Iron County Medical Care Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Crystal Falls, Michigan.
- Location
- 1523 U.s. Highway 2, Crystal Falls, Michigan 49920
- CMS Provider Number
- 235257
- Inspections on file
- 24
- Latest survey
- April 23, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Iron County Medical Care Facility during CMS and state inspections, most recent first.
Surveyors found that several doors equipped with 15-second delayed egress hardware lacked required signage and did not function as intended, with some doors failing to initiate the irreversible opening sequence and others bypassing it entirely. These deficiencies were confirmed during testing and observation with the Acting Maintenance Director.
Surveyors observed a large amount of cigarette butts scattered throughout the smoking area and in the grass, indicating that required smoking regulations and proper disposal methods, such as the use of approved ashtrays and metal containers, were not being followed. This was confirmed by the Acting Maintenance Director.
Surveyors observed that the facility did not label the generator's above ground diesel fuel tank with an NFPA 704 placard in a visible location, as required by NFPA 30. This deficiency was confirmed by the Acting Maintenance Director and represents noncompliance with multiple NFPA standards.
Empty and full oxygen cylinders were found mixed together on a cart in the Cedar Wing oxygen storage room, rather than being properly segregated as required by NFPA 99. This was confirmed by the Acting Maintenance Director during the survey.
The facility did not provide documentation that the kitchen hood fire suppression system in one wing had received the required hydrostatic testing, as confirmed by the Acting Maintenance Director during record review. This deficiency could impact up to 30 occupants in the event of a fire emergency.
An exercise bike in the inpatient gym area was found plugged into an extension cord, contrary to NFPA 99 and NFPA 70 standards for electrical safety. The improper use of the extension cord was confirmed by the Acting Maintenance Director during the survey.
The facility did not ensure that monthly Medication Regimen Reviews were reviewed, addressed by a physician, or maintained in residents' clinical records. For several residents with complex medical conditions, pharmacy reports were missing for multiple months, and facility leadership acknowledged that there was no process in place to ensure pharmacy consults were addressed or documented as required.
Surveyors identified a medication error rate of 13.33% after observing multiple instances where nurses crushed potassium chloride ER capsules against physician orders, allowed a resident to chew a capsule without water, failed to document or notify the physician about medication administration issues, and did not shake liquid medication before administration. These actions were not in accordance with facility policy or physician instructions.
Staff failed to perform hand hygiene between resident rooms during water pass and while providing catheter care, resulting in the use of contaminated gloves to touch environmental surfaces and resident items. Staff acknowledged not following hand hygiene protocols, and the DON was informed of the risk for cross-contamination.
A resident with COPD, anxiety, and dementia was given supplemental oxygen at a higher flow rate than ordered by the physician, with no documented assessment or physician notification to support the change. The oxygen tubing was not replaced according to facility protocol, and nebulizer equipment was not cleaned or stored in a sanitary manner as required. Staff interviews and record reviews confirmed these failures to follow physician orders and facility policies for respiratory care.
A resident with multiple diagnoses received both vitamin D2 and D3 concurrently after a physician accepted a pharmacy recommendation to switch formulations, but the original vitamin D2 order was not discontinued. This resulted in duplicate weekly administration and excessive dosing, which was not identified due to a missed step in the medication order review process.
The facility's QAPI committee failed to meet quarterly with all required members, with key personnel such as the Medical Director, DON, IP, and NHA frequently absent. This inconsistency placed all 115 residents at risk for quality care concerns.
A resident did not receive a dose of hydrocodone-acetaminophen that was signed out by an RN, leading to an investigation. The RN had a history of careless documentation and suspicious behavior, including increased PRN administration. The RN refused a drug test and was terminated as per facility policy.
The facility failed to report injuries of unknown source to the state agency for two residents with severe cognitive impairments. One resident was found with facial fractures, and another with multiple fractures, but neither incident was reported as required by facility policy.
The facility failed to complete an investigation for an incident where a resident with severe cognitive impairment and multiple medical conditions was found on the floor with fractures. Despite the severity, the investigation was not completed as required by the facility's procedures.
The facility failed to assess and monitor pressure injuries for a resident, leading to inadequate care. The resident had a pressure injury on the left gluteal area and a deep tissue injury on the left heel, but there was no proper documentation or treatment. A stage II pressure injury on the sacrum was also not documented or treated according to the facility's policies. The DON and staff were unaware of the current status of these injuries, and the required weekly skin assessments were not completed.
