Four Seasons Nursing Center Of Westland
Inspection history, citations, penalties and survey trends for this long-term care facility in Westland, Michigan.
- Location
- 8365 Newburgh Road, Westland, Michigan 48185
- CMS Provider Number
- 235578
- Inspections on file
- 33
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Four Seasons Nursing Center Of Westland during CMS and state inspections, most recent first.
Failure to Complete and Update PASARR Reviews: The facility did not timely complete or update PASARR Level I/II reviews for multiple residents with diagnoses including MI, dementia, PTSD, bipolar disorder, and depression. Records showed several residents had outdated or missing PASARR documentation, including cases where Level II reviews were not updated, not submitted, or still waiting for physician signature, despite residents having impaired cognition and qualifying diagnoses.
Failure to Apply Ordered Orthotic Devices: Four residents with ROM limitations and contractures had ordered orthotic devices documented on the MAR, but survey observations found the devices not in place at various times. Residents with diagnoses including muscle weakness, stiff-man syndrome, spinal stenosis, and stroke were seen without splints, knee braces, or PRAFO boots despite care plans and MAR directions for contracture prevention; one resident reported not wearing the boots in quite some time, and another said the splint was not applied regularly.
A resident with impaired cognition and physical weakness was sitting in the lobby when another cognitively impaired resident with a known history of agitation, confrontational behavior, and prior physical altercations followed and began hitting the resident on the head while yelling, as confirmed by the involved resident and a receptionist. The aggressive resident already had a behavior care plan identifying physical threatening behaviors and difficulty with redirection, but no new interventions or updated documentation were added to the behavior care plan or progress notes after this incident, despite the facility’s abuse policy stating residents have the right to be free from abuse and mistreatment.
Failure to Obtain Proper Psychotropic Medication Consent: A severely cognitively impaired resident with Alzheimer's Disease, depression, and anxiety was prescribed Seroquel, Buspirone, and Sertraline, but the psychotropic consent in the record showed the resident was educated and consented instead of the son listed as MPOA. The resident was unable to participate meaningfully due to cognition, and the facility policy required informed consent from the resident and/or authorized representative with review of risks, benefits, side effects, and Black Box Warnings.
Failure to keep a resident's PASARR Level II evaluation current. A resident with depression, anxiety, and psychotic disorder was cognitively intact and needed ADL assistance, but the record showed the last Comprehensive Level II Evaluation was an annual review with re-evaluation due later. When surveyors requested the Level II documentation, the facility could only provide a Level I screening with a note that no Level 2 OBRA had been completed since that evaluation. The NHA acknowledged the PASARR assessments were not up to date.
A resident with depression, Parkinson's Disease, and anxiety disorder had impaired cognition and was documented as unable to make their own medical decisions. The facility submitted a guardianship petition, but the court case was missed, the hearing was adjourned, and the petition was left behind while other residents were prioritized, delaying appointment of a guardian.
Soiled privacy curtains were observed for two residents, with one curtain showing a dried brownish substance and another with multiple white stains that remained present on repeat observation. One resident said the stain looked like dried blood, and the other said the curtain had last been changed about four months earlier. Staff and leadership gave differing accounts of when curtains were changed, including when rooms were deep cleaned, while the facility policy stated resident equipment should be cleaned and disinfected per CDC guidance.
An LPN used a personal cell phone to record video from the facility’s camera system as part of a fall investigation and the footage, showing multiple cognitively impaired residents with clearly visible faces in a common day room, was later posted as a social media story. A resident with Alzheimer’s disease, a resident with schizophrenia, and two residents with dementia were identifiable in the images. The DON reported believing the video would be encrypted and deleted, but the facility’s social media and electronic communications policy strictly prohibited transmitting or posting any resident-related images or information that could violate privacy or confidentiality.
A medication administration error occurred when an LPN entered a resident’s room and, finding the resident’s sister lying in the bed while the resident was away, left the resident’s scheduled medications with the sister after she stated she would ensure the resident took them. The sister subsequently ingested the medications, experienced dizziness, and called 911, resulting in transport to the hospital. The medications, which included Metformin, Tamsulosin, Lactulose, spironolactone, and liquid protein, were documented on the MAR as having been given to the resident. The DON later stated the nurse should have followed the rights of medication administration and remained with the resident until medication administration was complete.
The facility failed to ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate protective measures and oversight.
A resident with muscle weakness and impaired cognition, who required staff assistance, did not have compression stockings applied as ordered by the physician to address leg swelling. Despite documentation indicating the stockings were applied, multiple observations confirmed they were not in place, and both the LPN and DON acknowledged the deficiency.
A resident admitted with intact skin and requiring staff assistance for mobility developed an unstageable pressure ulcer on the buttocks due to lack of regular turning, repositioning, and delayed incontinence care. Staff interviews indicated that standard interventions were in place for at-risk patients, but the wound still developed. Facility policy did not address prevention of wound development.
