Medilodge Of Sault Ste. Marie
Inspection history, citations, penalties and survey trends for this long-term care facility in Sault Ste. Marie, Michigan.
- Location
- 1011 Meridian Road, Sault Ste. Marie, Michigan 49783
- CMS Provider Number
- 235292
- Inspections on file
- 32
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Medilodge Of Sault Ste. Marie during CMS and state inspections, most recent first.
Surveyors found systemic understaffing that led to multiple residents not receiving timely incontinence care, bathing, repositioning, restorative services, or assistance with preferred wake times and transfers. A resident was repeatedly observed lying in urine and feces while calling out for help without prompt staff response. Another cognitively intact resident with a leg fracture reported unanswered call lights for extended periods, missed or delayed meals, and having to phone the facility for help, with the call answered by other residents instead of staff. Additional residents described being left wet and soiled for hours, not receiving scheduled showers, and experiencing severe pain when left in bed far beyond their preferred wake times. Staff interviews confirmed frequent operation with only a few CNAs for dozens of residents, lack of coverage for call-ins, and an absence of restorative services on weekends or when the restorative aide was off. Facility records, complaints, and Resident Council minutes documented ongoing concerns about low staffing, long call light waits, and chronically late meal service, especially on weekends and nights.
A resident with dementia, severe cognitive impairment, and urinary/bowel incontinence was repeatedly left in urine- and feces-soiled bedding despite activating the call light and verbally calling for help. Staff confirmed the call light was functioning, but after a male staff member turned it off and said he would get an aide, no one returned for an extended period while the resident remained cold, wet, shivering, and visibly soiled, with feces on bedding, mattress, and hands. An LPN briefly entered and exited without providing care, and a CNA could not recall when the resident last received care. The resident expressed anger, sadness, and a desire to leave due to not being cared for, consistent with the facility’s own definition of neglect.
Surveyors identified systemic infection control failures, including delayed initiation of Enhanced Barrier Precautions (EBP) for multiple residents with surgical wounds, pressure injuries, dialysis catheters, and indwelling urinary catheters, despite clear criteria in facility policy. Several residents on EBP did not have appropriate door signage or PPE carts in place, and staff such as an OT and an LPN provided direct care without required gowns. Medication and treatment carts were observed with open drinks, food crumbs, stains, dust, and debris, even though they housed wound care supplies. A CNA assisted three residents with feeding, moving between them and handling utensils, cups, and trays without performing hand hygiene. Food carts on two halls contained both unserved and soiled meal trays together, with dirty trays placed above or next to clean ones, contrary to food separation standards. The infection preventionist acknowledged that EBP initiation was often missed when she was absent and confirmed that the existing infection control policies were the most current versions, which required an annual review of the infection prevention and control program.
Surveyors found that the facility did not adequately maintain cleanliness and repair in multiple resident and common areas. At the main entrance, a wet floor sign and a container partially filled with water were placed under a skylight with visible water damage, and the Maintenance Director reported he had been told not to continue roof repairs due to warranty concerns. On one resident hall, a shared bathroom had a soiled floor and chipped, worn paint on the door and frame, while several resident rooms had damaged walls with missing paint exposing bare plaster, additional areas of missing paint, and cove base molding peeling away from the wall.
Inaccurate Daily Nurse Staffing Form Posting: The facility failed to post an accurate daily nurse staffing form. Surveyors observed a posted form that was outdated and reflected an older census, while the NHA reported a higher current census. The scheduler said she provided pre-filled forms for weekend use and that nursing staff were supposed to adjust them for census and staffing changes, but the reviewed form did not include a census number and did not accurately reflect the facility’s current staffing needs.
Unqualified Dietary Director: The facility failed to provide a qualified dietitian, clinically qualified nutrition professional, and/or food and nutrition services director within the required timeframe. The Dietary Director stated he was still working on his CDM certificate and was not a Certified Professional Food Manager through a nationally accredited program, and the NHA confirmed he could not produce proof of certification after hiring.
