Hampton Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bay City, Michigan.
- Location
- 800 Mulholland Road, Bay City, Michigan 48708
- CMS Provider Number
- 235411
- Inspections on file
- 19
- Latest survey
- June 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Hampton Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain adequate nursing staff coverage, particularly on weekends and certain shifts, resulting in unmet resident care needs such as long wait times for assistance, missed showers, and resident frustration. Staffing records and interviews confirmed frequent call-ins, difficulty filling open positions, and reliance on bonuses to encourage staff to work extra shifts, but these measures were insufficient to ensure consistent coverage.
Residents reported that their care needs were frequently unmet due to insufficient staffing and the conduct of a specific aide, resulting in long wait times for assistance, missed showers, and lack of help with meals. Multiple residents described being treated disrespectfully, with one aide characterized as rushed and rude, leading to feelings of diminished self-worth and unmet needs.
Surveyors found that the facility failed to maintain clean and safe shower rooms, with black residue, chipped tiles, and a non-functioning shower, resulting in an environment that did not meet regulatory standards for cleanliness and comfort.
Surveyors found that the facility did not follow care plans for ADL and wound care for three residents, resulting in missed showers, inadequate hygiene, and a missed dressing change for a post-surgical wound. Documentation was inconsistent, and required interventions for refusals or missed care were not in place.
Multiple dependent residents did not receive scheduled showers or bed baths, resulting in poor hygiene, greasy hair, body odor, and unshaven appearances. Only one shower was available for all residents due to facility infrastructure issues, and care plans lacked interventions for refusals or alternative hygiene measures. Residents expressed dissatisfaction and emotional distress, and documentation did not reflect appropriate hygiene care or strategies for managing refusals.
A resident with a post-surgical back incision did not receive a daily dressing change as ordered, with observation showing the same dressing in place for two days. Nursing staff documented the dressing change as completed, but the physical evidence and resident interview indicated otherwise. The DON confirmed that dressing changes should be completed as ordered and by the next shift if missed.
A resident with severe cognitive and physical impairments, identified as very high risk for pressure injuries, was repeatedly found without required positioning devices and developed multiple open areas of skin breakdown under the left breast. Staff failed to follow care-planned interventions for repositioning and did not document or report the new skin breakdown, despite clear risk factors and facility guidelines.
A medication cart was found unlocked and unattended in a hallway, allowing access to medications by residents, visitors, and staff. The assigned RN was in a resident's room at the time, and the cart was accessible to the state surveyor, who was able to open its drawers. The RN had previously received inservice training on the requirement to keep medication carts locked when not in use, and facility policy prohibits leaving carts unlocked and unattended.
A resident who refused the RSV vaccine did not have a signed refusal form or documentation of vaccine education in the medical record. The electronic record included a blank consent form, and no progress notes indicated that education or refusal was addressed, even after the resident was readmitted with RSV.
A deficiency was cited due to the facility not being fully protected by an approved automatic sprinkler system as required by the 2012 standards for existing nursing homes and hospitals.
Surveyors found that the facility basement, which houses the laundry, employee break room, maintenance office, boiler room, storage, electrical room, and employee bathroom/locker room, had only one exit instead of the two required by NFPA 101. This deficiency was confirmed by interviews with facility leadership and could affect about 10 occupants in an emergency.
Surveyors found that a sprinkler head in the main lobby near the front egress door was installed too close to a light fixture, in violation of NFPA 13 requirements. This placement could alter the water flow pattern and does not provide proper sprinkler protection, as confirmed by interviews with facility leadership.
The facility failed to ensure that call lights and privacy curtains were accessible to residents, leading to unmet care and privacy needs. Observations showed that privacy curtains were out of reach in several rooms, and a resident's call light was placed four feet away, making it inaccessible. A CNA admitted to not using the privacy curtain during a care task, further compromising resident privacy.
