Grandvue Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in East Jordan, Michigan.
- Location
- 1728 South Peninsula Road, East Jordan, Michigan 49727
- CMS Provider Number
- 235062
- Inspections on file
- 20
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Grandvue Medical Care Facility during CMS and state inspections, most recent first.
A resident with dementia, aphasia, urinary incontinence, and severely impaired decision-making was being assisted with a brief change by a CNA, with a second CNA called in to help due to the resident’s history of combative behavior. During the interaction, the resident became agitated, stood up, removed his brief, and made physical contact with both CNAs before eventually returning to bed and making a rude remark. One CNA then responded by calling the resident a derogatory expletive while still in the room, an exchange overheard by a social worker who entered and found one CNA present and the other leaving. Subsequent interviews with both CNAs and the social worker confirmed that the CNA directed the expletive at the resident, constituting verbal abuse under the facility’s abuse policy and resulting in psychosocial harm and mental anguish based on a reasonable person standard.
A resident with Alzheimer's disease experienced significant, unaddressed weight loss after a CNA repeatedly falsified weight documentation over several weeks. Despite concerns raised by the resident's power of attorney about the resident's declining condition, facility staff assured them there was no weight loss, relying on inaccurate records. The deficiency was confirmed through interviews, record review, and video evidence, revealing that weights were not properly obtained or documented, resulting in neglect.
A resident with severe cognitive impairment and a history of falls was found sitting on the floor in another room with visible injuries, including skin tears and a bruised heel. Multiple staff assessed and treated the injuries, but did not immediately document the incident or injuries in the EMR, and required risk management documentation was not completed. Staff interviews revealed confusion about care plan instructions and reporting protocols, and facility policy confirmed that documentation should have occurred for unwitnessed falls and skin injuries.
Two residents were rehospitalized due to the facility's failure to follow physician orders. One resident received warfarin earlier than prescribed, resulting in a supratherapeutic INR, while another did not receive prescribed antibiotics for a UTI, leading to urosepsis. Communication breakdowns and procedural lapses contributed to these deficiencies.
The facility failed to ensure the QAPI committee met quarterly with required members, as the Medical Director or designee did not attend a meeting in one quarter, and no meetings were held in August or September. The DON was unaware of the absence and did not provide proof of attendance.
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for hospital transfers. This deficiency was identified for four residents, including one with dementia and Parkinson's disease and another with a traumatic brain injury. Despite having a procedure and form for issuing notifications, the facility did not complete the necessary documentation, and the reason for this lapse was not explained.
The facility failed to properly label and dispose of medications, with expired and incorrectly dated medications found in multiple medication carts and a storage room. Insulin pens lacked proper expiration dates, and a discontinued controlled substance was not destroyed promptly. The DON acknowledged the need for staff re-education on medication management processes.
A resident with severe cognitive impairment and a history of cerebrovascular accident was inaccurately documented in the MDS assessment as requiring a wander/elopement alarm. Despite staff reports indicating no attempts to leave the locked unit in over a year, the facility failed to conduct the necessary quarterly risk assessments. The oversight was acknowledged by the DON, and the facility did not provide a policy on alarm assessments upon exit.
A facility failed to update the care plan for a resident with severe cognitive impairment and pressure injuries. The care plan lacked specific instructions on repositioning frequency, despite the resident's dependence on staff for mobility and the presence of a Kennedy ulcer. Staff relied on a bedside care plan report, which also omitted necessary details, leading to potential unmet care needs.
A resident with a prosthetic heart valve on warfarin therapy experienced delays in INR testing due to the facility's contracted laboratory service's limited availability. The resident required daily INR checks, but the lab was closed on weekends and had early weekday cutoffs, leading to delayed results and a test not performed due to an expired collection device. Staff expressed concerns about the lab's service, impacting the resident's care.
The facility failed to administer the recommended pneumococcal vaccinations or document reasons for withholding them for three residents. Despite consent forms indicating their wish to receive the PCV20 vaccine, none of the residents received it, and there was no physician documentation addressing the vaccine consideration. The Infection Preventionist confirmed the lack of vaccine administration and documentation, contrary to the facility's policy.
