Corewell Health Rehab & Nursing Center-commons Far
Inspection history, citations, penalties and survey trends for this long-term care facility in Farmington Hills, Michigan.
- Location
- 21450 Archwood Circle, Farmington Hills, Michigan 48336
- CMS Provider Number
- 235462
- Inspections on file
- 25
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Corewell Health Rehab & Nursing Center-commons Far during CMS and state inspections, most recent first.
Surveyors found that the facility allowed the DON to function as a charge nurse while the census was over 60 residents. The staffing scheduler reported that, following multiple nurse and nursing assistant call-ins on a weekend, the DON and a nurse manager were placed on a medication cart and worked as charge nurses, and acknowledged this had occurred on other occasions when a charge nurse was needed. The DON confirmed working as a charge nurse when needed and was not able to provide job description documentation showing any limitations on serving in that role. This staffing practice had the potential to affect all 99 residents.
Two residents were found in a room with multiple unaddressed environmental issues, including a call light on the floor and difficult to keep within reach, an overbed tray table with peeling edges exposing non-cleanable particle board and dried dark residue, a bedside dresser soiled with a thick white substance, and a floor mat covered in dried debris and stains. One resident’s low air loss unit was turned off while the resident moaned in pain when repositioning, and the other resident’s surrounding carpet had crushed food debris and a thick red substance on the overbed table. Nursing staff acknowledged the conditions, had not placed work orders, and were unsure about the low air loss mattress, while Environmental Services staff confirmed their cleaning scope and reliance on work orders. On re-observation the next day, the soiled mat, dirty carpet, and contaminated surfaces remained unchanged, despite a facility policy requiring daily cleaning of used rooms, including floors, horizontal surfaces, visible soiling, and high-touch disinfection.
A resident with type 2 DM, a cardiac pacemaker, and dependence on staff for most ADLs was care planned to return home with HHC supports, including services from a specified home health agency starting shortly after discharge. However, the facility did not ensure that the home health referral was actually made and confirmed before discharge. The care coordinator stated they had not sent the referral and believed a former social worker had done so, and later learned from the agency that no referral had initially been received. The home health agency reported that the referral was not received until several days after discharge, at which point services were initiated, resulting in a delay between discharge and the start of home health care.
Two residents did not receive care in accordance with physician orders and nursing standards. One resident with diabetes and a pacemaker had midodrine orders with specific BP parameters, but the drug was administered multiple times outside those parameters, and leadership later acknowledged the parameters were incorrectly transcribed and not clarified with the physician. Another resident with severe cognitive impairment and multiple fractures had active orders for bilateral heel protectors, skilled care boots while in bed, and a LAL mattress, yet was observed in bed without heel protection and with the LAL unit turned off, while soft boots were stored in the room. The assigned nurse had documented these interventions as completed on the MAR/TAR despite not providing them and initially stated the resident did not use such devices, contrary to the active orders.
A resident with dementia and documented hearing impairment had physician orders for hearing aids to be applied upon awakening and removed at bedtime, with storage in the med cart, yet staff charted these tasks as completed over multiple days without using follow-up codes for missing or refused devices. On observation, the resident was in bed without hearing aids, and an RN confirmed the devices were kept on a charger at the nurses’ desk instead of in the med cart, admitted documenting application before actually doing it, and discovered that one hearing aid was missing; the DON confirmed the storage practice and could not explain how the loss went unidentified, while the care plan and MDS contained inaccurate or incomplete information about hearing aid use.
Surveyors found that the facility did not follow care-planned fall prevention interventions for two residents with severe cognitive impairment and extensive fall risk factors. One resident with Alzheimer’s disease and significant ADL dependence was repeatedly observed in a high bed without floor mats in place, despite a care plan requiring the bed in the lowest position and mats on the floor. Another resident with dementia, multiple fractures, and a documented history of a serious fall with injuries was observed in an elevated bed with a regular mattress, the call light on the floor and out of reach, and the floor mat folded against the closet instead of next to the bed, even though the care plan called for a low bed, perimeter mattress, and mats on the floor. The assigned nurse stated this resident was not considered a fall risk and was unaware of the perimeter mattress intervention, while the DON later stated staff should be aware of the resident’s fall risk and required interventions.
A resident sustained a fall and multiple injuries when a CNA attempted to provide care and reposition the resident without locking the bed wheels. The bed was in a high position and rolled backward as the CNA rolled the resident toward their body, causing the resident to fall to the floor and suffer a hematoma to the forehead, skin tears, bruising, and a closed displaced fracture of the left tibia, along with contusions and abrasions to the upper extremities. Facility documentation and staff statements confirmed that the unlocked bed wheels were the cause of the fall, despite a facility safety policy requiring bed wheels to be locked.
A resident with multiple neuropsychiatric diagnoses became less responsive, prompting a nurse to contact a PA who ordered STAT labs and later ordered D5% 0.45% NS IV fluids. The lab results showed a critically high blood glucose of 732, but the PA did not document reviewing these labs and still ordered continuous IV fluids containing dextrose, which nursing staff implemented and clarified over the next day. The resident remained on D5% 0.45% NS while serial nursing notes documented ongoing infusion, progressive lethargy, and repeated glucometer readings of "Hi," leading to insulin administration per NP orders and eventual EMS transfer to the hospital for high blood sugar and altered mental status. In interview, the PA stated they were unaware of the critical glucose level before ordering the dextrose-containing IV fluids, and the DON acknowledged the order could have been questioned by nursing staff, contrary to facility policy requiring provider review and analysis of abnormal labs.
Clean dessert cups were stored uncovered near a handwashing sink, and cooked pork loins were not properly cooled or logged according to FDA Food Code standards. The CDM confirmed the lapses in both storage and documentation practices.
A resident with hypertension did not receive a prescribed blood pressure medication for four days due to unavailability, and there was no documentation that the physician was notified or that alternative instructions were sought. The DON was unaware of the missed doses, and facility protocol for handling unavailable medications was not followed or documented.
A resident was repeatedly served pork products despite her stated preference to avoid pork, leading to frustration. The resident had communicated her dietary restriction, but the information was not consistently relayed or honored by dietary and nursing staff, resulting in inappropriate meal service.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Surveyors found widespread unclean conditions, including debris, food spills, and soiled curtains in resident rooms and common areas. Staff personal items were improperly stored in a resident dining area, and the Environmental Services Supervisor acknowledged that cleaning and spot checks had not been adequately performed. The facility's housekeeping policy was not available when requested.
