Harmony Village Of Clinton
Inspection history, citations, penalties and survey trends for this long-term care facility in Clinton Township, Michigan.
- Location
- 17001 17 Mile Road, Clinton Township, Michigan 48038
- CMS Provider Number
- 235405
- Inspections on file
- 24
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Harmony Village Of Clinton during CMS and state inspections, most recent first.
A resident under full guardianship and legal incapacity experienced financial exploitation when a Business Office Manager facilitated unauthorized transfers of trust funds without guardian approval, resulting in unaccounted funds and psychological distress. The resident, with a history of mental health disorders, suffered increased anxiety and self-harm following the incident, and interviews confirmed violations of professional boundaries and facility policy.
Surveyors found that the facility did not consistently complete or make available required daily nurse staffing postings, with missing or incomplete forms and gaps in documentation for several months, contrary to facility policy.
Surveyors found that several residents' nebulizer and bi-pap masks were not stored in accordance with facility policy, as the equipment was left directly on nightstands without protective barriers or bags. The residents, who used the equipment regularly and required staff assistance, had their equipment exposed despite clear facility guidelines for proper storage and cleaning.
A resident's care plan was not revised to reflect the loss of their dentures, despite the resident no longer having them and previous interventions for denture care remaining in place. The care plan continued to reference denture-related tasks, and there was no updated documentation in the medical record regarding the resident's current dental status. The DON acknowledged the care plan should have been updated.
A resident was found with an oxygen cylinder left unsecured in the seat of their wheelchair, covered in dust and cobwebs, indicating prolonged improper storage. The DON acknowledged the issue and facility policy requires oxygen tanks to be secured and stored in a designated room, which was not followed in this instance.
A resident who was admitted with ill-fitting dentures had impressions taken for a reline, but the process was not completed and the dentures were not returned. The resident did not receive updates or documented interventions for pain and difficulty chewing, and the medical record lacked information about the dentures, contrary to facility policy.
A resident with multiple medical conditions had conflicting code status information in their medical record, with a DNR order displayed but a signed form requesting full resuscitation also present. The discrepancy occurred because the social worker uploaded the new form without notifying nursing staff, resulting in the code status not being updated as required by facility policy.
A resident with intact cognition and multiple medical diagnoses was found living in a room with a large, dark brown stain on the ceiling tile above the bed. The resident reported the issue upon moving in and stated it had not been addressed, despite facility policy requiring a clean and comfortable environment and ongoing audits by maintenance staff.
A resident with diabetes, depression, and hypertension, who was cognitively intact and independent, did not have OBRA Level II Evaluation recommendations for discharge to a less restrictive setting addressed or documented. The resident's request for more independent living was not followed up by social work, and the DON confirmed the lack of action on these recommendations.
A resident with multiple sclerosis, dysphagia, and impaired cognition was observed eating unassisted on two occasions, despite a documented need for 1:1 feeding assistance. The resident was seen leaning to one side with food on their gown, and both the RD and DON confirmed the requirement for 1:1 feeding support, which was not provided as per facility policy.
A resident with a history of a Stage IV pressure ulcer and impaired cognition was repeatedly observed without required positioning devices and with heels resting flat on the mattress, despite documented care plans calling for heel offloading and frequent repositioning. Staff did not consistently implement these interventions as outlined in the resident's wound care plan.
A resident with dysphagia and impaired cognition, who required nectar thickened liquids and was not to have straws, was repeatedly observed with a straw in their water cup despite clear dietary orders and documentation. Staff were either unaware or did not confirm the restriction, and the DON stated that diet orders are expected to be followed, but the deficiency persisted.
A resident with vascular dementia and severe cognitive impairment was prescribed Seroquel without any documented attempt at a Gradual Dose Reduction (GDR), as required by facility policy for psychotropic drugs. The NHA could not provide evidence of a GDR attempt during the survey.
A resident with Alzheimer's and dementia experienced a fall and exhibited wandering and incontinence behaviors, but the facility failed to update the care plan to address these issues. Despite staff observations of increased confusion and restlessness, the care plan lacked interventions for the resident's wandering and bowel/bladder behaviors. The facility's policy on care planning was not followed, resulting in a deficiency.
The facility failed to provide adequate and meaningful weekend activities for residents, as there were no activities department staff working on weekends. Residents reported being bored, and the facility relied on other staff to facilitate activities, which was insufficient compared to weekday programming.