The facility failed to provide adequate ADL care for four residents, leading to issues such as long fingernails, missed showers, and unkempt appearances. One resident missed scheduled showers, another had long nails and dirty palms, a third reported missed showers due to staff availability, and a fourth was left in a nightgown for days with their call light out of reach. These deficiencies indicate a failure to adhere to the facility's policy on maintaining residents' ability to perform ADLs.
A resident developed a facility-acquired pressure injury on the left heel due to the facility's failure to prevent it and ensure timely nutritional care plans. Despite being alert and oriented, the resident experienced significant weight loss and inconsistencies in receiving prescribed nutritional interventions. Interviews revealed a lack of awareness and follow-up by the dietary manager and registered dietician regarding the resident's nutritional needs and preferences.
A resident with contracted hands was observed multiple times without the required bilateral palm protectors, as specified in their care plan. The Therapy Director confirmed the need for these protectors during the day, but they were found unused in the resident's nightstand. The resident's care plan included instructions for applying the protectors, and staff had been educated on their use.
A nurse improperly stored narcotics for a resident by placing them in a medication cart drawer instead of following proper storage procedures. The nurse prepared the medications, including Norco and Pregabalin, and when the resident requested to take them later, the nurse stored them in the drawer. The Director of Nursing acknowledged the error, noting it was against the facility's Controlled Substances Policy.
A resident experienced significant weight loss due to the facility's failure to honor her dietary preferences and provide palatable meals. Despite being on a Controlled Carbohydrate Diet and No Added Salt diet, the meals served were high in carbohydrates and sugar, contrary to her needs for managing Type 2 Diabetes. The resident's documented preferences, such as the inclusion of strawberries and cottage cheese, were not followed, leading to reduced food intake and frustration.
A facility failed to ensure proper communication and documentation of hospice services for a resident, leading to a lack of progress notes and assessments in the medical record. The resident was found uncomfortable, and the unit nurse had not notified the hospice agency about symptoms. The hospice services binder lacked documentation, and there was a delay in scanning progress notes into the EMR. Additionally, Morphine Sulfate was administered at incorrect intervals, with no changes in the prescribed order noted.
The facility failed to implement Enhanced Barrier Precautions, as staff were observed not wearing required PPE in designated rooms. A nurse and a CNA were seen without gowns during high-contact activities, and a housekeeper cleaned an EBP room without a gown. These actions violated the facility's policy and physician orders, risking cross-contamination.
Deficiency Due to Insufficient Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of residents, as evidenced by multiple resident interviews and review of staffing records. Residents reported long wait times for assistance, particularly on weekends and during certain shifts, with one resident stating she waited 30-45 minutes for help and experienced incontinence as a result. Several residents expressed frustration about insufficient staff coverage, especially on weekends and second shift, and noted that call lights were not answered promptly. Review of the facility's PBJ (Payroll-Based Journal) staffing data for the first quarter of 2025 revealed low weekend staffing. The facility's policy states that sufficient numbers of licensed nurses and CNAs are to be available 24/7, but interviews with staff and review of schedules indicated frequent call-ins and difficulty filling open positions, particularly on weekends. The facility attempted to address call-ins by offering bonuses and asking staff to stay over, but gaps in coverage persisted. The Human Resources staff confirmed that agency staff were not used and that new hires often did not remain after orientation, further contributing to staffing shortages. Staffing levels discussed included a requirement for 4 CNAs and 2 nurses on day and afternoon shifts, and 1-2 CNAs and 2 nurses on night shift, depending on census. Despite these requirements, both residents and staff reported that actual staffing often fell short, especially on weekends. The facility's inability to consistently provide sufficient nursing staff resulted in unmet resident care needs, including missed showers and delayed responses to call lights, leading to resident dissatisfaction and compromised care.