Surveyors found that food items brought in from outside and stored in a community refrigerator were not labeled with resident identifiers or dates, as required by facility policy. An RN acknowledged that these items should have been properly labeled.
A resident with metastatic cancer, COPD, and chronic respiratory failure who tested positive for influenza A and was on antiviral therapy did not receive complete and accurate sepsis screening as required. Nursing staff failed to fully complete the Severe Sepsis Screening Tool, leaving sections blank or incorrectly documenting the resident's infection status, despite ongoing isolation precautions and antiviral treatment.
A resident with multiple respiratory diagnoses and a new order for PRN oxygen was not properly monitored, as staff failed to document oxygen saturation levels prior to oxygen administration and did not record PRN oxygen use on the MAR/TAR. The DON confirmed the lack of required documentation and absence of a facility policy for monitoring PRN oxygen therapy.
The facility failed to maintain kitchen sanitation and proper food safety practices. Gnats were found near the handwashing sink, and the walk-in cooler had improperly stored and dated food items. Cooked pork butt was not cooled correctly, and the dish and ice machines showed signs of neglect. The dry storage room and areas around the ice machine were unclean, with food debris and cobwebs present.
The facility failed to employ a qualified full-time social worker to meet residents' psychosocial, mental, and behavioral health needs. During a survey, it was found that the only social worker, Staff 'D', was not licensed, with their last license expiring in 2019. The Administrator was aware of this but believed a license was unnecessary. The facility, licensed for 179 beds, had not employed a licensed social worker since July 2024, leading to concerns about unmet resident needs.
The facility failed to implement adequate infection control practices during wound care for a resident with pressure ulcers, as Enhanced Barrier Precautions were not utilized. Additionally, staff did not adhere to proper PPE protocols for residents on droplet precautions related to COVID-19, as observed with an LPN and a CNA who did not wear the required face shield or goggles. These lapses indicate a failure to follow established infection control protocols.
The facility failed to ensure call lights were within reach for three residents, preventing them from summoning help. A resident with severe cognitive impairment had the call light out of reach on two occasions. Another resident in Covid-19 isolation had the call light on the floor, and a third resident, also in isolation, had the call light out of reach. Staff confirmed and corrected the placement upon notification.
The facility failed to follow protocols for changing code status preferences for three residents with severe cognitive impairments. Discrepancies were found in documentation, with verbal consents obtained without proper follow-up or legal verification. This led to conflicting records regarding residents' CPR preferences.
A resident with Type 2 Diabetes Mellitus received their morning insulin dose hours before breakfast, contrary to professional standards. The insulin was administered between 5:24 AM and 6:23 AM, while breakfast was served at 8:30 AM, creating a 2.5-hour gap. The facility's DON acknowledged that insulin should be given closer to mealtime, highlighting a deviation from recommended practice.
A resident with Alzheimer's disease was found with multiple bruises on both arms, but the facility failed to document or assess the cause. Despite observations of discoloration, there were no recent skin assessments or incident reports, and staff were unaware of the bruising. The DON suggested a nutritional deficiency but did not document it in a care plan.
A resident in an LTC facility was without prescription glasses since July, leading to headaches and difficulty in activities. Despite a social work note indicating the issue, the facility's social services were unaware of the resident's need for vision services. The resident was placed on an ancillary services list without a specific request for vision services, delaying necessary care.
A resident in an LTC facility developed pressure ulcers due to the facility's failure to implement preventative interventions and administer treatment as per physician's orders. Observations showed the resident's feet were not protected by pressure-relieving boots, and wound care was performed without proper pain assessment or hand hygiene. The resident's clinical record indicated the ulcers developed while in the facility, and necessary interventions were not in place until identified by a surveyor.
The facility failed to provide fresh water within reach for two residents, risking dehydration and electrolyte imbalances. One resident had a water cup out of reach despite orders for increased fluid intake, while another had a full cup of water inaccessible. Additionally, the facility did not adequately monitor a resident's significant weight loss, with no documented plan for addressing the issue. Staff interviews revealed a lack of awareness and monitoring of residents' hydration and nutritional needs, indicating a failure to implement facility policies effectively.
Two residents experienced unnecessary pain due to inadequate pain management in an LTC facility. One resident was left in distress during a shower, with staff failing to document or address the pain. Another resident was not assessed for pain before wound care, leading to visible distress during the procedure. The facility did not follow its pain management policies, resulting in significant deficiencies.
A facility failed to provide adequate social services for a resident on psychotropic medication, resulting in a deficiency in monitoring and implementing individualized treatment. The resident, with severe cognitive impairment and multiple diagnoses, exhibited behavioral symptoms, but the facility lacked a comprehensive care plan and did not update medication changes. The social worker did not include historical information in assessments and deferred responsibility to a psychiatric provider, leading to inadequate guidance for staff. The behavior committee meetings did not address the resident's needs, and the DON acknowledged the lack of documentation.
The facility failed to ensure that monthly drug regimen reviews by the consultant pharmacist were reviewed and acted upon by the medical provider for two residents. One resident experienced delays in monitoring and medication adjustments, while another resident's Lexapro dosage recommendation was not addressed in a timely manner, despite agreement from the facility provider.
A facility failed to justify the use of antipsychotic medication for a resident with dementia, as no targeted behaviors or psychotic symptoms were documented. Despite episodes of yelling and refusal of care, the facility did not attempt a gradual dose reduction or develop individualized non-pharmacological interventions. Staff interviews revealed a lack of clarity in monitoring and addressing behaviors, with no explanation for the absence of targeted interventions.
The facility failed to maintain accurate medical records for two residents regarding advance directives. One resident's current medical directive was missing from the EMR, while another's records contained conflicting documentation about code status and lacked a medical power of attorney. Staff interviews revealed inconsistencies in the facility's process for handling advance directives, contributing to the deficiencies.