The facility failed to maintain sanitary conditions in the kitchen, including improper storage of food and utensils, lack of cleanliness, and inadequate staff training on sanitization procedures. These deficiencies were confirmed through observations and interviews with the Dietary Manager and staff.
The facility failed to ensure that the Activities Director (AD) met the required professional qualifications. The AD, a Physical Therapy Assistant with no recent or previous experience in an Activities department, was not currently participating in any training or education for credentialing. The facility Administrator acknowledged the AD did not meet the required qualifications, and the facility's policy on AD qualifications was not followed.
The facility failed to ensure an Advanced Directive was in place timely for a resident with End Stage Renal Disease and Type 2 Diabetes. The resident's electronic health record lacked a code status and a signed advance directive form, which was not completed until later, contrary to the facility's policy requiring completion by day three of admission.
The facility failed to initiate a care plan for a newly identified Stage 3 pressure ulcer for a resident. Despite the resident's severe cognitive impairment and total dependence for ADLs, the care plan did not address the newly acquired pressure ulcer, as confirmed by the DON. The facility's policy mandates a relevant care plan for pressure injury management, which was not followed.
A resident with severe cognitive impairment and multiple medical conditions developed a stage three pressure ulcer due to the facility's failure to ensure timely and appropriate repositioning. Observations revealed the resident lying on their back without proper heel protection, and interviews with staff indicated inconsistencies in repositioning practices and documentation. The facility's policy on pressure injury prevention was not followed, leading to the deficiency.
The facility failed to provide and document weight loss interventions for a resident, resulting in significant weight loss. Despite being aware of the resident's severe cognitive impairment and multiple diagnoses, the facility did not resume previously ordered supplements after a hospital stay and hospice placement. The resident's weight steadily declined, and the facility did not document daily food acceptance or provide necessary supplements.
The facility failed to administer a tube feeding according to the physician's orders for a resident with severe protein-calorie malnutrition and dysphagia. The resident's tube feeding was not consistently documented as given, and residual checks were inconsistently performed, contrary to the facility's policy and physician's orders.
The facility failed to obtain physician orders for dialysis treatment and to monitor the dialysis site for a resident with End Stage Renal Disease and Type 2 Diabetes. The necessary orders were not reactivated upon the resident's readmission, and the dialysis site was not assessed or documented, contrary to the facility's policy.
The facility failed to monitor the temperatures of the medication refrigerator in Station One, with multiple days lacking temperature documentation for both AM and PM shifts across several months. The LPN acknowledged the missing documentation, and the DON confirmed the expectation for temperature logs to be completed on both shifts. The facility's policy did not address the monitoring of medication refrigerator temperatures.
Failure to Prevent Financial Exploitation and Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent financial exploitation and misappropriation of funds for a resident under full guardianship and legal incapacity. The Business Office Manager (BOM) facilitated unauthorized transfers of the resident's trust funds to a debit card without the required approval from the legal guardian. The guardian was not informed about the absence of a patient pay amount and continued to send substantial monthly funds, which were managed by the BOM. The guardian later discovered that approximately $10,000 was unaccounted for, and that funds intended for specific resident needs, such as dentures, were not used as agreed. The resident involved had a history of anxiety disorder, bipolar disorder, narcissistic personality disorder, and adjustment disorder, and required staff assistance with mobility and transfers. Despite an intact cognitive score, the resident was legally incapacitated and unable to consent to financial transactions. The resident reported increased anxiety, paranoia, lack of sleep, and suicidal ideation following the incident, and was observed with self-inflicted injuries requiring psychiatric assessment and 1:1 monitoring. The resident expressed emotional distress related to the removal of the BOM and maintained that the BOM was supportive, while expressing distrust toward facility administration. Interviews and documentation revealed that the BOM engaged in unprofessional conduct, including maintaining an inappropriate relationship with the resident and facilitating financial transactions without guardian oversight. The BOM admitted to assisting the resident with financial matters and obtaining a lawyer for the resident without involving social work or the guardian. Facility staff and the legal guardian confirmed that the BOM's actions violated professional boundaries and facility policy, resulting in substantiated findings of misappropriation of funds and psychological abuse.
