materials, despite claims that equipment is wiped down between uses and deep cleaned monthly. The cleaning schedule lacked specific tasks, and the observed buildup suggested inadequate cleaning practices. Additionally, the seat and handle covering on one machine were damaged and deteriorating, further contributing to unsanitary conditions. In resident care areas, a resident who was totally dependent on staff and cognitively impaired was found with a soiled gown and a blanket with a large brown smear near the face, and the room had visible black wheelchair marks and chipped paint. Another room contained hygiene items and a bedpan left behind by a discharged resident, and several rooms on the 100 Hall were noted to be cluttered with resident items stacked on floors and surfaces, making the environment appear unkempt. These observations indicate a failure to ensure timely removal of soiled linens, proper disposal of hygiene products after discharge, and adequate decluttering and cleaning of resident rooms.

Plan Of Correction

Element Three: Administrator/Designee completed education with the IDT members who conduct room rounds to ensure any identified cluttered rooms are addressed as well as any black marks or paint chips are identified. Housekeeping Supervisor/Designee completed education with the Housekeeping staff to ensure all rooms identified with clutter are addressed immediately and personal belongings are removed timely when residents are discharged from the facility and room is clean and ready for new resident. Administrator/Designee completed education with the Housekeeping staff and Therapy staff on cleaning of gym equipment. Administrator/Designee completed education with the Nursing staff in regards to removal of soiled clothing/gowns and linen are removed from resident beds and placed in appropriate bin to be sent to laundry and removing clutter from rooms. Any staff not educated by May 20, 2025 will be educated on their next scheduled shift. Element Four: Housekeeping Supervisor/Designee will complete random weekly audits X4 weeks of resident rooms to assure rooms are free of clutter, soiled linen has been removed and discharged residents' personal hygiene products have been removed, no black markings or chipped paint with findings submitted to Administrator who will report findings to QAPI for review and recommendations. Therapy Director/Designee will completed random weekly audits X4 weeks of therapy equipment to ensure cleanliness, with findings submitted to QAPI for review and recommendations. Element Five: The Administrator is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the emergency backup generator annunciation panel was located in a place that is readily observed by operating personnel, as required by NFPA 99 standards. During an observation, it was found that the annunciation panel was installed in the maintenance office, which is not a location that allows for easy monitoring by staff responsible for facility operations. This setup could result in generator alarms not being noticed promptly. The maintenance director confirmed these findings during the surveyor's interview at the time of observation. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.

Plan Of Correction

1. Annunciator panel was moved to an area readily observed by staff. 2. Audit completed of emergency notification systems to ensure location is easily accessible by staff. Corrections made as needed. 3. Administrator/Designee completed education to Maintenance Department on requirement that remote annunciation must be located outside of any locked rooms and easily accessible for staff to be notified of generator alarms. 4. Maintenance Director/Designee will complete random audits of emergency equipment and alarm devices are easily accessible to general staff with findings submitted to QAPI for review and recommendations. 5. Maintenance Director is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During an observation on April 24, 2025, it was found that the exit sign outside the staff corridor directed occupants to exit through the staff corridor in the event of an emergency, which conflicted with the emergency egress diagram displayed on the wall. The exit sign was not in accordance with the requirements for exit and directional signage, which mandate continuous illumination and alignment with emergency egress routes. This discrepancy was confirmed through an interview with the maintenance director at the time of observation. The deficiency could potentially affect 25 occupants during an emergency evacuation, as the conflicting signage may delay or obstruct emergency egress down the restricted width staff corridor.

Plan Of Correction

1. Exit sign outside the staff corridor was corrected to direct occupants as indicated on the emergency diagram displayed on the wall. 2. Audit completed of exit signs to ensure correct and match emergency diagram posted. Corrections made as needed. 3. Administrator/Designee completed education to Maintenance Director on exit signage. 4. Maintenance Director/Designee will complete random audits of exit signage to ensure occupants are directed in the appropriate direction according to emergency diagram posted with findings submitted to QAPI for review and recommendations. 5. Administrator is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the fire-rated cross corridor double doors located outside the Salon did not fully close and latch when released from their magnetic hold open devices. This failure was identified during an inspection on April 24, 2025, at approximately 10:50 AM. The doors are required to resist the passage of smoke and, in this case, did not meet the necessary standards for protecting corridor openings as outlined by NFPA 19.3.6.3. The deficiency was confirmed through an interview with the maintenance director at the time of observation. The inability of these doors to close and latch properly could allow heat, smoke, and fire to pass from one compartment to another, potentially affecting up to 50 occupants. No specific residents or their medical conditions were mentioned in the report.