Failure to Ensure Dignity and Timely Care Due to Staff Conduct and Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and had their needs met in a timely manner, as required by resident rights regulations. Multiple residents reported that their care needs were only met about half the time, with specific complaints about insufficient staffing, long wait times for assistance, and lack of responsiveness to call lights. Residents described being left on the toilet for extended periods, missing scheduled showers due to staff shortages, and not receiving help with meal setup. One resident, who used a writing board for communication, reported that an aide told them to "do it on your own" when they requested help. During a resident council meeting, all residents present unanimously stated that they did not receive care when needed, citing frequent understaffing and inconsistent aide performance. Specific complaints were made about a particular aide, who was described as rushed, rude, and dismissive. Residents recounted instances where the aide snapped at them, made insensitive remarks, and failed to provide timely incontinence care. Two residents reported that their call light was left unanswered for extended periods, resulting in one resident being unable to access a bedpan in time. The aide's behavior was characterized as lacking in customer service, with residents feeling talked down to and experiencing diminished self-worth. These findings were based on direct resident interviews, observations, and review of facility records.
Deficient Shower Room Maintenance and Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in its shower rooms, as required by federal regulations. The only operational shower room in the building, located on the 100-Hall, had black residue on the wall tiles and caulking, with the residue appearing to be under the caulking and grout. Additionally, there was an area behind the shower curtain with approximately 10 inches of chipped-off tiles, exposing chipped drywall and sharp tile edges, all with visible black residue. The 200-Hall shower room was not in use, as the tub had been removed, and the shower was non-functioning. Interviews with facility staff confirmed awareness of the issues, with the Administrator providing repair quotes for both shower rooms and Maintenance staff indicating that repairs for the 100-Hall shower were scheduled to be completed within 30 days. The 200-Hall shower had a repair quote from several months prior, but repairs had not yet been initiated, as the plan was to address the 100-Hall shower first. These conditions resulted in a failure to provide a sanitary, orderly, and comfortable environment for residents requiring hygiene services.
Failure to Follow Care Plans for ADL and Wound Care
Penalty
Summary
Surveyors identified that the facility failed to follow comprehensive care plans for activities of daily living (ADL) and wound care for three residents. For one resident with Alzheimer's disease, anxiety, and depression, the care plan required staff assistance with bathing and showers twice weekly. However, documentation showed that over a 30-day period, the resident received only one shower and no bed baths, despite the care plan's requirements. There were also insufficient interventions documented for instances when the resident refused showers, and progress notes only sporadically recorded refusals. Another resident, newly admitted with a right toe amputation and a lack of self-care, was observed to have poor hygiene, including greasy hair, facial hair growth, and body odor. The care plan specified showers or bed baths twice weekly, but records indicated only one shower was provided in 14 days, with no documentation of refusals. Observations and interviews confirmed the resident's unkempt appearance and dissatisfaction with the frequency of personal care provided. A third resident, who had recently undergone back surgery, was observed with a surgical dressing that had not been changed as scheduled. The care plan required daily dressing changes, but the resident reported the dressing was not changed on the previous day due to a scheduled leave for a therapy evaluation. The nurse on duty stated that the dressing change was missed because the resident left before it could be completed, and the DON confirmed that dressing changes should be completed as ordered or by the next shift. Documentation inconsistencies were noted regarding whether the dressing change was performed as required.
Failure to Provide Scheduled ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically personal hygiene and showers, for five dependent residents. Observations and interviews revealed that residents often did not receive scheduled showers or bed baths, resulting in poor hygiene, greasy hair, body odor, and unshaven appearances. Documentation showed that some residents received only one shower in a 14- or 30-day period, with no evidence of bed baths being provided as alternatives. In several cases, there was no documentation of resident refusals for showers or baths, and care plans lacked interventions for refusals or alternative hygiene measures. The deficiency was further compounded by facility infrastructure issues, as only one shower was available for 48 residents due to the removal of a tub in one shower room, which was being used for storage. This limited access to bathing facilities made it difficult to meet the scheduled shower frequency for all residents. Residents expressed dissatisfaction and emotional distress due to missed showers, with some reporting feelings of neglect and sadness. Medical records indicated that the affected residents had significant self-care deficits due to conditions such as Alzheimer's disease, recent amputation, stroke, muscle weakness, Parkinson's disease, and obesity. Despite these needs, care plans did not address the lack of hygiene care or provide strategies for managing refusals. Observations confirmed ongoing issues with personal hygiene, including greasy hair, unshaven faces, and skin irritation, with no evidence of appropriate interventions being implemented.