Food service sanitation and storage practices were deficient when soiled meal trays were mixed with unserved trays in food carts during meal service, kitchen hood filters and storage surfaces were visibly soiled, a garbage disposal was backed up with wastewater, and a dietary cook handled cleaned equipment after drinking without washing hands. Single-service items were also observed stored on the floor of the dry storage room.
Incomplete Facility Assessment and Staffing Plan: The facility failed to maintain an accurate facility assessment to determine staffing needs for resident care. Census records showed the resident count exceeded the assessment’s maximum on many days, while the assessment listed significant ADL dependency levels and a staffing plan based on budgeted baseline staffing. The contingency planning section was left blank, and the NHA stated the issue was a call-in problem, with no retention or recruiting efforts or use of staff from other facilities.
QAPI program failed to identify and address systemic quality deficiencies. The NHA stated staffing was adequate and described weekend low staffing as a call-in problem, while also acknowledging the facility had not discussed a contingency staffing plan in QAPI. Review of performance improvement projects did not show staffing concerns or other systemic issues had been identified through the QAPI process, and the RDO stated, "Our QAPI program needs work."
Failure to Use QAPI to Address Repeated Staffing Concerns: The facility did not incorporate repeated feedback from residents, resident representatives, and staff into its QAPI process. Quality Assistance Forms, Resident Council minutes, and staff interviews repeatedly identified low staffing, late mealtimes, delayed call light response, and poor resident care concerns, but management stated staffing guidelines were met and that issues were being handled through write-ups and attendance policy.
Surveyors found that meals were routinely delivered on trays with disposable plastic utensils instead of standard silverware, with some trays including only plastic cutlery and others mixing regular forks and spoons with plastic knives. Staff reported that trays often did not return in time to be washed for the next meal, believed residents were keeping silverware, and acknowledged knowing plastic utensils were being used without ordering more silverware. Multiple residents in a confidential group interview voiced frustration that plastic cutlery, including knives that would not cut meat, was being used at mealtimes, and a prior complaint to the State Agency alleged meals were not adequately served due to limited utensils, despite a facility policy stating residents have the right to a dignified existence.
The facility failed to provide palatable meals at safe and appetizing temperatures, as multiple residents reported that food and coffee were often cold or lukewarm and that trays sat in serving windows or delivery carts for extended periods due to staffing issues. Resident council minutes over several months documented ongoing, unresolved complaints about cold room trays, lukewarm dining room meals, and pre-poured coffee served at inadequate temperatures. A cognitively intact resident with lower leg fractures, dependent on staff for some ADLs and blood glucose checks, reported that breakfast and lunch were frequently cold because staff were late checking blood sugar. During a lunch observation, surveyors measured beverages at 59°F and hot food items at 106–107°F on a tray from a food cart, which did not meet FDA Food Code hot and cold holding standards, despite a facility policy requiring prompt meal service and accommodation of preferences.
Surveyors found that the facility repeatedly failed to follow documented food preferences and standing diet orders, and did not consistently offer substitutes when meals were incorrect or uneaten. Multiple residents received the wrong type or amount of juice, were served disliked or non‑listed vegetables without alternatives, or were given different sandwiches and entrées than those specified on their tray cards or handwritten menus (such as receiving hamburgers instead of requested hot dogs). Some residents who required extra sauces or gravy received dry ground or chopped meats, and one resident reported not eating the meal because it was too dry. Trays were removed from at least two residents, including one with malnutrition and severe cognitive impairment, without offering alternative food or beverages. Residents also reported that the kitchen frequently ran out of items listed on the Always Available menu (e.g., ice cream, yogurt, pudding, cookies, hamburgers, hot dogs), and one resident on a gluten‑free diet stated they were served salad for two meals a day, five days a week and wanted something other than salad. Resident council minutes documented ongoing, unresolved complaints about receiving disliked foods and the kitchen running out of preferred items.
Meals Left Out of Reach or Not Set Up for Residents Needing Assistance. Four residents had meals left out of reach or were not assisted with meal setup despite care plan directions and tray cards indicating meal assistance or set-up assistance. Observations showed untouched trays left on bedside tables or across the room, one resident received the wrong tray, and staff removed a tray without offering food or beverage. The affected residents included individuals with severe cognitive impairment, intact cognition, mild cognitive impairment, and total dependence for bed mobility.