Plan Of Correction

1. Fire-rated cross corridor double doors outside the Salon were adjusted to close properly. 2. Audit completed of fire-rated doors to ensure proper closing. Corrections made as needed. 3. Administrator/Designee completed education to Maintenance Department on requirement that fire doors fully close and latch when released from the magnetic hold open devices. 4. Maintenance Director/Designee will complete random audits of corridor double doors to ensure doors close and latch properly with findings submitted to QAPI for review and recommendations. 5. Maintenance Director is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that electrical receptacles or cover plates supplied from the life safety and critical branches in the original side of the facility were not marked with a distinctive color or marking as required by NFPA 99 standards. During the inspection, it was noted that the emergency generator provided power only to dedicated outlets, and some outlets in the corridors were on emergency power but lacked the required distinctive color marking. The maintenance director confirmed during the interview that these outlets were not properly identified, which could result in staff not recognizing or using them during a power outage. These findings were confirmed at the time of observation with the maintenance director present. No specific residents or patient medical histories were mentioned in the report, and the deficiency was based solely on facility infrastructure and staff interviews.

Plan Of Correction

Electrical receptors that are connected to the back up generator were changed to red cover plates. Audit completed of all electrical receptors connected to the back up generator to ensure those receptacles are identified with a red cover plate. Corrections made as needed. Administrator/Designee completed education to Maintenance Department on requirement that all electrical receptacles connected to the back up generator must have a distinctive red cover plate so it is easily identified by staff during an emergency situation. Maintenance Director/Designee will complete random audits of electrical receptacles to ensure emergency receptacles are identified with a red cover plate with findings submitted to QAPI for review and recommendations. Maintenance Director is responsible for maintaining compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct a comprehensive nursing assessment following a significant change in condition for a resident who experienced a fall. The resident, who had a history of multiple health issues including end-stage kidney disease, heart disease, and recent spinal surgery, fell on 7/2/24. Despite complaints of hip pain, the initial x-ray conducted on 7/3/24 showed no acute fractures or dislocations. However, the facility did not perform a complete pain assessment as per their policy, and the resident's pain was only managed with medication without further investigation. The resident continued to experience significant pain, which was noted by the occupational therapist on 7/4/24. The therapist informed the nursing staff of the resident's increased pain and decline in therapy participation, but this was not documented in the nursing notes. The resident's pain levels were recorded as high on multiple occasions, yet there was no comprehensive assessment or documentation of the pain's intensity, pattern, or impact as required by the facility's pain management policy. The situation escalated when the resident was eventually taken to the hospital on 7/12/24, where a CT scan revealed multiple fractures and pneumonia. The lack of thorough assessment and documentation by the facility led to a delay in the resident receiving appropriate medical attention. Interviews with staff indicated a breakdown in communication and documentation, contributing to the oversight in addressing the resident's worsening condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The report details a deficiency in providing appropriate pressure ulcer care and prevention for Resident #69 in the facility. Resident #69, a 61-year-old admitted post-Motor Vehicle Accident (MVA) with a primary diagnosis of Traumatic Subarachnoid Hemorrhage, developed an unstageable sacral pressure ulcer during their stay. The wound nurse noted a significant increase in the wound area within a week of discovery, indicating a lack of effective interventions to prevent worsening. Despite the resident's complaints of pain and limited mobility for repositioning, the care plan did not address poor compliance, tolerance to movement, or pressure relief interventions. The facility's failure to implement adequate interventions is evident in the lack of documented pressure relief measures, offloading strategies, or turning/repositioning schedules in the care plan. The wound nurse acknowledged the facility-acquired nature of the pressure ulcer and the absence of a wound specialist for assessment. The physician had not assessed the wound since its discovery, highlighting a gap in monitoring and treatment oversight. Additionally, discrepancies in treatment documentation and missed treatments in the Treatment Administration Record raise concerns about the consistency and effectiveness of care provided to Resident #69. The facility's policies on skin management and medication/treatment orders emphasize the importance of proactive skin assessments, timely treatment orders, and consistent documentation. However, the report indicates lapses in adherence to these policies, as evidenced by missing treatment documentation, delayed physician assessment, and incomplete skin worksheets.