A resident admitted for hospice respite care did not have proper documentation for the administration and accountability of controlled substances, including morphine and lorazepam. Medication Administration Records were left blank despite controlled substance logs showing medication removals, with some entries later marked as errors and lacking clear staff identification. Facility staff could not explain the discrepancies or provide supporting documentation, and the required policy for documenting both removal and administration was not followed.
An unlocked medication cart was found unattended with an open monitor displaying personal information and an insulin pen stored on top. Multiple medicine cups containing pills, including some that should have been wasted, were discovered in the cart. A nurse confirmed the improper handling and storage of these medications, and the DON acknowledged these actions were not in accordance with facility policy.
A resident with functional quadriplegia and anxiety, dependent on staff for all ADLs, was found with excessively long and dirty fingernails. The resident wanted their nails trimmed but was anxious about the process. Nursing staff confirmed that regular nail care should be provided as part of ADLs, but this care was not given.
A resident requiring substantial assistance for ADLs and mobility experienced a prolonged delay of 33 minutes after activating their call light, during which staff failed to address their needs in a timely manner. Despite facility expectations for call lights to be answered within 10-20 minutes and for staff to address resident needs upon response, the resident remained wet and anxious until assistance was finally provided.
The facility failed to provide pureed food of the proper consistency, as observed with the pureed carrots served during lunch. The carrots contained small chunks requiring chewing, contrary to the IDDSI standards for a smooth, pudding-like texture. Both the dietician and chef confirmed the inconsistency.
The facility failed to reposition four dependent residents as required, leading to a deficiency in care. A resident with severe cognitive impairment was left in the same position for hours, despite needing assistance for mobility. Another resident with Parkinson's and stroke was not repositioned frequently, as their care plan required. Two other residents, one with a pressure ulcer, were also not repositioned as needed, despite facility policy mandating repositioning every two hours.
A resident with a brain tumor and dysphagia was incorrectly administered Jevity 1.5 instead of the prescribed Nutren 2.0 due to conflicting active orders. The dietician's order for Nutren was more recent, but both formulas were marked as given in the MAR. The DON confirmed that only one order should be active, highlighting a failure to follow the facility's policy on verifying physician orders.
The facility exceeded the acceptable medication error rate with a 6.25% error rate. A resident did not receive Lanthanum Carbonate due to unavailability, and two residents received incorrect Sennasides medication. The errors were observed and involved miscommunication and failure to adhere to medication administration policies.
The facility failed to properly label and date medications in two medication carts and two medication rooms. An Arnuity inhaler and lispro insulin were found without resident identifiers or opening dates. Tuberculin vials in two storage rooms were also not dated when opened, contrary to manufacturer instructions. The DON confirmed the requirement for dating tuberculin vials upon opening.
The facility failed to maintain infection control practices by allowing used urinals to remain on overbed tables for three residents. Observations showed urinals filled with urine on overbed tables, despite the facility's policy against such practices. The residents involved had various medical conditions and cognitive statuses. An interview with the Infection Control Nurse confirmed the breach of protocol.
The facility failed to ensure call lights were within reach for two dependent residents, leading to a deficiency. One resident, affected by a stroke, was unable to reach the call light due to limited mobility, while another resident with severe cognitive impairment had the call light out of reach. Both staff and facility policy confirmed the requirement for call lights to be accessible.
A resident with multiple health issues experienced a significant change in condition that was not addressed in a timely manner by the LTC facility staff. Despite family concerns and noticeable symptoms, the resident's deteriorating condition was not documented or communicated to the physician promptly. This led to the resident being transferred to the hospital in critical condition with severe complications, including a blood sugar level of 1200 mg/dl and respiratory distress.
A resident on anticoagulant medication sustained a fall with head trauma and bleeding, but the facility failed to conduct a comprehensive nursing assessment or ensure a timely hospital transfer. The initial response involved only applying a cold compress, and there was a lack of documentation and follow-up with the physician. It took over five hours for the unit manager to contact the medical director, who then ordered the resident's transfer to the hospital for treatment.
Two residents were involved in an incident where one poured water on the other after repeated requests for a room change were ignored. The resident who poured the water expressed frustration over the lack of response to their complaints about their roommate's disruptive behavior. Both residents have intact cognition and require assistance with mobility. The facility's failure to address the situation led to the abusive incident, contrary to its policy on preventing abuse.
A resident with dysphagia and multiple sclerosis did not receive a divided plate as per their nutritional care plan, leading to difficulty in self-feeding. The oversight was acknowledged by facility staff, including a CNA and the Dietary Manager, who confirmed the error occurred in the kitchen.
A resident with multiple sclerosis and intact cognition reported inadequate colostomy care, leading to the colostomy filling and bursting. The facility's Treatment Administration Record showed multiple instances of undocumented care, which the DON acknowledged and was working to address.
A resident admitted for short-term rehab fell and sustained injuries when a CNA failed to use a gait belt during a transfer, instead holding the resident's pants. The facility's policy mandates the use of gait belts for manual transfers, which was not followed, resulting in the resident's fall and injuries.
