Lincoln Haven Nursing & Rehabilitation Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Lincoln, Michigan.
- Location
- 950 Barlow Road, Lincoln, Michigan 48742
- CMS Provider Number
- 235543
- Inspections on file
- 20
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Lincoln Haven Nursing & Rehabilitation Community during CMS and state inspections, most recent first.
Food and nutrition services staffing did not meet required qualifications because the DM was not a CFPM or RD and had only been employed for 6 weeks. The RD stated she visited bi-weekly, completed remote assessments, and was a consultant, while invoice review showed only 26.75 billed hours over 3 months. The NHA stated she handled food ordering and essentially ran the kitchen due to the DM being new.
Premises repair was not maintained when the vegetable wash sink, the 3-compartment sink, and the ice machine were observed with drain lines extending into and below the lip of floor drains, with no air gap present at the ice machine. A closet door in a room was also observed askew with a damaged top track and part of the door hanging away from the frame.
Failure to obtain informed consent for psychotropic meds: two residents received antipsychotic/antidepressant therapy without documented consent for the current order or dose/form change. One resident with bipolar disorder and anxiety had a switch from IM risperidone to oral Risperdal without a new consent, and another resident with MS and depression had venlafaxine ordered without a consent found in the EMR; the SSD also could not locate one.
Missing Bed Hold Documentation for Residents Transferred to ED: The facility failed to provide and document bed hold information for three residents who were transferred to the ED. EMR review showed blank bed hold paperwork and no record that the information was given to the resident and/or representative during hospital transfers. The SSD confirmed the bed hold information was not provided or scanned into the EMR.
Inaccurate MDS coding for resident receiving Hospice services. A resident with CHF, AFib, acute respiratory failure with hypoxia, and HTN was receiving Hospice care, but the MDS assessments and CMS 802 did not reflect Hospice status. The MDS Coordinator confirmed the resident was not coded for Hospice and stated the assessment may not have been updated after Hospice began.
Failure to document follow-up care and physician notification for elevated blood glucose: A resident with DM was on sliding-scale insulin and ordered BG monitoring. Records showed 40 BG readings over 400 mg/dL, but the MD was documented as notified only six times, and no follow-up BG rechecks were documented in the EMR to show whether levels were trending down or still elevated.
Failure to Allow A Resident to Use Own Power Wheelchair: A resident with MS and depression was not allowed to use her own PWC in the facility, despite OT documentation that she used it at home, was safe to operate it, and could transfer independently without a slide board. She reported she could only tolerate a couple of hours in the facility wheelchair, had not been up for days, and was not told at admission she could not keep her PWC. Staff interviews showed the BOM did not review the PWC policy during admission, and the NHA acknowledged the resident would benefit from using her custom PWC in her room.
Failure to follow a resident’s fluid restriction and diet order. A resident with MI and CKD had orders for 1500 cc fluid restriction, NAS diet, Lasix for edema, and daily weights, but was observed consuming fluids beyond the ordered limit, the tray card listed beverages totaling 1800 cc per day, and staff did not consistently document fluid intake or daily weights. Staff interviews showed confusion about tracking fluids, and the care plan did not reflect the ordered fluid restriction and related monitoring.
A facility failed to notify a physician of a resident's elevated blood glucose levels, which exceeded 400 mg/dL on multiple occasions. Despite the facility's protocol requiring physician notification for such levels, there was no documentation of this occurring. Interviews with staff confirmed the protocol was not followed, leading to a deficiency in care.
The facility failed to monitor and assess two residents' blood glucose levels adequately. A resident with diabetes had a high blood glucose level that was not re-checked as ordered, and another newly admitted resident lacked a baseline care plan and had missing blood glucose and vital sign records. The DON confirmed that these actions were against facility policies.
A resident with peripheral vascular disease and cellulitis was not consistently provided with physician-ordered protective boots to prevent pressure ulcers. The boots were not included in the care plan, leading to staff being unaware of the requirement. The resident was observed without the boots on multiple occasions, despite a moderate risk of pressure ulcers.
A resident admitted for rehabilitation after foot amputation did not receive timely pain management due to a delay in processing the necessary C-2 form for controlled substances. The resident, experiencing significant pain, did not receive prescribed oxycodone with acetaminophen until 20 hours post-admission. The delay was attributed to a failure in the facility's process for obtaining controlled substances, as the form was not sent to the medical director for authorization promptly.
