Greentree Of Hubbell Rehabilitation And Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Hubbell, Michigan.
- Location
- 52225 B Avenue, Hubbell, Michigan 49934
- CMS Provider Number
- 235551
- Inspections on file
- 26
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Greentree Of Hubbell Rehabilitation And Health during CMS and state inspections, most recent first.
The facility failed to ensure adequate weekend CNA staffing to meet resident needs, as shown by CMS PBJ data indicating excessively low weekend staffing and by internal schedules and payroll records reviewed with the COO. On multiple weekend day and afternoon shifts, only 3 to 3.5 CNAs were scheduled, which did not meet the facility’s own Facility Assessment requirement of at least 4–5 CNAs on day shift and 4 CNAs on afternoon shift. This deficiency, occurring under CMS rules that require staffing to be determined by the facility assessment, had the potential to affect all residents’ physical, mental, and psychosocial well-being.
The facility did not complete required annual performance reviews for five CNAs, as confirmed by personnel record review and interviews with the BOM and DON. Staff files for CNAs hired over multiple years lacked any documented evaluations, despite the expectation that reviews be conducted annually. The facility was unable to provide a performance review policy, and this failure created the potential for inadequate care and unmet needs for all residents.
A resident with colon cancer and severe cognitive impairment had an order for scheduled hydrocodone-acetaminophen, but 120 tablets of this Schedule II narcotic were found to be missing when staff attempted to administer a dose. Internal review showed the medication had not been administered, destroyed, or documented as wasted, and chain-of-custody records did not account for its disposition. At the time, pharmacy medications, including controlled drugs, were delivered in unsecured cardboard boxes via common carriers, often left unattended in the front office among other packages, and opened by nursing staff without tamper-evident safeguards. Facility policies on pharmacy services and medication storage did not describe the actual delivery process, did not specify who was responsible for receiving and inspecting shipments for tampering, and did not address the handling of courier-delivered medications, contributing to the misappropriation of the resident’s narcotic pain medication.
Surveyors found that the facility failed to maintain a clean, homelike, and odor-free environment, with strong urine odors noted at the entrance, in hallways, on both A and B units, and in multiple resident rooms and nursing station areas. Several resident rooms had heavily soiled privacy curtains and bathrooms with dried urine buildup and smeared feces on and around toilets, along with strong urine odors. A bathroom door was also observed with a large area of chipped paint. A housekeeper reported that resident room and bathroom floors are not mopped daily and that soiled linens and briefs are sometimes not promptly removed, especially on weekends when staffing is limited.
Surveyors found that multiple CNAs had not received the required 12 hours of annual in‑service training, despite facility policy stating that each nurse aide must complete at least 12 hours of training per year based on their hire date. Review of training records showed several CNAs with no documented training for extended periods after hire, and the DON acknowledged that these staff did not meet the annual training requirement.
A cognitively severely impaired resident with colon cancer had an order for scheduled Hydrocodone-Acetaminophen, but during a routine med pass staff discovered the narcotic supply was missing. Pharmacy records indicated 120 tablets should have been on hand, yet review of proof-of-use sheets and shift counts showed no documentation of administration, destruction, or waste. Staff interviews revealed that pharmacy medications were delivered in unsecured cardboard boxes left among other packages in the front office, without consistent signing or verification, and that the entire inventory sheet, narcotic count sheets, and four 30-tablet packages of the drug were missing. The facility’s abuse, neglect, and exploitation policy referenced preventing misappropriation of resident property but did not include specific protocol for misappropriation under F602.
Surveyors found that two CNAs did not have any documented initial or annual competency evaluations or skills demonstrations in their personnel files, despite facility policy requiring competency assessment during orientation and annually thereafter. A manager confirmed that staff are expected to have yearly competency training, but these two CNAs’ records lacked any such documentation.
A resident with dementia, dysphagia, chronic kidney disease, and recent treatment for walking pneumonia experienced a drop in SpO2 to 82% during a breathing treatment. An RN applied supplemental O2 under standing orders but did not document repeat vitals, follow-up SpO2, or the use of an oxygen mask, and began O2 without a specific physician order beyond standing orders. Later, an LPN documented that the resident’s O2 saturation dropped with O2 titration, along with decreased appetite, weakness, and increased sleep, and the resident requested hospital transfer, which was ordered by the MD. The EMR showed an order for O2 at 8 L/min via nasal cannula but no repeat vitals after the change in condition. The DON reported that standing orders allowed only up to 2 L O2 without an MD order and that titration required physician direction, while facility policies required physician notification for SpO2 below 89% and for significant changes in condition.
A resident with dementia, dysphagia, and chronic kidney disease developed a congested cough, bilateral rhonchi, and weakness, but was not tested for COVID-19 despite existing PRN orders for SARS-CoV-2 testing and facility policy requiring testing of anyone with even mild COVID-19 symptoms. The ADON/IP stated that symptomatic residents should be tested and acknowledged that testing "slipped" their mind because the resident was being treated for pneumonia. This inaction conflicted with the facility’s Infection Prevention and Control Program and CDC guidance to test residents and HCP with new respiratory illness signs or symptoms.
Two residents with cognitive impairments and special dietary needs were inadequately supervised, resulting in one resident repeatedly accessing and eating discarded food not suitable for her diet, and another sustaining serious burns from hot coffee served without a lid. Staff interviews and documentation revealed persistent staffing shortages, leading to lapses in supervision and failure to follow dietary orders.
The facility did not provide enough nursing staff to meet resident needs, resulting in missed hygiene and grooming, lack of supervision for residents at risk of choking, extended call light wait times, and a severe burn injury to a resident. Staff reported frequent mandatory overtime, burnout, and an inability to complete care tasks, which directly contributed to these deficiencies.
Multiple residents were observed with poor personal hygiene, including soiled clothing, dirty fingernails, and matted hair, while staff interviews revealed that chronic understaffing and frequent mandatory overtime led to rushed care and missed hygiene tasks. Residents reported long wait times for assistance and sometimes refused care due to staff being rushed or perceived as rude. Facility policies required maintaining resident dignity, but these standards were not met due to insufficient staffing.
The facility failed to adhere to food safety standards, risking foodborne illness for 53 residents. An uncovered ice container was left unattended, hamburger patties were improperly reheated, and sanitizing solutions were inaccurately tested. Staff lacked knowledge of proper procedures, violating FDA Food Code 2017.
The facility failed to maintain a safe and sanitary environment, affecting all 53 residents. An exit door had a gap allowing cold air and vermin entry, and a shower room wall had missing tiles with sharp edges. In the kitchen, a vacuum breaker was defective, risking contamination of the water supply.