The facility failed to report PBJ information to CMS, resulting in inaccurate staffing level reports. A review of the CMS PBJ Staffing Data Report for FY Quarter 1 2024 revealed multiple instances of no RN hours and a lack of licensed nursing coverage for 24 hours a day. An RN responsible for PBJ data submission confirmed that the facility missed the submission deadline, potentially affecting all 115 residents.
Noncompliance with Delayed Egress Door Requirements
Penalty
Summary
Surveyors observed that several doors in required means of egress were equipped with 15-second delayed egress hardware but did not meet the requirements set forth by NFPA 101. Specifically, the door to the main nurses station from Willow Wing and Door 12 were missing the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." Additionally, the Birch Wing Alcove exit, Door 17, and other doors failed to initiate the irreversible opening sequence when tested multiple times, indicating that the delayed egress function was not operating as intended. In contrast, Door 9 and Door 8, while appropriately signed, immediately opened and bypassed the irreversible opening sequence upon testing, further demonstrating noncompliance with the required delayed egress operation. These deficiencies were confirmed through direct observation and testing by the surveyor, with the Acting Maintenance Director present at the time. The report does not mention any specific residents or their medical conditions in relation to these findings. The focus of the deficiency is on the improper installation, signage, and functioning of delayed egress hardware on multiple doors, which did not comply with the standards for special locking arrangements as required by NFPA 101.
Failure to Enforce Smoking Regulations and Proper Disposal of Cigarette Butts
Penalty
Summary
The facility failed to ensure that smoking regulations were fully implemented and adhered to as required by regulatory standards. During an exterior tour of the building, a large number of cigarette butts were observed scattered on the ground throughout the designated smoking area and in the surrounding grass. This observation was confirmed by the Acting Maintenance Director at the time of discovery. The presence of cigarette butts indicates that proper disposal methods, such as the use of metal containers with self-closing covers and noncombustible ashtrays, were not being utilized as required in areas where smoking is permitted.
Failure to Label Generator Fuel Tank with Required NFPA 704 Placard
Penalty
Summary
The facility failed to comply with requirements for labeling the generator's above ground diesel fuel tank with an NFPA 704 placard. During an observation on April 23, 2025, it was noted that the fuel tank was not marked with the required placard in a location visible upon approach, as mandated by NFPA 30, 21.7.2.1. This deficiency was identified during a survey and confirmed by the Acting Maintenance Director at the time of discovery. The report specifies that this failure to label the fuel tank properly is not in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. The deficiency could potentially affect all occupants in the event of a fire, as the lack of proper labeling may hinder emergency response or safety procedures. No specific residents or patient conditions are mentioned in the report.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to ensure proper storage of nonflammable gas cylinders in accordance with NFPA 99 requirements. During an observation in the Cedar Wing oxygen storage room, it was found that empty oxygen cylinders were not segregated from full oxygen cylinders. Specifically, 38 cylinders were observed mixed together on a cart, rather than being separated as required by regulations. This deficiency was confirmed at the time of discovery by the Acting Maintenance Director. The report does not mention any specific patients or their medical conditions in relation to this deficiency. The focus of the finding is on the improper storage practice of oxygen cylinders, which did not meet the established standards for gas equipment storage.
Failure to Complete Required Hydrostatic Testing of Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to ensure that cooking facilities were protected in accordance with NFPA 96 standards. During a record review, it was found that the kitchen hood fire suppression system in the Cedar Wing had not undergone the required hydrostatic testing, as the two most recent inspection records did not show evidence of this testing being completed. No documentation was provided by the end of the survey to confirm that the hydrostatic test had been performed. This deficiency was confirmed by the Acting Maintenance Director at the time of the record review. This lapse could affect up to 30 occupants in the event of a fire emergency, as noted in the findings.