Verbal Abuse of Cognitively Impaired Resident by CNA During Personal Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA during in-room care. The resident was an elderly male with dementia, aphasia, overactive bladder, urinary incontinence, and a need for assistance with personal care, and his MDS showed severely impaired cognitive skills for daily decision-making. On the morning in question, a social worker (SW A) was entering her office when she overheard a staff member down the hall say, "You're being a complete [expletive]." SW A then entered the resident’s room and found one CNA (CNA B) bagging trash and observed another CNA (CNA/Perpetrator E) quickly leaving the room. When SW A informed CNA B of what she had overheard, CNA B indicated that CNA/Perpetrator E had made the statement toward the resident. In a later interview, CNA B reported that she had been assisting the resident with a brief change and, although the resident was known to be combative at times, he was initially in a good mood and cooperative. When CNA B could not complete fastening the brief alone, she called CNA/Perpetrator E for help and believed the loud tone and speed of CNA/Perpetrator E’s work may have upset the resident. The resident then stood up, removed his brief, and moved toward the door; CNA B attempted to redirect him by closing the curtain, during which he nudged her and laid hands on CNA/Perpetrator E. CNA B stated the resident eventually lay back down and made a rude remark under his breath, prompting CNA/Perpetrator E to say, "You're being a complete [expletive]." In a separate interview, CNA/Perpetrator E confirmed that after the resident had twisted her wrist and arm, attempted to push CNA B, and later kicked her in the back as she turned to leave, she called him an "[expletive]" while still in the room and acknowledged he probably heard her. The facility’s abuse policy defines verbal abuse as willful use of disparaging or derogatory language within a resident’s hearing, regardless of their ability to comprehend, and the incident was substantiated as mental abuse causing psychosocial harm and mental anguish based on a reasonable person standard.
Failure to Accurately Monitor and Record Resident Weights Resulting in Unaddressed Significant Weight Loss
Penalty
Summary
The facility failed to monitor and accurately record the weights of a resident with Alzheimer's disease, resulting in a significant, unaddressed weight loss. The resident was admitted at a weight of approximately 205 pounds and was noted to have severe cognitive impairment. Over a period of several weeks, staff, specifically a CNA, falsified weight documentation, recording inaccurate weights for at least eight consecutive weekly entries. This led to the facility not recognizing or intervening in the resident's substantial weight loss, which was eventually discovered to be 25.5 pounds. The resident's designated power of attorney repeatedly raised concerns about the resident's declining condition and appearance, but the facility assured them that no weight loss had occurred, based on the falsified records. Interviews and record reviews confirmed that the CNA responsible for obtaining and documenting weights did not consistently perform the task and instead entered false data. The CNA's skills checklist for measuring and recording weight was left incomplete, and the DON confirmed through video review that weights were not being properly obtained. The resident was observed to appear thin and expressed a lack of appetite. The facility's own policy defines neglect as the failure to provide necessary goods and services to avoid harm, and the investigation concluded that both abuse and neglect had occurred in this case.