A facility failed to secure medications and keep medication and treatment carts locked. A resident had mupirocin ointment at the bedside without any self-administration order or assessment, and two other residents had full cups of meds at the bedside, including an albuterol inhaler. Multiple medication and treatment carts were also observed unlocked and unattended, with a nurse and an LPN acknowledging carts and supplies should not be left unsecured.
Failure to provide ordered adaptive dining equipment. During meal observations, several residents did not receive the assistive devices listed on their tray cards, including built-up utensil handles, a red plate, straws, and 2-handled cups with a flat lid. Facility policy stated that assistive devices, including eating utensils, will be provided to residents who need them, and that residents should receive the correct diet with assistive devices made available as needed.
A resident with a leg fracture, who was cognitively intact, reported that four hydrocodone/acetaminophen tablets she had brought from home in her purse were missing when she attempted to use them for pain, and the admission inventory did not list any medications. The DON acknowledged uncertainty about whether nurses routinely asked about or inventoried medications at admission. Around the same time, staff described an RN as appearing under the influence, not passing meds as expected, wobbling, falling asleep at the med cart, and prompting concerns that residents were not receiving correct pain meds. The administrator later found an empty hydrocodone bottle and other medications in the resident’s purse, and a room search revealed marijuana gummies, cigarettes, and a lighter, demonstrating a failure to safeguard and properly account for the resident’s personal narcotic medication.
A resident with a left leg fracture, cognitively intact per BIMS, reported that a night shift nurse had taken four hydrocodone/acetaminophen tablets the resident brought from home and kept in a purse. The concern was reported to facility staff and discussed by the NHA and a nurse with the resident, but the NHA acknowledged the allegation was not promptly reported to the SA. The SA report was submitted later than required, despite facility policy mandating that such violations be reported to the administrator, SA, APS, and other required agencies within specified timeframes, including within 24 hours for events not involving abuse or serious bodily injury.
A cognitively intact resident with a left leg fracture reported that a night shift nurse took four hydrocodone/acetaminophen tablets the resident stated were brought from the hospital and kept in a purse, and this concern was documented by the DON. Despite a policy requiring immediate and thorough investigation of alleged abuse, exploitation, and misappropriation, the facility did not conduct or document a complete investigation: 16 potentially involved or knowledgeable staff were not interviewed, and the DON could not initially provide investigation documentation. The DON also indicated that only clothing was routinely inventoried at admission and was unsure whether nurses asked about medications, showing that resident medications were not consistently inventoried or accounted for as required by facility policy.
A resident at risk for pressure ulcers who required assistance with turning and repositioning was observed lying on her back for an extended period without staff entering to assist or encourage repositioning. Another cognitively intact resident with diabetes and a hip fracture was noted to have long facial hair and reported not having been shaved in a long time, while a CNA acknowledged that residents were supposed to be shaved on admission, on shower days, or upon request, but that residents were sometimes neglected due to staffing issues. A third cognitively intact resident with fractures, diabetes, and chronic kidney disease requiring dialysis reported being left wet and soiled in urine and feces for over two hours and stated she had not received a shower during her two-week stay, despite documented preferences for showers and dependence on staff for bathing and toileting; records and CNA statements confirmed multiple missed showers and lack of bathing interventions in her ADL care plan.
The facility failed to complete a timely admission assessment and to initiate bowel protocols according to orders and residents’ needs. A cognitively intact resident admitted with a recent leg fracture reported that on arrival staff briefly entered and left without explanation, no vital signs or head-to-toe assessment were done, dinner was delayed, and repeated call lights went unanswered, leading the resident to phone the facility, where other residents answered before staff responded. Another resident with multiple comorbidities, including a sacral pressure ulcer and constipation, reported no bowel movement for several days despite repeated alerts by the resident and family; documentation showed no bowel movement since admission, frequent opioid use, delayed administration of PRN Milk of Magnesia beyond three days without escalation to ordered suppository or enema, and late initiation of scheduled laxative and stool softener. A third resident with neurologic disease and mild cognitive impairment experienced ongoing nausea, declined meals, and had no bowel movement documented for several days, yet no bowel assessment or use of ordered PRN bowel medications was recorded, and the DON acknowledged inconsistent use of bowel elimination reports and the absence of a bowel protocol policy.