Noncompliant Use of Extension Cord for Exercise Equipment in Patient Care Area
Penalty
Summary
A deficiency was identified when, during an observation in the inpatient gym area, an exercise bike was found plugged into an extension cord. This setup did not comply with NFPA 99 and NFPA 70 requirements regarding the use of power strips and extension cords for electrical equipment in patient care areas. The observation was confirmed by the Acting Maintenance Director at the time. The report specifies that extension cords are not to be used as a substitute for fixed wiring and must be removed immediately after temporary use, which was not adhered to in this instance. No additional details about the specific occupant affected, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain and Address Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were properly reviewed, addressed by the physician, and maintained in the clinical records for four out of five residents reviewed. For multiple residents with complex medical histories, including dementia, diabetes, anxiety, depression, and other conditions, pharmacy reports documenting the MRR were missing for several months. The Director of Nursing (DON) was unable to locate these reports in the electronic medical record and acknowledged that she did not keep them as required. The DON also confirmed that there was no way to determine what recommendations the pharmacist had made, whether the medical director or nurse practitioner had agreed or disagreed with those recommendations, or if any rationale for decisions was documented. Interviews with facility leadership, including the DON and Nursing Home Administrator (NHA), revealed that there was no designated staff member ensuring that pharmacy consults were being addressed. The NHA admitted that the system for handling pharmacy consults was broken and deficient. Review of the facility's own policy confirmed that written communications from the pharmacist should become a permanent part of the resident's medical record, but this was not being followed. As a result, the facility was unable to demonstrate compliance with federal requirements for drug regimen review and documentation.
Plan Of Correction
For Resident #67, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #36, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #65, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #90, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. The DON/designee audited the EMR for all residents and identified those residents who did not have a DRR in April 2025. The DON notified the pharmacist that these reviews needed to be completed. DON and ADON had a phone conference with the pharmacy consultant about our process and how to correct it. To ensure the pharmacy recommendations are being answered according to policy, the process needs to come back to an in-house process instead of reports being sent electronically to an outside source, Theoria. DON and ADON met with the DNP about changing the processing of pharmacy consultation reports by bringing the process back internally instead of sending them to Theoria to process. The DNP was in agreement. On 4/21/2025, it was confirmed that the pharmacist would be at the facility in person on 4/24/2025 to meet and discuss survey findings and finalize the plan to bring the process back to an in-house process. On 4/24/2025, the DON and ADON met with the consulting pharmacist to review the Medication Regimen Review policy and discussed the new process as follows: 1) After receiving monthly pharmacy recommendations, the ADON will print and separate them for delivery as follows: a. Nursing will be handed the recommendations to be given to the Administrative Medical Assistant to initiate processing. b. The physician will be handed the recommendations to be reviewed and responded to by the DNP and/or medical director. c. GDRs — a meeting will be scheduled for the Behavior Team to review and give their recommendations to the DNP/medical director for review and response. 2) Once all recommendations have been reviewed and have a response, all reports will be given to the charge nurse for processing. 3) A copy of the summary of MRRs will be given to charge nurses to indicate orders they process. 4) Recommendations will then go to HIM to be scanned into the residents' medical records. 5) The DON/ADON will review the completion of recommendations weekly. On 4/25/2025, the current Pharmacy Consultation Reports from the pharmacist with new and outstanding recommendations were received. On 4/28/2025, the DON and ADON reviewed all GDRs with the IDT. The ADON distributed all pharmacy recommendations to either the Administrative Medical Assistant for processing or the DNP for review. One-on-one direction was given to the DNP about the internal process by the ADON. To prevent pharmacy recommendations responses from being delayed and to ensure they are part of the residents' medical records, the following has been completed and/or initiated: DON, ADON, and pharmacy consultant reviewed and updated the Medication Regimen Review Policy and changed the response timeframes for the attending physician/DNP to: 1) 45 days (from 60 days), after which the DON will bring them back to the attending physician/DNP. 2) 50 days (from 65 days), after which the DON will notify the Medical Director and/or the Administrator. The ADON completed one-on-one education with all charge nurses on the change of the internal process. On 5/5/2025, the DON verified that the processing of April's pharmacy recommendations had been completed and all had been sent to HIM to be scanned into the residents' medical records. To ensure the changes implemented are followed, the DON/ADON or designee will review: 1) The monthly Pharmacy Consultation Summary Reports weekly for progress. 2) If by Day 30, a pharmacy recommendation has still not been addressed, the DON will bring it back to the attending physician/DNP for review per the ICMCFS Medication Review Policy. The DON/ADON or designee will audit completed recommendations for: 1) Completion of pharmacy recommendations by the attending physician/DNP with signature and rationale. 