DON Inappropriately Assigned as Charge Nurse During High Census
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Director of Nursing (DON) did not serve as the charge nurse when the census exceeded 60 residents, as required by regulation. During an interview, the staffing scheduler reported that on a recent weekend night shift there were usually two nursing assistants per hall and a nurse, but due to several nurse and nursing assistant call-ins, the DON and a nurse manager were assigned to a medication cart and worked as charge nurses. The staffing scheduler stated this was not typical but acknowledged there were additional times when the DON helped out as a charge nurse when needed. In a separate interview, the DON confirmed working as a charge nurse that past weekend, stated it did not happen often but would occur when needed, and indicated they were going to look further into the regulatory requirements. When requested, the facility did not provide documentation such as a DON job description that included any limitations related to serving as charge nurse. This practice had the potential to affect all 99 residents in the facility. No specific residents, medical histories, or clinical conditions were described in the report; the cited issue centers on staffing assignments and the DON’s dual role as both DON and charge nurse during periods of staffing shortages.
Failure to Maintain Clean and Safe Resident Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for two residents when surveyors observed multiple instances of unclean and poorly maintained equipment and surfaces in their shared room. One resident was seen lying in bed with a green wedge pillow, with the call light on the floor under the overbed tray table, which lacked a clip and could not be kept within reach. The overbed tray table had lifted and peeled edging that exposed non-cleanable particle board, and the metal stand was covered with a dried dark substance. The bedside dresser surface was soiled with a thick white substance, and a blue floor mat stored against the dresser/television cabinet was covered in thick, dried, unidentifiable debris and stains. The low air loss unit attached to the bed’s footboard was set to off, and the resident was observed moaning and saying "Ow" when attempting to reposition, with eyes closed and not responding to verbal interaction. The second resident in the same room was observed in bed with carpet around the bed containing crushed food debris and a red, thick substance on the overbed tray table. Nursing staff acknowledged the low air loss mattress was off, were unsure if the current mattress was a low air loss mattress, and stated they were not aware of equipment concerns. The nurse confirmed the call light was on the floor and that no work orders had been placed for environmental or equipment issues. Environmental Services staff reported that daily cleaning included overbed tables and bedside dressers but not floor mats, which they stated were the responsibility of nursing, and that they would contact the front desk for maintenance issues such as peeling tray tables. On re-observation the following day with Environmental Services leadership, the floor mat remained stained, the carpet still had food debris, the overbed tray table remained soiled with a thick dark red substance, and the bedside dresser was still soiled with a white substance, despite the facility’s policy stating that used patient rooms are to be cleaned at least once daily, including floors, horizontal surfaces, visible soiling, and disinfection of high-touch surfaces.
Failure to Confirm Home Health Referral Prior to Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure a home health care referral was made and confirmed prior to a resident’s discharge to the community. The resident had diagnoses including type 2 diabetes and a cardiac pacemaker and required staff assistance with most ADLs, with a BIMS score of 15 indicating intact cognition. The resident’s care plan documented a focus of returning home with home health care supports, with interventions directing staff to arrange required community resources such as home care, PT, OT, MD, and wound nurse. The post-discharge plan of care identified a specific home health agency and listed a planned start date for in-home services of 1/24/26. Despite this documented plan, the facility did not complete and confirm the home health referral before discharge. The care coordinator reported they had not made the referral and believed a former social worker had done so. The care coordinator also acknowledged awareness of a concern that the home health agency had not received the referral prior to discharge and later learned from the agency that no referral had been received at that time. When the home health agency was contacted by surveyors, the agency reported receiving the medical referral for services by fax on 1/27/26, with services beginning on 1/28/26, confirming a delay between the resident’s discharge and the initiation of home health services.
Failure to Follow Physician Orders and Accurately Document Medication and Pressure-Relief Interventions
Penalty
Summary
The deficiency involves failure to follow nursing professional standards of practice and physician orders for medication administration and ordered treatments for two residents. One resident with type 2 diabetes, a cardiac pacemaker, and intact cognition had physician orders for midodrine with specific blood pressure parameters. The initial order directed midodrine 10 mg by mouth three times daily for hypotension with instructions to hold the dose if systolic blood pressure (SBP) was less than 110. A subsequent order changed midodrine to 10 mg by mouth every 8 hours as needed for hypotension with instructions to hold if blood pressure was greater than 110. Review of the January MAR showed the resident received midodrine when SBP was below 110 on multiple occasions and also when SBP was above 110 on multiple occasions, meaning the medication was administered outside the stated parameters. During interviews, the nurse manager acknowledged that the parameters transcribed into the midodrine order were incorrect because midodrine is intended to be given when blood pressure is low, not held when it is low, and stated that nursing staff should have clarified the order with the physician and corrected the parameters. The DON also confirmed that the parameters in the scheduled midodrine order were incorrect and should have been clarified. These findings show that the resident’s midodrine orders were not accurately transcribed or followed as written, and that the MAR documentation reflected administration inconsistent with the physician’s parameters. For a second resident with severe cognitive impairment, multiple fractures, dementia-related diagnoses, and hospice enrollment, active physician orders included bilateral heel protectors at all times when in bed, skilled care boots while in bed and off when out of bed for heel pressure reduction, and a low air loss (LAL) mattress. MAR/TAR documentation from the beginning through most of the month showed these interventions as completed each shift, with no charting exceptions. However, observation found the resident in bed without heel protectors or soft boots in place, and the LAL mattress unit at the foot of the bed was powered off. A pair of soft boots labeled for heel protection was found stored in the room rather than on the resident. The assigned nurse initially reported the resident did not use soft boots or heel protectors, was unaware of the active LAL mattress order, and then confirmed they had documented these interventions as completed that morning despite not having actually provided them, offering no explanation. The DON stated that nurses are expected to document on the MAR/TAR after completion of ordered care, underscoring that documentation did not reflect the care actually provided.