Failure to Document Unwitnessed Fall and Injuries in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following an unwitnessed fall. The resident, who had a history of dementia, repeated falls, bone density disorder, and severe cognitive impairment, was found sitting on the floor in another resident's room. Multiple staff members, including CNAs and LPNs, observed and assessed the resident, noting visible injuries such as skin tears on the right forearm and bruising on the left heel. Despite these findings, there was no immediate documentation of the incident or injuries in the resident's electronic medical record (EMR) by the staff who first responded. The care plan for the resident indicated that sitting on the floor was only considered intentional and not a fall if it was witnessed. In this case, the event was unwitnessed, and staff were uncertain whether to classify it as a fall. As a result, required risk management documentation and event reporting were not completed at the time of the incident. The lack of documentation persisted even after subsequent staff discovered and treated the injuries, with some staff expressing confusion about the care plan and reporting requirements. Interviews with staff and review of facility policy confirmed that risk management documentation should have been completed for any unwitnessed fall or skin injury, including skin tears. The omission of this documentation was acknowledged by several staff members, including the DON, who stated that the expected protocol was not followed. The deficiency was identified through observation, interviews, and record review, revealing a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Medication Management Failures Lead to Rehospitalization
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to their rehospitalization. Resident #25, who had a history of gastrointestinal bleeding and was on warfarin therapy, was readmitted to the facility with specific instructions to resume warfarin on a later date. However, the facility administered the medication earlier than prescribed, resulting in a supratherapeutic INR and subsequent rehospitalization. The facility's inability to monitor INR levels effectively due to laboratory service limitations further exacerbated the situation. Resident #15 was discharged from the hospital with a prescription for amoxicillin to treat a urinary tract infection and sepsis. However, the facility failed to administer the antibiotic as it was not reflected in the Medication Administration Record. The resident's condition worsened, leading to a return to the hospital with urosepsis. The facility's on-call provider was unable to access the resident's chart or receive the hospital discharge instructions, contributing to the failure to administer the prescribed medication. Interviews with facility staff revealed communication breakdowns and procedural lapses. The Director of Nursing and Medical Director were unaware of the medication errors until after the residents' conditions had deteriorated. The facility's practice of having providers enter their own orders into the electronic medical records contributed to the oversight, as the necessary orders were not entered or followed. These deficiencies highlight significant lapses in medication management and communication within the facility.
QAPI Committee Meeting Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members, which could potentially lead to quality-of-care concerns for all 93 residents. A review of the facility's QAPI sign-in sheets revealed that meetings were held on several dates, but the Medical Director or designee did not attend the meeting on 7/17/24. Additionally, there were no QAPI meetings held in August or September 2024, and the Medical Director or designee did not attend any meetings during the quarter of July, August, and September. During an interview, the Director of Nursing (DON) was unaware of the Medical Director's absence and failed to provide proof of attendance by the survey exit date.
Failure to Provide Written Notification for Resident Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding the reasons for transfers to the hospital. This deficiency was identified for four residents who were transferred out of the facility. For Resident #87, the electronic medical record indicated a transfer to an acute care hospital due to swelling in the left lower extremity and thigh, but the Notification of Transfer and Bed Hold Authorization document did not include the reason for the transfer. Similarly, Resident #34 was sent to the hospital for possible sepsis, but the corresponding notification document lacked the reason for the transfer. Resident #25 was transferred to the hospital multiple times, yet the facility's documentation did not specify the reasons for these transfers. Resident #15 also experienced several hospital transfers, with no documented reasons provided in the notification forms. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility had a procedure for issuing written notifications of transfer, but the forms were not completed for the residents in question. The facility had a form titled Notice of Resident Transfer or Discharge, which included the necessary requirements, but it was not utilized, and the reason for discontinuing its use was not explained.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to properly label medications and dispose of expired or discontinued medications, as observed in three out of four medication carts and one out of two medication rooms. On March 18, 2025, an insulin pen with an expiration date of March 9, 2025, was found in the Valleyvue B medication cart, and a registered nurse confirmed it should not have been there. Additionally, the Lakevue B medication cart contained expired epinephrine auto-injector pens and an insulin pen without an expiration date. A registered nurse confirmed the epinephrine was expired and acknowledged the requirement for insulin pens to have expiration dates. Further observations revealed that the Lakevue A medication cart contained a haloperidol liquid without an expiration date and an insulin lispro pen with an incorrect expiration date. The cart also had two other insulin pens with incorrect dates. A registered nurse admitted the dates were incorrect. Additionally, a discontinued controlled substance, Lorazepam, was found in the Valleyvue B narcotic book, despite a physician's order to discontinue it on February 7, 2025. The nurse acknowledged that discontinued medications should be destroyed as soon as possible. In the medication storage room on Lakevue, an expired bottle of geri-tussin was found. The Director of Nursing was informed of these findings and confirmed that expired medications should be discarded and discontinued narcotics destroyed promptly. The facility's policies on medication disposal, labeling, and storage were reviewed, indicating that medications should be labeled with open and expiration dates, and expired or discontinued medications should be removed from active supply areas.