2) That completed recommendations have been added to the residents' medical records. Audits will be conducted as follows: 10 audits for 1 month, 6 audits for 1 month, and 4 audits for 1 month. The DON will present a compliance report based on the audit findings at monthly QAPI meetings for review by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. Ongoing monitoring thereafter will be continued by the DON/ADON to ensure compliance in accordance with the policy. The DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 13.33% based on four medication errors out of thirty opportunities. Surveyors observed multiple instances where nursing staff did not follow physician orders or facility policy during medication administration. For example, a registered nurse crushed potassium chloride extended-release capsules for two residents, despite clear physician instructions and labeling that the medication should not be crushed. In both cases, there were no physician orders or care plan indications permitting the medications to be crushed. Another resident was observed chewing a potassium chloride capsule, which was not administered with water as required by FDA guidelines and facility policy. The nurse did not document the resident's difficulty swallowing the medication, nor was the physician notified that the resident did not receive the full prescribed dose or that a change to a liquid form might be needed. Additionally, a nurse failed to shake a bottle of senna oral syrup before administration and combined the unshaken liquid with other crushed medications in coffee, again without a physician's order or care plan direction to do so. The Director of Nursing confirmed that medications labeled as "do not crush" should not be altered without a physician's order, and that proper procedures for medication administration, documentation, and disposal were not followed in these cases. Facility policy also requires hand hygiene between residents, destruction of unused medications, and notification of the physician if a resident does not take medications as prescribed, none of which were consistently observed during the survey.
Plan Of Correction
The facility will develop a plan to maintain a medication error rate of 5% or less. For Resident #95, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #8, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #70, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #23, a review of bowel movements was completed by DON to assure that the resident did not have any unusual increased or decreased frequency of bowel movements. The resident was also monitored through daily nursing notes and CNA task documentation. ADON identified all residents who receive potassium and all who receive crushed, opened, or modified medications that had the potential to be affected. Immediate 1:1 education was given to nurses in the facility on Do Not Crush medications. DON and ADON reviewed the Medication Administration Policy and updated the Oral Crushed Medication section to reflect that a physician order is needed to crush any medication and to administer multiple crushed medications together. DON and ADON completed a Root Cause Analysis (RCA). They created a Relias module and posttest reinforcing the following: - If a pill is dropped onto the cart or floor, place it in the Drug Buster and retrieve a new pill to administer. - Shake well to mix suspensions. - Crushed medications require a Physician order to crush. - Potassium orders require a DO NOT CRUSH order but may be opened and sprinkled. - If a resident refuses medications, document in EHR and notify the Charge Nurse. - If medication has been prepared and then refused, destroy it in the Drug Buster. - Perform hand hygiene prior to administering medication. - Perform hand hygiene after medication administration. - If a resident is displaying difficulty with any medication (e.g., taste, form, size), notify the physician. - For employees who are casual/student status, on vacation, or on leave of absence (LOA), training will be completed before or during their next scheduled shift. DON provided a full list of residents who receive crushed medications to DNP for review and to write an order for long-acting medications indicating: 1) Do Not Crush OR 2) Do Not Crush, but may open and sprinkle and combine OR 3) May crush and Do NOT combine OR 4) May crush and combine Once orders are processed, MDS will update the Care Plan to reflect this. DON created a new form: Refusal of Medication/Medication Change Request Form, for charge nurses (notified by neighborhood nurses) to fill out for residents who may require a change in medication for any reason. Completed forms will be given to DNP for any necessary action. DON verified that audits are performed monthly by the pharmacy consultant for any residents who should have an order stating Do Not Crush. The Omniviews DO NOT CRUSH medication list was added to all units' medication information binders, placed at the north side nurses' station, and given to Administrative Medical Assistants. To ensure the policy review and changes are followed, DON/ADON or designee will randomly audit a medication pass with a focus on: - Medications are not being altered or combined without an order - No prepared medication stored in the medication cart - Performing hand hygiene - Medication disposed of appropriately if contaminated or refused - Shaking of liquid medications - Notification to the charge nurse for medication refusal Audits will occur on two nurses weekly on each shift for one month, then one nurse on each shift weekly for two months, and then one nurse monthly on an ongoing basis to ensure compliance with facility guidelines. The pharmacy consultant will audit residents' orders monthly and ensure Do Not Crush orders are present for medications that should not be crushed, sending recommendations if an order is missing. The MDS coordinator or designee will conduct quarterly audits to verify that any resident on crushed, opened, modified, or combined medications has a corresponding intervention in their care plan. DON will present a compliance report based on the audit findings at monthly QAPI meetings for review by the team for three months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. Ongoing monitoring thereafter will be continued by DON to ensure compliance in accordance with the plan of correction. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Failure to Perform Hand Hygiene During Resident Care and Water Pass
