Eastwood Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Negaunee, Michigan.
- Location
- 900 Maas Street, Negaunee, Michigan 49866
- CMS Provider Number
- 235554
- Inspections on file
- 14
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Eastwood Nursing Center during CMS and state inspections, most recent first.
The facility did not have documented agreements with a water supplier for emergency drinking water and relied on an onsite well that had not been observed to function by maintenance staff, resulting in a failure to ensure subsistence needs for staff and patients during emergencies.
The facility did not provide or document required initial and annual emergency preparedness training for all staff, individuals providing services under arrangement, and volunteers. An interview with the education director confirmed the lack of annual refresher training and absence of documentation, resulting in noncompliance with federal emergency preparedness regulations.
A review of facility records and staff interviews revealed that the dry sprinkler system in the attic was not functioning properly, with the system capped and only six operational heads, resulting in non-compliance with required building construction and sprinkler system standards.
A review of facility records revealed that the dry sprinkler system in the attic had been capped off, leaving the attic without full sprinkler protection as required by NFPA 13. This was confirmed by the Maintenance Director during the survey.
The facility did not ensure that automatic sprinkler system supervisory attachments were properly installed and monitored, as the system was found capped and failed inspection, with supervisory or trouble alarms present on the fire alarm control panel indicating part of the system was shut down.
A deficiency was identified when the facility did not maintain or test its automatic sprinkler system as required, with inspection records showing the attic dry system was capped and only six heads were active. No documentation was available to indicate ongoing repairs or which parts of the system were functional, as confirmed by the Maintenance Director.
The facility did not implement a fire watch or post required signage when the sprinkler system was out of service, and staff including a CNA and the ADON were unaware of the outage, as revealed by inspection and interviews.
The facility did not ensure staff were informed or educated about changes in fire response procedures after a portion of the sprinkler system was found inoperable, with only six active heads in the attic. Both a CNA and the ADON were unaware of the system's status, and the deficiency was confirmed by the Maintenance Director.
A facility failed to implement interventions for a resident with bilateral hand contractures, as the resident was observed without required palm grips or splints on her left hand. Despite the care plan indicating the need for palm grips at all times, observations showed the resident without them, and staff confirmed the oversight. The resident, diagnosed with conditions like Parkinson's disease and dementia, was undergoing therapy to improve hand function.
A resident with blindness and chronic pain expressed loneliness and boredom, stating that interaction alleviated his pain. Despite this, the facility failed to provide necessary behavioral health care or make an outside referral, as confirmed by staff interviews and the Director of Nursing.
Deficient Emergency Preparedness for Subsistence Needs
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure the provision of subsistence needs for staff and patients during an emergency, as required by federal regulations. Specifically, the emergency preparedness plan did not include documentation of an established relationship or emergency contract with a water supplier to provide drinking water in the event of an emergency. Although the plan referenced the intention to secure such an agreement, no evidence was provided to confirm that this had been accomplished by the time of the survey exit. Additionally, the facility's emergency plan cited the use of an onsite well as an alternative water source during emergencies. However, interviews with the Maintenance Director and his assistant revealed that neither had observed the well functioning during their respective tenures of approximately three and sixteen years. This lack of operational verification further demonstrated the facility's failure to ensure reliable access to water for subsistence needs in emergency situations.
Plan Of Correction
1. The facility failed to establish relations and obtain an agreement with a water supplier to provide the facility water in the event of an emergency. 2. Failure to ensure the facility has an agreement with a drinking water supplier could affect all residents, employees, and visitors in the event of an emergency. 3. The maintenance director has obtained an emergency drinking water agreement with Norway Springs to provide the facility with drinking water in the event of an emergency. The maintenance director has been educated on the importance of maintaining drinking water sources/agreements. 4. The Administrator is responsible for ensuring drinking water agreements are established and implemented at the facility and report to the QA committee. 5. The facility failed to maintain an accurate policy for emergency water within the emergency preparedness plan, specifically pertaining to the use of an existing onsite water well resource. 6. Failure to ensure all water emergency water sources are in place and accurate could affect all residents, employees, and visitors in the event of an emergency. 7. The onsite water well is currently not in use and has been removed from the facility emergency preparedness plan. The maintenance director has been educated on the importance of maintaining accurate emergency water resources and policies within the facility. 8. The Administrator is responsible for the implementation of accurate policies and procedures pertaining to emergency water in the event of an emergency and report to the QA committee.