Failure to Complete Daily Dressing Change as Ordered
Penalty
Summary
A deficiency occurred when a resident with a post-surgical lower back incision did not receive a dressing change as ordered. Observation revealed that the dressing on the resident's back was dated two days prior, despite orders for daily dressing changes. The resident confirmed that dressing changes were supposed to occur every day and noted that he left the facility for a physical therapy home evaluation the previous day, but not until after 11:00 AM. Interview with the RN on duty indicated that she did not perform the dressing change before the resident left, and she cited frequent new admissions and discharges as factors affecting her ability to complete treatments. Review of the Treatment Administration Record showed that the night shift nurse had documented the dressing change as completed, but the physical observation contradicted this, showing the dressing had not been changed since two days prior. The DON confirmed that dressing changes should be completed as ordered and, if missed by one shift, should be done by the next.
Failure to Implement Care-Plan Interventions Leads to New Skin Breakdown
Penalty
Summary
A resident with a history of stroke, aphasia, and hemiplegia, who was totally dependent on staff for all activities of daily living and had severely impaired cognition, was identified as being at very high risk for pressure-related skin injuries based on a Braden Scale score of 8. Despite care plan interventions that included regular repositioning and the use of assistive devices to minimize skin breakdown, the resident was repeatedly observed resting in bed without positioning devices under their left arm. Multiple observations noted a strong odor in the room and under the resident's left breast, where open areas of skin breakdown were found. The care plan also required daily observation of skin condition and reporting of abnormalities, but the new skin breakdown under the left breast was not documented in the skin and wound evaluation prior to surveyor discovery. Further review revealed that the resident's left arm was nearly closed over the left breast, with no positioning device in place to aid in pressure reduction, and staff noted the resident sweated excessively. The facility's own skin management guidelines identified excessive perspiration as a risk factor for moisture-associated skin damage, yet these risks were not adequately addressed. The failure to implement care-planned interventions and to document and report new skin breakdown resulted in the development of multiple open areas under the resident's left breast, indicating a lack of adherence to professional standards of practice for the prevention and management of pressure ulcers.
Medication Cart Left Unlocked and Unattended in Hallway
Penalty
Summary
A medication cart on the 200 Hall was observed left unlocked and unattended in the hallway, making medications accessible to residents, visitors, and staff. The state surveyor was able to open drawers on the cart while the assigned RN was in a resident's room checking blood sugar and conversing with the resident. The RN acknowledged that the cart was left unlocked unintentionally when questioned by the surveyor. Review of the RN's employee record showed that she had previously received a one-on-one inservice in March 2025 regarding the requirement to keep medication and treatment carts locked at all times when not in use. The facility's policy also states that unlocked medication carts are not to be left unattended. The Director of Nursing confirmed awareness of the incident and reiterated that medication carts should remain locked when the nurse is not present.
Failure to Document Immunization Education and Refusal
Penalty
Summary
The facility failed to provide proper documentation and education regarding immunization refusal for one resident among five reviewed for immunizations. Specifically, the resident had refused the RSV vaccine in December 2024, but there was no signed refusal form or progress note in the medical record to indicate that education about the vaccine's benefits and potential side effects had been provided, nor was there documentation of the refusal itself. The electronic medical record contained a blank vaccine consent form with no refusals or signatures, and the Infection Control Preventionist confirmed that the form was not filled out by staff. Further review of the resident's progress notes from late 2024 through mid-2025 revealed no entries regarding RSV vaccine education or refusal, even after the resident was readmitted from the hospital with a diagnosis of RSV following a respiratory illness. The lack of documentation persisted throughout the resident's stay, indicating that the facility did not follow its own policies and procedures for recording immunization education and refusal, as required by regulation.