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during routine care activities, specifically during the distribution and collection of water mugs and during catheter care. Certified Nurse Aide (CNA) "A" was observed delivering fresh water and removing used water mugs from multiple residents' rooms without performing hand hygiene between rooms. CNA "A" admitted to not using hand sanitizer between rooms and acknowledged the importance of hand hygiene in preventing cross-contamination. During catheter care for a resident, CNA "O" and CNA "C" donned gloves as part of Enhanced Barrier Precautions. CNA "O" performed perineal care and, without removing contaminated gloves, touched environmental surfaces such as closet handles and retrieved a clean incontinence brief. The same contaminated gloves were used to change the resident's brief and assist with clothing and protective boots. CNA "O" acknowledged that hand hygiene and glove changes should have occurred after cleaning the resident's genitals and catheter tubing. A registered nurse confirmed that gloves should be removed and hand hygiene performed before touching other surfaces. The facility's hand hygiene policy requires staff to perform hand hygiene before donning gloves and immediately after removing them, emphasizing that glove use does not replace hand hygiene. The Director of Nursing was made aware of the observations and expressed understanding of the deficiency related to the failure to perform hand hygiene and the potential for cross-contamination within the facility.
Plan Of Correction
The facility will develop a plan to ensure hand hygiene will be performed during a fresh water pass and post catheter care. For resident #11, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #32, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #33, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #38, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #50, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #52, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #55, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. Housekeeping disinfected the high-touch surfaces in room. The DON/ADON and designees identify residents on Enhanced Barrier Precautions who were potentially affected. For any identified, the DON/ADON will monitor daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. Immediate 1:1 education was provided to Resident Assistants in the facility on proper hand hygiene protocol between residents when passing water jugs. All others were educated before or during their next working shift. DON and ADON completed policy reviews on the following: 1) Hand Hygiene Policy reviewed and updated to indicate when it's appropriate to perform hand hygiene: a. Perform Hand Hygiene before and after: i. Performing invasive procedures ii. Handling medications iii. Handling contaminated items iv. Contact with blood and body fluid, secretions, excretions, mucous membranes, etc v. Assisting with/providing personal care vi. Eating vii. Using the restroom viii. Sneezing, coughing, blowing or wiping nose. b. When in doubt, wash your hands. 2) Catheter Care Policy—updated to indicate it’s appropriate to remove gloves and perform hand hygiene after performing catheter care but before touching clean items. Then don new, clean gloves. 3) Drinking Water Distribution Policy—updated to indicate hand hygiene is to be performed before entering a resident’s room and after placing the empty jug on the cart. DON and ADON created an education module with posttest on Relias for: 1) All Resident Assistants on performing hand hygiene between resident rooms 2) All CNAs on when to perform hand hygiene after performing catheter care, but before touching clean items such as closet handle, clothing, or clean brief. Per facility policy, you are required to remove gloves, perform hand hygiene, and don new, clean gloves. For those employees who are casual/student status, on vacation, or on LOA, training will be completed before/during their next scheduled shift. To ensure compliance with hand hygiene after education, DON/ADON or designee will perform hand hygiene audits during a water pass 6x/week for 2 weeks, 4x/week x 2 weeks, then 2x weekly for two months. Audits for hand hygiene for residents on Enhanced Barrier Precautions will be completed by DON/ADON or designee with focus on reducing the risk for cross-contamination. Two audits weekly for 1 month, one audit weekly for 2 months. The DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Failure to Administer and Maintain Oxygen and Nebulizer Equipment per Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), anxiety, and dementia was observed receiving supplemental oxygen at a flow rate of 3 liters per minute (L/min) via nasal cannula, despite the active physician order specifying oxygen at 2 L/min as needed. Multiple observations confirmed the oxygen was being administered at the higher rate without any documented assessment or physician notification to justify the change. The resident's medical record did not contain documentation supporting the increased oxygen flow, and the most recent vital signs indicated an oxygen saturation of 97% on room air, with no evidence of a clinical need for the higher oxygen rate. Additionally, the oxygen tubing in use was found to be dated over a month prior to the observation, exceeding the facility's protocol for changing tubing every two weeks. Staff interviews confirmed the tubing was out of date and that the protocol for timely replacement was not followed. The resident was unaware of the oxygen concentration being administered and reported feeling more short of breath recently. Further observations revealed that the resident's nebulizer equipment, including the medication chamber and mouthpiece, was left resting directly on the nightstand without a protective barrier and was not stored in a sanitary manner as required by facility policy. Staff confirmed that the nebulizer equipment should have been cleaned, dried, and stored in a plastic bag after each use, but this was not done. Facility policies for both oxygen and nebulizer care were not followed, resulting in deficiencies in both the administration and maintenance of respiratory equipment.