Inaccurate MDS Assessment for Resident with Alarm
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment documentation for a resident, identified as Resident #23, who was admitted with diagnoses including cerebrovascular accident, hemiplegia, and dementia. The MDS assessment indicated the use of a wander/elopement alarm daily, despite multiple staff interviews revealing that the resident had not attempted to leave the locked unit in over a year. The last risk assessment for the alarm was completed on 8/9/24, and the resident had not been assessed quarterly as required. Interviews with various staff members, including LPNs, CNAs, and the Director of Nursing, confirmed that the resident's condition had changed, and the use of the alarm was no longer necessary. The facility's policy on elopement and wandering residents emphasized the need for systematic monitoring and assessment, which was not adhered to in this case. The Director of Nursing acknowledged the oversight in not conducting the required quarterly assessments, and the facility failed to provide a policy regarding the assessment or use of alarms upon exit.
Failure to Update Care Plan for Resident with Pressure Injuries
Penalty
Summary
The facility failed to update the person-centered care plan for a resident with severe cognitive impairment and dependence on staff for all transfers and bed mobility. The resident, who was admitted with diagnoses including Parkinson's Disease and dementia, was observed with pressure injuries that were not adequately addressed in the care plan. The care plan lacked specific instructions on repositioning frequency, despite the resident's inability to reposition independently and the presence of a Kennedy ulcer noted in a provider's assessment. During observations and interviews, it was revealed that the care staff relied on a bedside care plan report, which also did not include necessary details on repositioning frequency or weight offloading for the resident's wounds. The Nursing Care Coordinator confirmed that the care plan was not updated to reflect the resident's current condition and needs, including the presence of the Kennedy ulcer and the requirement for repositioning every two hours. This oversight resulted in the potential for unmet care needs for the resident.
Failure to Provide Timely Laboratory Services for Anticoagulation Monitoring
Penalty
Summary
The facility failed to provide timely and adequate laboratory services for a resident with a prosthetic heart valve who was prescribed warfarin, an anticoagulant requiring regular monitoring through INR tests. The resident was transferred to the hospital multiple times due to supratherapeutic INR levels, indicating excessive blood thinning. Upon returning from a hospital stay, the discharge instructions specified daily INR checks, but the facility was unable to comply due to limited laboratory service availability on weekends and evenings. This resulted in delayed INR testing and reporting, with one instance where a specimen was submitted in an expired collection device, leading to a test not being performed. Interviews with facility staff, including the Clinical Care Coordinator and the Assistant Director of Nursing, revealed ongoing challenges with the contracted laboratory service provider. The laboratory was not open on weekends, and specimens had to be ready for pick-up by 4:00 PM on weekdays, with testing conducted out of state, causing further delays in receiving results. Despite management being aware of these issues, the facility continued to experience significant delays in obtaining critical laboratory results, impacting the care and safety of the resident.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to administer the recommended pneumococcal vaccinations or document the clinical reasons for withholding them for three residents. Resident #36, who was cognitively intact upon admission, had signed a consent form to receive the PCV20 vaccine as per CDC guidelines. However, the resident did not receive the PCV20 vaccine, and there was no documentation from the physician addressing this request. Resident #36 was later transferred to the emergency department with pneumonia. Similarly, Resident #75 and Resident #15, both of whom had consented to receive the PCV20 vaccine, did not receive it, and there was no physician documentation in their EMRs regarding the consideration of the vaccine. The Infection Preventionist confirmed that the residents did not receive the PCV20 vaccine as per their consent forms and that there was no documentation of the vaccine being considered for administration. The facility's policy requires offering pneumococcal vaccinations in accordance with CDC guidelines and documenting the provision of education and the administration or refusal of the vaccine. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and administration of the PCV20 vaccine for the residents in question.
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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