Church Of Christ Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton Township, Michigan.
- Location
- 23575 15 Mile Rd, Clinton Township, Michigan 48035
- CMS Provider Number
- 235619
- Inspections on file
- 27
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Church Of Christ Care Center during CMS and state inspections, most recent first.
A resident with intact cognition and significant medical conditions repeatedly called out for help at night because they could not reach the call light and needed to be turned due to pain. An LPN and CNA delayed responding, told the resident to stop yelling and that they were not the only patient, and refused to turn the resident, stating it had not been two hours and that pain medication had already been given before saying "Goodnight" and leaving. The resident’s continued calls for help were ignored, and when the CNA later re-entered and exited the room, the CNA told the resident that if they became soiled, "that's on you." The resident later reported that the staff were mean and would not help despite their repeated calls.
A resident with significant physical limitations and a care plan requiring two-person assistance for incontinence care and bed mobility was assisted by only one CNA, who turned away during care, resulting in the resident falling from bed and sustaining a right arm fracture. The CNA was aware of the two-person assist requirement but proceeded alone due to lack of available staff, contrary to the care plan and facility policy.
Two residents did not receive necessary ADL assistance: one with severe cognitive impairment was left without the required 1:1 feeding help, resulting in food on their clothing and face, while another was not assisted with shaving according to their preference, receiving grooming only on scheduled shower days. Staff and policy reviews confirmed these lapses in providing individualized care.
A resident with dementia was physically abused by a CNA in the presence of other staff members. The incident was reported by a witness, leading to an investigation and the termination of the involved CNA. The resident was unable to recall the incident due to severely impaired cognition.
Two residents in an LTC facility experienced worsening pressure ulcers due to inadequate assessment and treatment. One resident's coccyx wound was not properly documented or treated, leading to significant deterioration, while another resident developed new Stage 2 ulcers. The facility failed to follow pressure injury prevention guidelines, resulting in a lack of individualized interventions and documentation.
The facility failed to review and report monthly pharmacist medication recommendations for four residents with various diagnoses, including Major Depression and Alzheimer's. Despite completed medication regimen reviews, records showed blank fields for actions and responses. The NHA couldn't obtain the pharmacist's reports, and the DON admitted the need for a better system to ensure irregularities and recommendations are reviewed and communicated.
The facility failed to develop comprehensive wound care plans for two residents with existing wounds. One resident had multiple wounds and cognitive impairment, while another had a spinal infection and a coccyx wound. Both care plans lacked specific wound details and treatment, focusing only on general skin integrity measures. The DON and Unit Manager acknowledged the need for more detailed care plans.
A resident expressed dissatisfaction with their living conditions and requested a cell phone to communicate with others, but the facility failed to follow OBRA II Evaluation recommendations. The resident was not informed about their trust funds, which could have been used for personal items, and there was no documented follow-up or communication regarding their request. Additionally, the resident's guardianship had expired, and there was no clear progress in appointing a new guardian. The facility lacked specific policies on social work services, guardianship, and resident rights, contributing to the oversight.
A resident with moderately impaired cognition and a diagnosis of acute respiratory failure with hypoxia did not receive scheduled showers for three weeks. The resident reported that agency staff were sometimes rude and did not change briefs timely. Documentation showed showers were not given on scheduled days, and the Unit Manager confirmed the CNA involved was agency staff.
The facility failed to follow hospital discharge instructions for a resident, including removing a Foley catheter and scheduling follow-up appointments. Additionally, the facility did not adequately assess and manage pain for another resident who experienced multiple falls and severe pain, leading to hospitalization for acute kidney injury and dehydration. Interviews with staff revealed a lack of adherence to policies regarding notification of changes and pain management.
A resident with severe cognitive impairment and a high fall risk experienced multiple falls, resulting in a right femur fracture. The facility failed to promptly establish and update a fall prevention care plan, leading to repeated falls and inadequate interventions.
A resident with a documented DNR order received CPR due to a lack of a physician's signature on the form, leading to a change in code status to full code. The family was unaware of the CPR administration, and the facility acknowledged the oversight during a transition to state-compliant forms.