Plan Of Correction
The facility will ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences. For Resident #65, the DON and practitioner reviewed the resident's recent oximetry readings and assessed the resident's respiratory status, clarifying the oxygen liter flow ordered. The DON replaced, labeled, and dated the resident's oxygen tubing. The DON placed a barrier under the equipment and ensured a baggie was available to store tubing when not in use, per facility policy. The DNP reviewed the resident's record and completed an assessment with ongoing treatment for a diagnosis of COPD. No noted ill effects. On 4/17/2025, the DON identified those residents who are currently receiving oxygen and audited tubing for accuracy on labeling and to ensure correct storage units to coil and place tubing in a baggie when not in use. One of three was noted to have out-of-date oxygen tubing. The tubing was changed and labeled correctly. The DON also audited care plans for accuracy, and all three were up to date. The DON verified orders on all residents receiving oxygen to determine accuracy on the rate of flow the resident is receiving. The ADON obtained the current list of residents receiving nebulizer treatments. In each unit where these residents reside, the DON ensured nurses had proper cleaning supplies, an area to allow equipment to dry, and proper storage containers for nebulizer equipment. To prevent oxygen tubing from becoming outdated, ensure it is stored in a sanitary manner, and ensure oxygen is administered per physician order, the following has been completed and/or initiated: On 4/18/2025, the DON and ADON reviewed the following policies and deemed them appropriate with evidence-based practices: 1) Cleaning and Disinfecting Nebulizers Policy, 2) Oxygen Use and Set-up Policy, 3) Medication Administration Policy. On 5/1/2025, all nurses currently working in the facility received 1:1 education on the following: 1) Cleaning and Storage of oxygen tubing & nebulizer equipment, 2) 5 Rights of Medication Administration with a focus on checking the order to assure that oxygen is being administered at the ordered liter flow, 3) Hand Hygiene with a focus on during medication administration. For those employees who are casual/student status, on vacation, or on LOA, training will be completed before/during their next scheduled shift. The DON and ADON created a Relias education module and post-test for all licensed nursing staff, including a review of the Cleaning and Disinfecting Nebulizer Policy and Oxygen Use and Set-up Policy. The focus was on storing oxygen tubing, cleaning equipment after each use, changing oxygen tubing, and how/what to use to clean equipment. They also created a Relias education module and post-test for all CNAs, emphasizing storing tubing when not in use. 1:1 education was provided to AMA and NAA staff on the delivery of oxygen tubing and humidifier bottles, with an emphasis on: - Placing new tubing themselves and not delegating it out to another staff member. - Reapproaching the resident if unable to apply when they first attempt. - Reviewing the Oxygen Use and Set-Up Policy. To ensure the education and changes implemented are followed, monitoring has been implemented to ensure sustainability of compliance: - DON/ADON or designee will complete audits of oxygen administered per physician order and labeling of oxygen tubing for accuracy, weekly for 2 months, and with random audits for 1 month. - Storing of equipment in a sanitary manner will be audited 2 times per week for one month, weekly for one month, and randomly for one month. The facility will schedule follow-up evaluations to ensure that these practices are maintained over the long term and that any trends are addressed promptly. The DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. The DON/ADON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Duplicate Vitamin D Therapy Administered Due to Failure to Discontinue Prior Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including a left femur fracture, mild cognitive impairment, urinary tract infection, and vitamin D deficiency received duplicate therapy of vitamin D. The resident was initially prescribed ergocalciferol (vitamin D2) 50,000 units weekly. Following a pharmacy recommendation, the physician accepted a change to cholecalciferol (vitamin D3) 50,000 units weekly, but the original vitamin D2 order was not discontinued. As a result, both vitamin D2 and D3 were administered concurrently throughout June, leading to an excessive total weekly dose of 100,000 units. The duplicate administration was confirmed through review of the medication administration record and pharmacy consultation reports. The DON and ADON acknowledged the error after reviewing the records and confirmed that the duplication was not detected due to a missed step in the double-checking process for physician orders. The facility's policy required thorough medication regimen reviews to prevent such issues, but the process failed to identify and resolve the duplicate therapy in this instance.