Failure to Maintain and Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing postings were completed and readily accessible for all residents, families, and visitors. During the survey, the Nursing Home Administrator was unable to provide complete staffing postings for the past 18 months as required. The binder provided contained forms that were incomplete, missing dates, and lacking necessary staffing information. The staffing coordinator acknowledged that the forms were incomplete, and the facility was unable to provide postings for certain months by the end of the survey. A review of the facility's own policy confirmed that nurse staffing information should be posted daily, including specific details such as facility name, current date, resident census, and the total number and actual hours worked by RNs, LPNs, and CNAs per shift. The policy also required that this information be maintained for at least 18 months. The survey found that these requirements were not met, as postings were missing or incomplete for several dates within the required retention period.
Improper Storage of Respiratory Equipment
Penalty
Summary
Surveyors observed that three residents' respiratory equipment, including nebulizer masks and a bi-pap mask, were not properly stored according to facility policy. Specifically, the masks were found sitting directly on nightstands without any barrier or protective bag. The residents involved had intact cognition and required staff assistance with bed mobility and transfers. Each resident reported regular use of their respiratory equipment. The facility's policy requires that nebulizer masks be stored dry in mesh bags, clear plastic bags, or other clean storage as per facility preference, and that bi-pap masks be cleaned weekly and stored properly in a bag. During an interview, the Infection Control Preventionist confirmed these requirements. The failure to follow these procedures was directly observed and confirmed through staff interview and record review.
Failure to Update Care Plan for Resident's Dental Status
Penalty
Summary
The facility failed to revise a resident's care plan to accurately reflect their current dental status. The resident, who was admitted with diagnoses including Type II Diabetes, Depression, and Hypertension, reported that their dentures did not fit properly upon admission and that a dental visit for realignment had not resulted in the return of the dentures. Despite the resident no longer having dentures, the care plan continued to list interventions related to denture care, such as ensuring proper fit and secure placement. Record review showed that the care plan had not been updated since its initiation, and there was no documentation in the medical record regarding the current status of the dentures. The Director of Nursing acknowledged that the care plan was outdated and did not reflect the resident's present condition. The facility's policy requires that care plans be reviewed and revised as necessary by the interdisciplinary team, but this was not done in this case.
Oxygen Cylinder Improperly Stored in Wheelchair
Penalty
Summary
A deficiency was identified when a resident was observed with an oxygen cylinder/tank placed in the seat of their wheelchair, leaning against the back of the chair. The oxygen cylinder/tank was covered in dust and cobwebs, indicating it had been left in this position for an extended period. When asked, the resident could not specify how long the tank had been there. The Director of Nursing (DON) confirmed awareness of the oxygen cylinder/tank in the wheelchair and explained that facility policy requires oxygen tanks to be secured in a carrier and stored in the designated oxygen storage room when not in use. A review of the facility's policy on oxygen safety and storage revealed that oxygen cylinders must be properly secured in racks, carriers, or approved stands to prevent them from falling, and must be stored in an enclosed, secure area when not in use. The observed practice of leaving the oxygen cylinder/tank unsecured in the wheelchair did not comply with these requirements, resulting in a failure to provide safe and appropriate respiratory care for the resident.
Failure to Timely Follow-Up on Denture Services
Penalty
Summary
A resident who was admitted with a pair of dentures reported that the dentures did not fit properly upon admission. The resident was seen by a dentist in June of the previous year, at which time full impressions were taken for a laboratory reline of the upper and lower complete dentures, and the dentures were sent to the laboratory. Since that time, the reline has not been completed, and the resident no longer has the dentures. The resident stated that they were told a follow-up would occur but have not received any updates, and they are now experiencing jaw pain and difficulty chewing. A review of the resident's medical record did not reveal any information regarding the status of the dentures. The facility's policy requires referral for dental services within three days for lost or damaged dentures and outlines interventions to ensure residents can eat and drink while awaiting dental services, such as notifying the physician of pain, modifying diet consistency, and referring to a dietician or speech therapist. These interventions were not documented as being implemented for this resident.