The facility failed to ensure accurate and timely completion of advance directives for four residents. One resident's Code Status form was improperly witnessed before the legal guardian's signature, another resident's previous form was missing, and a third resident did not have a directive completed upon admission. Additionally, a fourth resident's documentation lacked the required witness signatures. These deficiencies were identified through interviews and record reviews, contrary to the facility's policy of quarterly review.
The facility failed to maintain a sanitary and homelike environment, as evidenced by persistent odors of urine and feces and inadequate room aesthetics. Strong odors were noted near the Hall B nurses' station and other areas, with staff unable to identify the source. Additionally, window draperies were improperly fastened, and cork bulletin boards were insecurely attached in residents' rooms. Maintenance issues were not documented, leading to delays in addressing these deficiencies.
The facility failed to ensure staff in food and nutrition services had the necessary skills, leading to potential unsafe practices. The Kitchen Manager (KM) A and another staff member were unable to demonstrate proper sanitizing procedures, and KM A had not completed the required Certified Dietary Manager program, holding only a Certified Food Manager credential.
The facility failed to provide meals at a palatable temperature and in a consumable form for several residents. Observations showed that food was served cold from un-insulated carts, and residents expressed dissatisfaction with the quality and temperature of their meals. One resident, unable to peel a hard-boiled egg due to arthritis, received no assistance, highlighting a lack of consideration for residents' needs.
A facility failed to obtain consent for psychotropic medications for a resident with severe cognitive impairment. The resident was prescribed quetiapine fumarate and sertraline without prior consent from the guardian, who reported a lack of communication from the facility. Interviews revealed that obtaining consents for mood-altering medications was a known issue, and verbal consent was obtained long after the medications were initiated.
A facility failed to conduct quarterly care conferences and notify the responsible party for a resident with severe cognitive impairment. The resident's guardian was only involved in two care conferences since admission, with significant gaps between meetings. Staff confirmed the absence of a regular care conference process under previous administration, contrary to facility policy requiring quarterly reviews.
A facility failed to conduct the required quarterly assessments for a resident self-administering medication, despite the resident having intact cognition and a diagnosis of peripheral vascular disease. The last assessment was documented months prior, and interviews with staff confirmed the oversight. Facility policy required quarterly reassessments, which were not completed, leading to the resident self-administering medication without appropriate evaluations.
Two residents experienced discomfort and dissatisfaction due to inappropriate incontinence briefs provided by the facility. One resident was given briefs that were too small, while another preferred a different style that was not available. The ADON acknowledged the need for accurate sizing and respecting resident preferences, and the NHA was informed of the deficiency.
A facility failed to obtain written authorization before withdrawing $500 from a resident's trust fund, intended for personal use, and applied it to the facility bill. The resident, with severe cognitive impairment, had a guardian who reported the unauthorized transaction. The Business Office Manager admitted to receiving verbal consent but did not provide a receipt or written documentation, contrary to facility policy.
A facility failed to provide quarterly resident trust fund financial statements for a resident with severe cognitive impairment, despite requests from their guardian. The facility had recently switched to using their own EMR system for managing resident fund accounts, and the BOM noted that the previous management service did not allow access to verify if statements were sent. The NHA planned to contact the management service to confirm the status of the statements, but none were provided by the survey exit.
The facility failed to provide timely 48-hour notices of Medicare benefit termination for three residents, preventing them from appealing non-coverage decisions. A resident with severe cognitive impairment did not receive any notification, while two others received notices only one day before coverage ended, contrary to the facility's policy requiring a two-day notice.
A facility failed to provide a resident and their representative with written notification of transfer reasons before hospitalizations. The resident, with intact cognition, was hospitalized three times due to medical emergencies, but no transfer notices were documented. The Social Services Designee was unfamiliar with the notification process, indicating a deficiency in policy adherence.
A resident with dementia, diabetes, hypertension, and anemia experienced multiple falls over several months. Despite these incidents, the facility failed to revise the resident's care plan after each fall, contrary to their policy on incidents and accidents, which requires immediate interventions and corrective actions to prevent recurrences.
The facility failed to maintain infection control and implement effective pressure ulcer prevention for three residents. An LPN contaminated wound supplies by using a personal cell phone without changing gloves. A resident's heels were not properly elevated, and another developed a Stage 2 pressure ulcer due to lack of timely pressure redistribution measures. The facility did not follow its own policies, leading to these deficiencies.
A resident with intact cognition and multiple diagnoses sustained a burn injury while smoking, which was not investigated by the facility. The resident reported burning himself when smoking cigarettes down to the filter, and staff failed to notice. The facility did not document or investigate the incident, contrary to their policy requiring such actions for resident injuries.
The facility failed to obtain consent, document non-pharmacological interventions, and monitor the effects of psychotropic medications for three residents with cognitive impairments and mental health conditions. Medications were administered without proper consent or documentation, and required assessments were not conducted as per facility policy.
A facility failed to maintain a medication error rate below 5 percent, resulting in a 7.69 percent error rate during insulin administration for a resident. Errors included not disinfecting the insulin pen hub and failing to prime the pen properly, leading to potential inaccurate dosing. The RN acknowledged the mistakes, and the ADON confirmed the errors, which were against the instructions for proper insulin pen use.
The facility failed to perform pre-employment and pre-admission TB screenings for several newly hired staff and recently admitted residents, as required by CDC guidelines. The Nursing Home Administrator confirmed the lapse in infection control practices, resulting in the potential for TB exposure and transmission.
A visually impaired resident was repeatedly unable to locate her call light, which was found out of reach on multiple occasions. The resident expressed frustration and helplessness, and staff confirmed the call light was not properly secured near her. The DON acknowledged that call lights should always be accessible, especially for residents with severe visual impairments.
The facility failed to ensure privacy and dignified treatment for two residents. One resident was left exposed during incontinence care, while another was fully visible from the hallway while sitting on the toilet. The Director of Nursing confirmed that residents should be cared for in a manner that preserves their dignity.
The facility failed to maintain safe and clean resident rooms for two residents. One resident's mattress was on the floor without proper coverings, and the floor was visibly soiled. The mattress and fall mat protruded into another resident's space, causing difficulty in maneuvering a wheelchair. Additionally, the room had an uncovered utility box and wall damage.
The facility failed to ensure safe transfers for two residents, both of whom were transferred without the use of gait belts as required by their care plans. This resulted in the potential for falls and injury, with staff not adhering to standard practices or checking care plans for transfer needs.