Failure to Provide and Accurately Document Ordered Hearing Aid Use
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered hearing assistive devices and accurately document their use for a resident with known hearing impairment. The resident had physician orders for hearing aids to be applied upon awakening daily at 7:00 AM and removed at bedtime, with storage in the medication cart. MAR/TAR documentation from 4/1–4/20 showed the tasks as completed with check marks and nurse initials, without any codes indicating refusal, missing devices, or other issues. On the morning of 4/20, the resident was observed in bed without hearing aids in place, moaning and saying “Ow” while repositioning, with eyes closed and no response when spoken to. The MDS indicated severe cognitive impairment and minimal difficulty with hearing, but incorrectly documented that the resident did not use a hearing aid, and the communication care plan noted the resident was slightly hard of hearing but did not include interventions for hearing aid use. During interview, the nurse assigned to the resident stated the hearing aids should have been in a charger at the nursing desk, not in the medication cart as ordered, and confirmed the resident was not wearing hearing aids despite having documented on the MAR that the 7:00 AM application had been completed. The nurse acknowledged marking the task as done even though it had not yet been performed, stating they had the entire shift to put the hearing aids in, and later reported that only one hearing aid was available and the other was missing, without knowing when both were last seen. The DON confirmed the hearing aids were kept at the nursing desk on a charger rather than in the medication cart and could not explain how the missing hearing aid had not been identified earlier despite ongoing documentation that the devices were being applied and removed. The facility’s Hearing and Vision Services policy referenced ensuring residents receive proper treatment and assistive devices, including hearing aids, but did not address a process for ensuring placement per the plan of care.
Failure to Implement Care-Planned Fall Prevention Interventions for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for two cognitively impaired residents identified as being at risk for falls. For the first resident, who had Alzheimer’s disease, hearing loss, severely impaired cognition (BIMS score of six), and required staff assistance with most ADLs, the care plan documented a focus of being at risk for falls related to dementia, gait and mobility impairments, incontinence, osteopenia, and weakness, with a history of a fall and readmission. The care plan interventions included keeping the bed in the lowest position and placing mats on the floor with non-slip footwear at all times. On multiple observations in the same day, surveyors found this resident in bed with the bed in a high position (approximately 3.5 feet off the floor) and no floor mats in place; the mat was seen propped on its side against the wall at the foot of the bed. When shown these conditions, the nurse acknowledged the bed should be lowered and the mat placed on the floor and confirmed the resident was a fall risk. For the second resident, who had a long history in the facility, severe cognitive impairment, and multiple diagnoses including late-onset Alzheimer’s disease, dementia, prior fractures of the femur and fibula, contusion of the head, glaucoma, convulsions, manic episode, major depressive disorder, and a prior left hip fracture, the care plan documented that the resident was at risk for falls and injury related to decreased mobility, hypertension, osteoarthritis, COPD, anxiety, dementia, incontinence, high-risk medication use, and a history of falls with hematoma and multiple injuries. The care plan further specified that the resident used a sit-to-stand device for transfers, had the bed against the wall with a mat next to the bed for safety, and had interventions including a perimeter mattress, bed in low position, mats on the floor, and placement of personal items within reach. Progress notes documented a prior fall in which the bed was in a high position and unlocked, resulting in the resident falling to the floor and sustaining a hematoma to the forehead, skin tears, and pain to the left foot, with subsequent hospital transfer and diagnoses including head contusion and fibula fracture. During the current survey, this second resident was observed lying in bed with the bed elevated rather than low, a regular non-perimeter mattress in use, and the call light on the floor under the overbed tray table and out of reach. A soiled blue floor mat was folded and resting against the closet instead of being placed next to the bed as care planned. When interviewed, the nurse assigned to the resident stated they did not consider the resident a fall risk and were unaware that a perimeter mattress was an intervention for this resident. The nurse unfolded the mat and placed it next to the bed only after being questioned, and stated staff had probably forgotten to put the mat back after assisting with breakfast. The DON later stated that nursing staff should be aware of the resident’s fall risk and that interventions should be in place, consistent with the facility’s Fall Prevention Program policy, which requires individualized fall prevention interventions to be included in the care plan and communicated to staff.
Failure to Lock Bed Wheels During Repositioning Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident care area was free from accident hazards and that adequate supervision and safety practices were used during resident care, specifically by not locking the bed wheels before repositioning a resident. According to a nursing progress note, a CNA reported that while providing care, they rolled the resident toward themselves, but the bed was in a high position with the wheels unlocked and rolled backward, causing the resident to fall from the bed to the floor. The resident was found on the floor next to the bed in a curled position leaning toward the right side, with a hematoma to the forehead, a skin tear on the left deltoid, and a skin tear on the right elbow, and complained of pain to the left foot. The facility’s post-fall analysis and investigation documented that staff rolled the resident toward themselves and the bed rolled away due to unlocked wheels, which was identified as the root cause of the fall. A written statement from the CNA confirmed that while performing care and rolling the resident from the wall side toward their body, the bed slid and the resident fell onto her side, resulting in bruising to the head, arm, and leg. Hospital imaging and assessment documented a closed displaced fracture of the left tibia, a contusion of the left upper extremity, and an abrasion of the right upper extremity, with the resident made non–weight bearing on the left lower extremity. The facility’s Resident Safety and Precautions policy in effect at the time required that bed wheels be locked as part of resident safety standards, which was not followed in this incident.
Failure to Review Critical Glucose Result Before Ordering Dextrose-Containing IV Fluids
Penalty
Summary
The deficiency involves the failure of the attending provider to review and act upon critical laboratory results before ordering and continuing IV fluids containing dextrose. A resident with psychotic disorder with delusions, delirium, Alzheimer's disease, stroke, and mood disorder was noted by a CNA as "wasn't herself" on the morning of 12/8/25. Nurse B contacted the on-call PA, who ordered STAT labs including a CBC and CMP. Labs drawn that morning and reported at 12:37 PM showed a critically high blood glucose level of 732 (normal 70–99). Nurse B later documented at 3:24 PM that they reviewed the lab results with the PA while the PA was in the building, and that new orders were received for D5% 0.45% NS at 125 ml/hr for 3 liters, with an IV started but then pulled out by the resident. The PA’s progress note for 12/8/25 documented an assessment of acute kidney injury and a plan to give 2 liters of IV fluid continuous, but did not document review of the STAT labs or specify the type of IV fluid. Subsequent nursing notes show that on the afternoon of 12/8/25 the PA called back with new orders for hypodermoclysis, which was initiated. On 12/9/25, Nurse G documented placement of a new PIV and that the resident was hooked up to IV fluids as ordered, specifically D5% 0.45% NS per the PA’s prior order. Nurse H documented an order clarification for D5% 0.45% NS infusing at 125 cc/hr times 2 liters, and Nurse I documented that the resident had a peripheral IV in the right forearm with D5% 0.45% NS infusing at 125 cc, bag 2 of 2. In the early hours of 12/10/25, Nurse C documented that the resident was resting in bed with D5% 0.45% NS infusing via right arm PIV, and that the resident was hard to arouse. A blood sugar check at that time read "Hi" on the glucometer, and the on-call NP was contacted. New orders were received to give 12 units of Lispro insulin, recheck in 2 hours, and repeat 12 units if the blood sugar still read "Hi," with instructions to call back if it remained "Hi" after the second dose. Subsequent notes by Nurse C documented repeated "Hi" blood sugar readings, administration of Lispro insulin, the resident being lethargic and difficult to arouse, and that an ambulance was called for transfer to the hospital. Hospital records indicated the chief complaint was high blood sugar and altered mental status, and EMS reported the patient was receiving D5 fluid hydration on their arrival. In an interview, the PA stated they were not aware of the glucose level of 732 prior to ordering D5% 0.45% NS, acknowledged they did not document lab review, and stated they would not have ordered IV fluid with dextrose if they had known. The DON indicated that the PA’s order for D5% 0.45% NS could have been questioned by the nurse who received the critical glucose result and implemented the order. The facility’s policy requires providers to review laboratory tests during visits and analyze abnormal results with documented rationale and interventions.
