Maple Woods Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Clio, Michigan.
- Location
- 13137 North Clio Road, Clio, Michigan 48420
- CMS Provider Number
- 235518
- Inspections on file
- 22
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Maple Woods Manor during CMS and state inspections, most recent first.
A resident admitted with stroke, pneumonia, dysphagia, and type 2 DM, and ordered NPO with PEG tube feeding and insulin, experienced neglect when staff changed the ordered Glucerna formula to Jevity without rationale and significantly delayed initiation of tube feeding and water flushes. Facility staff failed to enter and follow discharge insulin orders on admission, did not start oral DM medication and basal insulin until nearly two weeks later, and did not consistently act on repeated BG readings over 300–500+ despite a policy to notify a practitioner for BG >400. Therapy staff and CNAs reported progressive lethargy, weakness, and increased dependence for transfers, while the record lacked nursing assessments of change in condition, respiratory assessments or monitoring for pneumonia, documentation of antibiotic use for pneumonia, or PEG site assessments. EMS later documented that staff reported the resident had been in an altered mental status with BG levels above 500 for several days before transfer, and hospital records showed admission for altered mental status, severe hypernatremia, hyperglycemia, AKI, and sepsis, demonstrating that the resident’s change in condition went unrecognized and undocumented by facility nursing staff.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure that treatment and supports for daily living were delivered safely to residents.
A resident who was fully dependent and non-ambulatory exhibited increased pain and abnormal behaviors over several days, which were observed and reported by multiple CNAs to nursing staff. Despite these reports and visible signs such as an externally rotated leg, nursing staff did not conduct or document a thorough assessment, and no timely pain management was provided. The resident was only sent to the hospital after family intervention, where bilateral femoral neck fractures were discovered. The facility lacked a pain management policy and did not follow its change in condition notification policy, resulting in delayed recognition and treatment.
The facility failed to maintain appropriate hot water temperatures and chlorine levels, crucial for preventing Legionella growth. Despite policies for daily temperature checks, records showed inconsistent monitoring, with many readings below recommended levels. Maintenance staff acknowledged issues with a mixing valve and inconsistent temperature checks, creating potential risks for residents.
The facility failed to document and make accessible the code status of six residents, leading to potential miscommunication of treatment preferences. For one resident, the EMR lacked clear code status information, and the care plan did not reflect their wishes. Similar issues were found for other residents, with staff relying on a cumbersome binder system not part of the official medical record. The facility's policy did not ensure easy access to code status information.
The facility failed to conduct timely assessments and maintenance checks for enabler bars for several residents, leading to a deficiency in care. A resident had enabler bars without a care plan, and maintenance logs were incomplete. Another resident's assessments were delayed, and maintenance documentation was unclear. A third resident had no follow-up assessments after the initial one. The facility's policy required quarterly evaluations, which were not followed, indicating a systemic issue.
A facility failed to include a resident and his representative in the care planning process. Despite the resident having full cognitive abilities, he was not involved in any care planning meetings, and his wife, who is his representative, was not asked to participate in a care conference. The Clinical Care Coordinator confirmed that no interdisciplinary team members were present during the meeting with the wife, and there was no documentation of the meetings. This oversight contradicts the facility's policy on collaborative care planning.
The facility failed to update care plans for two residents, one with a suspected deep tissue injury and another with significant weight loss. The care plans did not reflect the current conditions or interventions, leading to deficiencies in care management.
A resident with multiple diagnoses, including paraplegia and heart failure, was observed with a hand brace provided by her daughter, but the facility failed to document, assess, or monitor its use. Despite an order for the brace, there was no documentation in the EMR, MAR, TAR, or care plans, and staff interviews confirmed the absence of a restorative nursing department. This lack of documentation and monitoring constitutes a deficiency in care.
A resident experienced new visual hallucinations and delusions, reporting seeing cats and rats in her room. Despite these symptoms being noted by staff on multiple occasions, the facility failed to act promptly, with no immediate assessment or monitoring conducted. The issue was only addressed during a survey process, highlighting a deficiency in the facility's response to the resident's change in mental status.
A facility failed to prevent a pressure ulcer for a resident and ensure timely skin assessments for another. One resident's pressure ulcer worsened due to a delay in replacing a worn wheelchair cushion, while another resident's skin issues were not promptly identified due to missed assessments. The facility did not adhere to its skin care protocols, contributing to these deficiencies.