Inadequate Weekend CNA Staffing Below Facility Assessment Requirements
Penalty
Summary
The facility failed to provide adequate nursing staff on weekends to meet resident needs and to comply with its own Facility Assessment (FA) and CMS requirements, potentially affecting all 44 residents. CMS Payroll Based Journal (PBJ) staffing data for fiscal year quarter 4 of 2025 showed the facility triggered for excessively low weekend staffing. During an interview and record review, the Chief Operating Officer (COO) confirmed that weekend schedules and payroll records revealed low Certified Nurse Aide (CNA) staffing on specific weekend dates and shifts, including day and afternoon shifts staffed with only 3 to 3.5 CNAs. These staffing levels were below the FA, last updated 2/1/25, which specified a minimum of 4–5 CNAs on day shift and a minimum of 4 CNAs on afternoon shift. The deficiency occurred in the context of a CMS final rule, effective 8/8/24, requiring that facility assessments directly inform and determine staffing requirements. The report does not identify specific residents by condition or medical history but states that the inadequate staffing had the potential to affect all 44 residents residing in the facility, in terms of their physical, mental, and psychosocial well-being.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete required annual performance reviews for all five reviewed CNAs, creating a deficiency in monitoring and evaluating staff performance. Personnel record review showed that one CNA hired in November 2021, one CNA hired in February 2023, one CNA hired in July 2023, one CNA hired in November 2023, and one CNA hired in January 2024 each had no documented performance review completed at least every 12 months. The Business Office Manager stated there were no evaluations for any of these five staff members and acknowledged that evaluations were supposed to be done annually. The DON also acknowledged that annual performance reviews had not been completed. The facility did not provide a policy regarding performance reviews prior to exit. This deficient practice resulted in the potential for inadequate care and unmet care needs for all 44 residents residing in the facility. All 44 residents in the facility were identified as being potentially affected by the lack of annual performance reviews for the CNAs, but no specific resident medical histories or conditions at the time of the deficiency were described in the report.
Misappropriation of Controlled Pain Medication Due to Inadequate Delivery and Storage Controls
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its own policies for the delivery, receipt, and secure storage of controlled medications, resulting in the misappropriation of 120 hydrocodone-acetaminophen tablets prescribed for Resident #51. Resident #51 was originally admitted on 8/6/2024 with diagnoses including colon cancer and had a physician’s order for hydrocodone-acetaminophen 10-325 mg, one tablet three times daily. A Minimum Data Set dated 10/24/2025 documented a BIMS score of 9/15, indicating severe cognitive impairment. On 9/19/2025, during a routine medication pass, nursing staff discovered that the resident’s scheduled narcotic pain medication was missing when they attempted to obtain it from the StatSafe and were informed by the pharmacy that the facility should already have 120 tablets on hand. The facility’s internal investigation determined that the hydrocodone tablets for Resident #51 had not been administered, destroyed, or documented as wasted and were unaccounted for. Review of proof-of-use sheets, shift counts, and chain of custody records showed no documentation explaining the disposition of the medication. A nurse was identified as potentially involved in the missing medication based on the chain of custody review, and that nurse was no longer employed at the facility as of 9/14/2025. The incident was reported as misappropriation of 120 narcotic pain medications for Resident #51. Interviews and observations revealed that, at the time of the incident, pharmacy medications, including controlled substances, were delivered to the facility in regular cardboard boxes sealed with standard packaging tape, without locks or tamper-evident features. Nurses reported that these boxes were often left unattended in the front office among other facility and resident packages, and a nurse would have to search through multiple boxes to locate the pharmacy shipment. A single nurse would open the box, check inventory, and fill the medication cart with routine medications, and later call another nurse to sign off on the narcotic inventory sheet, even though the box itself could be easily opened and re-taped, including from the bottom. Staff interviews indicated that there was no clear, written procedure in the facility’s Pharmacy Services or Medication Storage policies describing who was responsible for receiving delivered medications, checking the box for tampering, or ensuring secure handling upon delivery. Policy review confirmed that, although the policies addressed storage and reconciliation of controlled substances, they did not address the actual delivery process or current courier methods, contributing to the conditions under which the controlled medications for Resident #51 were misappropriated. Additional staff interviews further supported that the delivery process lacked defined safeguards. RN B and RN C both described that pharmacy boxes arrived via UPS or FedEx, were not locked, and could be opened and re-taped without detection. They acknowledged that, even after the missing narcotic incident, pharmacy boxes sometimes continued to be retrieved from the front office among other packages, and there was uncertainty about who was responsible for inspecting boxes for signs of tampering. Observation of a pharmacy-labeled box delivered by UPS showed it to be a standard cardboard box with packaging tape and no locking or tamper-proof features. The Assistant DON confirmed that the facility’s policies did not specify the current procedures for receiving medications, did not address how medications were delivered, and did not identify who was responsible for checking in delivered medications or inspecting for tampering, which were key process gaps associated with the misappropriation of Resident #51’s controlled medication supply.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike, clean, and odor-free environment for all residents, staff, and visitors. On multiple observations over several days, surveyors noted a strong odor of urine upon entering the facility, in the hallways leading to the A and B units, and throughout the nursing station areas. Strong urine odors were repeatedly documented on both units, including the back unit rooms 1–20 and the unit with rooms 21–31, as well as during environmental inspections and resident pool observations. Individual resident rooms were also affected, with some rooms having a strong urine odor when toured by the surveyor. In addition to pervasive odors, surveyors observed visibly soiled environmental surfaces. Privacy curtains in at least two rooms were heavily soiled with brown smudge marks in multiple areas. Bathrooms in at least two rooms had dried urine buildup around the toilet seat, seat fasteners, and base, and dried feces smeared on the toilet tank, rim of the toilet seat, and underneath the toilet seat on the tank bowl, with strong urine odors present. A bathroom door in another room had a large area of chipped paint greater than 12 inches in diameter. A housekeeper reported that resident room and bathroom floors are not mopped daily and attributed the strong urine smell to infrequent mopping, soiled linens, and soiled briefs not being promptly removed to the off-site laundry and garbage building, particularly on weekends when the facility is short staffed.
Failure to Provide Required Annual In‑Service Training for CNAs
Penalty
Summary
The facility failed to ensure that CNAs received at least 12 hours of annual in‑service training as required by its Nurse Aide Training Program policy. During an interview, the Business Office Manager (BOM) stated that the annual 12-hour CNA training requirement is based on each CNA’s hire date. Facility documents reviewed showed that CNA E, hired on 11/10/21, had 0 hours of training since 5/28/24; CNA K, hired on 11/10/23, had 0 hours of training since 11/10/23; CNA L, hired on 1/15/24, had 0 hours of training since hire; CNA M, hired on 7/13/23, had 0 hours of training since hire; and CNA N, hired on 2/24/23, had 0 hours of training since 11/15/23. In a subsequent interview, the DON acknowledged that these five CNAs did not have the required 12 hours of annual training, despite the written policy stating that each nurse aide shall be provided at least 12 hours of in‑service training annually based on their employment date. No specific residents, medical histories, or resident conditions were described in relation to this deficiency, and the report focused solely on staff training records and staff interviews.