The facility failed to implement required fall-prevention interventions for a resident with moderate cognitive impairment and a history of seizure disorder and fracture, whose care plan called for fall mats on both sides of the bed. Surveyors observed the bed in a high position with the mats folded behind a chair in another room, while a CNA and an RN confirmed the mats were supposed to be in place but were not set up as a CNA task. The facility also failed to ensure safe smoking practices for another resident with mobility limitations and moderate cognitive impairment, who repeatedly went outside in very cold, snowy conditions to smoke just outside the door, retained his own cigarettes and lighter, and inconsistently used a sign-out book, despite a written non-smoking campus policy prohibiting smoking on facility property and resident possession of smoking materials.
Failure to honor resident choice was cited for three residents. One cognitively intact resident with severe CP and total transfer dependence was repeatedly left in bed past the preferred wake-up time, with staff confirming delays due to staffing shortages and workload. Two other residents with moderate cognitive impairment reported being awakened at night for wound care or a roommate’s dressing change despite stating a preference for daytime care, and an LPN/unit manager said dressing changes were scheduled at night without asking the resident’s preferred time.
Inaccurate Advance Directive Documentation: A resident with autistic disorder had conflicting code status documentation in the EMR, including Full Resuscitation orders and chart banner entries, alongside a DNR guardian consent form and other signed documents indicating life-sustaining treatment. Staff interviewed were unsure whether the resident was full code or DNR after reviewing the records.
Unsecured Resident Health Information on Open Laptop: A facility laptop on a med cart was observed with a resident’s PHI displayed on the screen while no staff were nearby. An LPN stated the screen should not have been left open with resident information available for anyone to access, and the NHA acknowledged the medical record information was not secured when the LPN walked away from the cart.
A facility failed to obtain physician diet orders for two residents at admission. One resident reported missing breakfast and lunch after arrival, and another cognitively intact resident reported missing meals after admission as well. EMR review showed each resident’s diet order and dietary notification were entered later than the admission time, and the RN and DON acknowledged that diet orders should be written upon admission and dietary alerted.
Failure to provide restorative nursing services for two residents. One resident with quadriplegia and anoxic brain damage reported staff were not working with her contracted hand and were not consistently applying her splint, while records showed very limited documentation of PROM and brace assistance and no current MD order for restorative or splint use. Another resident with paraplegia said he no longer received ROM exercises and was having increasing difficulty using his arms and hands to feed himself. Staff stated restorative care was handled by the restorative aide, that CNAs did not usually do it, and that no one covered the program when the aide was unavailable.
Failure to Document Non-Pharmacological Pain Interventions Before PRN Opioids: Two residents received repeated PRN oxycodone-acetaminophen doses for pain, but the MAR and EMR contained no documentation of pain location or any non-pharmacological interventions attempted and failed before administration. Both residents had care plans calling for non-pharmacological pain relief measures, and the DON stated that such interventions should be attempted and documented before PRN opioids are given.
Missing Hospice Follow-Up and Communication: The facility failed to ensure a hospice consult was carried out and documented for one resident after a physician order and guardian consent were obtained, and failed to maintain hospice communication and visit documentation for another resident receiving hospice. The DON and social services staff reported they did not have the hospice results or visit information, and the hospice binder lacked MSW, HHA, and SN documentation, including weekly SN visit records.
Two residents at high risk for skin breakdown, both with existing wounds and significant mobility and incontinence issues, did not receive timely and consistent pressure ulcer prevention and treatment interventions. One resident’s buttock skin progressed from moisture-associated skin damage to unstageable necrotic pressure ulcers requiring hospitalization and surgical debridement, while documentation showed delayed ordering and placement of a low air loss mattress despite ongoing deterioration. Another resident admitted with multiple pressure injuries and requiring maximal assistance for mobility was repeatedly observed in bed without a low air loss mattress, without effective offloading of the buttocks or heels, and with heel protection boots left unused on the nightstand. Facility records and staff interviews showed that identified risk factors and care plan recommendations for pressure redistribution and offloading were not consistently translated into physician orders and implemented interventions, contrary to the facility’s own pressure injury prevention policy.