Failure to Protect Resident From Verbal Abuse and Ignored Requests for Assistance
Penalty
Summary
The deficiency involves a failure to protect a cognitively intact resident from verbal abuse and neglect of care needs by staff on the night shift. On the night in question, the resident repeatedly called out for help beginning around 11:30 p.m. because they could not reach the call cord and needed to be turned and repositioned. Video and audio from the hallway showed the resident yelling for help while an LPN remained outside the room for several minutes before the LPN and a CNA entered. When they did enter, the LPN told the resident to stop yelling and stated the resident was not the only patient on the floor. After leaving, the resident again called out, stating they could not reach the call light. When the LPN and CNA returned to the room, the resident told them they needed to be turned due to pain. The LPN responded that it had not been two hours and, when the resident again stated they were in pain, the LPN replied that pain medication had already been given and said, "Goodnight," before exiting the room. Both staff then ignored the resident’s continued calls for help and request to be turned. Later, the CNA re-entered the room, exited, and told the resident, "Goodnight. If you get messed up (soil on self), that's on you." During an interview conducted later, the resident, who had diagnoses including malignant neoplasm of the brain and thoracic radiculopathy and a BIMS score of 12/15 indicating intact cognition, reported that the staff on that shift were mean and would not help, and that they kept yelling for help.
Failure to Provide Required Two-Person Assistance During Incontinence Care Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who required the assistance of two staff members for incontinence care and bed mobility due to physical weakness, right hemiparesis, morbid obesity, and a history of cerebrovascular accident, was provided care by only one Certified Nursing Assistant (CNA). The resident's care plan and Kardex clearly indicated the need for two-person assistance for all activities of daily living, including incontinence care and bed mobility. During morning care, the CNA assisted the resident alone, instructing the resident to grab the bed bar and turning away to retrieve cream. At this moment, the resident rolled out of bed, fell to the floor, and sustained a proximal humerus fracture of the right arm. The resident was alert, verbal, and complained of pain, and was subsequently transferred to the hospital for further evaluation and treatment. The CNA acknowledged awareness of the two-person assist requirement but stated that another staff member was not available at the time. The Director of Nursing confirmed that staff are expected to follow the care plan and minimum staffing requirements as outlined in the facility's policies. The facility's fall prevention policy required individualized interventions based on assessed risk, but this was not followed in the resident's case, directly resulting in the fall and injury.
Failure to Provide Required ADL Assistance for Feeding and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents. One resident with diagnoses of cerebrovascular disease and Alzheimer's disease, and a Brief Interview for Mental Status score of 0/15 indicating impaired cognition, was observed multiple times with food on their clothing protector and face, attempting to eat with their fingers, and without staff present to provide the ordered 1:1 feeding assistance. The resident's medical record included an active physician's order for 1:1 feeding assistance, and both staff and the registered dietitian confirmed the resident required significant help with meals, especially when eating in their room. Another resident, recently admitted with hypertensive heart disease and a mood disorder, was observed to have facial stubble for several days and reported a preference to remain clean shaven but was unable to shave independently. The resident stated that staff had assisted with shaving, but not frequently. Staff interviews revealed that shaving was only provided on shower days, twice a week, and the DON confirmed that the facility protocol did not specifically assess or address resident preferences for shaving frequency in the care plan. Facility policy required that residents unable to perform ADLs receive necessary services for grooming and hygiene, but this was not consistently implemented.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. The incident involved a Certified Nurse Aide (CNA) who was observed physically slapping a resident during care, with two other staff members present. The resident, who has a diagnosis of dementia, adjustment disorder, and anxiety, was unable to recall the incident due to severely impaired cognition. The incident was reported by a witness, another CNA, who immediately informed the nurse supervisor. The Director of Nursing confirmed that the incident was reported to the State Agency and the police, and an investigation was conducted, resulting in the termination of the involved CNA. The facility's policy on abuse, neglect, and misappropriation of resident funds or property clearly states that any form of abuse will not be tolerated and must be reported immediately. Despite the resident's inability to remember the incident, the facility's failure to prevent the abuse led to the citation.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess, identify, and provide treatment for pressure ulcers in two residents, leading to the development and worsening of their conditions. Resident R78 was admitted with multiple wounds and was identified as high risk for developing pressure ulcers. Despite this, there was a lack of documentation and treatment for R78's coccyx wound from 5/24/24 to 7/6/24, and only two weekly skin assessments were completed between 5/28/24 and 7/11/24. The wound care physician noted the worsening condition of R78's coccyx wound, which was not properly assessed or treated, leading to a significant increase in size and the presence of thick slough tissue. Additionally, R78 developed new unstageable pressure ulcers on the left foot and ankle, which were not documented or treated. The nursing staff failed to notify the nurse practitioner of changes in R78's condition, and the Director of Nursing confirmed that wound care orders were not implemented or documented in the treatment record. This lack of communication and documentation contributed to the deterioration of R78's pressure ulcers. Resident R21 also experienced a decline in skin integrity, developing a new Stage 2 pressure ulcer on the coccyx and buttocks. Despite being cognitively impaired and dependent on staff for daily living activities, R21's care plan and skin evaluations did not adequately address the risk of pressure ulcers. The facility's pressure injury prevention guidelines were not followed, as evidenced by the lack of individualized interventions and documentation of compliance with treatment orders. The facility acknowledged the issue and was aware of it during Quality Assurance meetings.