Failure to Maintain Accurate and Updated Advance Directive Information
Penalty
Summary
The facility failed to ensure that updated and accurate advance directive information was maintained for a resident. The resident, who had diagnoses including cerebral infarction, major depressive disorder, and dysphasia, was dependent on staff for transfers and toileting. Upon review of the resident's medical record, there was a discrepancy between the code status displayed at the top of the record, which indicated DNR (do not resuscitate), and a signed Medical Treatment Decision Form in the record that indicated the resident requested full resuscitation (CPR) in the event of cardiac or respiratory arrest. Interviews with facility staff revealed that the resident had changed their mind regarding code status, but the updated form was uploaded by the social worker without notifying nursing staff, resulting in the code status not being updated in the medical record. The facility's policy requires that any decision-making regarding a resident's choices be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. This failure led to conflicting information regarding the resident's advance directives.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident was observed sitting in their room beneath a large, approximately 12-inch round dark brown stain on the ceiling tile directly above the head of the bed. The resident reported that the stain was present when they moved into the room and had previously informed someone about it, but no corrective action had been taken. The resident, who has diagnoses of hemiplegia, hemiparesis following cerebral infarction, and chronic obstructive pulmonary disease, was assessed as having intact cognition. During a subsequent observation with the Maintenance Director, it was acknowledged that an audit of rooms with concerns was ongoing, and the expectation was for resident rooms to be maintained in good condition to provide a homelike environment. Facility policy requires the provision of a safe, clean, comfortable, and homelike environment, with necessary housekeeping and maintenance services.
Failure to Follow PASARR Level II Recommendations for Resident Discharge Planning
Penalty
Summary
The facility failed to follow the recommendations of an OBRA Level II Evaluation for one resident who was reviewed for PASARR compliance. The resident, who was admitted with diagnoses including Type II Diabetes, Depression, and Hypertension, was found to be cognitively intact and independent with transfers. The OBRA evaluation recommended that the facility's social work staff assist the resident in searching for a less restrictive setting, such as a senior apartment with home healthcare support, if the medical team agreed. However, there was no documentation in the resident's medical record indicating that these recommendations were addressed or followed up on. During an interview, the resident reported having asked social work about the possibility of discharge to a more independent living situation but felt their request was dismissed. The Director of Nursing acknowledged the lack of follow-up on the OBRA recommendations and stated that corporate staff would investigate further, but no additional information was provided by the end of the survey. The facility's policy requires that PASARR Level II recommendations be incorporated into the resident's assessment, care planning, and transitions of care, which was not done in this case.
Failure to Provide 1:1 Feeding Assistance for Resident with Dysphagia and Impaired Cognition
Penalty
Summary
The facility failed to provide required 1:1 feeding assistance to a resident with multiple sclerosis, dysphagia, and impaired cognition, as documented in their medical record and diet order. On two separate occasions, the resident was observed eating lunch unassisted, despite a meal ticket and diet order specifying the need for 1:1 feeding assistance. The resident was noted to be leaning to one side with food on their gown during one observation. Interviews with the registered dietitian and DON confirmed that the resident requires 1:1 feeding assistance and is followed by speech therapy, with staff expected to assist those needing help after passing trays. Facility policy states that residents unable to perform activities of daily living should receive necessary services to maintain nutrition and hygiene.
Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency was identified when staff failed to implement pressure ulcer prevention interventions for a resident with a history of a Stage IV pressure ulcer. Multiple observations over two days showed the resident lying in bed on their back with their heels flat on the mattress and without positioning wedges or pillows in place, despite care plans and wound care notes specifying the need for heel offloading and frequent repositioning. The resident was also noted to have impaired cognition and required staff assistance for bed mobility and transfers, further emphasizing the need for staff-initiated interventions. Medical records indicated the resident was admitted with moderate protein-calorie malnutrition and a Stage IV pressure ulcer of the left buttock, and the most recent wound care note documented the need for preventative measures such as heel protectors or pillows and regular repositioning. Despite these documented interventions, observations revealed that the resident's heels were not consistently offloaded and that positioning devices were not always in use. Interviews with the unit manager confirmed the expectation for frequent repositioning and heel elevation, but these interventions were not consistently observed in practice.