Failure to Provide and Document Annual Emergency Preparedness Training
Penalty
Summary
The facility failed to provide initial and annual emergency preparedness training to all new and existing staff, individuals providing services under arrangement, and volunteers, as required by federal regulations. The deficiency was identified during a record review and interview with the facility education director, who confirmed that annual emergency preparedness refresher training had not been conducted as mandated by 42 CFR 483.73(d)(1)(2). No documentation was available to demonstrate that staff had received the required refresher training on emergency preparedness policies and procedures. The absence of such documentation indicated that the facility did not maintain records of emergency preparedness training for its staff, as required by regulation. Additionally, the facility was unable to demonstrate staff knowledge of emergency procedures, as there was no evidence that training had occurred. This deficiency could potentially affect all occupants in the event of an emergency, as staff may not be adequately prepared to respond to emergency situations.
Plan Of Correction
1. The facility failed to provide annual emergency preparedness refresher training to all facility employees. 2. Failure to provide the annual emergency preparedness refresher training to facility employees could affect all residents, employees, and visitors in the event of an emergency. 3. The education director has educated all employees on the emergency preparedness plan via the Relias education platform. The education director has been educated on the importance of the annual emergency preparedness refresher training. 4. The administrator is responsible for ensuring all employees are educated during the annual emergency refresher training and report to the QA committee.
Non-Compliance with Sprinkler System Requirements in Attic Space
Penalty
Summary
The facility failed to ensure that its building construction type and number of stories complied with the requirements outlined in Table 19.1.6.1, as required unless otherwise permitted by specific exceptions. During a record review and interview, it was found that the dry sprinkler system in the attic space did not pass inspection because the system was capped and only six sprinkler heads were operational. The annual dry sprinkler inspection report confirmed this deficiency, and the Maintenance Director verified that the attic sprinkler system was not functioning properly. This failure is in violation of the requirement that all LTC facilities be fully sprinklered and maintain their systems as mandated by 73 CFR 47075.
Plan Of Correction
1. The facility did not maintain the dry sprinkler system in proper working condition throughout the building. 2. A malfunctioning dry sprinkler system poses a risk to the safety of all residents, staff, and visitors in the event of a fire emergency. 3. Corrective actions have been completed as follows: - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics installed a second air compressor and replaced 12 feet of main sprinkler piping. - The sprinkler system was flooded and tested, revealing two leaks (located above a resident room and in the boiler room); both have been repaired. - Superiorland Electronics will conduct a trip test to confirm the system is functioning properly. - The Maintenance Director has been educated on the critical importance of maintaining the dry sprinkler system in working order. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is responsible for ongoing monitoring of the dry sprinkler system to ensure it remains operational at all times and will report system status and maintenance updates to the Quality Assurance (QA) Committee.
Attic Sprinkler System Not Installed per NFPA 13
Penalty
Summary
The facility failed to provide a sprinkler system installed in accordance with NFPA 13, as required by federal regulations. During a record review, it was found that the dry sprinkler system throughout the attic space had been capped off, resulting in the attic space lacking complete sprinkler protection. This deficiency was confirmed by the Maintenance Director at the time of the review. The report does not mention any specific residents or their medical conditions in relation to this deficiency.
Plan Of Correction
1. The facility failed to maintain the dry sprinkler system in proper working condition throughout the entire building. 2. A non-functioning dry sprinkler system poses a serious risk to the safety of all residents, staff, and visitors during a fire emergency. 3. Corrective actions have been implemented as follows: - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics was engaged to install a second air compressor and replace 12 feet of main sprinkler piping. - The system was water-tested, during which two leaks were identified (above a resident room and in the boiler room); both were repaired. - A trip test will be conducted by Superiorland Electronics to verify full functionality of the system. - The Maintenance Director has received training on the importance of routine inspection and upkeep of the dry sprinkler system. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is now responsible for ensuring the sprinkler system remains fully operational and will report on system status and any maintenance issues during regular Quality Assurance (QA) Committee meetings.