Failure to Review and Report Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly drug regimen review and reported medication recommendations for four residents. The residents involved had various diagnoses, including Major Depression, Hypertension, Diabetes, Generalized Anxiety Disorder, Schizoaffective Disorder, Alzheimer's Disease, and Dementia. Despite the completion of multiple medication regimen reviews, the records for these residents showed blank fields for actions and responses to the pharmacist's recommendations, indicating a lack of follow-up on identified irregularities. Interviews with facility staff revealed that the Nursing Home Administrator was unable to obtain the pharmacist's reports, and the Director of Nursing acknowledged the need for a better system to ensure that irregularities and recommendations are reviewed by the physician and communicated to the pharmacist. The facility's procedure for drug regimen reviews requires that irregularities be documented and sent to the attending physician, medical director, and director of nursing, with urgent issues reported immediately. However, the attending physician's documentation of review and action taken was missing, highlighting a breakdown in the communication and documentation process.
Failure to Implement Comprehensive Wound Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive wound care plan for two residents, R78 and R91, as observed during a survey. R78 was admitted with multiple wounds on the sacrum/coccyx, left hip, left foot, and left thigh, alongside diagnoses of muscle weakness, need for assistance with personal care, and unspecified encephalopathy. Despite these conditions, R78's care plan only addressed general skin integrity risks and interventions, such as using cushions, encouraging nutrition, and repositioning, without specific mention of the existing wounds or tailored treatment plans. Similarly, R91, who was admitted with a diagnosis of osteomyelitis of the vertebra and a wound on the coccyx, had a care plan that failed to address the specific wound. The care plan included general interventions for skin integrity, such as using a pressure-reducing mattress and monitoring skin changes, but lacked details on the wound's location and treatment. Interviews with the DON and Unit Manager revealed an expectation for more detailed care plans that include specific wound locations and treatment plans, which were not met in these cases.
Failure to Address Resident's Preferences and Guardianship
Penalty
Summary
The facility failed to adhere to the OBRA II Evaluation recommendations for a resident, identified as R22, who expressed dissatisfaction with their living conditions and a desire for a cell phone to communicate with individuals outside the facility. Despite being cognitively intact, R22 was not informed about their resident trust funds, which could have been used to purchase personal items like a cell phone. The facility's social worker and staff were aware of the resident's request and the need for a state ID to obtain a cell phone, but there was no documented follow-up or communication with the resident, their guardian, or phone service providers. Additionally, the guardianship for R22 had expired, and there was no clear progress or communication regarding the appointment of a new guardian. The facility also lacked specific policies on social work services, guardianship, and resident rights, which contributed to the oversight in addressing R22's needs and preferences. The Director of Nursing acknowledged the importance of following OBRA assessment recommendations and the necessity of having a guardian in place but admitted to insufficient knowledge about the resident trust concerns. The absence of communication and action regarding R22's requests and the lack of policy guidance highlight the facility's failure to honor the resident's preferences, choices, values, and beliefs, as required by federal regulations.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide showers for a resident, identified as R19, who was unable to perform activities of daily living independently. R19 reported that it had been three weeks since they last received a shower, despite being scheduled for showers on Tuesday PM and Friday AM shifts. On one occasion, a Certified Nursing Assistant (CNA) informed R19 that they could not receive their scheduled shower because they returned to their room too late. The facility's documentation in the Electronic Medical Record (EMR) for R19's showers showed entries marked as 'N/A' for the scheduled shower dates, indicating that the showers were not given. R19, who has a diagnosis of acute respiratory failure with hypoxia and moderately impaired cognition, expressed dissatisfaction with the care provided by agency staff, noting that they were sometimes rude and did not change briefs in a timely manner. The Unit Manager was unable to explain why the shower was not given and confirmed that the CNA involved was agency staff. The facility's policy on Activities of Daily Living (ADLs) emphasizes the need for personalized care plans based on comprehensive assessments to ensure residents' needs and preferences are met, which was not adhered to in this case.