A resident's enteral nutrition was administered at an incorrect rate, contrary to physician orders, and the DPOA was not informed of the change. Additionally, there were no documented orders for the routine care of the resident's PEG tube site. The facility's policy on resolving discrepancies before medication administration was not followed.
A facility failed to follow policies for skin and wound assessments, resulting in pressure ulcers in three residents. One resident developed a Stage III ulcer and multiple deep tissue injuries due to inconsistent repositioning and lack of documentation. Another resident developed Stage II and IV ulcers, with inadequate care plans and infection control breaches during dressing changes. A third resident's skin assessments were not conducted regularly. The facility's policies for weekly assessments and documentation were not followed, leading to these deficiencies.
Neglect in Enteral Nutrition, Diabetes Management, and Infection Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect related to enteral nutrition, diabetes management, and monitoring for infection and respiratory status. The resident was admitted with diagnoses including cerebral infarction, pneumonia, dysphagia, and type 2 diabetes, and was NPO with orders for PEG tube feeding using Glucerna 1.5 at a specified rate, along with insulin lispro on a sliding scale. Upon admission, the facility changed the ordered Glucerna to Jevity 1.5 without documented rationale and did not initiate tube feeding until many hours after admission, with documentation showing Jevity first administered approximately 23 hours after admission and water flushes about 6 hours after admission. The resident’s insulin from the hospital discharge orders was not entered and administered on admission; instead, the facility delayed ordering and starting diabetic medications, with oral Jardiance initiated about 13 days after admission and Lantus insulin about 14 days after admission. The facility did not consistently follow its own parameters and standing orders for hyperglycemia management and failed to timely intervene or notify practitioners despite numerous critically elevated blood glucose readings. Facility policy required notifying the practitioner when blood sugar exceeded 400, yet the resident’s blood sugars were above 300 on at least 29 occasions and repeatedly above 400, including readings of 435, 455, 509, and 510, without documented timely intervention or consistent communication to the practitioner. Progress notes show that on one day a blood sugar of 510 led to an order for 20 units of regular insulin and that the resident’s wife reported noticing a change in condition days earlier and requested transfer to the emergency room. However, there was no documentation of ongoing nursing assessments addressing the persistently elevated blood sugars, no A1C results despite being ordered, and the DON acknowledged that the facility could not identify who was closely monitoring these levels or provide other interventions implemented during the period of sustained hyperglycemia. The facility also failed to assess and document the resident’s pneumonia, respiratory status, and PEG tube site, and did not maintain adequate documentation of changes in condition leading up to the resident’s transfer to the hospital. The resident was admitted on an antibiotic for pneumonia, but the record lacked respiratory assessments, monitoring of pneumonia progression or improvement, documentation of antibiotic use related to pneumonia, or a short-term care plan for this diagnosis. Therapy staff and CNAs reported that over time the resident became increasingly lethargic, weak, and more dependent for transfers, with observations of posterior lean, difficulty with transfers, dizziness, and appearing as “dead weight,” and a speech therapist documented concern for a change in status that was communicated to nursing and the NP. Despite these reports, there were no corresponding nursing assessments or transfer forms in the record. EMS documentation indicated that staff reported the resident had been in an altered mental status with blood glucose levels sustained above 500 for several days prior to transfer, and hospital records described admission for altered mental status, hypernatremia, hyperglycemia, acute kidney injury, and sepsis. The DON and Administrator were unable to locate documentation of PEG site assessments or explain the lack of pneumonia-related assessments and monitoring, confirming gaps in required nursing assessment and documentation. The combination of delayed initiation and inappropriate change of enteral nutrition, failure to follow discharge insulin orders or timely implement diabetes treatment, lack of timely intervention and communication regarding persistently elevated blood glucose levels, and absence of documented respiratory and PEG site assessments for an admitted pneumonia diagnosis constituted neglect of the resident’s care needs. These inactions and omissions led to an unnoticed and undocumented change in condition that ultimately required hospitalization, as evidenced by EMS and hospital records describing the resident’s deteriorated state at the time of transfer.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that residents did not consistently receive treatment and supports for daily living in a manner that ensured their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Assess and Document Change in Condition Resulting in Delayed Pain Treatment
Penalty
Summary
A deficiency occurred when staff failed to promptly assess and document a change in condition for a fully dependent, non-ambulatory resident with multiple comorbidities, including dementia, schizoaffective disorder, and heart failure. The resident exhibited increased pain and abnormal behaviors, such as intense rocking, grimacing, and vocalizations, which were observed by several CNAs and reported to nursing staff. Despite these observations, nursing staff attributed the behaviors to the resident's baseline diagnoses and did not conduct or document a thorough assessment or follow-up, even when the resident's leg was noted to be externally rotated and he displayed pain upon touch. Multiple staff members, including CNAs and nurses, reported noticing the resident's increased discomfort and abnormal leg positioning over several days. These changes were communicated during shift reports and to the responsible nurse, but no progress notes or assessments were completed to address the resident's change in condition. Pain assessments documented a score of zero on the day the leg abnormality was discovered, and pain medication was administered only twice in the days preceding the event. The resident's family member ultimately insisted on hospital transfer, where imaging revealed acute, complete bilateral femoral neck fractures. The facility's investigation did not identify abuse or neglect but concluded that the injuries were likely subacute and possibly pathological in nature. However, the lack of timely assessment, documentation, and communication with the medical director regarding the resident's increased pain and change in condition resulted in a delay in treatment and recognition of the fractures. The facility did not have a specific pain management policy, and staff failed to follow the existing policy for change in resident condition, which required physician and family notification for significant changes.