The facility failed to properly store and dispose of medications, with discontinued controlled substances remaining in medication carts and loose pills found in another cart. The DON admitted to being too busy to destroy medications promptly, and the NHA was unclear about the frequency of medication destruction. Facility policies on medication disposal and storage maintenance were not adhered to.
The facility failed to employ a qualified Certified Dietary Manager, resulting in issues with meal quality and resident satisfaction. Residents reported minimal entree choices, decreased palatability, and some missed meals. The Registered Dietician confirmed the absence of a CDM, and the Director of Nursing temporarily assumed the role without starting CDM classes. A resident experienced significant weight loss, which was not addressed with nutritional supplementation. The Nursing Home Administrator, overseeing the department without CDM qualifications, was unaware of these concerns.
The facility failed to maintain resident equipment, including two residents' wheelchairs and bed remote controls, in safe and operational condition. One resident's wheelchair had worn wheels and lacked a cushion, while another's wheelchair had malfunctioning brakes and damaged upholstery. Additionally, bed remotes were removed from all residents' beds, causing inconvenience and potential safety concerns. Staff reported difficulties in providing care due to inaccessible bed remotes.
The facility failed to provide adequate meal choices and alternatives, affecting four residents who reported dissatisfaction with meal options, quality, and portion sizes. Residents expressed frustration with the lack of variety and the facility's failure to honor their dietary preferences and needs, including low-salt diets and fresh fruit. Staff confirmed the limited meal options and inadequate portions, leading to residents sometimes going hungry.
A resident, who was cognitively intact and the resident council president, reported that his clothing was returned from the facility laundry with bleach stains and damage. Despite raising the issue with laundry staff, no follow-up occurred, leading to frustration. The staff member acknowledged the oversight but did not report the issue due to time constraints. The facility failed to uphold the resident's rights to voice grievances and maintain personal clothing.
The facility failed to ensure fresh water was consistently offered and provided to four residents, resulting in dissatisfaction and potential dehydration. Observations and interviews revealed that residents had either warm, nearly empty water pitchers or no water at all, and fresh water was not passed out until late in the morning, contrary to the facility's policy.
Food and Nutrition Services Staffing Qualifications Not Met
Penalty
Summary
Employ sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services, including a qualified dietitian, was not met because the facility did not have a director of food and nutrition services who met the required qualifications within the allowed timeframe. During interview, the dietary manager stated she did not have a Certified Professional Food Manager Certification and was not a Registered Dietitian, and she said she had only been at the facility for a short time and had not yet obtained the certifications. She also stated the facility had a Registered Dietitian. In a phone interview, the Registered Dietitian stated she came into the facility bi-weekly, with two visits per month, and also completed remote assessments, and said she was a consultant for the corporation. The nursing home administrator stated the Registered Dietitian was full-time for the facility, but also stated the dietary manager had been employed for 6 weeks. Review of the Registered Dietitian’s invoices showed a total of 26.75 billed hours for December 2025 through February 2026 combined, with 6.25 hours in December, 10 hours in January, and 10.5 hours in February. The nursing home administrator also stated she did all of the food ordering and pretty much ran the kitchen because the dietary manager was so new.
Premises Repair and Drain Line Deficiencies
Penalty
Summary
The facility failed to maintain general repair of the premises. During observation, the vegetable wash sink was found indirectly connected to the floor drain, with the drain line extending down into and below the lip of the floor drain, and the Dietary Manager stated that vegetables are washed in this sink. The double doors for the closet in room [ROOM NUMBER] were observed with the left door askew, the top track damaged and no longer working, and the upper left portion of the door hanging away from the frame about 5 inches. The drain line from the third bin of the three-compartment sink was also observed extending down into and below the lip of the floor drain, and the Dietary Manager stated this sink is used to wash, rinse, and sanitize utensils that do not go through the dish machine. In addition, the ice machine used for resident food prep and drinks had drain lines extending down into and below the lip of the floor bowl drain, with no air gap present.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were educated on the risks and benefits of prescribed psychotropic medications and that informed consent was obtained before administration for two residents. For Resident #7, the electronic medical record showed a diagnosis of bipolar disorder and generalized anxiety, and the resident was receiving Risperdal 0.5 mg by mouth at bedtime. The record also showed a prior psychoactive medication consent for Risperdal Consta IM, signed by the responsible party, but there was no signed informed consent for the change in form and dosage from Risperdal Consta IM every two weeks to oral Risperdal daily, including the risks and benefits of the change. For Resident #21, the record showed diagnoses of multiple sclerosis and major depressive disorder, recurrent and in full remission. Progress notes documented concerns about depression, sadness, and a request for another antidepressant, and physician orders showed venlafaxine (Effexor) was prescribed. The resident stated she did not recall signing a consent for the antidepressant and was not sure she was still taking one. The social services designee could not locate a consent for venlafaxine in the electronic medical record and did not know why one was not on file. The facility policy stated residents and/or representatives would be educated on the risks and benefits of psychotropic medication use, including alternatives, before use.