Failure to Follow Discharge Instructions and Manage Pain
Penalty
Summary
The facility failed to follow hospital discharge instructions and orders for a resident who was admitted with a displaced intertrochanteric fracture of the left femur, retention of urine, and dementia. The hospital discharge instructions included removing a Foley catheter on a specific date and scheduling follow-up appointments with various specialists. However, the facility did not make these appointments, and the unit secretary was unable to provide documentation or copies of the appointments. Interviews with staff, including the unit manager and the Director of Nursing (DON), revealed that there was an expectation for nurses to follow up on orders and instructions, but this was not done in this case. In another instance, the facility failed to assess and address a change in condition and control pain for a resident with Alzheimer's and essential hypertension. The resident experienced multiple falls and complained of severe pain, which was not adequately managed. Despite being prescribed Tramadol for pain management, the resident continued to report severe pain and a decrease in food intake. The facility's records indicated that the resident's condition deteriorated, leading to hospitalization for acute kidney injury, dehydration, and hypotension. The hospital records also revealed that the resident had healing rib fractures, which were not previously identified or addressed by the facility. Interviews with the DON and other staff members highlighted a lack of adherence to the facility's policies regarding notification of changes and pain management. The DON stated that the process for handling falls and pain complaints involved assessing the resident, notifying the physician, and conducting further evaluations, but these steps were not followed. The Unit Manager acknowledged that the pain was not addressed appropriately and emphasized the importance of following up on issues noted in progress reports. The facility's failure to manage the resident's pain and follow hospital discharge instructions contributed to the resident's decline and subsequent hospitalization.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement measures to prevent multiple falls for a resident with severe cognitive impairment, resulting in a right femur fracture that required surgical repair. The resident, who had a high fall risk score upon admission, experienced their first fall one week after admission. Despite this, a fall prevention care plan was not established until four days later. Subsequent falls occurred on multiple occasions, but new fall prevention interventions were not consistently added to the care plan in response to these incidents. The resident's care plan history indicated that after the initial fall, the only intervention added was monitoring for signs and symptoms of pain and other issues. After subsequent falls, minimal or no new interventions were added, even though the resident continued to fall. The resident's condition worsened, requiring additional assistance with transfers and pain management following the fracture. The facility's Director of Nursing acknowledged that the fall prevention care plan was not established promptly and that new interventions were not consistently added after each fall. The facility's policy on fall prevention was not followed, as it required immediate initiation of prevention protocols for high-risk residents and revision of the care plan after each fall. The policy also outlined specific interventions that should be considered for high-risk residents, such as assistive devices, increased frequency of rounds, and therapy services referral. However, these interventions were not consistently implemented for the resident, leading to repeated falls and a significant injury.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor the advance directive/code status wishes for a resident (R707) who had a documented Do Not Resuscitate (DNR) order. Despite having a DNR status documented and signed by the family member and facility staff, the form lacked a physician's signature. This led to confusion and a change in the resident's code status to full code during a transition to state-compliant forms. Consequently, when R707 was found unresponsive, CPR was administered, contrary to the resident's and family's wishes. The family was not aware that CPR had been performed and expressed concern over the incident. The Director of Nursing (DON) and the facility Administrator acknowledged the situation, explaining that the code status was changed due to the lack of a physician's signature on the DNR form. The Vice President of Clinical Operations (VPCO) confirmed that the form had been unsigned by the physician since the resident's transfer to hospice services, which prompted the change to full code status. The facility's policy on residents' rights regarding treatment and advance directives was reviewed, revealing that the facility is supposed to support and facilitate a resident's right to request, refuse, and/or discontinue treatment, which was not adhered to in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