Misappropriation of Resident Narcotic Medication Due to Inadequate Control of Pharmacy Deliveries
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property, specifically a controlled pain medication, from misappropriation. A cognitively severely impaired resident with colon cancer was admitted with an order for Hydrocodone-Acetaminophen 10-325 mg, one tablet three times daily. During a routine medication pass, nursing staff discovered that the resident’s scheduled narcotic medication was missing and contacted the pharmacy to obtain a refill. The pharmacy reported that the facility should already have 120 tablets of the medication on hand, prompting a review of medication records and counts. Review of proof-of-use sheets and shift narcotic counts showed that the 120 tablets of Hydrocodone-Acetaminophen had not been administered, destroyed, or documented as wasted and were unaccounted for. Chain-of-custody review identified a nurse as potentially involved in the missing medication, and this nurse was no longer employed at the facility as of several days prior to the discovery. Interviews with nursing staff indicated that the medication was likely taken by a staff member when the pharmacy shipment was delivered, and that the nurse in question had not been signing for the pharmacy medication box upon delivery. Further interviews revealed that the pharmacy medication boxes arrived as regular cardboard packages taped with packaging tape, without locks or tamper-proof features, and were sometimes left in the front office among other delivered packages. Staff reported that it would have been easy for anyone, including staff or delivery personnel, to open and retape the boxes, and that in this case the entire inventory list, four narcotic count sheets totaling 120 pills, and four packages of 30 pills each were missing from the box. The facility’s Abuse, Neglect and Exploitation policy stated that the facility would prohibit and prevent misappropriation of resident property, but the policy did not address or reference the State Operations Manual or protocol specific to misappropriation (F602).
Missing Initial and Annual Competency Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that two CNAs had the required initial and annual competency evaluations and documented skills demonstrations as required by facility policy. Review of personnel records showed that one CNA hired on 1/15/24 had no dated competency skills documented in the file from the date of hire onward, and another CNA hired on 2/24/23 likewise had no dated competency skills documented since hire. During an interview, the Business Office Manager confirmed that two CNAs did not have competency trainings in their personnel files, despite the expectation that staff receive annual competency training. The facility’s written Competency Evaluation policy, last reviewed/revised on 1/1/25, states that each employee is to be evaluated to assure appropriate competencies and skills for their job, with initial competency evaluated during orientation and subsequent or annual competency evaluated thereafter, but these evaluations were not documented for the two CNAs. No resident-specific information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Monitor and Notify Physician After Resident’s Respiratory Decline
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and notify a physician of a change in condition for one resident and to document follow-up assessments after initiating supplemental oxygen. The resident was an elderly female with dementia, dysphagia, and chronic kidney disease who had recently been treated with antibiotics and prednisone for walking pneumonia. On 1/7/26 at 2:10 PM, an RN documented that the resident’s SpO2 was 82% during a breathing treatment, that the resident attempted to eat breakfast and did not want to continue the treatment, and that oxygen was applied and tolerated. However, there was no documentation of repeat vital signs or oxygen saturation after the administration of supplemental oxygen, and the RN acknowledged in interview that she believed she had entered follow-up information but it was not present in the EMR. She also confirmed she began oxygen without a physician’s order, relying on standing orders, and recalled use of an oxygen mask that was not documented. On 1/8/26 at 11:35 AM, an LPN documented that the resident’s oxygen saturation dropped with oxygen titration after finishing the course of antibiotics and prednisone for walking pneumonia, and that the resident had decreased appetite, weakness, and was sleeping during the shift, and stated she wanted to go to the hospital. The LPN contacted the medical director, who ordered transfer to the ER, but could not recall who ordered the titration of supplemental oxygen and suggested it may have been something they “just tried” or possibly directed by the ADON. Review of the EMR showed an order for oxygen at 8 L/min via nasal cannula starting 1/7/26, but no repeat vital signs were documented after the change in condition. The DON stated she expected to see follow-up documentation, including repeat vitals and physician notification if the condition did not improve, and clarified that standing orders allowed only up to 2 L of oxygen without a physician’s order and that titration should occur only under physician direction. Facility policies required initiation of 2 L O2 and physician notification if SpO2 was below 89%, and prompt physician notification for significant changes in condition requiring alteration of medical treatment.
Failure to Test Symptomatic Resident for COVID-19 per Facility Protocol and CDC Guidance
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program and CDC guidance for testing residents with new respiratory symptoms. A female resident with dementia, dysphagia, and chronic kidney disease was admitted on an unspecified date and later developed respiratory symptoms. On 12/29/25, a physician communication note documented that the resident presented with a congested cough, rhonchi throughout both lungs, and some weakness. The resident had existing physician orders dated 12/20/25 and 12/26/25 for SARS-CoV-2 (COVID-19) testing as needed per facility protocol, but there was no evidence that a COVID-19 test was ordered or performed after the onset of these symptoms. A complaint submitted to the State Agency on 1/28/26 stated that the resident was transferred to an emergency room on 1/8/26 with severe respiratory issues and was confirmed COVID-positive, and that the nursing home did not test her when she first showed symptoms, treating her only for pneumonia. During interviews, the ADON/Infection Preventionist explained that symptomatic residents should be tested for COVID-19 per facility protocol and identified symptoms warranting testing as sore throat, congestion, cough, fever, and fatigue. The ADON/IP confirmed that the resident was not tested for COVID-19 after respiratory symptoms began on 12/29/25 and stated that because the resident was being treated for pneumonia, it had “slipped my mind” to test for COVID-19, acknowledging that the resident should have been tested at symptom onset. This failure was inconsistent with the facility’s written Infection Prevention and Control Program, which required viral testing for anyone with even mild COVID-19 symptoms, and with CDC guidance directing testing of residents and HCP with new respiratory illness signs or symptoms.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for two residents with cognitive impairments and special dietary needs. One resident with Alzheimer's disease and a mechanical soft diet was observed repeatedly accessing and consuming discarded food from an unattended meal cart in the dining room without staff intervention. The resident was also given a sandwich that did not meet her dietary restrictions, resulting in her struggling to eat and dropping food on the floor. Multiple staff interviews confirmed that there were not enough staff present to monitor residents adequately, and that dietary orders were not consistently followed, increasing the risk of choking for the resident. Another resident with dementia and severe cognitive impairment, who required substantial assistance with eating, was left unsupervised in the dining room. This resident sustained second- to third-degree burns after spilling hot coffee on herself. The coffee was provided without a lid, despite care plan instructions, and staff acknowledged that the coffee was too hot and that a lid was needed. The staff member responsible was distracted due to short staffing and did not return with the lid before the resident was given the coffee. The burn resulted in significant injury, including blistering and pain, as documented in the resident's medical record and skin evaluation photos. Staff interviews consistently reported ongoing staffing shortages, which contributed to lapses in supervision, failure to follow dietary orders, and inability to provide adequate care. Staff expressed concerns about being unable to monitor all residents, leading to missed care and increased risk of harm. Grievance forms and care plan reviews further documented these deficiencies, with staff acknowledging that the current staffing levels made it difficult to ensure resident safety and compliance with care requirements.