Failure to Complete and Update PASARR Reviews
Penalty
Summary
The facility failed to timely complete annual PASARR Level I assessments and submit the required reviews to the appropriate State-appointed authority for six residents. The report states that the PASARR process is used for residents with mental illness and/or intellectual/developmental disabilities, and that the Social Service employee or designee is responsible for verifying that PAS and/or ARR processes are completed appropriately and timely. The facility policy also required PASARR completion prior to admission, after a significant change in condition, and not less than annually. For Resident #5, the record showed diagnoses of schizoaffective disorder, depressive disorder, and vascular dementia with behavioral disturbance, with a BIMS score of 15/15, but the chart contained only a PASARR Level I assessment dated 2/16/26 and no updated Level II/3878 acknowledging the mental illness diagnoses. For Resident #6, the record showed major depressive disorder and anorexia, with a BIMS score of 3/15, and the chart contained a PASARR/3878 dated 1/22/26 for hospital exempted discharge, but no updated PASARR/3878 acknowledging dementia or referral for Level II. For Resident #11, the record showed psychotic disorder with delusions, dementia, and hemiplegia/hemiparesis, with a BIMS score of 9/15, but there was no updated PASARR/3878 in the record acknowledging dementia or other mental illness diagnoses. For Resident #14, the record showed PTSD, major depressive disorder, dementia, and anxiety disorder, with a BIMS score of 13/15, but there was no updated PASARR/3878 acknowledging dementia and mental illness. The report also identified Resident #59, whose diagnoses included bipolar disorder and dementia, with moderately impaired cognition on the most recent MDS. A Level II evaluation dated 3/28/25 required re-evaluation by 3/25/26, but on 4/9/26 the surveyor was given the Level I screening with a handwritten note stating, "Waiting for [Doctor] to sign [Level II]." Resident #117 had diagnoses of bipolar disorder, dementia with psychotic disturbance, and anxiety disorder, with a BIMS score of 00/15 indicating severe cognitive impairment. The Level I screening dated 3/18/26 indicated a current diagnosis for mental illness and dementia and that the resident received treatment for mental illness and psychotropic medications within the last 14 days, but the record did not show that a Level II screening had been submitted and signed by the physician.
Failure to Apply Ordered Orthotic Devices
Penalty
Summary
The facility failed to apply ordered orthotic equipment for residents with limited ROM and mobility needs, including hand splints, knee braces, heel lift boots, and elbow extensions. The deficiency involved four residents who had physician-ordered or care-planned devices for contracture prevention and related conditions, but the devices were not consistently in place during survey observations even though the MAR showed they were to be applied daily and checked for skin integrity before and after use. R9 had diagnoses including muscle weakness and peripheral vascular disease, impaired cognition, and required assistance with bed mobility and transfers. The MAR directed a left resting hand splint and right elbow splint for 4 hours daily for contracture prevention, and checkmarks indicated application on April 1 through April 9. However, on 4/7/2026 and 4/9/2026, R9 was observed without the splint or brace in place, and a contracture to the left hand was noted. R22 had muscle weakness and stiff-man syndrome, intact cognition, and required assistance with bed mobility and transfers. A rehab recommendation for PRAFO boots was documented for foot drop, and the care plan and MAR directed bilateral PRAFO boots for 2 to 3 hours as tolerated. Although the MAR showed checkmarks for April 1 through April 9, surveyors observed R22 in bed without the boots in place on multiple occasions, and the resident stated they had not worn the boots in quite some time and had not been asked if they wanted them applied. R48 and R144 were also observed without their ordered devices in place despite MAR documentation showing application; R48 was seen with a towel rolled in the right hand and a knee brace in the windowsill, while R144 was observed with a left-hand contracture and a splint sitting in the windowsill, and the resident stated the splint was not applied regularly.
Failure to Protect Resident From Peer Physical Abuse and Update Behavior Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident and to update care planning and documentation following a known behavioral incident. One resident with anemia, muscle weakness, impaired cognition, and dependence on staff for bed mobility and transfers was sitting in the front lobby when another cognitively impaired resident with major depressive disorder, vascular dementia with agitation, and a documented history of increased agitation, physical threatening behaviors, confrontational behaviors, and prior physical altercations followed and began hitting them. An incident report and progress note documented that the resident was hit in the head, assessed for pain and vital signs, and that family and facility leadership were notified. The assaulted resident later confirmed in interview that the other resident came from behind, banged them on the head, yelled, and that staff then separated the residents and assessed the injured resident. The resident who initiated the aggression had an existing behavior care plan, initiated years earlier, that already identified physical threatening behaviors, confrontational behaviors, and prior physical altercations with other residents, as well as difficulty with redirection after a room change off the dementia/behavioral unit. Despite this history and the new incident in the lobby, the behavior care plan showed no updated interventions after the event, and the most recent interventions on the plan pre‑dated the incident by approximately two years. Interviews with staff confirmed awareness that this resident had aggressive behaviors and could become agitated when others were in their personal space, yet there were no new care plan interventions documented and no updated progress notes for either resident after the incident. This occurred despite a facility abuse policy stating that residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.