A resident with a recent lumbar fusion and multiple comorbidities did not receive timely dressing changes or proper documentation for a post-operative back wound. Nursing staff failed to notify the provider of wound dehiscence and changes in the wound's condition, resulting in the resident developing a surgical site infection that required hospital admission and surgical intervention.
A resident reported visible mold in a community shower room, which was confirmed by direct observation. Staff interviews revealed that although daily and monthly cleaning routines were in place, the mold was not identified or reported by housekeeping, and maintenance was not notified. Facility leadership acknowledged the issue and the need for repairs.
A resident with moderate cognitive impairment engaged in inappropriate touching of other residents, including kissing and touching on the thigh and breast. Staff witnessed and reported these incidents, but no evaluation was conducted to determine the affected residents' capacity to consent. The facility's policy on abuse prevention was not effectively implemented, leading to repeated incidents.
A facility failed to thoroughly investigate allegations of sexual abuse involving a resident who had inappropriate interactions with other residents. The investigation lacked detailed documentation, including specific dates, times, and locations of incidents, and witness statements were inconsistent or missing. The Nursing Home Administrator acknowledged these deficiencies, which posed a potential risk for further exposure to abuse for other residents.
The facility failed to maintain adequate staffing levels, as evidenced by low staffing ratings and interviews with residents and staff. On multiple occasions, the number of CNAs scheduled was below the required levels, leading to unmet resident needs. Residents and family members reported delayed responses to call lights and inadequate care, with some residents left in soiled clothing or experiencing distress due to long wait times.
The facility failed to ensure safe and sanitary conditions for six residents with personal refrigerators in their rooms. Observations revealed that these refrigerators lacked thermometers and temperature logs, with internal temperatures ranging from 37 F to 54 F. The facility's policy for refrigerator use, which included maintenance inspections and temperature monitoring, was not followed, as confirmed by the housekeeping supervisor.
The facility failed to provide proper respiratory care for four residents, including incorrect oxygen flow rates, lack of physician orders for CPAP use, and improper storage of equipment. One resident had an outdated nasal cannula and incorrect oxygen flow, while two others had CPAP machines without orders or proper documentation. Another resident's oxygen bubbler was empty, causing discomfort, with no physician orders for oxygen use. Facility policies requiring physician orders and proper equipment management were not followed.
The facility failed to secure medications properly, with an unlocked treatment cart containing topical creams and wound care supplies, and a resident's Nystatin cream left in her bathroom despite her not wishing to self-administer medications. Additionally, the D-hall medication cart had unlabeled crushed medications, loose pills, and a nurse's beverage stored improperly, violating the facility's medication storage policy.
The facility failed to update care plans for four residents, resulting in plans that did not reflect their needs. One resident's care plan was unclear to staff after an altercation, another's lacked updates after hospitalizations for catheter issues, a third's did not address contracture management, and a fourth's was not updated after an altercation. The DON and RN acknowledged these oversights.
A resident with moderate cognitive impairment experienced verbal abuse from a CNA, who used inappropriate language after the resident had an accident. The incident was reported by other staff members who overheard the altercation, and the resident expressed feeling bad about the situation. The facility's policy on abuse prevention was not followed, leading to this deficiency.
A resident with severe cognitive impairment and contractures did not receive appropriate treatment to maintain or improve range of motion. Despite being on the facility's case load for contracture treatment until September, no interventions were in place to prevent further decline. Staff acknowledged the need for restorative therapy, but the program had not been implemented.
A facility failed to provide adequate social services for a resident with severe cognitive impairment after an altercation with another resident. Despite the incident being documented, the resident's care plan was not updated, and there was no evidence of follow-up by social services. Interviews revealed that expected actions, such as care plan updates and documentation, were not completed, indicating a deficiency in providing necessary social services.
A facility failed to maintain a medication error rate below 5%, resulting in an 11.54% error rate. A resident with diabetes and hypertension received insulin injections improperly, leading to leakage, and was given carvedilol despite low blood pressure. The RN was unaware of the blood pressure parameters and the facility's policy on medication administration was not followed.