Failure to Provide Sufficient Nursing Staff Resulting in Resident Harm and Missed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations and interviews. Several residents were found with poor hygiene, such as long, dirty fingernails, soiled clothing, and unclean bedding. Staff reported being frequently mandated to work extended shifts, leading to burnout and an inability to complete all required care tasks. Certified Nurse Aides (CNAs) and an LPN described having to cut corners on resident care, including missing nail care, hygiene, and timely response to call lights, due to chronic understaffing and high rates of staff call-ins and turnover. One resident with a seizure disorder and severe cognitive impairment was observed in a disheveled state, with soiled clothing and untrimmed, dirty fingernails. Another resident, who was cognitively intact but fully dependent for toileting and bathing, reported waiting over an hour for call light responses and experiencing soiled bedding and skin. This resident also described refusing care at times because staff were rushed and unable to provide care in a respectful manner. Staff confirmed that these issues were due to insufficient staffing levels, which made it difficult to provide adequate supervision and assistance to all residents. A resident with Alzheimer's disease and swallowing difficulties was observed eating food from discarded trays and being given food inconsistent with her prescribed mechanical soft diet, without adequate staff supervision in the dining area. Another resident suffered a third-degree burn from hot coffee when a CNA, distracted by other resident needs and short staffing, failed to ensure the coffee was safe before serving it. Staff interviews consistently attributed these incidents to inadequate staffing, which resulted in missed care, lack of supervision, and direct harm to residents.
Failure to Maintain Resident Dignity and Personal Hygiene Due to Inadequate Staffing
Penalty
Summary
The facility failed to maintain resident dignity and provide adequate personal hygiene for three residents, as evidenced by multiple observations and interviews. Residents were noted to be disheveled, with soiled clothing, untrimmed and dirty fingernails, and, in one case, matted hair. One resident with severe cognitive impairment was observed with dried food on his shirt, food crumbs in his lap, and significant dirt under his fingernails. Another resident, who was cognitively intact but physically dependent, was found with very dry, peeling skin, untrimmed and dirty fingernails, and soiled bedding with food crumbs and stains. This resident reported waiting extended periods for staff to respond to call lights and sometimes refused care due to staff rushing and perceived rudeness, attributing these issues to short staffing. Staff interviews confirmed that chronic understaffing and frequent mandatory overtime led to rushed care and the need to cut corners, particularly in areas such as nail care, hygiene, and timely response to call lights. Certified Nurse Aides reported being mandated to work double shifts, frequent call-ins, and burnout, which resulted in residents not receiving the care they deserved. Staff also indicated that other personnel with CNA licenses rarely assisted with time-consuming tasks like bathing, nail care, and feeding, further exacerbating the problem. Facility policies and job descriptions reviewed during the survey emphasized the importance of maintaining resident dignity and providing assistance with activities of daily living according to care plans. Despite these policies, the observed deficiencies in personal hygiene and resident appearance, as well as resident and staff reports of inadequate care, demonstrated a failure to uphold these standards. The lack of sufficient staffing and support directly contributed to the inability to provide dignified and respectful care to residents.
Food Safety Violations in LTC Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among the 53 residents. During an observation, a snack cart was left unattended in the hallway with an uncovered container of ice cubes used for filling resident drinking water cups. The Activity Aide confirmed he was not instructed to cover the ice cubes, which is a violation of the FDA Food Code 2017 that requires food to be protected from contamination. In another instance, during the noon meal service, hamburger patties were found at an unsafe temperature of 120 F in the steam table. The staff member responsible admitted to not reheating the patties to the required 165 F for 15 seconds before placing them in the steam table, which is only meant for maintaining food temperature. The staff member was unaware of the proper reheating requirements, indicating a lack of knowledge about food safety standards. Additionally, the facility's procedure for testing sanitizing solutions was inadequate. Staff members were observed using test strips incorrectly, not measuring the water temperature, and failing to achieve the proper concentration of sanitizer. The water temperature was too high, and the concentration of sanitizer was below the required level. Staff admitted they were not aware of the correct procedures for testing sanitizing solutions, which is a violation of the FDA Food Code 2017 that requires accurate measurement of sanitizing solutions.
Facility Environment Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functional environment for its residents, staff, and the public, potentially affecting all 53 residents. During an inspection, an exit door identified as Exit #4 was found to have a gap between the threshold and the bottom of the door, allowing cold air and potentially insects and vermin to enter the building. The Maintenance Director confirmed the door was in disrepair and needed replacement. Additionally, a community shower room was observed with a vertical wall missing eight ceramic tiles, exposing sharp edges that could cause injury. The Maintenance Director acknowledged the missing tiles and stated that replacements were unavailable, leading to the removal of the remaining tiles, which left the underlying drywall board exposed. Further inspection revealed issues in the kitchen's dishwashing area, where an atmospheric vacuum breaker connected to the garbage disposal was not intact, with the top bell housing missing. This defect could lead to a failure in the device during a negative pressure event in the potable water supply system, potentially causing contaminated liquids to backflow into the drinking water supply for the entire building. These deficiencies highlight significant lapses in maintaining a safe and functional environment within the facility.