Failure to Implement Dietary Restrictions for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when staff failed to implement dietary restrictions for a resident with dysphagia and muscle wasting, who was admitted with an order for nectar thickened liquids (NTL) and a specific restriction against the use of straws. Despite the diet order and documentation on the diet ticket indicating no straws, the resident was repeatedly observed with a straw in their water cup on multiple occasions. Staff interviews revealed a lack of awareness or confirmation of the dietary restriction, and the occupational therapist confirmed that the resident should not have a straw due to the risk of coughing and aspiration. The Director of Nursing acknowledged that diet orders are printed and expected to be followed, but the resident continued to have access to a straw. A facility policy regarding special dietary instructions was requested but not provided during the survey. The resident involved had impaired cognition, required staff assistance with mobility and transfers, and was at risk due to the failure to follow prescribed dietary restrictions.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) for an antipsychotic medication, Seroquel, for one resident diagnosed with vascular dementia and adjustment disorder with anxiety. The resident had a severely impaired cognition, as indicated by a BIMS score of 3/15, and required staff assistance with bed mobility and transfers. Medical records showed active physician orders for Seroquel 25 mg once daily and 50 mg at bedtime. During the survey, the Nursing Home Administrator was unable to provide documentation of any GDR attempt for this resident, despite facility policy requiring gradual dose reductions and behavioral interventions for residents on psychotropic drugs unless clinically contraindicated.
Failure to Update Care Plan for Resident with Wandering and Incontinence Issues
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R901, to reflect their wandering behavior, falls, and bowel and bladder issues. The resident, who was admitted with Alzheimer's Disease, Dementia, Muscle Weakness, Difficulty Walking, and Hearing Loss, experienced a fall on 06/21/24, resulting in a head injury and hospitalization. Despite documented incidents of increased confusion, restlessness, and wandering, the care plan did not include interventions for these behaviors. The resident's wandering was not captured in the Minimum Data Set (MDS) assessments, and the care plan lacked updates to address the resident's changing needs. Interviews with staff and other residents revealed that R901 frequently wandered into other residents' rooms, sometimes taking items or sitting on their beds. The resident was also reported to have bowel incontinence incidents in inappropriate locations, such as other residents' beds. Staff noted that R901 was often confused, unsteady, and required frequent redirection. Despite these observations, the care plan did not include specific interventions to manage the resident's wandering and bowel/bladder behaviors. The facility's policy on care planning, which requires the development and implementation of a comprehensive care plan based on the resident assessment instrument, was not followed. The care plan for R901 did not reflect the resident's current condition and behaviors, and there was no care plan addressing the identified concerns of wandering and inappropriate bowel and bladder use. The Director of Nursing acknowledged the worsening dementia and roaming behaviors but had not considered one-to-one supervision or other interventions to address these issues.
Inadequate Weekend Activities for Residents
Penalty
Summary
The facility failed to provide adequate and meaningful weekend activities for its residents, as evidenced by interviews and record reviews. Eight anonymous group participants reported that the facility no longer had activities department staff working on weekends, resulting in a lack of organized or meaningful activities. The facility's activities calendar for March and April 2024 indicated only independent leisure activities on Saturdays and limited activities on Sundays. The Activities Director confirmed that the facility no longer employed activities aides and that other staff, such as CNAs and nurses, were expected to assist residents with activities on weekends. However, this arrangement was insufficient compared to the weekday activities programming. The facility Administrator verified that the activities aides positions were eliminated and that there were no dedicated activities department staff scheduled on weekends. The Administrator stated that other facility staff were instructed to facilitate activities on weekends, but the residents reported being bored and having nothing to do. The facility's policy on activities, dated January 1, 2024, stated that the facility would provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. The lack of dedicated activities staff on weekends led to the deficiency in providing meaningful activities for the residents.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during an initial tour. A personal cell phone was found on the food preparation counter, which was confirmed by the Dietary Manager (DM) as inappropriate. Additionally, a scoop was improperly stored inside a flour bin with its handle resting in the flour. A box of orange juice concentrate was used to prop open the dry storage room door, and the top surface of the Southbend steamer had a buildup of grease and crumbs. A wet wiping cloth was found lying on the food preparation counter instead of being stored in a sanitizer bucket, and there were no prepared sanitizer buckets in the kitchen. The inside surface of the microwave had dried food splatter, and the shelf at the front of the steam table was warped with large cracks and exposed, porous particle board, making it difficult to clean. The DM acknowledged the need for a new shelf. Dietary staff members were also observed using the dish machine without knowing how to check for adequate sanitization or chemical sanitizer levels, and the sanitization log was blank for two meals. These observations indicate multiple violations of the 2017 FDA Food Code, including improper storage of food and utensils, lack of cleanliness, and inadequate staff training on sanitization procedures. The deficiencies were confirmed through interviews with the DM and dietary staff, who acknowledged the issues and their non-compliance with the FDA Food Code standards.