Plan Of Correction
The facility will develop a plan to ensure residents receive medications that are appropriate, necessary, and free from duplication. Review of the medical record indicates that Resident #90 has received the ordered dose of Vitamin D3 since July 1, 2024. The DON/designee reviewed the Drug Regime reviews for the month of April 2025. There was no duplicative therapy identified that the physician had not addressed. Physician Orders Policy given to the Nursing Administration Team and charge nurses in house for review, to verify and evaluate our current process. RCA completed by DON and ADON to identify how error occurred. Upon process review, we identified our transcription of orders would improve with redundancy built into the system. The Nursing Administrative Team revised the process to include a double note signature. 1:1 Education on the importance of double noting orders occurred for all charge nurses, neighborhood licensed staff, and nursing administrative team currently in the facility. All other nursing staff not in the building will be educated before or during their next shift. DON and ADON created a Physician Order Policy review with post-test for all licensed staff on Relias with focus on: double noting by licensed staff ensuring no duplicate orders and to identify the same medication under a different name. For those employees who are casual/student status, on vacation, or on LOA, Relias education will be completed before/during their next scheduled shift. To ensure the education and changes implemented are followed, monitoring has been implemented to ensure sustainability of compliance. ADON updated Provider Visitation Log Sheets for DNP and Medical Director to include space to verify the order has been double noted by a licensed staff member. DON/ADON or designee will audit 2 Provider Visitation Log Sheets (that contain up to 22 orders) and 6 Omnicare pharmacy recommendation sheets weekly for one month to ensure order was processed per facility policy to ensure double noting was completed by second licensed staff. Then 1 provider visitation log sheet and 4 Omnicare pharmacy recommendation sheets weekly for one month, then 1 provider visitation log sheet and 2 Omnicare pharmacy recommendations weekly for one month. DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months; with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. During an interview and record review, it was found that the QAPI meeting sign-in sheets revealed inconsistent attendance by key members. On multiple occasions, essential members such as the Medical Director, Director of Nursing (DON), Infection Preventionist (IP), and Nursing Home Administrator (NHA) were absent. Specifically, the Medical Director was absent in three out of six meetings, the DON was absent in two meetings, and the IP and NHA were each absent in one meeting. This deficiency placed all 115 residents at risk for quality care concerns as the QAPI committee did not consistently meet with the required members to ensure proper oversight and quality improvement initiatives.