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives related to code status were accurately and timely completed for four residents. Resident #6 had a Code Status form that was improperly documented, with the facility staff witnessing the form before the resident's legal guardian signed it. Resident #26's previous Code Status form was missing, and a new form was completed on the day of the survey, indicating a lack of documentation from admission until that day. Resident #46 did not have an advance directive completed upon admission, and the Social Services Designee admitted to not filling out a new directive as required. Resident #50's documentation was incomplete, with only one witness signature instead of the required two. The facility's policy mandates that residents' code status be reviewed at least quarterly, but this was not adhered to in these cases. The deficiencies were identified through interviews and record reviews, highlighting the facility's failure to properly document and manage advance directives for these residents, which included those with conditions such as dementia, heart failure, and diabetes.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary, clean, and homelike environment for its residents, as evidenced by multiple observations of strong odors and inadequate room aesthetics. On several occasions, surveyors noted a pervasive odor of urine and feces in various areas of the facility, including near the Hall B nurses' station, the resident room hall, and the hall outside the kitchen and dining room. Certified Nurse Aide (CNA) Q and other staff members were unable to identify the source of the odors, although it was suggested that they might be emanating from the air vents or the soiled utility room. The odors were persistent over several days, indicating a systemic issue with odor management in the facility. In addition to the odor issues, the facility also failed to maintain the aesthetic quality of resident rooms. Observations revealed that window draperies in some rooms were improperly fastened with paper clips and could not be fully closed, which was acknowledged by residents as unsatisfactory. Maintenance Director (Staff) D confirmed that the condition of the draperies was not conducive to a homelike environment and should have been addressed by the staff. Furthermore, cork bulletin boards in residents' rooms were found to be insecurely attached or leaning against walls, posing potential safety hazards. Staff D admitted that these issues were not recorded in the maintenance binder, which is used to track and address maintenance concerns. The facility's failure to address these environmental deficiencies was further highlighted by the lack of communication and documentation regarding maintenance needs. Staff D and the Nursing Home Administrator (NHA) acknowledged that the state of the bulletin boards and draperies did not meet the facility's aesthetic expectations. The NHA noted that these issues should have been documented in the maintenance binder to ensure timely repairs. The facility's policy on resident rights emphasizes the importance of providing a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Inadequate Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that staff in the food and nutrition services had the appropriate competencies and skills, which could potentially lead to unsafe practices in the kitchen and dietary services affecting all 53 residents. During an observation, the three-compartment sink was used for washing, rinsing, and sanitizing food contact surfaces. However, the Kitchen Manager (KM) A was unable to demonstrate the proper testing procedure to ensure the correct concentration of sanitizing chemicals. Additionally, another staff member, [NAME] C, was also unable to demonstrate the procedure and confirmed that no training had been provided by KM A. Further investigation revealed that KM A had not completed the Certified Dietary Manager (CDM) program, having only finished one out of ten required modules over two years. Despite being in the position of manager of dietary services for almost three years, KM A only held a Certified Food Manager (CFM) credential. The FDA Food Code requires the person in charge of a food service operation to demonstrate knowledge of foodborne disease prevention and other critical principles, which was not adequately demonstrated by KM A.
Deficient Food Service Practices
Penalty
Summary
The facility failed to provide food in a manner that was palatable and at a safe and appetizing temperature for 10 residents. During a group interview, several residents expressed dissatisfaction with the cold temperature of their meals, including pizza and noodles, which were described as undercooked and bland. One resident mentioned receiving a hard-boiled egg with the shell on, which they could not peel due to arthritis, and no assistance was provided. Another resident complained about the quality of their meal, which included plain pasta, mushy zucchini, and hard cauliflower. A resident also reported significant weight loss due to the poor quality of food. Observations revealed that meal trays were delivered from un-insulated metal carts, resulting in food temperatures ranging from 102°F to 109°F, which is below the recommended serving temperature. The kitchen manager admitted that the staff was supposed to peel eggs for residents who couldn't do it themselves but had not considered the difficulty of removing all the shells. The menu did not specify that the eggs would be served unpeeled. These findings indicate a failure to ensure that meals were served at appropriate temperatures and in a form that residents could consume comfortably.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications before initiating them for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, was prescribed quetiapine fumarate and sertraline without prior consent from the guardian. The guardian, who had legal authority over the resident's treatment decisions, reported a lack of communication from the facility regarding these treatment decisions. Interviews with the Director of Nursing and the Social Services Designee revealed that obtaining consents for mood-altering medications had been a recognized issue within the facility. The facility's policy required that residents and/or their representatives be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments. However, verbal consent for the medications was only obtained from the guardian approximately 1 year and 8 months after the medications were initiated, indicating a significant lapse in following the facility's policy and ensuring informed consent.
Failure to Conduct Quarterly Care Conferences and Notify Responsible Party
Penalty
Summary
The facility failed to ensure that care conferences were scheduled on a quarterly basis and that the responsible party was notified, resulting in a deficiency in resident rights. This issue was identified for one resident, who had severe cognitive impairment due to Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression. The resident's guardian reported not being given the opportunity to participate in regular care conferences, having only been involved in two since the resident's admission. The facility's records showed that care conferences for the resident were held on three occasions, with significant gaps of 9 and 5 months between them, despite the requirement for quarterly meetings. Interviews with facility staff, including the Social Service Designee and the Nursing Home Administrator, confirmed the lack of a regular care conference process under previous administration. The facility's policy mandates that comprehensive care plans be reviewed and revised after each comprehensive and quarterly MDS assessment, which was not adhered to in this case.
Failure to Conduct Quarterly Assessments for Self-Administering Resident
Penalty
Summary
The facility failed to perform a resident assessment for a resident who was self-administering medication, resulting in a deficiency. The resident, who had been admitted with diagnoses including peripheral vascular disease, scored a perfect 15 on the Brief Interview for Mental Status, indicating intact cognition. Despite this, the facility did not conduct the required quarterly assessments to ensure the resident's continued ability to safely self-administer medication. The last documented assessment was on 7/23/24, and no subsequent assessments were found in the resident's electronic medical record. Interviews with the Assistant Director of Nursing and a Registered Nurse revealed that the facility's policy required quarterly assessments for residents self-administering medication. However, it was acknowledged that the quarterly assessment for the resident in question was missed. The facility's policy also stipulated that a licensed nurse should complete a Medical Self-Administration screening tool in the electronic medical record, and reassessments should be considered quarterly by the interdisciplinary team. The failure to adhere to these procedures led to the resident self-administering medication without the appropriate assessments being conducted.
Inappropriate Incontinence Briefs Provided to Residents
Penalty
Summary
The facility failed to provide appropriately sized and styled incontinence briefs to meet the needs and preferences of two residents, resulting in discomfort and dissatisfaction. Resident #23 expressed dissatisfaction with wearing incontinence briefs that did not fit properly, as the size had been changed from XXL to Large, which did not cover the waist adequately. The resident had been complaining to a CNA for at least a week. Observation confirmed that only size Large briefs were available in the resident's closet, which did not fit properly. Resident #26 was observed wearing an incontinence brief that appeared too small, causing discomfort. The resident expressed a preference for pull-up style briefs, which were not provided, as they were told the current style held more urine. The Assistant Director of Nursing acknowledged the need for accurate waist measurements to determine the appropriate size and style of briefs, and confirmed that the residents' preferences should be considered. The Nursing Home Administrator was informed of the deficiency concern.