Failure to Maintain Safe Water Temperatures and Chlorine Levels
Penalty
Summary
The facility failed to monitor and respond to abnormally low hot water temperatures, which is crucial for the prevention and management of Legionella. The Infection Prevention and Control (IPC) Nurses and the Maintenance Director were responsible for reviewing the water management program and monitoring water for Legionella. However, there was a lack of communication and awareness about any issues with the water system, as the IPC Nurse was not informed of any problems. The water management program book showed outdated testing, with the last test conducted in 2023, and the Administrator provided conflicting information about the testing dates. The facility's water testing results indicated that the chlorine levels in certain areas were significantly below the required minimum, and the hot water temperatures were not maintained at the recommended levels. The Corporate Maintenance Director acknowledged that the water temperatures were often below 110 degrees Fahrenheit, which is below the recommended range of 114-118 degrees Fahrenheit due to low chlorine levels. Despite the facility's policy to test water temperatures daily, there were many days without recorded temperatures, and the facility did not consistently test on weekends. The facility's water temperature records revealed numerous instances of temperatures below the recommended levels, with some readings even below 100 degrees Fahrenheit. Maintenance staff admitted to not taking daily temperature checks consistently and acknowledged issues with a mixing valve. The facility's failure to maintain appropriate water temperatures and chlorine levels, as well as the lack of consistent monitoring, created conditions conducive to the growth of Legionella, posing a potential risk to the residents.
Deficiency in Documenting and Accessing Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status of six residents was documented and accessible in their medical records, which could lead to miscommunication regarding their treatment preferences. For Resident #12, the electronic medical record (EMR) did not clearly indicate the resident's code status, and the physician's order only referred to a Preferred Treatment Option without specifying the details. Additionally, the care plan for Resident #12 did not mention the code status, and similar issues were found for Residents #21, #53, #79, and #158, where the EMR contained forms with options but lacked specific orders or care plans reflecting the residents' wishes. Resident #92, who had moderate cognitive loss and was receiving hospice services, also had no clear documentation of code status in the medical record. The Clinical Care Coordinator acknowledged the absence of specific orders or care plans for code status and mentioned that staff would need to search through the EMR or refer to a binder at the nurse's desk to find this information. However, the binder was not part of the official medical record, and the process of locating a resident's code status was cumbersome due to the binder's organization. During interviews, it was revealed that the binders containing code status information were difficult to navigate, and some documents, like the one for Resident #92, were of poor quality and unreadable. The facility's policy on Advanced Directives did not provide a clear process for ensuring that residents' code status was easily accessible in the medical record, contributing to the deficiency in maintaining accurate and accessible documentation of residents' treatment preferences.