Missing Bed Hold Documentation for Residents Transferred to ED
Penalty
Summary
The facility failed to provide required bed hold information for three residents who were transferred to the ED. Resident #3 was transferred on 12/16/25, Resident #6 was transferred on 1/8/26, 3/19/26, and 3/27/26, and Resident #17 was transferred on 12/10/25 and 3/7/25. For each of these residents, the EMR did not contain documentation showing that bed hold information was provided to the resident and/or the resident representative at the time of transfer. During record review, each resident’s bed hold paperwork was found blank and not completed. On 3/30/26, the Social Services Designee was interviewed and provided a binder with the facility’s transfer and bed hold information, and confirmed that Residents #3, #6, and #17 did not have bed hold information provided during the transfers and that none was scanned into the EMR. The facility policy stated that bed hold information is to be provided at admission and again prior to transfer due to hospitalization or therapeutic leave, and that a copy of the resident’s bed-hold or release record is to be filed in the medical record.
Inaccurate MDS coding for resident receiving Hospice services
Penalty
Summary
The facility failed to ensure accurate resident assessments for a resident receiving Hospice services. The resident was admitted to the facility with diagnoses including congestive heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and hypertension. The resident’s legal guardian reported that the resident was currently receiving Hospice services, and the EMR showed a Hospice admission notification signed by the Hospice provider, with the resident listed as having Hospice as the primary payer. Hospice records also showed the resident was admitted to Hospice with an active benefit period through 4/26/2026. Despite this, the resident’s MDS assessments dated 10/29/2025, 11/12/2025, and 1/27/2026 did not code Section O, K1 for Hospice Care and instead marked Z1, None of the Above, indicating the resident was not receiving Hospice care in the facility. The facility’s CMS 802 matrix also did not identify the resident as receiving Hospice care. The MDS Coordinator confirmed the resident was not coded for Hospice services and stated she was unsure why the MDS did not reflect the resident’s Hospice status, noting she may have forgotten to update the assessment after Hospice was initiated.
Failure to document follow-up care and physician notification for elevated blood glucose
Penalty
Summary
The facility failed to ensure follow-up care was documented for elevated blood glucose levels and failed to communicate with the physician as ordered for one resident receiving insulin therapy. The resident had diagnoses of diabetes mellitus, weakness, depression, and anxiety, and had physician orders for sliding-scale insulin lispro with blood glucose monitoring. One order required blood glucose checks three times daily before lunch, dinner, and bedtime, with the physician to be called if blood glucose was greater than 400; an earlier order required checks twice daily at 11:00 AM and 8:00 PM, with the physician to be called if blood glucose was greater than 400. Review of the resident’s blood glucose records from 10/1/25 through 4/1/26 showed 40 blood glucose results over 400 mg/dL, but the physician was documented as notified only six times. No follow-up blood glucose rechecks were documented in the EMR to show whether the blood glucose was trending down or remained elevated. The NHA stated that when a resident’s blood glucose was greater than 400, the nurse should contact the physician, perform a follow-up blood glucose, and document it in the EMR. The facility policy also stated to call the physician immediately if blood glucose was greater than 300 or as ordered, recheck blood glucose per physician order, and document blood sugar results, treatment, and resident response in the medical record.