Failure to Obtain Proper Psychotropic Medication Consent
Penalty
Summary
The facility failed to obtain consent and provide risk versus benefit information for psychotropic medication use for one severely cognitively impaired resident, R109, who was reviewed for unnecessary medications. R109 was observed sitting in the dining room with eyes closed and drifting in and out of sleep, and attempts to speak with the resident were unsuccessful due to cognition. The resident was admitted with diagnoses including Alzheimer's Disease, Depression, and Anxiety, was severely cognitively impaired, required assistance with Activities of Daily Living, and had a medical power of attorney naming the son as representative. Review of the resident's active physician orders showed prescriptions for Seroquel 25 mg, Buspirone HCl 10 mg, and Sertraline HCl 100 mg. The medical record contained a psychotropic medication consent dated 6/20/25 stating the resident, rather than the authorized representative, was provided education regarding risks versus benefits and consented to the medication use. When asked about medication consents being completed by the appropriate party, the Nursing Home Administrator stated the social worker is responsible for ensuring the consents are accurate. The facility's psychotropic medication use policy stated that informed consent is to be obtained from the resident and/or authorized representative, with review of the medication, dosage, side effects, risks versus benefits, and any Black Box Warnings.
Failure to Keep PASARR Level II Evaluation Current
Penalty
Summary
The facility failed to timely coordinate with the appropriate State-appointed authority to complete a PASARR Level II Comprehensive Evaluation for one resident reviewed for PASARR Level II recommendations. The resident was admitted with diagnoses of Depression, Anxiety, and Psychotic Disorder, was cognitively intact, and required assistance with Activities of Daily Living. The medical record showed a Comprehensive Level II Evaluation dated 7/7/2022 that was identified as the Annual Resident Review and noted to require re-evaluation in 363 days. During survey review, a request for the resident's Level II evaluation was made to the facility, and the facility provided a Level I screening with a written note stating that there had been no Level 2 OBRA since 7/7/2022. The Nursing Home Administrator stated that the facility was aware the PASARR assessments were not up to date and was working with the Director of Social Work to bring them up to date. The facility policy stated that residents with mental illness and/or intellectual/developmental disabilities are to be screened through the PASARR process to ensure appropriate nursing facility services and specialized services are provided.
Delayed Guardianship Appointment for Resident With Impaired Cognition
Penalty
Summary
The facility failed to ensure the timely appointment of a guardian for one resident, R99, who was admitted with diagnoses of depression, Parkinson's Disease, and anxiety disorder. The most recent MDS dated 1/26/2026 showed a BIMS score of 11/15, indicating impaired cognition. A physician's note dated 8/16/2024 stated that R99 was not capable of making their own medical decisions, and the facility submitted a petition for guardianship on 4/7/2025. During an interview on 04/09/2026, the Director of Social Work stated that R99 had been their own responsible party on admission but was later found to be incapacitated and in need of a guardian. The DSW stated the guardianship petition was sent in April 2025 and a court hearing was scheduled for June 2025, but the DSW did not attend because of another hearing, the case was adjourned, and they were told the petition would need to be resubmitted. The DSW also stated R99's guardianship petition was left behind due to many other residents being in more urgent need of guardianship. The facility policy stated that if no legal paperwork is in place and the family member or emergency contact does not obtain guardianship, the facility or contracted vendor should petition the probate court system for a third-party court appointed guardian.
Soiled Privacy Curtains Observed for Two Residents
Penalty
Summary
The facility failed to maintain clean privacy curtains for two residents, R13 and R64, during observations related to homelike environment. On 4/7/26, R13's privacy curtain was observed with a dried brownish substance on the bottom of the curtain, and on 4/9/26 it was still soiled. When asked about it, R13 stated, "I think it's dried blood. It's not good." Floor Services Staff later removed the curtain and said it would be cleaned. R13's EMR showed diagnoses including Bi-polar disorder and Osteoarthritis, and the most recent quarterly MDS indicated intact cognition. R64's privacy curtain was observed on 4/7/26 with multiple white stains, and the same stains were still present on 4/9/26. R64 stated the curtain had last been changed about four months earlier. R64's EMR showed diagnoses including Spinal Stenosis and Heart Disease, and the most recent quarterly MDS indicated intact cognition. During interview, the Environmental Services Director stated new privacy curtains had recently been ordered and that a curtain changing schedule binder was being planned, while the Nursing Home Administrator stated the curtains should be cleaned when a room is deep cleaned. The facility policy reviewed stated resident equipment should be cleaned and disinfected in accordance with CDC recommendations.