Failure to Ensure Activities Director Met Professional Qualifications
Penalty
Summary
The facility failed to ensure that the Activities Director (AD) met the required professional qualifications. The AD, who had been in the position for approximately one month, was a Physical Therapy Assistant (PTA) with no recent or previous experience in an Activities department. The AD reported plans to pursue Therapeutic Recreation-related credentialing but was not currently participating in any training or education. The facility Administrator acknowledged that the AD did not meet the required qualifications and stated that the facility had provided resources for the AD to pursue credentialing and arranged for mentoring from an AD at a sister facility, but these processes were not completed before the AD assumed the role and responsibilities in the facility. The facility's policy on Activities Director Qualifications, dated 01/01/24, requires that the AD be licensed or registered by the State and meet one or more specific criteria, such as being eligible for certification as a therapeutic recreation specialist, having relevant experience, being a qualified occupational therapist or assistant, or having completed a State-approved training course. The qualifications of the AD were not verified prior to hire, leading to the deficiency identified during the survey.
Failure to Timely Complete Advance Directive
Penalty
Summary
The facility failed to ensure an Advanced Directive (AD) was in place timely for one resident (R73) of four reviewed for Advance Directives. The electronic health record (EHR) revealed that R73 did not have a code status in the banner or a signed advance directive form. R73 was originally admitted to the facility and later readmitted with pertinent diagnoses including End Stage Renal Disease and Type 2 Diabetes. A Minimum Data Set (MDS) assessment indicated that R73 had no cognitive impairment and required dialysis. An advance directive was requested for R73, but it was not completed until a later date, contrary to the facility's policy that an AD should be completed by day three of admission. In an interview, the Social Worker (SW) confirmed that the AD for R73 was completed late and should have been done prior to the day it was actually completed. The facility's policy on Resident's Rights Regarding Treatment and Advance Directives states that the facility will determine if a resident has executed an advance directive upon admission and, if not, will determine whether the resident would like to formulate one. The failure to complete the AD in a timely manner resulted in the potential for R73's preferences for medical care to not be followed by the facility or other healthcare providers.
Failure to Initiate Care Plan for Newly Identified Pressure Ulcer
Penalty
Summary
The facility failed to initiate a care plan for a newly identified facility-acquired pressure ulcer for one resident. On multiple observations, the resident was seen lying in bed on their backside, grimacing in pain. The resident's medical record indicated severe cognitive impairment and total dependence for Activities of Daily Living. Despite a wound doctor's report identifying a Stage 3 pressure ulcer on the resident's sacral area, the care plan did not address this newly acquired pressure ulcer. The Director of Nursing confirmed that the care plan should reflect the resident's current status, which it did not in this case. The facility's policy on Skin and Pressure Injury Risk Assessment and Prevention mandates that the interdisciplinary team develop a relevant care plan with measurable goals for pressure injury management, which was not done for this resident. The existing care plan only addressed the risk of impaired skin integrity related to incontinence and did not include interventions for the newly identified pressure ulcer.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure timely and appropriate repositioning for a resident, resulting in the development of a stage three pressure ulcer. The resident, who had severe cognitive impairment and multiple medical conditions including atrial fibrillation, myocardial infarction, and morbid obesity, was observed multiple times lying on their back with heels on the bed surface without proper heel protection. Despite having a foam pressure-reducing mattress, the resident's care plan did not include specific interventions for pressure wound care or prevention, and there was no documentation of repositioning or refusal to reposition in the electronic medical record (EMR). Nursing staff, including a nurse and two certified nursing assistants (CNAs), were interviewed and revealed inconsistencies in their knowledge and practices regarding repositioning schedules and documentation. The nurse was unaware of where refusals to reposition were documented, and the CNAs had different understandings of the repositioning schedule and documentation process. The Director of Nursing (DON) also indicated that the repositioning schedule mentioned by one of the CNAs was not a facility practice and did not see the need for a specific care plan for the resident, as the resident could stand. The facility's policy on skin and pressure injury risk assessment and prevention was not followed, as evidenced by the lack of documented interventions in the care plan and the absence of evidence-based treatment for the resident's pressure injury. The resident's sacral wound, identified as a stage three pressure ulcer, was not properly addressed, and there were multiple incidents where the resident's heels were not floated as required. This failure to provide appropriate pressure ulcer care and prevent new ulcers from developing led to the deficiency noted in the report.