Failure to Allow Resident to Use Own Power Wheelchair
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve a resident’s range of motion and mobility when it did not allow Resident #21 to use her own power wheelchair in the facility. R21 was admitted with multiple sclerosis and major depressive disorder, and during interviews she stated she had been using a power wheelchair at home, could tolerate only a couple of hours in the high-back wheelchair provided by the facility, and had not been up in her wheelchair for several days. She also stated she was not aware at admission that she would not be able to use and keep her power wheelchair during her stay. The record showed that occupational therapy had previously documented that R21 used a power wheelchair in her home environment, spent all day in it, and could transfer without a slide board. A wheelchair assessment found she was safe to use the power wheelchair and could navigate the joystick for positioning and driving, with recommendations to resume power wheelchair use upon return home. During later interviews, OT staff stated it would be life changing for her to have the power wheelchair, and one OT noted her left leg contracture had worsened, her muscle tone had decreased, and she had not been getting out of bed related to pain. The facility’s admission agreement lacked discussion of the policy regarding electrical appliances, including power wheelchairs. The BOM stated she did not cover the power wheelchair policy during admission, and the NHA stated R21 was not allowed to have her power wheelchair because she was not safe to use it in the facility, while also acknowledging she should be re-evaluated and would benefit from using her own custom power wheelchair in her room. The facility policy stated motorized equipment such as wheelchairs are not permitted in house for safety, with the administrator having final decision if limited use is required, and the ADL policy stated the facility would provide necessary care and services to ensure a resident’s abilities do not diminish unless unavoidable.
Failure to Follow Fluid Restriction and Document Intake
Penalty
Summary
The facility failed to monitor fluids and provide the diet as ordered for a resident with a history of myocardial infarction and chronic kidney disease. The resident had a physician order for a 1500 cc fluid restriction, a regular no added salt diet, and daily weights related to bilateral lower extremity swelling and weight gain. The resident was observed with swollen legs, sitting with his feet elevated, and later was seen drinking chicken noodle soup, water, and grape juice at lunch. The tray card did not include the no added salt order and listed beverages that totaled 1800 cc per day on the meal tray card alone, not including fluids given with medications. Record review showed inconsistent and incomplete fluid documentation. Daily weights were missing on multiple dates, and the MAR had a section for the fluid restriction order but no indication of the amount of fluids consumed, even though nurses signed it twice daily. CNA and LPN interviews showed confusion about who was responsible for totaling fluids and documenting fluids given with medications, and one LPN stated he did not record fluids given with medications. The EMR also showed several dates with no fluid documentation, and the nursing home administrator could not present documentation showing how the 1500 cc restriction was totaled each day. The resident’s care plan addressed risk of dehydration related to diuretic use, but did not include the fluid restriction, salt limitation, Lasix use for edema, or weight monitoring focus reflected in the physician orders.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of a change in condition related to blood glucose monitoring for a resident with type two diabetes mellitus. The resident's electronic medical record indicated several instances of elevated blood glucose levels exceeding 400 mg/dL, which required physician notification according to the facility's protocol. Despite these elevated readings, there was no documentation that the physician had been informed, as required by the physician's order and the facility's policies. Interviews with the facility's staff, including a Registered Nurse and the Director of Nursing, confirmed that the protocol for notifying a physician when blood glucose levels are out of range was not followed. The facility's policies, including the Notification of Change and Diabetic Management Program, clearly outlined the necessity of notifying a physician for blood glucose levels greater than 400 mg/dL. However, the failure to adhere to these protocols resulted in a deficiency in the care provided to the resident.
Failure to Monitor and Assess Residents' Blood Glucose Levels
Penalty
Summary
The facility failed to adequately monitor and assess two residents, leading to deficiencies in their care. Resident #5, who has Parkinson's disease and type two diabetes mellitus, had a blood glucose level of 518 mg/dL, which was not followed up with a re-check as per the physician's order. The Licensed Practical Nurse (LPN) involved was unsure why the follow-up was not documented, and the Director of Nursing (DON) confirmed that the blood glucose levels should have been re-checked and documented according to the physician's orders. This oversight was contrary to the facility's policy on notification of change, which requires monitoring and reassessment of the resident's status and response to interventions. Resident #177, admitted with osteomyelitis, peripheral vascular disease, hypertension, and diabetes mellitus, did not have a baseline care plan accessible to Certified Nursing Assistants, and there was a lack of documented blood glucose monitoring and vital signs for several days following admission. The DON acknowledged that new admissions should have a full set of vital signs taken twice a day and that blood glucose monitoring should be completed for diabetic residents, especially those on a sliding scale. The facility's diabetic management program policy was not adhered to, resulting in a failure to provide standardized guidance for diabetic management.