Deficiency in Sprinkler System Installation
Penalty
Summary
A deficiency was identified regarding the installation of the sprinkler system. The report notes that nursing homes and hospitals, where required by construction type, must be protected throughout by an approved automatic sprinkler system. The facility did not meet this requirement, as the necessary sprinkler system installation was not in place as specified by the 2012 standards for existing buildings.
Plan Of Correction
Element 1: No residents were identified in this concern. The light fixture in the lobby was moved to accommodate the required distance from the sprinkler head. Completed by 7/24/2025
Failure to Provide Required Number of Basement Exits
Penalty
Summary
Surveyors observed that the facility failed to provide the required number of exits from the basement, as mandated by NFPA 101, sections 19.2.4.1 through 19.2.4.4. During an inspection, it was found that there was only one exit available from the basement, which is occupied by the laundry area (including a linen chute from the first floor), employee break room, maintenance office, boiler room, storage room, electrical room, and employee bathroom/locker room. This observation was confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of the survey. Approximately 10 occupants could be affected by this deficiency in the event of a fire emergency, as the basement does not meet the requirement for at least two remote and accessible exits from every story and compartment.
Plan Of Correction
Element 1 No residents were identified. Residents do not have access to the basement. Staff are aware of the emergency exit. Element 2 All other areas where residents have access to, have required exits. Element 3 The facility administrator has contracted with the LSC Specialist to conduct a Fire Safety Evaluate System (FSES) survey for a waiver request. The FSES will be completed on 7/18/2025 and forwarded to Life Safety for a waiver request. Element 4 Audit will be completed weekly regarding accessible exits on every story. Results will be reviewed with the Administrator and brought to monthly QAPI for review and recommendations. Administrator is responsible for compliance.
Sprinkler Head Installed Too Close to Light Fixture
Penalty
Summary
Surveyors observed that the facility failed to provide a sprinkler system installed in accordance with NFPA 13 requirements. Specifically, during an inspection, it was found that the sprinkler head located in the main lobby near the front egress door was positioned too close to a light fixture. This proximity was determined to be within a few inches, which does not comply with NFPA 13, 8.3.2.5, Table 8.3.2.5(c), as it could alter the water flow pattern and prevent proper sprinkler protection. These findings were confirmed through interviews with the Director of Facilities and the Maintenance & Environmental Services Director at the time of observation.
Plan Of Correction
Element 2: An audit of the facility determined that 3 additional light fixtures are located too close to the sprinkler heads. Element 3: Electrician is scheduled to move overhead lights to be completed by 7/24/2025. Element 4: EVS Director or designee will audit sprinkler heads weekly to ensure that they are not blocked and provide proper sprinkler protection. Results will be brought to weekly QA for review and recommendations. EVS Director is responsible for compliance.