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food products were properly labeled with an opened and/or use by date and dispose of expired food items. During an initial tour of the kitchen, it was observed that multiple food items, including milk, juice, mustard, and pickles, were not labeled with appropriate dates. Additionally, there were instances of expired food items such as instant coffee and cocoa powder. The Dietary Manager confirmed that these items should have been labeled and dated correctly. The facility also failed to monitor and document temperatures of a refrigerated unit consistently. The temperature logs for the dairy cooler showed multiple entries with dashes instead of recorded temperatures, indicating that the temperatures were not being properly monitored. The Dietary Manager acknowledged that staff should be recording the actual temperatures rather than using dashes. Furthermore, the facility did not maintain sanitary conditions in the kitchen. Observations included dirty knives, oily muffin tins, wet and dirty metal trays, a dirty meat slicer, and a juice machine with sticky residue. Additionally, personal staff items were found in the tray prep area, and several pieces of cooking equipment were found to be wet and improperly stored. The Dietary Manager confirmed that these items should have been cleaned and stored correctly to prevent potential contamination and foodborne illness.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely care and services to maintain dignity for multiple residents, resulting in long call light response times, delays in fulfilling resident requests, lack of nail care, limited access to the dining room during meal times, lack of personal grooming, and call lights being out of reach. Residents reported waiting for extended periods, sometimes up to three hours, for staff to respond to call lights and fulfill requests. Specific instances included residents waiting for cups of ice, medications, and assistance with personal hygiene. Observations confirmed that call lights were often out of reach, and residents expressed frustration with the delays and lack of timely care. Several residents were observed with unmet personal grooming needs, such as long fingernails and unshaven beards. For example, one resident's wife and daughter had been shaving him because the facility staff did not provide this care. Another resident expressed discomfort with long fingernails and stated that staff had not offered to trim them. The facility's policies on call light use and nail care were not consistently followed, leading to residents feeling neglected and undignified. The Resident Council Meeting Minutes also highlighted ongoing issues with call light response times, late medication administration, and residents not receiving care during the night. Additionally, residents reported that their food preferences were not honored, and meals were often delivered cold when served in their rooms. The dining room was not open for breakfast, and residents who arrived late for lunch or dinner were told they had to eat in their rooms. These deficiencies indicate a systemic problem with the facility's ability to provide timely and respectful care to its residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents received their mail on Saturdays, which resulted in residents not being able to exercise their right to receive mail and access communication. During an interview with a group of residents, it was revealed that they did not receive mail on Saturdays because the mail lady had weekends off. The Activity Director and Activities Aide both confirmed that they did not recall mail being delivered on weekends, and the Front Desk Receptionist was unsure if mail was actually being delivered on Saturdays. The Administrator was also unaware if the residents were receiving mail on Saturdays. A review of the facility's policy titled 'Mail and Electronic Communication' indicated that residents should receive mail within twenty-four hours of delivery, including Saturdays. Additionally, the 'Rights of Residents in Michigan Nursing Facilities' document stated that residents have the right to send and receive mail. The facility's failure to ensure mail delivery on Saturdays was a clear violation of these policies and residents' rights.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that resident rooms and equipment were clean and in good repair, leading to an unsanitary environment. Observations revealed that the Sit-to-Stand mechanical lifts in the 100 and 200-unit hallways had whitish/yellowish debris on the pads and base, where residents' legs and feet would rest. Additionally, resident rooms and shared bathrooms were found to be unclean and in disrepair. For instance, a bathroom shared by rooms 101 and 103 had unlabeled basins and a bedpan on the floor, while room 101-1 had a soiled brief, wipes, and washcloths on the floor. The CNA and DON acknowledged the debris but indicated it should not have been left from the night shift. Other rooms, such as 208, had chipped floor tiles and scrapes on the walls, and the bathroom shared by rooms 204 and 206 was very soiled with plumbing pipe pieces in the basins. The facility's Infection Prevention and Control program was reviewed, and it was noted that the Maintenance Director had recently resigned, leaving the interim Maintenance Director unavailable for an interview. The report highlights that the facility did not adhere to the residents' rights to live in a clean and safe environment, as outlined by the Michigan Long Term Care Ombudsman Program. The lack of proper labeling and storage of personal items, as well as the general uncleanliness and disrepair of the facility, contributed to the unsanitary conditions observed by the surveyors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly dispose of wasted medications and secure treatment carts containing prescription treatment medications and medical supplies. On multiple occasions, treatment carts were observed unattended with drawers partially open, allowing access to medications and supplies. Specifically, on the 200 Hall Unit, a treatment cart was found with a drawer that was not fully closed, leaving it accessible despite being locked. Similarly, on the 400 Hall Unit, a treatment cart was observed with a partially open drawer containing wound treatment supplies. Nurses acknowledged that the carts should have been locked and secured properly. Additionally, during medication administration, a nurse was observed discarding medications, including Metformin and a Tums tablet, into a garbage container attached to the medication cart. The garbage container did not have a lid, making the discarded medications accessible to residents. The nurse left the medication cart unattended in the hallway while retrieving backup medications, during which time a resident in a wheelchair was observed near the cart. The Director of Nursing confirmed that medications should not be disposed of in the garbage and that the facility's policy requires medication carts to be kept closed and locked when out of sight of the administering nurse or aide.