Failure to Provide and Document Weight Loss Interventions
Penalty
Summary
The facility failed to provide and document weight loss interventions for a resident (R5), resulting in significant weight loss. R5 was observed to be very thin and emaciated, with visible bones beneath the skin surface. The resident's medical record revealed a history of severe cognitive impairment and multiple diagnoses, including Protein-Calorie Malnutrition and Dysphagia. Despite being aware of R5's significant weight loss of 17.97% over a six-month period, the facility did not resume the previously ordered supplements after R5 returned from a hospital stay and was placed on hospice care. The Registered Dietician (RD) confirmed that R5 often refused supplements, but there was no documentation of these refusals in the medical record. Additionally, the facility's electronic medical record (EMR) showed a steady decline in R5's weight over several months, with no documented interventions to address the weight loss after the resident's return from the hospital. The Director of Nursing (DON) stated that all residents should be assessed and receive appropriate interventions regardless of their hospice status. However, the facility failed to document daily food acceptance and did not provide supplements as previously ordered. The nutritional summary indicated that R5's caloric needs were not being met, and the resident's appetite fluctuated significantly. Despite consuming 75% or more of most meals before the hospital stay, R5's weight continued to decline, highlighting the facility's failure to implement and document effective weight loss interventions for the resident.
Failure to Administer Tube Feeding According to Physician's Orders
Penalty
Summary
The facility failed to administer a tube feeding in accordance with the physician's orders for a resident with severe protein-calorie malnutrition and dysphagia. Observations revealed that the resident's tube feeding pump was present but not running. The resident had a physician's order for Jevity 1.5 to be administered once daily at 5 p.m. until the dose was complete. However, the Medication Administration Record (MAR) showed multiple instances where the tube feeding was not documented as given, and residual checks were inconsistently documented. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the tube feeding should be documented after administration and that residual checks should be performed before feedings and medication administration, although the physician indicated that routine residual checks were not necessary unless there was a concern with the PEG tube or feeding. The facility's policy on the care and treatment of feeding tubes stated that feeding tubes should be utilized according to physician's orders and that tube placement should be verified before beginning a feeding and before administering medications. Despite this policy, the facility did not consistently document the administration of the tube feeding or perform residual checks as required. The Nurse Practitioner (NP) also noted that chronic tube feeding residents do not require consistent residual checks unless there is an identified concern. This lack of adherence to the physician's orders and facility policy resulted in the potential for weight loss and dehydration for the resident.
Failure to Obtain Physician Orders and Monitor Dialysis Site
Penalty
Summary
The facility failed to obtain physician orders for dialysis treatment and to monitor the dialysis site for a resident who required such services. The resident, who had diagnoses of End Stage Renal Disease and Type 2 Diabetes, was readmitted to the facility without reactivating the necessary orders for dialysis. Licensed Practical Nurses (LPNs) confirmed that there were no active orders for the resident to receive dialysis or to monitor the dialysis site. The Director of Nursing (DON) also acknowledged that the orders were not reactivated upon the resident's readmission. Observations and record reviews revealed that the dialysis site was not assessed or documented, and the resident was observed with a port in the right upper chest. The deficiency was identified through interviews, record reviews, and observations. The resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment, and required dialysis on specific days of the week. Despite this, the facility did not have the necessary physician orders in place, and the dialysis site was not monitored as required. The facility's Dialysis Special Needs Care policy, which mandates providing care and treatment consistent with professional standards and physician orders, was not followed in this case.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor the temperatures of the medication refrigerator in Station One, which stored drugs and biologicals. During an observation on 4/25/24, it was found that the temperature log for April 2024 had no documentation for the AM shift and was missing entries for the PM shift on 4/23, 4/24, and 4/25. Similar issues were noted for March, February, and January 2024, with multiple days lacking temperature documentation for both AM and PM shifts. When questioned, the LPN acknowledged the missing documentation and expressed embarrassment. The Director of Nursing was informed of these findings and confirmed that the expectation was for temperature logs to be completed on both shifts. The facility's policy on the storage and stability of medications did not address the monitoring of medication refrigerator temperatures.
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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