Improper Storage and Cooling of Food Items
Penalty
Summary
Surveyors observed that clean dessert-sized cups were stored uncovered in bins next to a handwashing sink. When questioned, the Certified Dietary Manager (CDM) acknowledged that the cups should have been covered. This storage practice did not comply with the 2022 FDA Food Code, which requires clean equipment and utensils to be stored in a clean, dry location, protected from contamination, and either covered or inverted. Additionally, two pans of whole, cooked pork loins were found on a speed rack in the food preparation area, covered with plastic wrap and dated from the previous day. The internal temperatures of the pork loins ranged from 48-51°F, and review of the facility's cooling log showed that the pork loins had not been logged to ensure proper cooling. The CDM was unsure why the cooling log was not used. This practice did not meet FDA Food Code requirements for cooling cooked food to 41°F or less within the specified timeframe.
Failure to Notify Physician and Administer Prescribed Blood Pressure Medication
Penalty
Summary
A deficiency occurred when a resident admitted with a diagnosis of hypertension did not receive a prescribed blood pressure medication, candesartan-hydrochlorothiazide, for four consecutive days following admission. The medication was not available on the medication cart or in the backup medication dispensing machine, and although it was ordered from the pharmacy, there was no follow-up or documentation indicating that the medication had been received or administered during this period. Progress notes and the Medication Administration Record confirmed the medication was not given on four specific days, and there was no documentation that the attending physician was notified of the unavailability of the medication. Interviews with the resident and the Director of Nursing (DON) revealed that the resident expressed concern about not receiving the medication and that the DON was unaware of the missed doses until after the fact. The DON stated that facility protocol required contacting the pharmacy and notifying the medical provider for further instructions or alternative orders when a medication was unavailable, but there was no evidence this occurred. The pharmacy technician also failed to communicate with the facility regarding the delay. Documentation from the physician and provider progress notes did not mention the medication's unavailability, and there was no indication that alternative measures were considered during the four-day lapse.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
A resident was observed during a lunch meal with a container of food pushed aside, stating she did not eat the meal because it contained pork, which she does not consume. The resident reported that the facility repeatedly served her pork products despite her clear communication that she did not eat pork. She also mentioned previous instances where she was served eggs mixed with pork products. The meal ticket for that day confirmed that pork tenderloin was served to her. Interviews with the Registered Dietician (RD) and the Director of Nursing (DON) revealed that dietary assessments are typically completed within seven days of admission, and any dietary preferences expressed prior to that should be communicated to both the RD and kitchen staff. The DON confirmed that nursing staff are expected to relay residents' food preferences to dietary staff. Despite these protocols, the resident's dietary preferences were not consistently honored, resulting in her frustration.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances of unclean and unsafe environmental conditions throughout the facility, including scattered straw wrappers, crumbs, and debris in hallways and resident rooms. Dried food matter was noted on walls, and partition curtains in several rooms were soiled and unkempt. In the dining areas, there were moderate-sized dried food spillages on carpets, and the carpet near the medication cart was heavily soiled. Additional observations included hardwood flooring with scattered debris and food crumbs, as well as soiled hallway carpeting with liquid spills and old food matter that appeared to have been run over by a wheel. Staff personal belongings were found improperly stored in a residential dining room cabinet, which was acknowledged by staff as inappropriate. During a tour with the Environmental Services Supervisor, the supervisor confirmed that the areas of dried food and soiled curtains should have been identified and cleaned. The supervisor also acknowledged that the resident rooms and hallways appeared cluttered with debris and had not been vacuumed for some time, despite claims of recent cleaning. The facility's policy for environment and housekeeping was requested but was not available at the time of exit. These findings indicate a failure to maintain a safe, clean, and comfortable environment for residents.
Failure to Label and Date Resident Food Items in Community Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to ensure that food items brought in from outside sources and stored in the community residential refrigerator in the 2107 Dayroom were properly labeled and dated. During an inspection, several food items, including a brown paper bag from a fast food restaurant, a black three-compartment container with cornbread, a small clear container with white dressing, a Styrofoam cup with a brown liquid, a container of vanilla ice cream, and another Styrofoam cup with an unidentified frozen substance, were found in the refrigerator and freezer without any resident identifiers or dates. The facility's policy requires that all food brought in for residents be labeled with the resident's name and the date it was brought in, but this procedure was not followed. The unit manager RN confirmed that the items should have been labeled accordingly.
Failure to Complete Sepsis Screening for Resident with Active Infection
Penalty
Summary
The facility failed to conduct accurate and thorough sepsis screening for a resident who was admitted with multiple serious diagnoses, including metastatic cancer, COPD, and chronic respiratory failure. The resident tested positive for influenza A and was placed on droplet precautions, receiving antiviral therapy as ordered. According to facility policy and the Infection Control Preventionist, residents with infections treated with antibiotics or antivirals are to be monitored for sepsis using a Severe Sepsis Screening Tool throughout the duration of the illness and isolation precautions. A review of the resident's sepsis screening documentation revealed that, although the presence of infection and antiviral therapy was noted on some days, the remainder of the screening tool was left incomplete, omitting required assessments for SIRS and organ dysfunction. On subsequent days, the documentation incorrectly indicated the absence of infection and therapy, despite the resident's ongoing positive influenza status and antiviral treatment. The facility's own infection control surveillance confirmed the resident had an active infection and was under isolation precautions, but the required sepsis monitoring was not properly completed or documented.