Unauthorized Social Media Posting of Resident Images by LPN
Penalty
Summary
The facility failed to protect residents’ privacy and right to confidentiality when an LPN used a personal cell phone to record video footage of a resident fall from the facility’s camera system and that video was subsequently posted to a social media account. The LPN reported that she recorded the fall as part of the facility’s fall investigation process using her personal phone and believed she had deleted the video before leaving the facility. However, a former facility employee later notified her that the video had been posted as a social media “story” clip. Photo stills taken from the LPN’s social media account showed residents sitting in a common day room area of the facility with their faces clearly visible. Four residents were identified as having their images and identities exposed in the social media post. One resident had been admitted with Alzheimer’s disease and was documented as severely cognitively impaired. A second resident had schizophrenia with a moderate cognitive impairment, and the third and fourth residents had dementia, with one having moderate and the other severe cognitive impairment. The DON stated that the LPN took a video of the camera system using her cell phone to better understand the resident’s fall and believed the video would be encrypted and deleted prior to her leaving the facility. The facility’s Social Media and Electronic Communications policy explicitly prohibited employees from transmitting any resident-related images or information via electronic media that could violate resident confidentiality or privacy, including posting or sharing any information regarding a resident, and this policy was not followed in this incident.
Improper Medication Administration to Visitor Instead of Resident
Penalty
Summary
A medication administration deficiency occurred when an LPN failed to properly identify and administer medications to the correct individual and did not remain with the resident until medications were taken. The resident involved had been admitted with diagnoses including diabetes, other cirrhosis of the liver, and heart failure, was cognitively intact, and required assistance with activities of daily living. On the morning in question, the resident’s sister was lying in the resident’s bed while the resident was not in the room. The LPN entered to administer the resident’s scheduled morning medications, which included Metformin, Tamsulosin (Flomax), Lactulose, spironolactone, and house liquid protein, and left the medications with the sister after she stated she would ensure the resident took them upon returning. Shortly thereafter, the sister independently contacted 911 and was transported to the hospital after consuming the medications that had been left in the room. The resident later reported that upon returning from the dining room, the sister informed them she had taken the medications and was feeling dizzy, leading her to call 911. The facility’s documentation and the February MAR showed that the medications were documented as administered to the resident at the scheduled time. The DON stated that the nurse should have followed the facility’s medication administration policy, including the rights of medication administration and remaining with the resident until medication administration was complete.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect residents from all forms of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's protective measures and oversight. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
A deficiency occurred when staff failed to apply compression stockings as ordered by the physician for one resident. The resident, who had diagnoses of muscle weakness and disorder of muscle, was admitted with an order to have compression stockings applied to both lower extremities at 6:00 AM and removed at 10:00 PM daily. Despite this order, the resident was observed multiple times throughout the day without compression stockings in place, although the Medication Administration Record indicated they had been applied. The resident reported that the stockings had only been put on once or twice, and staff confirmed the absence of the stockings during interviews. The resident had impaired cognition, requiring staff assistance with bed mobility and transfers, and was noted to have swollen and painful legs. Observations confirmed the resident was only wearing heel boots and not the prescribed compression stockings. When questioned, the LPN acknowledged the resident did not have the stockings on and would attempt to locate them. The Director of Nursing was aware of the issue and stated that compression stockings were expected to be applied as ordered. The facility's policy on physician and practitioner orders did not address the need to follow physician orders.
Failure to Prevent Development of Unstageable Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with intact skin and medical diagnoses of muscle weakness and lymphedema. The resident required staff assistance for bed mobility and transfers and had an intact cognitive status. Upon admission, the skin evaluation showed no abnormalities. However, an open area was first observed on the resident's buttocks nearly a month after admission. Subsequent skin evaluation documented the wound as unstageable, with measurements indicating deterioration. The wound was attributed to the resident not being turned and repositioned as needed, as well as delays in incontinence care. Interviews with facility staff revealed that the wound care nurse was informed of the wound during routine rounds and immediately involved the wound care physician for assessment and intervention. The wound care nurse stated that turning and repositioning are standard interventions for at-risk patients but was unsure how the wound developed in this case. The Director of Nursing confirmed being notified of the wound after its discovery and that interventions were implemented at that time. Review of facility policy showed that the skin and wound guidelines did not address prevention of wound development.
Failure to Document and Account for Controlled Substances
Penalty
Summary
The facility failed to ensure proper documentation and accountability of controlled substances for a resident admitted for a five-day hospice respite stay. The resident, who had multiple complex diagnoses including palliative care, multiple sclerosis, and seizures, had orders for controlled substances such as liquid morphine and lorazepam for pain and anxiety. Review of the Medication Administration Records (MARs) showed no documentation of administration for these medications, despite controlled substance proof of use records indicating that doses were removed from inventory. Controlled substance records showed multiple entries for removal of lorazepam and morphine, with some entries initialed by a nurse and others with illegible or unidentifiable initials. Several entries for morphine were later marked as errors and corrected, but there was no documentation of medication being wasted or administered, and the MARs remained blank. Progress notes and vital signs did not indicate the resident experienced pain or anxiety that would correspond with the medication removals, and there was no explanation in the clinical record for the discrepancies. Interviews with facility staff, including the DON and unit manager, revealed they were unable to explain the discrepancies or identify all staff involved in the documentation. The facility's policy required nurses to document both the removal and administration of controlled substances, but this was not followed. Attempts to contact the nurse responsible for the entries were unsuccessful, and staff acknowledged concerns with the documentation but could not provide further clarification.