Failure to Implement Physician-Ordered Pressure Ulcer Prevention
Penalty
Summary
The facility failed to implement physician-ordered interventions for a resident with a moderate risk of pressure ulcers. The resident, who had diagnoses including peripheral vascular disease and cellulitis, was observed without the prescribed protective boots on multiple occasions. The boots were intended to be worn while the resident was in bed to reduce pressure on the heels, which were noted to be soft and slightly red. Despite the physician's order for the boots to be applied every shift, the resident reported that staff did not consistently apply them, and there was no record of refusal from the resident. The deficiency was further compounded by the lack of communication and documentation within the facility. The Certified Nursing Assistant (CNA) was unaware of the requirement for the resident to wear the protective boots, as it was not included in the care plan. The Licensed Practical Nurse (LPN) confirmed the existence of the physician's order but acknowledged that it was not reflected in the care plan, which CNAs rely on for resident care instructions. The Director of Nursing (DON) admitted that the omission of the boots from the care plan was an oversight, as CNAs do not have access to physician orders, highlighting a gap in the facility's documentation and communication processes.
Failure in Timely Pain Management for Post-Operative Resident
Penalty
Summary
The facility failed to provide timely pain management for a resident who was admitted with a history of osteomyelitis, peripheral vascular disease, hypertension, and diabetes mellitus, and had recently undergone an amputation of his right toes and partial foot. Upon admission, the resident had a prescription for oxycodone with acetaminophen to manage post-operative pain. However, due to a breakdown in the facility's process for obtaining controlled substances, the resident did not receive his prescribed pain medication until approximately 20 hours after admission. This delay occurred because the necessary C-2 form was not sent to the medical director for authorization in a timely manner, resulting in the resident experiencing significant pain, rated at 8-9 on a scale of 0-10. The medical director expressed frustration over not receiving the C-2 form promptly, which was supposed to be faxed by the admitting night nurse. The Director of Nursing confirmed that the process for obtaining controlled substances involves faxing the C-2 form to the doctor for a signature, then to the pharmacy for an authorization code, which was not completed as required. The resident underwent a dressing change without pain medication, further exacerbating his discomfort. Interviews with the resident and staff highlighted the failure in communication and procedural adherence that led to the delay in pain management, impacting the resident's comfort and quality of care.
Improper Medication Storage and Disposal
Penalty
Summary
The facility failed to ensure proper storage and timely destruction of medications, as observed in two medication carts. In one instance, three controlled substances that had been discontinued were still present in the medication cart. These included tramadol and lorazepam tablets belonging to residents who had either been discharged or had their medication orders discontinued. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were unclear about the frequency of medication destruction, and the DON admitted to being too busy to destroy the medications promptly. Additionally, the East medication cart was found to contain loose tablets of alendronate and a blister pack with remaining tablets, which were supposed to be administered to an unidentified resident. The presence of loose pills indicated that the resident might not have received the full prescribed dose. The DON acknowledged that loose pills should not be present in the cart and that the carts had been recently cleaned. The facility's policies on the disposal of discontinued medications and maintenance of medication storage areas were not followed, contributing to the deficiencies observed.
Lack of Qualified Dietary Manager Leads to Meal Quality Issues
Penalty
Summary
The facility failed to employ a qualified Certified Dietary Manager (CDM) to manage the food service department, leading to several issues with meal quality and resident satisfaction. During a lunch meal, five residents expressed concerns about minimal entree choices, limited or no alternates, decreased palatability, and some missed meals due to the limited choices and poor quality of the food. The Registered Dietician (RD) confirmed that there was no current CDM or Dietary Manager (DM) working in the food services department, and the Director of Nursing (DON) had assumed the role temporarily but had not yet started CDM classes. The RD also noted a significant weight loss of 5% in one resident over the past month, which they were not informed about, and no nutritional supplementation had been added. Interviews with staff and the Nursing Home Administrator (NHA) revealed that the DON had been pulled from the DM role to cover nursing shifts, and the NHA was overseeing the kitchen staff and food services department in the interim, despite not being a CDM or DM. The NHA denied awareness of resident-reported concerns and the weight loss issue. The Regional Director of Operations acknowledged the absence of a CDM or DM and was not aware of the food concerns or weight loss. The lack of a qualified CDM or DM led to inadequate food service management, impacting meal quality and resident nutrition.