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure ongoing surveillance of infectious illnesses for employees was maintained, documented, analyzed, and reported. During a review of the Infection Prevention and Control Program, the Infection Preventionist (IP) acknowledged that while he reviewed employee call-in logs for illnesses during morning Interdisciplinary Team Meetings, he did not document or analyze this data for trends or compare it with resident infections. The IP only collected ongoing data for employee COVID-19 infections and did not report employee illness information at the Infection Control Committee meetings, despite the facility's policy requiring such surveillance and reporting. A review of the facility's monthly infection surveillance line listings and summary reports from August 2023 to March 2024 revealed no surveillance data for employee illnesses, although resident infection data was documented. The facility's policy on Infection Prevention and Control Program emphasized the importance of tracking both employee and resident infections and using this data to oversee infections and spot trends. However, the IP admitted to not monitoring, analyzing, or reporting infection surveillance for employees, which is a deviation from the facility's established policies and procedures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to review and revise care plans with resident changes to ensure necessary interventions for care and services were provided for Resident #45. During a tour, it was observed that Resident #45 had poor personal hygiene, with soiled clothes and bed linens, and an unwashed appearance. Interviews with staff revealed that the resident often refused help with personal care and preferred to perform hygiene tasks privately in his room. Despite these observations, the care plan did not reflect specific interventions that staff described, such as setting up supplies for the resident to use in his room or encouraging visits to the facility salon, which the resident seemed to respond positively to. The care plan for Resident #45 contained generic and sometimes contradictory interventions. It repeatedly noted the resident's aversion to water but did not include alternative interventions like waterless bathing and hair washing products. The care plan also failed to address the impact of the resident's hygiene habits on his roommate. Staff interviews indicated that the resident had a history of living alone without running water and had neighbors who complained about his hygiene. Despite this background, the care plan lacked specific, personalized strategies to manage his hygiene needs effectively. The facility's policy on comprehensive, person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs. However, the care plan for Resident #45 did not align with this policy, as it did not build on the resident's strengths or reflect recognized standards of practice. The interdisciplinary team did not update the care plan to include effective interventions, resulting in unmet care needs for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were administered per the physician's order for two residents, resulting in multiple medication administrations not being documented in the Electronic Health Record (EHR) and improper administration of a lidocaine patch. Resident #53 had several instances where medications, including daptomycin, donepezil, mirtazapine, atorvastatin, amlodipine, calcitonin, losartan, and senna, were not signed out on the Medication Administration Record (MAR). There was no documentation of refusal or a reason for not administering these medications. The Director of Nursing (DON) acknowledged the omissions but did not provide an explanation for why they occurred. Resident #237 had an order for a Lidocaine Pain Relief 4% patch to be applied to the back every morning and removed at bedtime. During a medication administration observation, it was found that the nurse did not remove the old patch before applying a new one. The nurse admitted that the old patch should have been removed. These deficiencies indicate a failure to follow proper medication administration protocols, potentially leading to adverse reactions and skin irritation for the residents involved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in ineffective collaboration between the facility and hospice service. The resident, who had diagnoses including chronic obstructive pulmonary disease, depression, anxiety, and dependence on supplemental oxygen, was under hospice care but was unaware of the hospice schedule and did not have a calendar to refer to. The hospice binder contained outdated information, and there was a lack of documentation of hospice nursing assessments in the resident's medical record. During an interview, the Director of Nursing (DON) acknowledged the absence of an up-to-date calendar and the lack of documentation in the medical record. The DON confirmed that hospice notes, assessments, and all related documentation should be included in the resident's medical record. The deficiency resulted in the potential for unmet care needs due to the lack of proper communication and documentation of hospice services.