Unauthorized Withdrawal of Resident Funds
Penalty
Summary
The facility failed to obtain authorization prior to withdrawing personal funds for a resident with severe cognitive impairment. The resident, diagnosed with Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, had a BIMS score of 3, indicating severe cognitive impairment. The resident's guardian reported that the facility withdrew $500 from the resident's trust fund without authorization and applied it to the facility bill. The guardian stated that the funds were intended for personal use, such as haircuts, shopping, and snacks. The Business Office Manager (BOM) confirmed the withdrawal and stated that verbal consent was received from the guardian, but no receipt or written documentation was provided. The facility's policy requires a receipt for any transaction involving resident funds, and the Nursing Home Administrator confirmed the need for written authorization before withdrawing money from resident accounts. The BOM acknowledged the oversight and recognized the need for proper documentation in future transactions.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly resident trust fund financial statements for a resident with severe cognitive impairment, as required by their policy. The resident, who has Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, did not receive the necessary financial statements despite requests from their guardian. The facility had recently transitioned to using their own EMR system to manage resident fund accounts, and the Business Office Manager (BOM) indicated that the previous management service did not provide access to verify if statements were sent. The Nursing Home Administrator (NHA) acknowledged the issue and intended to contact the management service to confirm the status of the statements, but no statements were provided by the time of the survey exit.
Failure to Provide Timely Medicare Termination Notices
Penalty
Summary
The facility failed to provide a 48-hour notice of termination of Medicare benefits for three residents, which resulted in the residents' inability to appeal their non-coverage decision in a timely manner. Resident #8, who had severe cognitive impairment due to Alzheimer's disease and other mental health conditions, did not receive any beneficiary notification since admission, as confirmed by both the complainant/guardian and the responsible registered nurse. The Director of Rehabilitation confirmed that Resident #8 received skilled therapy services under Medicare Part B, but there was no record of a notification being issued. For Resident #204, the Notice of Medicare Non-Coverage (NOMNC) form was signed one day before the effective date of coverage termination, and similarly, for Resident #205, the NOMNC form was signed one day before the end of coverage. The facility's policy requires that such notices be provided at least two days before the end of Medicare-covered services, but this was not adhered to in these cases. The failure to provide timely notifications is a violation of the facility's policy and federal regulations, impacting the residents' rights to make informed decisions about their care and financial responsibilities.
Failure to Provide Transfer Notification
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding the reasons for transfers to an acute care hospital. The resident, who had intact cognition as indicated by a BIMS score of 15, was hospitalized three times since their initial admission. Despite these hospitalizations, the resident did not recall receiving or signing any transfer notification documents prior to being transferred. The facility's records confirmed the resident's transfers occurred on three separate occasions due to medical emergencies, including a dehisced surgical incision, uncontrollable shaking with cyanosis, and a need for evaluation and treatment in the emergency room. However, a review of the electronic medical record revealed no written transfer notices were provided before any of these hospitalizations. Additionally, an interview with the Social Services Designee revealed a lack of familiarity with the transfer notification process, further indicating a deficiency in the facility's adherence to its own policy on transfer and discharge.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update or revise the care plan for a resident after multiple falls, which was identified as a deficiency. The resident, who has active diagnoses including dementia, diabetes, hypertension, and anemia, was admitted to the facility and was noted to rarely or never be understood or make decisions. The resident experienced one fall in August, two falls in October, and two falls in November. Despite these incidents, the care plan was not revised after any of the falls. The facility's policy on incidents and accidents emphasizes the importance of implementing appropriate and immediate interventions and corrective actions to prevent recurrences, which was not adhered to in this case.
Inadequate Pressure Ulcer Prevention and Infection Control
Penalty
Summary
The facility failed to maintain proper infection control and implement effective interventions for the prevention and treatment of pressure injuries for three residents. For Resident #11, during a wound care observation, an LPN used her personal cell phone without changing gloves, contaminating the wound supplies and the wound itself. The LPN also placed a foam dressing on the resident's bed linens instead of a sterile barrier, further compromising infection control standards. Resident #26 reported a sore area on the tailbone, and during a wound care observation, it was noted that the resident's heels were in contact with the bed mattress, with one heel showing signs of redness and sponginess. The facility's standing orders and policies were not followed, as the resident did not have an air mattress or proper heel elevation to prevent pressure injuries, despite being at risk. Resident #54 developed a Stage 2 pressure ulcer on the coccyx after admission, despite not having any pressure ulcers upon entry to the facility. The DON acknowledged that an air mattress should have been provided earlier, and the resident was not educated on the risks of pressure ulcers. The facility's failure to implement timely and appropriate pressure redistribution measures contributed to the development of the pressure ulcer.
Failure to Investigate Resident's Burn Injury
Penalty
Summary
The facility failed to investigate an accident involving a resident who sustained a burn injury while smoking. The resident, who has intact cognition and a history of diabetes mellitus, anxiety disorder, depression, and hypertension, was observed with a scab on his right middle finger. The resident reported that he burned himself while smoking cigarettes down to the filter, and staff did not notice his actions. The resident was informed that his smoking privileges would be revoked if the incident occurred again. The facility's policy requires staff to report, investigate, and review any accidents or incidents involving residents. However, there was no incident or accident report for the resident's burn injury. The Assistant Director of Nursing was aware of the blister but not the cause. The facility's failure to document and investigate the incident is a deficiency in adhering to their policy, which mandates documentation of the date, time, nature of the incident, location, initial findings, immediate interventions, notification, and follow-up interventions for unobserved injuries.
Failure to Obtain Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain consent, document non-pharmacological interventions, and monitor the effects of psychotropic medications for three residents. Resident #8, diagnosed with Alzheimer's disease, vascular dementia, and other mental health conditions, was prescribed quetiapine fumarate and sertraline without documented consent or specific non-pharmacological interventions in the care plan. The Director of Nursing acknowledged missing AIM assessments and consent issues, while the Social Services Designee confirmed the lack of timely consent. Resident #33, with multiple diagnoses including anxiety disorder and dementia, was prescribed several psychoactive medications without justification for continued use or proper consent documentation. The facility failed to provide signed consents for the use of haloperidol and other medications until recently, despite the medications being administered for an extended period. The Social Services Designee admitted to the absence of previous consents before the newly signed documents. Resident #38, with Alzheimer's disease and schizophrenia, was prescribed olanzapine without a signed consent from the legal guardian. Additionally, the resident had not received an AIM assessment since March 2022. The facility's policy requires education on psychotropic drug use and non-pharmacological interventions, as well as regular AIM assessments, which were not adhered to in these cases.