Deficiency in Sprinkler System Supervisory Signal Monitoring
Penalty
Summary
The facility failed to ensure that automatic sprinkler system supervisory attachments were properly installed and monitored for integrity in accordance with NFPA 72 requirements. During a record review, it was found that the annual dry sprinkler inspection indicated the system had been capped and failed the inspection. Additionally, review of the fire alarm control panel (FACP) revealed that supervisory and/or trouble alarms were present, indicating that a portion of the sprinkler system had been shut down. These findings were confirmed by the Maintenance Director at the time of discovery. No information about specific residents or their medical conditions was provided in the report.
Plan Of Correction
1. The facility failed to maintain the automatic sprinkler system's supervisory attachment panel in proper working condition. 2. A malfunctioning supervisory panel compromises the effectiveness of the sprinkler system, potentially placing all residents, staff, and visitors at risk during a fire emergency. 3. Corrective actions are underway as follows: - Superiorland Electronics has been contacted and has ordered a new dry pipe valve and a new control valve equipped with a tamper switch. - Once parts are installed, the system will be tested to ensure full functionality. - The Maintenance Director has been educated on the importance of maintaining a properly functioning automatic sprinkler system supervisory panel. 4. The Maintenance Director is responsible for ensuring the panel remains operational and will report system status and maintenance updates to the Quality Assurance (QA) Committee.
Failure to Maintain and Test Sprinkler System per NFPA 25
Penalty
Summary
The facility failed to provide required maintenance and testing for its automatic sprinkler system in accordance with NFPA 25. During a record review, it was found that the annual dry sprinkler inspection revealed the system did not pass inspection because the dry system in the attic was capped and only six sprinkler heads were active. At the time of the survey, there was no documentation available to show that corrective work was being performed or to specify which parts of the system were operational. This deficiency was confirmed by the Maintenance Director during the record review. No information was provided regarding the specific impact on residents or staff at the time of the deficiency.
Plan Of Correction
1. The facility failed to provide documentation confirming that corrective work on the dry sprinkler system was being completed to ensure proper system function. 2. Inadequate documentation and maintenance of the dry sprinkler system may compromise the safety of residents, staff, and visitors in the event of a fire emergency. 3. Corrective actions have been implemented as follows: - Excel Fire Protection replaced the 3-inch and 4-inch piping in the system. - Superiorland Electronics installed a second air compressor and replaced 12 feet of main sprinkler piping. - The system was flooded and tested; two leaks were identified (above a resident room and in the boiler room) and have been repaired. - A trip test will be conducted to confirm proper system functionality. - Both Excel and Superiorland Electronics have submitted full documentation of all repair and maintenance work to the facility. - The Maintenance Director has received training on the importance of maintaining a functional dry sprinkler system and retaining documentation of all related work. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Maintenance Director is responsible for ensuring the sprinkler system remains operational, for maintaining complete documentation of all service and repairs, and for reporting system status to the Quality Assurance (QA) Committee.
Failure to Provide Fire Watch and Staff Notification During Sprinkler System Outage
Penalty
Summary
The facility failed to ensure that when the sprinkler system was out of service for more than 10 hours in a 24-hour period, the affected areas were either evacuated or an approved fire watch was provided, as required by relevant fire safety codes. Record review showed that the annual dry sprinkler inspection revealed the system failed due to the attic dry system being capped and only six heads active. Despite this, the facility was not conducting fire watch in the unprotected areas, and required 'out of service' signage was not posted throughout the building, contrary to the facility's fire watch policy. Additionally, staff interviews indicated a lack of awareness regarding the non-operational status of the sprinkler system. A CNA stated she was not informed about the sprinkler system being out of service and expressed that this information was important for responding to a fire. Similarly, the ADON was unaware that a portion of the sprinkler system was not working. These findings demonstrate that both procedural and communication lapses contributed to the deficiency.