Improper Medication Storage and Handling
Penalty
Summary
Surveyors observed an unlocked medication cart on the Spring Unit with no licensed staff present. The cart had an open monitor displaying personal information for a resident, and an insulin pen was stored on top of the cart. Upon opening the top drawer, several clear medicine cups containing pills were found, including one cup with five pills identified as medications for a specific resident. Two other cups contained single white pills. A registered nurse later confirmed the medications and explained that the other two cups were intended to be wasted, one because the pill had fallen on the floor and the other because the medication was no longer ordered for the resident. The nurse did not provide a reason for not immediately wasting the medications or for removing a medication that was not part of the current order. The Director of Nursing confirmed that the observed practices did not align with facility policy, which requires all medications and biologicals to be stored in locked compartments and for medications to be under direct observation or locked during medication passes. The failure to lock the medication cart, improper storage of insulin, and the presence of unadministered and unaccounted-for medications in the cart constituted a breach of medication storage and handling protocols.
Failure to Provide Regular Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, functional quadriplegia, and anxiety, who required substantial staff assistance for all activities of daily living (ADLs) and mobility, was observed to have very long fingernails extending about 3/4 of an inch beyond the fingertips, with visible debris that was yellow and darker in color. The resident expressed a desire to have their nails trimmed but also reported anxiety about the process, fearing their skin might be nipped. Interviews with nursing staff, including an RN and the ADON, confirmed that regular nail care should be provided as part of ADLs, indicating that the facility failed to provide necessary nail care for this resident.
Delayed Call Light Response and Failure to Address Resident Needs
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, functional quadriplegia, and anxiety, who required substantial assistance for all activities of daily living and mobility, experienced significant delays in having their call light answered. The resident reported that after activating the call light, it often took a very long time for staff to respond, and expressed concern that frequent use of the call light was discouraged by staff. During observation, the resident activated the call light and waited 33 minutes before their needs were addressed. During this period, a registered nurse entered the room, was informed of the resident's needs, and stated they would notify the assigned CNA. Another CNA entered, turned off the call light, and left without addressing the resident's needs, stating the assigned CNA would be there soon. The resident remained wet and anxious until the assigned CNA arrived and provided assistance. Interviews with nursing staff revealed that the facility's expectation for answering call lights is within 10 to 20 minutes, and that the person responding to the call light is expected to address the resident's needs directly, rather than turning off the light and leaving. The observed delay and failure to address the resident's needs upon initial response did not meet these expectations, resulting in the resident remaining in discomfort and distress for an extended period.
Improper Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food items were of the proper consistency, specifically affecting the pureed carrots served during lunch. During an observation of the lunch tray-line service in the main kitchen, a pan of pureed carrots was noted to contain small chunks of orange carrot bits mixed with a pale orange viscous substance. A taste test confirmed that the pureed carrots contained small chunks that required chewing before swallowing, which is inconsistent with the requirements for a pureed diet. According to the IDDSI chart posted in the facility kitchen, pureed foods should be smooth and have a pudding-like texture with no lumps. Both the dietician and the chef acknowledged that the pureed carrots did not meet the proper consistency standards for a pureed diet.
Failure to Reposition Dependent Residents
Penalty
Summary
The facility failed to provide timely repositioning for four dependent residents, leading to a deficiency in care. Resident #34 was observed multiple times over several days to be in the same position for extended periods, despite a care plan that required repositioning every two hours. The resident had severe cognitive impairment and required substantial assistance for mobility, yet was left in the same position for hours, indicating a lack of adherence to the care plan. Resident #44, who had diagnoses including Parkinson's and stroke, was also observed to remain on their backside in bed for extended periods without repositioning, despite requiring frequent turning and repositioning as per their care plan. The resident's condition necessitated a two-person assist for bed mobility, yet observations showed a lack of repositioning, which could contribute to further health complications. Similarly, Resident #97 and Resident #118 were observed in positions that did not change over several hours, with no visible positioning devices used to aid in repositioning. Both residents had severe cognitive impairments and were dependent on staff for mobility. Resident #118 had a documented pressure ulcer, yet was not repositioned as required, which could exacerbate their condition. The facility's policy required repositioning every two hours, but this standard was not met, as confirmed by the Director of Nursing.