Failure to Conduct Timely Assessments and Maintenance for Enabler Bars
Penalty
Summary
The facility failed to complete necessary assessments and maintenance checks for enabler bars for four residents, leading to a deficiency in care. Resident #2 was observed with bilateral enabler bars affixed to her bed, but her care plan did not include any information related to these bars. The maintenance logs for Resident #2 were incomplete, with no record of the initial four-day monitoring after installation. The Maintenance Director confirmed that the resident needed the enabler bars, but there was no documentation to support this need. Resident #71 had a care plan for assist rails to enhance mobility, but the quarterly assessments for the continued use of enabler bars were not completed on time. The last assessment was five months late. The maintenance logs were unclear, with an 'X' next to the room number, making it uncertain whether the enabler bars were inspected for safety and functionality. Similarly, Resident #76's assessments were not completed at the appropriate intervals, and the maintenance logs showed lines through the initial monitoring days, indicating a lack of clarity in the documentation. Resident #75 had an initial assessment for enabler bars, but no subsequent assessments were completed. The facility's policy required quarterly evaluations of residents' need for rails, which was not adhered to. The Clinical Care Coordinator acknowledged the responsibility of unit managers to ensure assessments were completed, but the last monthly audits of enabler bars were conducted months prior, indicating a systemic issue in maintaining compliance with the facility's policies.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to include and document the participation of a resident and his representative in the care planning process. The resident, who had been at the facility for nearly three weeks, was not involved in any care planning meetings. His wife, who is his representative, reported that she had not been asked to participate in a care conference or care planning meeting with the resident and the facility. The resident confirmed that he had not been included in any care planning meetings. The resident's medical history includes dementia, heart failure, kidney failure, an intestinal disorder, sepsis, a history of falls, rib fractures, and gait and mobility abnormalities. Despite having full cognitive abilities, as indicated by a BIMS score of 13/15, the resident was not involved in the care planning process. The Clinical Care Coordinator (CCC) responsible for conducting care conferences stated that a meeting was held with the resident's wife over the phone, but no other staff from the interdisciplinary team was present. The CCC also confirmed that the resident was not included in the meeting and that there was no documentation of the meetings with the resident or his wife. A review of the facility's policy on the care planning process emphasized the importance of a collaborative partnership with the interdisciplinary team, resident, and/or resident representative, and the need to provide an opportunity for the resident to participate in planning care and treatment changes. However, this policy was not followed in the case of this resident.
Failure to Update Care Plans for Skin and Nutrition
Penalty
Summary
The facility failed to timely revise and update care plans for two residents, resulting in care plans not reflecting the current status and needs of the residents. Resident #33, who has a history of dementia, major depressive disorder, chronic systolic heart failure, anxiety, and hypertension, was found to have a suspected deep tissue injury (SDTI) on her right heel and ankle. Despite this, the care plan for skin impairment had not been revised since February and did not mention the current skin conditions. The Unit Manager acknowledged that the care plan should have been updated to include a short-term care plan for the SDTI and the actual skin issue, but it was only revised after being notified of the oversight. Resident #63, with diagnoses including dementia, major depressive disorder, encephalopathy, and hypertension, experienced a significant weight loss of 17% over six months. Despite being started on supplement shakes to aid in weight gain, the care plan for nutrition had not been updated since 2021 and did not include a specific plan for addressing the weight loss. The Certified Dietary Manager admitted to not creating a specific care plan for weight loss, instead incorporating it into the general nutritional care plan. This lack of timely updates and specific care plans for the residents' changing conditions led to deficiencies in their care management.
Failure to Document and Monitor Hand Brace for Resident
Penalty
Summary
The facility failed to ensure proper documentation, assessment, and monitoring of a hand brace/splint for a resident who was reviewed for rehab and restorative services. The resident, who was observed with a splint/brace on her right hand, reported that her daughter had provided the brace and staff assisted her in putting it on and off. However, the resident did not perform any exercises for her right hand or arm. The resident's medical records, including the Face sheet, Minimum Data Set (MDS) assessment, and physician orders, indicated that she had multiple diagnoses, including paraplegia, heart failure, COPD, diabetes, and others. Despite an order allowing the use of a soft brace, there was no documentation of restorative services or assistance with the brace in the electronic medical record (EMR), Medication Administration Record (MAR), Treatment Administration Record (TAR), or care plans. Interviews with facility staff, including the Therapy Director and Clinical Care Coordinator, revealed that the facility did not have a dedicated restorative nursing department, but nurse aides were trained to perform restorative functions. The Clinical Care Coordinator acknowledged the existence of an order for the brace but confirmed the absence of further documentation or a care plan related to the brace. The facility's policy on the Restorative Nursing Program emphasized evaluating residents individually to maintain their highest functional level, yet there was no evidence of such evaluation or documentation for the resident's hand brace. This lack of documentation and monitoring represents a deficiency in the facility's care for the resident.