Failure to Prevent Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident (R266). R266, who was cognitively intact and admitted with diagnoses including a spinal fracture and ankylosing spondylitis, did not receive a dose of hydrocodone-acetaminophen that was signed out by RN H. The discrepancy was discovered when R266 requested the medication for back pain, and it was noted that RN H had signed out the medication but not documented its administration in the electronic Medication Administration Record (MAR). R266 confirmed he had not received the medication at the time it was signed out, leading to an investigation by the facility's Director of Nursing (DON) and other staff members. The investigation revealed that RN H had a history of careless documentation, including a previous incident where she signed out a controlled substance in the MAR but not in the narcotic sign-out log. During the investigation, RN H admitted to administering the medication but could not provide a consistent account of the event. RN H's behavior, including leaving the facility without permission and a history of increased PRN administration, raised further suspicion. When asked to submit to a drug test, RN H refused, leading to her immediate termination as per facility policy. The facility's policies on medication administration and drug testing were reviewed, confirming that refusal to submit to a drug test is treated as a positive result. The DON and Nursing Home Administrator (NHA) confirmed the termination of RN H due to her refusal to submit to the drug test. The facility had previously re-educated RN H after the first documentation incident but had not changed its policy at that time. The report highlights the failure to prevent the misappropriation of narcotic medication and the subsequent actions taken by the facility to address the issue.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report injuries of unknown source to the state agency for two residents with severe cognitive impairments. Resident #87, who was admitted with Alzheimer's Disease and was dependent on staff for all activities of daily living, was found on the floor with facial injuries and bleeding. Despite the severity of the injuries, which included facial fractures confirmed by a CT scan, the event was not reported to the state agency. The Director of Nursing admitted that the new cameras were not yet installed, making it impossible to validate the employees' statements, and the Nursing Home Administrator confirmed that the event was not reported because the investigation results ruled out abuse, although the facility was not able to immediately rule out abuse at the time of the incident. Resident #34, also admitted with Alzheimer's Disease and severe cognitive impairment, was found on the floor of her room and was sent to the hospital for x-rays and a CT scan, which revealed multiple fractures. Despite the resident's severe cognitive impairment and the unwitnessed nature of the injury, the event was not reported to the state agency. The Director of Nursing did not provide an explanation for the failure to report. The facility's policy on incident reporting clearly states that any incident requiring hospitalization should be reported to the Administrator and the State Health Department.
Incomplete Investigation of Resident Incident
Penalty
Summary
The facility failed to conduct a thorough and complete investigation for an incident involving a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, anxiety disorder, major depressive disorder, type 2 diabetes, chronic pain, congestive heart failure, and primary hypertension. The resident, who requires substantial to maximum assistance to transfer, was found on the floor next to her wheelchair, complaining of left pelvic pain. The incident report revealed that the resident sustained a left inferior pelvic fracture, an anterior pelvic fracture, and a patella fracture. Despite the severity of the incident, the Director of Nursing acknowledged that the investigation into the incident was not completed, which is a violation of the facility's Incident Report Procedure that mandates investigations to be started within two working days and completed within fourteen days.
Failure to Assess and Monitor Pressure Injuries
Penalty
Summary
The facility failed to assess and monitor pressure injuries to promote the healing of a facility-acquired pressure injury for one resident. Resident #109 was admitted to the facility and initially had no pressure injuries. However, a pressure injury on the left gluteal area was identified on 3/7/24, but subsequent assessments and documentation were lacking. Additionally, a deep tissue injury on the left heel was identified on 3/12/24, but there was no further documentation or assessment of this injury in the resident's medical record. The Director of Nursing (DON) and other staff were unaware of the current status of these injuries, and there was no physician documentation on the pressure injuries. A skin assessment on 4/24/24 revealed a stage II pressure injury on the resident's sacrum, which had not been properly documented or treated according to the facility's policies. During interviews, the resident stated that nurses had not been assessing or treating the pressure injury on his bottom, and the DON confirmed that there was no additional documentation of the wounds in the resident's medical record. The facility's policies required weekly skin assessments and documentation for residents at risk for pressure injuries, but these were not completed for Resident #109. The lack of proper assessment, monitoring, and documentation of the pressure injuries led to a deficiency in the care provided to the resident. The facility's failure to follow its own policies and procedures for pressure injury assessment and treatment resulted in inadequate care for Resident #109. The DON and other staff members were not aware of the resident's pressure injuries, and there was no evidence of physician involvement in the assessment and treatment of these injuries. The facility's documentation practices were insufficient, and the required weekly skin assessments were not conducted, leading to a deficiency in the quality of care provided to the resident.
Failure to Report PBJ Information to CMS
Penalty
Summary
The facility failed to report Payroll Based Journal (PBJ) information to CMS, resulting in inaccurate reporting of staffing levels. This deficiency was identified through a review of the CMS PBJ Staffing Data Report for FY Quarter 1 2024, which revealed multiple instances of no RN hours and a lack of licensed nursing coverage for 24 hours a day on specific dates. An interview with an RN responsible for PBJ data submission confirmed that the facility missed the deadline for submitting the PBJ information to CMS. This failure had the potential to affect all 115 residents in the facility.
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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