Incorrect Tube Feeding Formula Administered
Penalty
Summary
The facility failed to administer the correct tube feeding formula to a resident, identified as R119, who was observed to have been receiving Jevity 1.5 instead of the prescribed Nutren 2.0. This discrepancy was noted during observations on consecutive days, where bottles of Jevity 1.5 were found in the resident's room and trash can. A review of R119's medical records revealed conflicting active orders for both Jevity and Nutren, with the Nutren order being the more recent and prescribed by the dietician. Despite this, both formulas were marked as administered in the resident's Medication Administration Record (MAR) for several days. R119, who has a diagnosis of a benign brain tumor and dysphagia, was admitted with specific nutritional needs that required precise tube feeding management. The Registered Dietician confirmed that the Nutren 2.0 order was based on the resident's nutritional requirements, while the Jevity order was incorrectly entered by a nurse. The Director of Nursing acknowledged that only one tube feeding order should be active, as per the facility's policy, which mandates verification of physician orders prior to administration. This oversight in following the correct tube feeding order led to the administration of an incorrect formula to the resident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate. During a medication pass observation, a Registered Nurse (RN) was unable to administer Lanthanum Carbonate, 1000 mg, to a resident because it was not available. Instead, the RN attempted to substitute it with two calcium carbonate 500 mg tablets, but the order was not reviewed properly, and the Lanthanum Carbonate was not given. The medication administration records indicated that the medication was documented as given 19 times, despite not being available. Communication from the Director of Nursing revealed that the medication order should have been discontinued based on lab results and nephrology recommendations, indicating a lack of coordination and communication regarding the resident's medication needs. Additionally, two separate incidents involved the incorrect dispensing of Sennasides. An RN and an LPN both dispensed Sennasides 8.6 mg pills from over-the-counter stock instead of the ordered Sennasides with Docusate Sodium 8.6 mg/50 mg pills for two different residents. These errors were observed and later reviewed with the Director of Nursing. The facility's policies on medication administration and error definitions were not adhered to, as evidenced by the wrong medication being dispensed and the omission of a prescribed drug.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and dating of medications in two of five medication carts and two medication rooms. During an inspection, it was observed that an Arnuity inhaler on the Spring unit front cart was not labeled with a resident identifier and lacked a date of opening on both the inhaler and its box. Similarly, a lispro insulin on the Spring unit back cart was found without a date of opening and resident identifier. In the Winter medication storage room, a tuberculin derivative vial was not dated when opened, and the same issue was noted in the Summer medication storage room. The Director of Nursing confirmed that tuberculin vials should be dated upon opening. Manufacturer instructions for the tuberculin vial indicated that vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency. Additionally, the prescribing information for the Arnuity Inhaler specified that it should be discarded 6 weeks after opening or when the counter reads 0, whichever comes first.
Infection Control Lapse with Urinals on Overbed Tables
Penalty
Summary
The facility failed to maintain proper infection control practices by allowing used urinals to remain on overbed tables for three residents. During observations, it was noted that one resident had a urinal half-filled with urine on the overbed table while preparing for breakfast. Another resident had a urinal quarter-filled with urine on the overbed table after having breakfast, and a third resident was observed with a urinal filled with urine on the overbed table. These observations were made during a specific time frame, indicating a lapse in infection control protocols. The medical records of the residents involved revealed various diagnoses, including atherosclerotic heart disease, muscle weakness, atrial fibrillation, cervical disc disorder, anemia, fracture of the lower end of the right ulna, disorder of the muscle, and osteoarthritis. The cognitive assessments of the residents varied, with one resident being cognitively intact and the others having moderate cognitive impairment. An interview with the Infection Control Nurse confirmed that urinals should not be stored on overbed tables, aligning with the facility's infection control policy, which emphasizes standard precautions to prevent the spread of infection.
Deficiency in Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two dependent residents, leading to a deficiency in resident care. Resident 42, who had limited mobility due to a stroke, was observed in a recliner and later in bed with the call light tucked under the pillow, out of reach. Despite attempts to reach the call light with their right hand, Resident 42 was unable to do so due to the inability to move their left arm. The care plan for Resident 42, which noted an alteration in mobility and a self-care deficit, did not include an intervention for call light placement. Resident 24, diagnosed with unspecified dementia and having a severe cognitive impairment, was repeatedly observed in bed with the call light hanging on the wall behind the bed, out of reach. When asked, Resident 24 confirmed they could not reach the call light and did not know what to do if they needed help. Both a Licensed Practical Nurse and the Director of Nursing confirmed that call lights should always be within reach of residents. The facility's policy on call light accessibility and timely response mandates that call lights be plugged in, functioning, and within reach of residents.
Failure to Address Change in Condition Leads to Resident Hospitalization
Penalty
Summary
The facility failed to address a significant change in condition for a resident, leading to a critical health emergency. The resident, who had a history of acute kidney failure, type 2 diabetes mellitus, dysphagia, dementia, seizures, hypertension, and aphasia, was found to have a blood sugar level of 1200 mg/dl, fever, and difficulty breathing, requiring mechanical ventilation upon transfer to the hospital. The resident's family had reported noticeable swelling and increased sleepiness as early as December 21, but these concerns were not adequately addressed by the facility staff. On January 3, the resident was found in respiratory distress with low oxygen saturation and was only responsive to painful stimuli. Despite these alarming signs, there was a delay in notifying the physician and transferring the resident to the hospital. The facility's staff, including LPNs and CNAs, failed to document the resident's deteriorating condition and did not follow the protocol for notifying the physician of significant changes in the resident's status. The physician was eventually contacted, and the resident was transferred to the hospital, but by then, the resident was in critical condition with sepsis and other severe complications. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition. The unit manager and the Director of Nursing did not provide clear guidance or follow-up on the resident's change in condition. The facility's policy on change in condition notification was not adhered to, as the nurse did not document the resident's condition or notify the physician in a timely manner, contributing to the resident's critical health emergency.