Failure to Monitor and Document PRN Oxygen Administration
Penalty
Summary
The facility failed to appropriately monitor and document the respiratory status of a resident who experienced a change in condition. The resident, who had diagnoses including influenza A, COPD, metastatic prostate cancer with bone involvement, obstructive sleep apnea, and chronic respiratory failure, was admitted without a need for oxygen therapy. After testing positive for influenza A, a physician's order was written for PRN oxygen at 2 liters for shortness of breath. However, there was no corresponding order or documentation area on the MAR/TAR for PRN oxygen, and no consistent documentation of when oxygen was administered. Throughout the resident's stay, oxygen saturation levels were recorded only while the resident was already receiving oxygen, with no documentation of oxygen saturation prior to administration. Progress notes indicated episodes of labored breathing and low oxygen saturation while on oxygen, but failed to provide information about the resident's status before oxygen was applied. The Director of Nursing confirmed that documentation of PRN oxygen administration and pre-administration oxygen levels was lacking, and the facility did not have a policy regarding monitoring respiratory status for PRN oxygen.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner and ensure potentially hazardous food items were properly cooled, as observed during a survey. Several gnats were found flying around the handwashing sink near the kitchen entry door, and the trash can for the sink lacked a liner, attracting more gnats. The presence of insects violated the 2017 FDA Food Code, which requires premises to be free of pests. Additionally, the walk-in cooler had milk pooled on the floor, an opened cooked ham past its use-by date, an undated sliced onion, and a tub of ricotta also past its use-by date. Raw turkey was improperly stored above raw beef, which could lead to cross-contamination. The facility also failed to properly cool cooked pork butt, which was tightly covered with foil and stored in the walk-in cooler without recorded temperatures on the cooling log. The internal temperature of the pork was measured between 50-53 degrees Fahrenheit, not meeting the FDA Food Code requirements for cooling potentially hazardous food. The dish machine had a heavy buildup of limescale, and the ice machine had dust and black stains, indicating a lack of proper cleaning and maintenance. In the dry storage room, the floor was observed with cobwebs, food debris, and a leaking can of soda. The area under the ice machine had debris, a juice cup, and an ice cream cup, while the floor drain in front of the ice machine had a heavy accumulation of food debris and grease. The steam table had a bin of thickener with scattered powder, a soiled toaster, and a buildup of crumbs mixed with standing water. These observations highlight the facility's failure to maintain cleanliness and adhere to the FDA Food Code standards for food safety and sanitation.
Facility Lacks Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time social worker to meet the psychosocial, mental, and behavioral health care needs of its residents, as identified during a recertification survey. The survey, conducted from October 28 to October 30, 2024, revealed multiple concerns regarding the facility's social work practices, including mood and behavior management, psychotropic medication, psychosocial assessments, and processes for completing advance directives and coordinating decision-makers. Interviews with the Director of Nursing (DON) and Staff 'D' confirmed that Staff 'D' was the only social worker employed at the facility, which is licensed for 179 beds. Staff 'D' reported that they had been working as a social worker since January 2024 but were not currently licensed, with their last license having expired in 2019. The facility's Administrator was aware of Staff 'D's lack of licensure but believed, based on advice from other facilities and their corporate team, that a license was not necessary. The Administrator confirmed that the last licensed social worker was employed until July 5, 2024, and acknowledged the difficulty in filling the social worker role. The surveyors identified concerns with the facility's hiring of a non-licensed individual for the social worker position, which could potentially lead to unmet psychosocial needs of the residents.
Inadequate Infection Control Practices in Wound Care and Droplet Precautions
Penalty
Summary
The facility failed to ensure adequate infection control practices during wound care for a resident identified as having pressure ulcers. During observations, it was noted that Enhanced Barrier Precautions (EBP) were not in place or utilized during the wound care process. The nurse involved did not wash hands or use hand sanitizer before donning gloves and proceeded to touch multiple surfaces before handling wound care supplies. Additionally, the nurse did not change gloves after touching contaminated surfaces, which compromised the aseptic technique required for wound care. In another instance, the facility did not implement proper infection control practices for residents on droplet precautions related to COVID-19. A Licensed Practical Nurse (LPN) entered a resident's room marked for droplet isolation without donning the appropriate Personal Protective Equipment (PPE), such as a gown, gloves, or face shield. The LPN acknowledged the oversight upon being questioned and subsequently donned a gown and gloves but still failed to wear a face shield or goggles as required by the facility's policy. Similarly, a Certified Nursing Assistant (CNA) entered another resident's room on droplet precautions wearing only a gown and gloves, without the necessary face shield or goggles. The CNA admitted to the oversight when questioned. The facility's policy clearly states the need for protective eyewear and respiratory protection for droplet isolation, which was not adhered to in these instances, indicating a lapse in following established infection control protocols.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were easily accessible and within reach for three residents, resulting in their inability to summon help when needed. Resident R8 was observed on two occasions with the call light out of reach, once draped across the end of the footboard and another time tucked behind the wall and mattress. R8 had severe cognitive impairment, physical behavioral symptoms, and was always incontinent of bowel and bladder. The Director of Nursing acknowledged the issue and mentioned the need for staff re-education. Resident R7 was found with the call light on the floor, several feet from the bed, while in isolation for Covid-19. R7 had moderate cognitive impairment and was diagnosed with muscle weakness and chronic obstructive pulmonary disease. Similarly, resident R333, also in isolation for Covid-19, was observed with the call light on the floor, out of reach. R333 was dependent on oxygen. In both cases, staff confirmed the call lights were out of reach and placed them within reach upon notification.