Failure to Ensure Accessibility of Call Lights and Privacy Curtains
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents by not providing timely responses to call lights, ensuring call lights were within reach, and ensuring privacy curtains were accessible and used. Observations revealed that privacy curtains in rooms 100, 103, 107, 108, and 110 were tucked away out of reach, compromising the residents' privacy. Additionally, a resident was found with their call light placed approximately four feet away on a chair, making it inaccessible. This resident expressed a feeling of neglect, suggesting that the call light was intentionally placed out of reach. Further observations confirmed that privacy curtains remained out of reach in multiple rooms, even after the issue was brought to the attention of the Assistant Director of Nursing (ADON). A Certified Nursing Assistant (CNA) admitted to not pulling the curtain during a personal care task, citing the task's nature as the reason. These actions and inactions resulted in unmet care and privacy needs for the residents involved.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for four residents, resulting in issues such as long jagged fingernails, missed showers, and an unkempt appearance. Resident #5, who is totally dependent on staff for personal hygiene, missed two scheduled showers within a 30-day period. Resident #21, who requires assistance due to anoxic brain damage and physical limitations, was observed with long, jagged nails and dirty buildup on their palms, despite the care plan indicating the need for hand hygiene and the use of hand protectors. Resident #33, who requires limited assistance with bathing, reported not receiving scheduled showers due to staff availability, missing two showers in a 30-day period. Resident #36, who requires extensive assistance with dressing, was found in their nightgown for three consecutive days, with their call light out of reach, indicating a lack of assistance in dressing and potential neglect in responding to their needs. The facility's policy states that residents should receive care to maintain or improve their ability to carry out ADLs, including grooming and personal hygiene, which was not adhered to in these cases.
Failure to Prevent Pressure Ulcer and Ensure Nutritional Care
Penalty
Summary
The facility failed to prevent the development of a facility-acquired pressure injury and ensure timely nutritional care plans were updated and implemented for a resident. The resident, who was admitted with a diagnosis of pulmonary embolism and type 2 diabetes, developed a deep tissue pressure injury on the left heel a few weeks after admission. The wound nurse noted the injury as a blackened area measuring 2.55 cm by 2.57 cm, and the resident experienced pain during treatment. Despite the resident's alertness and orientation, the facility did not have any wounds indicated in the admission diagnosis, and the care plan was only revised on the day the state survey began. The resident experienced a significant weight loss of 10 pounds, or 9.13%, within approximately three weeks of admission. The facility's dietary management failed to consistently provide the prescribed nutritional interventions, such as protein shakes and cottage cheese, which were intended to aid in wound healing. The resident and their significant other reported inconsistencies in receiving the prescribed nutritional supplements and meals that were not aligned with the resident's dietary needs for diabetes and wound healing. Interviews with the dietary manager and registered dietician revealed a lack of awareness and follow-up regarding the resident's nutritional needs and preferences. The dietary manager admitted to not being aware of the resident's complaints and the registered dietician acknowledged the need for better monitoring of the resident's protein intake. The facility's wound policy aimed to identify residents at risk for skin alterations and implement specific interventions, but these measures were not effectively executed for the resident in question.
Failure to Apply Palm Protectors for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident to maintain or improve their range of motion, specifically by not applying bilateral palm protectors as required. Resident #21, who was admitted on 8/14/2020, was observed multiple times over two days without the necessary palm protectors on their hands, despite having contracted hands. The resident's care plan, as noted in the Kardex, specified that bilateral hand protectors should be worn during the day after hand hygiene and removed at night with skin checks for redness. The Therapy Director (TD) confirmed that Resident #21 had been on therapy with a discharge recommendation for palm protectors to be worn during the day. During an observation with the TD, the palm protectors were found in the resident's nightstand drawer, not in use. The TD cleaned the resident's hands, performed nail care, and applied the palm protectors. An instruction photo in the resident's closet showed how the palm protectors should be placed, and the TD stated that staff had been educated on their application.
Improper Storage of Narcotics During Medication Administration
Penalty
Summary
The facility failed to properly store narcotics for a resident during a medication administration task. On the morning of July 16, Nurse B prepared morning medications for a resident, including a Norco 5/325 tablet and a Pregabalin 150 mg tablet, and placed them in a clear medication cup. When the resident requested to take the medications later, Nurse B capped the cup, wrote the room number on it, and placed it in the top drawer of the medication cart instead of following proper storage procedures for narcotics. Later, Nurse B retrieved the medication cup from the drawer, counted the medications, and administered them to the resident. When questioned about the counting, Nurse B explained it was because the medications had been placed in the drawer. The Director of Nursing was informed of the incident and acknowledged that Nurse B should not have stored the narcotics in the drawer. The facility's Controlled Substances Policy states that medications not given should be destroyed and not returned to the container, indicating a breach of protocol in this instance.