Delayed Response to Resident's Change in Mental Status
Penalty
Summary
The facility failed to act timely on a change in mental status for Resident #11, who was observed experiencing visual hallucinations and delusions. On 4/9/2025, the resident reported seeing cats on her dresser, which she described as resembling wolves. This was a new onset for the resident, who had no prior history of delusions or visual hallucinations. Despite the resident's ability to communicate her needs and the presence of a major depressive disorder among her diagnoses, the facility did not address these symptoms promptly. The resident's hallucinations were first noted on 3/31/2025, when a CNA reported the resident talking about seeing live rats, but no immediate action was taken. The delay in addressing the resident's change in condition was further highlighted by the Nurse Practitioner's documentation on 4/1/2025, which noted the resident's confusion and visual hallucinations but did not result in further assessment or monitoring. It was not until the survey process on 4/9/2025 that the facility began to take steps to address the issue, including initiating a behavior log and planning a medical workup. This lack of timely intervention represents a deficiency in the facility's response to a significant change in the resident's mental status.
Failure to Prevent Pressure Ulcers and Conduct Timely Skin Assessments
Penalty
Summary
The facility failed to implement meaningful interventions to prevent the development of a pressure ulcer for Resident #83 and ensure timely skin assessments for Resident #33. Resident #83, who was admitted with multiple diagnoses including a Stage 3 pressure ulcer, was observed to have a worsening condition of her pressure ulcer on the left buttock. Despite being reliant on staff for assistance with turning and repositioning, the facility did not replace her worn wheelchair cushion for over a month, which was a significant factor in the development and progression of her wound. The facility's care plan lacked proactive measures to prevent further skin breakdown, and interventions were only added after the wound had developed. Resident #33, who was admitted with conditions such as dementia and heart failure, had a suspected deep tissue injury on her right heel and ankle. The facility failed to conduct timely skin assessments, as there was a gap between assessments from March 14 to March 28, during which no skin assessment was completed. This oversight was acknowledged by the unit manager, who stated that skin assessments should have been conducted twice weekly in conjunction with shower days. The lack of timely skin assessments contributed to the failure to identify and address skin issues promptly. The facility's policy on skin risk assessment and treatment was not adequately followed, as evidenced by the lack of daily skin inspections and timely reporting of abnormal skin conditions. The deficiencies in both cases highlight a failure to adhere to established protocols for skin care and prevention, leading to the development and progression of pressure ulcers in the residents.
Failure to Follow Enteral Nutrition Orders and Notify DPOA
Penalty
Summary
The facility failed to adhere to a physician's order for enteral nutrition for Resident #95, who was observed with an incorrect infusion rate of 50 mL/hour instead of the prescribed 60 mL/hour. This discrepancy was noted on 4/8/2025, despite the physician's order being updated on 4/1/2025. The nurse responsible for Resident #95 was unaware of the change in the infusion rate, and the error was not corrected until later in the day when the rate was temporarily increased to compensate for the missed volume. Additionally, the facility did not notify Resident #95's Durable Power of Attorney (DPOA) about the change in the tube feed rate from 50 mL/hour to 60 mL/hour. The resident's daughters, who are frequently present at the facility, were not informed of this change or the temporary increase in the infusion rate to make up for the missed volume. This lack of communication with the resident's responsible party was confirmed by both the daughters and the Registered Dietitian. Furthermore, there were no documented orders for the routine cleansing, assessment, and monitoring of Resident #95's PEG tube site following her readmission on 3/21/2025. The Clinical Care Coordinator and Corporate Nurse confirmed the absence of such orders, which are essential for maintaining the site. The facility's policy on medication administration emphasizes resolving any discrepancies before proceeding, yet this was not adhered to in the case of Resident #95.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to operationalize policies and procedures for skin and wound assessments, leading to the development of pressure ulcers in three residents. Resident #1 developed a Stage III pressure ulcer on the coccyx and multiple suspected deep tissue injuries on the feet. The resident was severely cognitively impaired, dependent on staff for repositioning, and had a poor appetite. Despite being on a pressure-relieving mattress, there was a lack of documentation regarding repositioning and the application of protective boots. The care plans lacked specific interventions for each wound, and skin assessments were not conducted consistently. Resident #2 developed a Stage II pressure ulcer on the right buttock and a Stage IV pressure wound on the right ischium. The resident had moderately impaired cognition and was dependent on staff for mobility. The care plan did not include specific positioning guidelines, and wound assessments were not conducted regularly. During a dressing change, infection control protocols were not followed, as the nurse used the same 4x4 gauze to clean multiple wounds without changing gloves or performing hand hygiene. Resident #3's skin assessments were not completed consistently, with gaps of up to 14 days between assessments. The Director of Nursing acknowledged the lack of consistent documentation and indicated that the air mattress settings were incorrect. The facility's policy required weekly skin assessments and documentation of wound characteristics, but these were not adhered to, leading to the deficiencies observed.
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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