Plan Of Correction
1. The facility failed to follow its fire watch policy and procedures when the dry sprinkler system was not functioning properly. Per policy, the facility must either evacuate or initiate a fire watch if the system is non-operational for 10 or more hours within a 24-hour period. 2. Failure to implement fire watch procedures as required could have endangered the safety of all residents, staff, and visitors during a fire emergency. 3. Corrective actions have been taken as follows: - The facility promptly initiated fire watch procedures once the system malfunction was identified, including posting Out of Service signage and conducting regular monitoring rounds. - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics installed a second air compressor, replaced 12 feet of main sprinkler piping, and conducted a system water test. Two leaks (above a resident room and in the boiler room) were identified and repaired. - A trip test will be performed to confirm the full functionality of the system. - Documentation of all system repairs has been received from Excel and Superiorland. - All staff have been re-educated on the fire watch policy, including the requirement for timely implementation when the sprinkler system is out of service. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Administrator is responsible for ensuring fire watch policies and procedures are implemented without delay during any future system outage and for reporting compliance status to the Quality Assurance (QA) Committee.
Failure to Maintain and Communicate Emergency Evacuation Plan Amid Inoperable Sprinkler System
Penalty
Summary
The facility failed to maintain a written plan for the protection and evacuation of all residents in the event of an emergency, as required by regulatory standards. During a record review, it was found that the annual dry sprinkler inspection revealed the attic dry system was capped, leaving only six sprinkler heads active, and the system failed inspection. At the time of the survey, both a CNA and the ADON were unaware that a portion of the sprinkler system was not operational and not functioning as designed and installed. No education or instruction was provided to staff regarding how their response to a fire should change given the inoperable sprinkler system. This finding was confirmed by the Maintenance Director during the survey. No information was provided regarding any specific residents' medical history or condition at the time of the deficiency.
Plan Of Correction
1. The facility failed to adequately communicate to staff that the dry sprinkler system was not functioning properly throughout the building and did not clearly define emergency evacuation procedures in the event of system failure. 2. Lack of communication regarding system malfunction and absence of defined evacuation procedures could place all residents, staff, and visitors at risk during a fire emergency. 3. Corrective actions taken include: - All facility staff were immediately notified that the dry sprinkler system was not functioning and responded appropriately by initiating fire watch procedures. - The Fire Watch policy has been revised to include specific evacuation protocols. The updated policy now requires immediate evacuation of the affected fire/smoke compartment upon any detection of smoke or fire. - The Maintenance Director was educated on the importance of prompt and clear communication to all staff regarding emergency system failures. - All staff have been re-educated on the updated Fire Watch policy and the emergency evacuation procedures. 4. The Maintenance Director is responsible for timely communication of any emergency system failures to facility staff and will report compliance and communication actions to the Quality Assurance (QA) Committee.
Failure to Implement ROM Interventions for Resident with Contractures
Penalty
Summary
The facility failed to implement necessary interventions to address range of motion (ROM) for a resident with limited ROM, specifically for a resident with bilateral hand contractures. The resident, who was diagnosed with conditions including Lewy bodies, Parkinson's disease, dementia, and muscle weakness, was observed without the required palm grips or splints on her left hand, which was visibly contracted. The resident's care plan indicated that palm grips should be worn on both hands at all times, except during hygiene activities, to prevent further contracture and maintain ROM. Observations and interviews revealed that the resident was not consistently wearing the prescribed palm grips, as noted during multiple instances when the resident was seen without them. The Occupational Therapist (OT) and Registered Nurse (RN) involved in the resident's care confirmed the absence of the palm grips and acknowledged the resident's ongoing therapy services aimed at improving hand function. The Director of Nursing (DON) also confirmed that the resident should have been wearing the palm grips, indicating a lapse in adherence to the care plan designed to manage the resident's contractures effectively.
Failure to Provide Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #59, who was blind and experiencing chronic pain, anxiety, and depression. Despite having intact cognition, the resident expressed feelings of loneliness and boredom, stating that interaction with others alleviated his pain. Interviews with staff, including CNAs and a social worker, confirmed that the resident was often isolated in his room, did not participate in activities, and had not received behavioral care support in the past quarter. The social worker acknowledged that a request for an outside behavioral care consult was made but not acted upon. The facility's policies on social services and behavioral health services emphasize the importance of providing or obtaining necessary services to maintain residents' mental and psychosocial well-being. However, the facility did not adhere to these policies, as evidenced by the lack of behavioral health support and failure to make an outside referral for the resident. The Director of Nursing confirmed that the resident did not receive the needed behavioral support, which was crucial given the resident's expressed loneliness and boredom.
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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