Failure to Follow Protocols for Code Status Changes
Penalty
Summary
The facility failed to adhere to appropriate protocols for changing residents' treatment preferences regarding code status, affecting three residents. Resident R32, who was admitted with Alzheimer's Disease and had a severely impaired cognition score, had conflicting documentation regarding their code status. The resident's legal guardian had signed a form indicating a preference for CPR, but a care conference note later indicated a change to DNR without evidence of the resident's involvement in the decision-making process. Resident R63, also with a diagnosis of dementia and severely impaired cognition, had discrepancies in their code status documentation. The legal guardian had signed a form indicating CPR, but the electronic medical record showed No CPR. There was no evidence that the resident was included in discussions about changing their code status, and verbal consent was obtained without a follow-up signature from the legal guardian. Resident R52, with severe cognitive impairment and functional quadriplegia, had conflicting documentation regarding their code status. The facility's records showed a lack of proper documentation for a Durable Medical Power of Attorney, and verbal consent for a DNR order was obtained from a daughter without verification of legal authority or the resident's prior wishes. The facility's process for handling advance directives was inconsistent, with verbal consents being used without proper follow-up, leading to discrepancies in residents' code status documentation.
Insulin Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure insulin administration was performed according to professional nursing standards of practice for a resident with Type 2 Diabetes Mellitus. The resident expressed concerns about receiving their breakfast tray late, around 9 AM, while their morning insulin dose was administered hours earlier, between 5:24 AM and 6:23 AM, over several days. The scheduled time for the morning insulin dose was 6 AM, but the breakfast trays were delivered at 8:30 AM, creating a gap of 2.5 hours between insulin administration and meal delivery. The resident's physician orders specified the use of Humalog KwikPen Subcutaneous Solution per sliding scale four times per day, which according to the manufacturer's guidelines, should be injected within 15 minutes before or right after a meal. The Director of Nursing confirmed that short-acting insulin should be given closer to mealtime, indicating a deviation from the recommended practice. This discrepancy between insulin administration and meal delivery times led to the deficiency identified by the surveyors.
Failure to Identify and Document Bruising in Resident
Penalty
Summary
The facility failed to identify, assess, and determine the root cause of bilateral arm bruising for a resident reviewed for skin conditions. The resident, who has Alzheimer's disease, was observed with multiple areas of discoloration on both arms, resembling bruises. Despite these observations, there was no documentation of recent skin impairments in the resident's clinical record, progress notes, or care plans. Additionally, the resident was not on any medications that would increase the risk of bruising, and no incident reports were available for the discoloration observed. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed a lack of awareness and explanation for the bruising. The DON stated that any skin impairments should be documented in weekly skin assessments or progress notes, but this was not done for the resident in question. A progress note was written after the discoloration was observed, but it lacked further assessment. The DON later suggested a possible nutritional deficiency as the cause, but this was not documented in a care plan or diagnosed by a medical provider. An incident report from four months prior noted a skin tear but did not mention any bruising.
Failure to Coordinate Timely Vision Services for Resident
Penalty
Summary
The facility failed to timely coordinate vision services for a resident who had been without prescription glasses since July. The resident, who was admitted with diagnoses including bipolar disorder, depression, and anxiety, reported to have lost their glasses prior to admission and only had reading glasses available. This situation led to the resident experiencing headaches, eye pain, and difficulties in reading television content and participating in activities like bingo. Despite the resident's intact cognition, as indicated by a perfect score on the Minimum Data Set assessment, the facility's social services were not aware of the resident's need for prescription glasses or the associated symptoms. A social work progress note from July indicated the resident's lack of prescription glasses, but no specific action for vision services was taken until the resident was placed on an ancillary services list without a specific request for vision services. Vision service providers were scheduled to visit the facility in November, but the resident's needs were not addressed in a timely manner.
Failure to Implement Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to implement preventative pressure ulcer interventions and administer treatment according to physician's orders for a resident identified as R70. Observations revealed that R70 was lying in bed on a low air loss mattress with their feet tucked under a blanket, adding pressure to the tips of the feet and toes. There were no pressure-relieving boots in use or available in the room, despite orders to suspend heels while in bed. Wound care supplies were found on the bedside table, and it was unclear if the treatment had been completed as documented by Nurse G. During wound care observation, it was noted that neither Nurse N nor Nurse L assessed the resident for pain or offered pre-medication before starting the wound care. The resident exhibited signs of pain during the procedure, and it was only after the resident expressed discomfort that pain medication was offered. Additionally, the wound care was performed without proper hand hygiene, as Nurse L used the same gloves to touch multiple surfaces and then proceeded to clean the wound. The resident's clinical record indicated that the pressure ulcers developed while in the facility, with a Stage II ulcer on the coccyx and a deep tissue injury on the left great toe. The care plan included interventions such as turning and repositioning every two hours and using skilled care boots, which had been discontinued without re-implementation. Interviews with the Director of Nursing and Wound Nurse E confirmed awareness of the issues, but the necessary interventions were not observed in place until identified by the surveyor.
Deficiencies in Hydration and Nutrition Management
Penalty
Summary
The facility failed to provide fresh water at the bedside, within reach, and offer it throughout the shift for two residents, resulting in the potential for continued dehydration and electrolyte imbalances. Observations revealed that one resident had a water cup dated from the previous day, placed out of reach, and containing room temperature water. Despite multiple physician orders to encourage oral fluid intake due to dehydration and other medical conditions, the resident's care plans did not address the need for increased hydration. Another resident was observed with a full cup of water out of reach, despite care plans indicating a risk for dehydration and the need for fresh water within reach. The facility also failed to ensure accurate assessment and adequate monitoring of weight loss for another resident. This resident expressed dissatisfaction with the facility's food and reported significant weight loss. The clinical record showed a substantial weight loss over a year, but there was no documented plan for monitoring this weight loss. The resident's nutritional assessments indicated a risk for malnutrition, yet the facility's documentation did not reflect ongoing monitoring or intervention for the resident's weight loss. Interviews with staff, including the Director of Nursing and a Registered Dietician, revealed a lack of awareness and monitoring of the residents' hydration and nutritional needs. The facility's policies on water distribution and nutrition monitoring were not effectively implemented, leading to deficiencies in resident care. The observations and interviews highlighted a failure to adhere to established protocols, resulting in potential harm to the residents due to inadequate hydration and nutrition management.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide timely and appropriate pain management for two residents, R32 and R70, leading to unnecessary pain. R32 was observed in significant distress while seated in a shower chair, yelling and crying due to pain. Despite the resident's clear expression of discomfort, the staff did not document the incident or implement new interventions to prevent future pain. The assigned nurse, LPN 'A', dismissed the resident's cries as a behavior rather than addressing the pain, and no additional measures were taken to alleviate the discomfort during showers. R70 experienced inadequate pain management during wound care. The resident was not assessed for pain or offered pre-medication before the procedure, resulting in visible and audible signs of distress. Despite the resident's cries of pain, the nurses continued the wound care without addressing the pain adequately. The facility's records showed a lack of documentation for pain management, and the care plan was not updated to include interventions for the resident's pressure ulcers until after the surveyor's observation. The facility's policies on pain assessment and management were not followed, as evidenced by the lack of timely interventions and documentation for both residents. The Director of Nursing acknowledged the issues but did not provide additional follow-up by the end of the survey. The failure to assess and manage pain effectively for R32 and R70 highlights significant deficiencies in the facility's care practices.