Medication Administration Errors Observed in Insulin Dosing
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a 7.69 percent error rate during the observation of medication administration for a resident. The errors were observed during the administration of insulin by a Registered Nurse (RN) to a resident. The RN did not disinfect the hub of the humalog insulin pen before attaching the needle and failed to prime the pen properly, which is necessary to ensure accurate dosing. The RN acknowledged the oversight and attempted to correct the process but still did not prime the pen before administering the insulin. Additionally, the RN made errors while preparing the lantus insulin pen by priming it incorrectly and not following the proper procedure to ensure accurate dosing. The Assistant Director of Nursing (ADON) was consulted and confirmed the errors in the insulin administration process. The instructions for both the humalog and lantus insulin pens clearly state the need for priming to avoid air bubbles and ensure accurate dosing, which was not adhered to during the administration process.
Failure to Perform TB Screenings for Staff and Residents
Penalty
Summary
The facility failed to perform pre-employment and pre-admission screenings for tuberculosis (TB) based on current professional guidelines. During a review of staff records from January 2024 through April 2024, it was found that no TB screening information was available for several newly hired employees, including dietary aides, certified nurse aides (CNAs), and housekeeping aides. The Office Manager confirmed that the head of each department was responsible for ensuring TB screenings, but no documentation was provided for the sampled employees. The Nursing Home Administrator (NHA), who was also the interim Infection Preventionist, acknowledged the issue but had not made any changes to the process as of the survey date. The NHA confirmed that no TB screening information was found for the newly hired staff members listed in the report. Additionally, a review of electronic medical records (EMRs) for residents admitted within the past 30 days revealed that several residents did not have TB screening information prior to or since their admission. The NHA confirmed that the staff responsible for TB screening of newly admitted residents did not understand the process. The facility's policy on TB screening, which aligns with CDC guidelines, was not followed, resulting in the potential for exposure and transmission of TB to susceptible residents. The NHA confirmed that residents admitted within the specified period were not screened for TB, highlighting a significant lapse in infection control practices.
Call Light Accessibility for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a visually impaired resident (R16). R16, who was admitted with diagnoses including legal blindness, dementia, anxiety, and depression, was observed on multiple occasions unable to locate her call light. On one occasion, R16 was found sitting in her wheelchair, facing the wall with an over bed table in front of her, and the call light wrapped around the left upper grab bar of the bed, out of her reach. R16 reported she often could not find the call light and was observed patting her hands around her lap and the table in an attempt to locate it. The call light was confirmed to be out of reach by both the resident and the surveyor's observations. On another occasion, R16 was heard calling for help repeatedly and was found in a similar position with the call light lying on the floor, two feet away from her and on the opposite side of the over bed table. R16 expressed frustration at not being able to find the call light and needing assistance to go back to bed. An LPN confirmed the call light was out of reach and activated it for assistance. The LPN also found a small metal clip on the call light cord that was not being used to secure the light near the resident. The Director of Nursing confirmed that call lights should always be accessible to residents, especially those with severe visual impairments like R16.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure privacy and dignified treatment during the provision of care for two residents. One resident, who had severe cognitive impairment and was dependent on staff for various activities, was observed lying naked from the waist down while the CNA and the Nursing Home Administrator were out of sight. This occurred during incontinence care when the CNA left to wash her hands and the NHA went to retrieve a clean brief, leaving the resident exposed and unattended on the bed. Another resident, also with severe cognitive impairment, was observed sitting on the toilet with her pants and brief pulled down below her knees, fully visible from the hallway. The privacy curtain was not drawn, and the door to the shower room was fully open. A staff member walking down the hallway noticed the exposed resident and subsequently drew the privacy curtain. The Director of Nursing confirmed that all residents should be cared for in a manner that preserves their dignity, including ensuring privacy during toileting and covering exposed body parts during care.
Failure to Maintain Safe and Clean Resident Rooms
Penalty
Summary
The facility failed to ensure resident rooms were maintained in a safe, clean, and homelike manner for two residents. Resident R13, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease and stroke, was observed with her mattress directly on the floor without sheets or a mattress protector. The floor around her mattress was visibly soiled with dirt and shoe prints, and a sticking sound was noted when walking on it. The mattress and a fall mat were positioned askew, protruding into the portion of the room belonging to Resident R19, who was cognitively intact and had diagnoses including COPD and bipolar disorder. R19 reported difficulty maneuvering her wheelchair around the mattress and had previously reported the issue to staff without resolution. Additionally, the wall near R19's dresser had deep gouges, and an uncovered utility box with a protruding screw was found, posing potential safety hazards. Certified Nurse Aide Supervisor (CNA) F confirmed that R13's mattress was on the floor as per her care plan, and that R13 often crawled around on the floor. Maintenance and Housekeeping Director (Staff L) was unaware of the uncovered outlet box and the disrepair in the room, confirming the visibly soiled floor. Housekeeping Aide (Staff T) reported not receiving notification about the soiled floor, and Housekeeping Aide (Staff S) stated the room was last cleaned the previous day but did not recall the time. The facility's maintenance log showed no entries for the uncovered outlet box or the wall damage. The Nursing Home Administrator (NHA) and Regional Administrative Consultant (Staff A) acknowledged the observations and instructed maintenance staff to inspect all utility outlets facility-wide and housekeeping staff to clean R13 and R19's room twice daily. However, these actions were taken after the surveyor's observations and are not part of the deficiency itself.
Failure to Ensure Safe Transfers for Residents
Penalty
Summary
The facility failed to ensure safe transfers for two residents, resulting in the potential for falls and injury. Resident 13, who has diagnoses including dementia, Parkinson's disease, muscle weakness, and abnormalities of gait/mobility, was observed being assisted to the toilet without the use of a gait belt, contrary to the care plan which required extensive assistance and the use of a gait belt. The care plan also indicated that Resident 13 was at high risk for falls. Similarly, Resident 18, who has severe dementia and a history of falls, was observed being transferred from a wheelchair to a bed without the use of a gait belt or any other assistive device, despite the care plan specifying the use of a gait belt and a front-wheeled walker for transfers. The CNA assisting Resident 18 was unaware of the resident's transfer needs and had not checked the care plan prior to the transfer. The Director of Nursing confirmed that the use of gait belts during transfers is a standard practice and that staff should check the care plan when unsure of a resident's transfer status. The facility's policy on Safe Resident Handling/Transfer, last reviewed in June 2023, mandates that residents be handled and transferred safely according to their individual care plans to prevent injury. The failure to adhere to these policies and care plans led to the observed deficiencies in resident care and safety during transfers.
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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