Deficient Maintenance of Resident Equipment
Penalty
Summary
The facility failed to maintain essential resident equipment in safe and operational condition, specifically concerning the wheelchairs of two residents and the bed remote controls. One resident, identified as R2, reported issues with their manual wheelchair, which had worn wheels causing it to veer to the side instead of moving straight. Additionally, R2 expressed discomfort due to the absence of a wheelchair cushion. Another resident, R10, was concerned about the malfunctioning brakes on their wheelchair, which did not lock properly, posing a risk of falling. R10's wheelchair also lacked brake covers and a seat cushion, and the upholstery was damaged. The facility's maintenance director confirmed the issues with both wheelchairs, acknowledging the need for repairs. The nursing home administrator was made aware of these concerns during an observation. Furthermore, the facility faced issues with bed remote controls, as several were not functioning, and the administrator had restricted the ordering of replacements to one per month. This led to the removal of all bed remotes from residents' beds, which were later reattached, but not without causing inconvenience and potential safety concerns for residents who could independently operate them. Staff interviews revealed that the removal of bed remotes was a directive from the nursing home administrator following a citation related to a hospital bed remote. The remotes were removed from all residents' beds, not just those with cognitive impairments, and were later zip-tied under the beds, making them difficult to access. Staff reported difficulties in providing care due to the lack of accessible bed remotes, which affected their ability to adjust bed heights and positions for dependent residents, leading to awkward body mechanics and delays in care.
Failure to Provide Adequate Meal Choices and Alternatives
Penalty
Summary
The facility failed to honor the residents' rights to self-determination and choice regarding their meals, as evidenced by the experiences of four residents. Resident 2, who was cognitively intact, expressed dissatisfaction with the limited meal options, stating that only fish and ravioli were available, neither of which she liked. She reported not receiving fresh fruit and described an incident where she was given a fried bologna sandwich, which she did not eat, leading to hunger. Resident 4, also cognitively intact, reported the poor quality of meals, such as Salisbury steak resembling a TV dinner, and the lack of alternative options when she disliked the meal. She expressed frustration with the food quality and portion sizes, stating that she was sometimes left hungry. Resident 1, with a cardiac diagnosis requiring a low-salt diet, was not receiving appropriate meals. A complaint noted that she was served a fried bologna sandwich and cream of mushroom soup without alternatives, and there was a lack of fresh fruit. On Mother's Day, she reportedly did not receive dinner until much later, after other residents had eaten. The facility's dietary manager confirmed that the menu was considered adequate for a no-added-salt diet, despite the resident's complaints about the food's saltiness and lack of variety. Staff reported that residents often had only one meal choice, and dietary staff were unavailable to provide alternatives after dinner service. Resident 7, who was cognitively intact, reported dissatisfaction with the meals, stating that she sometimes skipped meals due to the lack of variety and quality. The facility's menu cycle was outdated, with no listed alternatives, and leftovers were served for up to three days. Staff expressed concerns about inadequate meal portions and the lack of an always-available menu for entrees. The facility's policy stated that residents have the right to nutritious meals and reasonable food substitutes, which were not consistently provided, leading to the deficiency in honoring residents' rights to meal choices and preferences.
Failure to Address Resident Grievance Regarding Damaged Clothing
Penalty
Summary
The facility failed to address a grievance raised by a resident, identified as R8, who was cognitively intact with a BIMS score of 15/15. R8, who also served as the resident council president, reported that his pajama pants and other clothing items were returned from the facility laundry with bleach stains. Despite reporting this issue to the laundry staff two weeks prior, R8 did not receive any explanation or follow-up regarding the damage, leading to feelings of frustration. An observation confirmed the pajama pants were damaged beyond wear, with bleach stains, holes, and frayed edges. Laundry Staff B acknowledged being informed of the issue by R8 over a week before but failed to report it to the Business Office Manager, Staff F, as per the facility's protocol. Staff B admitted to not filing a grievance form due to time constraints and being off work for a week. The Nursing Home Administrator confirmed the expectation that a grievance form should have been completed and the issue reported. The facility's failure to act on the grievance violated the resident's rights to voice grievances without reprisal and to have personal clothing maintained in a clean, home-like environment.
Failure to Provide Fresh Water to Residents
Penalty
Summary
The facility failed to ensure fresh water was consistently offered and provided to four residents, resulting in dissatisfaction and potential dehydration. Observations on 2/6/24 revealed that residents had either warm, nearly empty water pitchers or no water at all. Interviews with the residents confirmed that they had not received fresh water since the previous night, despite requests made earlier in the morning. The residents' BIMS scores indicated varying levels of cognitive impairment, with some residents being moderately impaired and others having no cognitive impairment. Further observations and interviews with staff revealed that fresh water was not passed out until late in the morning, contrary to the facility's policy of providing fresh water at the start of each shift. The Director of Nursing confirmed that the night shift was responsible for collecting used water cups for cleaning, and fresh water should be distributed each morning. However, staff reported difficulties in receiving clean water cups from the kitchen, contributing to the delay in providing fresh water to the residents.
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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