Failure to Ensure Timely Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to ensure a comprehensive nursing assessment and timely acute care emergent hospital transfer for a resident who sustained a fall with head trauma and bleeding while on anticoagulant medication. The incident occurred when the resident was found sitting on the floor with a head laceration after hitting the back of their head on the wall. Despite the resident experiencing significant pain and being on a blood thinner, the initial response by the LPN involved only applying a cold compress and awaiting a call back from the physician, which was not documented as received. The resident's medical records revealed a lack of documentation regarding the extent of the wound, the amount of bleeding, and whether the bleeding had stopped. The resident's care plan indicated a risk for bleeding due to anticoagulant use, yet there was no immediate follow-up with the physician or an emergent transfer to the hospital. It was not until over five hours later that the unit manager contacted the medical director, who ordered the resident's transfer to the hospital, where the head wound was treated with staples. Interviews with facility staff highlighted a failure to follow protocol, as the LPN did not perform a comprehensive skin assessment or notify the medical director when the physician was unreachable. The unit manager and other LPNs expressed that the resident should have been sent to the hospital immediately after the fall, given the open head wound and the resident's anticoagulant medication. The facility's policies on fall management and physician services were not adhered to, resulting in a delayed response to the resident's acute condition.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, R700 and R701. The incident occurred when R701 poured water on R700, reportedly after months of requesting a room change due to R700's behavior, which R701 found disruptive. R700, who has diagnoses of Functional Quadriplegia, Depression, and Anxiety, reported the incident, stating that R701 poured water on them repeatedly. R701, diagnosed with Schizophrenia and Muscle Weakness, admitted to the act, expressing frustration over the lack of response to their requests for a new roommate. Both residents have intact cognition, as indicated by their Brief Interview for Mental Status scores. The facility's failure to address R701's repeated requests for a room change contributed to the escalation of the situation, resulting in the abusive incident. Interviews revealed that R701 had informed numerous staff members about their desire for a new roommate due to R700's constant screaming, which affected R701's ability to sleep. The Nursing Home Administrator was unaware of R701's complaints about R700, indicating a communication breakdown within the facility. The facility's policy on abuse emphasizes residents' rights to be free from abuse, neglect, and mistreatment, which was not upheld in this case.
Failure to Implement Nutritional Care Plan Intervention
Penalty
Summary
The facility failed to implement a nutritional care plan intervention for a resident with dysphagia and multiple sclerosis. The resident, who had an intact cognition and required assistance with bed mobility and transfers, was observed eating lunch in their room. The resident expressed difficulty in eating and was seen using a regular plate instead of the prescribed divided plate, which was intended to assist with self-feeding. This discrepancy was noted by a Certified Nursing Assistant who confirmed that the resident should have been provided with a divided plate as per the diet ticket. Interviews with the Director of Nursing and the Dietary Manager revealed that the oversight occurred in the kitchen, resulting in the resident not receiving the appropriate plate. The facility's policy on care plan comprehensive and revision emphasizes the importance of selecting interventions based on thorough data gathering and clinical decision-making. However, in this instance, the intervention to provide a divided plate was not implemented, leading to the deficiency noted by the surveyors.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility failed to provide and document adequate colostomy care for a resident, identified as R702, who was admitted with diagnoses of dysphagia and multiple sclerosis. The resident, who has intact cognition, reported that the facility staff did not empty their colostomy as frequently as required, leading to the colostomy filling, bursting, and necessitating frequent changes. This issue was corroborated by a review of the Treatment Administration Record (TAR) for September and October, which showed multiple instances where colostomy care was not documented during the AM shift. The Director of Nursing (DON) acknowledged receiving numerous complaints from the resident regarding the colostomy care, specifically about emptying and changing it. The DON mentioned that efforts were being made to address these complaints and improve documentation. The facility's policy on ostomy care requires documentation of the procedure in the resident's electronic health record, which was not consistently followed, as evidenced by the blank spaces in the TAR.
Failure to Use Gait Belt During Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to implement measures to reduce the risk of a fall with injury for a resident admitted for short-term rehab following a trigger finger repair surgery. The resident, who required minimal assistance for transfers, reported falling while being assisted by a CNA. The CNA admitted to not using a gait belt during the transfer, instead holding the resident's pants, which led to the resident falling forward and sustaining injuries to the forehead, right forearm, and knees. The facility's policy mandates the use of gait belts during transfers, which was not followed in this instance. The incident was confirmed through a review of the facility's Incident/Accident reports and interviews with the resident and the CNA involved. The Director of Nursing also confirmed that the expectation is for gait belts to be used with any resident requiring manual transfer assistance. The failure to adhere to this policy resulted in the resident's fall and subsequent injuries, highlighting a lapse in following established safety protocols.
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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