Failure to Provide Adequate Social Services for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to provide adequate medically related social services for a resident receiving psychotropic medication, leading to a deficiency in monitoring, identifying, and implementing individualized treatment and behavioral interventions. The resident, who was admitted with severe cognitive impairment and multiple diagnoses including psychotic disorder and dementia, exhibited physical and verbal behavioral symptoms. Despite these behaviors, the facility did not have a comprehensive care plan addressing the resident's specific behaviors or the use of antidepressant medication. The care plan was outdated and did not reflect changes in the resident's antipsychotic medication. The facility's social worker, Staff 'D', did not include historical information from the resident or family regarding mood, behaviors, and psychotropic medication in the initial assessment. Instead, they referred residents to a contracted psychiatric provider. There was a lack of follow-up from social work to address requests for evaluation, and the behavior committee documentation did not address the resident's use of antipsychotic and antidepressant medication or specific behaviors identified by nursing staff. The social worker deferred responsibility for identifying specific behaviors and interventions to the psychiatric provider, resulting in a lack of clear guidance for direct care staff. Interviews with Staff 'D' and the Director of Nursing (DON) revealed a lack of interdisciplinary communication and documentation regarding the resident's care. The behavior committee meetings did not adequately address the resident's needs, and there was no documentation of non-pharmacological interventions or specific targeted behaviors. The DON acknowledged the lack of documentation and concern but was unable to provide further explanation. This deficiency highlights a failure in the facility's processes for managing residents with complex behavioral and medication needs.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews conducted by the consultant pharmacist were reviewed by the medical provider for recommendations to act upon for two residents. For one resident, the pharmacist identified irregularities in the drug regimen on three separate occasions, recommending monitoring of serum magnesium levels, a dose reduction of Protonix, and a TSH level check. However, these recommendations were not reviewed or acted upon by the medical provider in a timely manner, resulting in delayed monitoring and adjustments to the resident's medication regimen. The resident's magnesium level was checked over two months after the recommendation, the Protonix dose was reduced two months later, and the TSH level was checked three months later, which revealed an abnormally high level requiring a dosage change. For another resident, the pharmacist recommended a gradual dose reduction of Lexapro, noting the resident's hospice status but emphasizing compliance with CMS regulations. The facility provider agreed with the recommendation but noted that the patient's medications were managed by hospice. However, there was no communication from the hospice provider regarding the pharmacist's recommendation, and the Lexapro dosage remained unchanged for over two months. The Director of Nursing later indicated that hospice would evaluate the Lexapro, suggesting that the recommendation had not been addressed in a timely manner.
Failure to Justify Antipsychotic Use and Implement Interventions
Penalty
Summary
The facility failed to provide justification for the use of antipsychotic medications in a resident with dementia, identified as R37, and did not develop or implement individualized non-pharmacological interventions. R37 was observed multiple times sleeping in a wheelchair, and their clinical record showed a prescription for Rexulti, an antipsychotic medication, for dementia, agitation, and delusion. Despite a documented attempt at a gradual dose reduction (GDR) being clinically contraindicated, there was no evidence of psychotic symptoms or targeted behaviors identified in the resident's care plan or behavior management committee meeting minutes. The facility's behavior management committee failed to document targeted behaviors or symptoms for R37, and no GDR of Rexulti was attempted as previously discussed. Progress notes indicated episodes of yelling, abusive language, and refusal of care, but there was no documented evidence of psychotic symptoms. Evaluations by the consulting psychiatry provider noted that non-pharmacological interventions had not sufficiently relieved target symptoms, yet no specific target symptoms were identified, and the GDR was deemed contraindicated. Interviews with facility staff, including Social Services Staff and the Director of Nursing, revealed a lack of clarity and responsibility in monitoring behaviors and developing interventions for residents prescribed antipsychotic medications. The interdisciplinary team approach was mentioned, but there was no explanation for the absence of individualized interventions or targeted behaviors for R37. The facility's behavior committee program was supposed to address these issues, but the Director of Nursing could not explain why this was not done for R37.
Deficiency in Maintaining Accurate Medical Records for Advance Directives
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R28 and R52, regarding their advance directives. For R28, the facility did not have current documentation in the electronic medical record (EMR) of a medical directive regarding decisions for code status since their admission. The only available documentation was from a previous admission, and the facility's process for documenting such directives was inconsistent, as noted by Social Services staff who indicated that medical directive forms were kept in binders and not formally loaded into the EMR. For R52, the facility's records were also incomplete and conflicting. The resident's profile identified two daughters as durable power of attorney, but the available documentation was only for financial decisions and did not include medical directives. The EMR contained a physician order for no CPR, but there was no corresponding medical directive form in the EMR. Additionally, there were discrepancies in the documentation by different medical staff regarding the resident's code status, with conflicting entries by a Physician Assistant and a Physician. The facility lacked documentation of a medical power of attorney and had not declared the resident incompetent as required to activate such a power. Interviews with facility staff, including the Director of Nursing and Social Services, revealed a lack of clarity and consistency in the process for handling advance directives. The Director of Nursing acknowledged the discrepancies and the need for immediate attention. Social Services staff admitted to the absence of a medical power of attorney in the records and could not explain why verbal consent was accepted without proper verification. The facility's practice of keeping medical directive forms in binders rather than integrating them into the EMR contributed to the deficiencies in maintaining accurate and complete medical records.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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