Failure to Honor Dietary Preferences and Provide Palatable Meals
Penalty
Summary
The facility failed to honor a resident's food preferences and provide palatable meals, leading to significant weight loss and potential health risks. The resident, who was on a Controlled Carbohydrate Diet and No Added Salt diet, reported dissatisfaction with the meals provided, which were high in carbohydrates and sugar, contrary to her dietary needs for managing Type 2 Diabetes. Despite her preferences being documented, the meals served did not align with her dietary restrictions or personal likes, such as the inclusion of white bread and sugar cookies, and the absence of requested items like strawberries and cottage cheese. The resident's significant other corroborated her complaints, noting that he often had to bring fresh fruits from home because the facility did not provide them. During a meal observation, the resident's lunch tray contained items she disliked and were inappropriate for her dietary needs, such as a thick slice of white bread and a sugar cookie. The resident expressed frustration over the facility's failure to follow her documented preferences, which contributed to her reduced food intake and subsequent weight loss. Interviews with the Dietary Manager and Registered Dietician revealed a lack of awareness regarding the resident's unmet preferences and inconsistent provision of protein drinks. The facility's policies on therapeutic diets and food preferences were not effectively implemented, as evidenced by the resident's documented weight loss of 10 pounds over three weeks. The care plan included interventions to monitor for signs of malnutrition and honor food preferences, but these were not adequately followed, resulting in the deficiency.
Deficiency in Hospice Service Documentation and Communication
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of progress notes and assessments in the resident's medical record. During an observation, the resident was found grimacing and uncomfortable, and although the resident was under hospice care, the unit nurse had not notified the hospice agency about the resident's symptoms of nausea and vomiting. The hospice services binder for the resident lacked progress notes, a facility communication log, and follow-up documentation after a certain date, indicating ineffective communication and collaboration between the facility and hospice services. The hospice services binder contained minimal documentation and lacked details of services provided to the resident. The hospice staff's visits were not clearly documented, and there was a delay in scanning hospice progress notes into the facility's electronic medical record (EMR). The Director of Nursing acknowledged the communication gap and the delay in documentation submission. The hospice RN confirmed that the information in the resident's binder was outdated and that progress notes were sent via fax to the facility, which then scanned them into the EMR. Additionally, there were discrepancies in the administration of Morphine Sulfate, with doses given at intervals shorter than prescribed. The medication administration record showed multiple instances where the medication was administered less than the required six-hour interval. There were no noted changes in the prescribed order from any medical personnel regarding the dosages and frequency of administering the medication. The facility's policy specified that it is the hospice's responsibility to manage the resident's care related to the terminal illness, but the lack of proper documentation and communication led to potential unmet needs and suffering for the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to properly implement Enhanced Barrier Precautions (EBP) in several rooms, leading to potential cross-contamination and spread of infections. On multiple occasions, staff members were observed not wearing the required Personal Protective Equipment (PPE) in EBP rooms. For instance, a nurse was seen sitting on a resident's bed without any PPE, and a CNA was caring for a resident who had an incontinent episode while only wearing gloves, without a gown to protect their uniform. These actions were contrary to the physician's order for enhanced barrier precautions, which required both gloves and gowns prior to high-contact care activities. Additionally, a housekeeper was observed cleaning the toilet and floor in an EBP room without wearing a gown, which is necessary to prevent contamination of their uniform. The facility's policy, based on CDC recommendations, mandates the use of gowns and gloves to protect residents and staff from hard-to-treat infections. Despite the presence of signs indicating the need for enhanced precautions, staff failed to adhere to these guidelines, as evidenced by the observations and record reviews conducted during the survey.
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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