The facility failed to implement effective infection control practices and proper PPE use for residents with COVID-19. Observations showed open doors for rooms requiring airborne precautions, unclear signage, and improper PPE handling. Staff were not adequately informed about isolation precautions, and PPE was worn from resident rooms into hallways, violating facility policy and CDC guidelines.
The facility did not post the contact information for the Office of the State Long-Term Care Ombudsman, affecting all 74 residents. During a group meeting, residents expressed unfamiliarity with the Ombudsman and lacked knowledge on how to contact the office. Observations confirmed the absence of posted information, and interviews with facility administrators revealed no existing policy for such postings.
The facility failed to accurately post the actual hours worked by nursing staff, including RNs, LPNs, and CNAs, on their daily staffing postings. The postings did not reflect adjustments for changes, such as a nurse calling in sick, leading to incomplete staffing information being available to residents and visitors. This deficiency potentially affected all 74 residents.
Two residents eloped from the facility undetected, despite wearing Wanderguard bracelets. The alarm system failed to alert staff due to a visitor holding the door open, and staff were desensitized to frequent alarm activations. The incident was not accurately reported initially, and staff failed to respond appropriately, leading to the residents being found on a roadway.
The facility failed to prevent two incidents of resident-to-resident sexual abuse. In one case, a resident with PTSD was inappropriately touched by another resident with dementia in the dining room, despite a care plan prohibiting the latter's presence there. In another case, a CNA found a resident with exposed genitalia and another resident nearby, but the incident was not documented. The facility's policies on abuse prevention and trauma-informed care were not effectively implemented, and communication about residents' behavioral histories was inadequate.
The facility failed to report an employee's criminal conviction for brandishing a firearm to the State Agency, potentially jeopardizing the safety of 69 residents. Administration was unaware of the conviction, believing charges were dropped, despite the employee claiming previous notification. Facility policies require reporting such convictions to authorities.
The facility failed to provide adequate staffing, resulting in unmet care needs and potential safety issues for residents. On a night shift, only one LPN and three CNAs were available for 80 residents, contrary to the staffing plan. Residents reported delays in care, including hygiene and wound treatments, and a resident experienced a 14-day delay in surgical staple removal due to low staffing.
Systemic Understaffing Leading to Unmet ADL Needs, Delayed Call Responses, and Late Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs for ADLs, timely incontinence care, repositioning, restorative services, and prompt response to call lights, as well as to provide timely, dignified, and palatable meal service. Staff, including an LPN and multiple CNAs, reported that there were never enough CNAs, that they worked short all the time, and that management did not replace staff who called in. Residents repeatedly reported fear, frustration, and distress related to long call light response times, lack of assistance, and inadequate staffing. Facility records, including Payroll Based Journal data, complaint logs, Quality Assistance Forms, and Resident Council minutes, documented ongoing concerns about low staffing, delayed call light response, and late meals, particularly on weekends and nights. One resident was repeatedly observed lying in bed in urine and feces with feces on bedding, mattress, and hands, shivering and yelling for help over extended periods on multiple days, without timely staff response. Another resident, cognitively intact and recently admitted with a leg fracture, documented in a notebook and reported that call lights went unanswered for long periods, that no vital signs or assessments were done at admission, that meals were missed or significantly delayed, and that a call to the facility was answered by other residents rather than staff. This resident described waiting approximately 55 minutes for assistance to the bathroom after activating a call light and reported not receiving needed ice for a surgical wound. Additional residents described being left wet and soiled in urine and feces for over two hours, not receiving showers for weeks despite documented shower schedules and preferences, and not being assisted out of bed as desired. One resident with spastic quadriplegic cerebral palsy, intact cognition, and total dependence for transfers reported not being gotten out of bed by the preferred wake time, experiencing significant pain when left in bed for extended periods, and having submitted multiple written grievances about staffing and delayed care. Another resident with quadriplegia and anoxic brain damage, totally dependent for mobility, reported not receiving restorative therapy or consistent splint use, while CNAs stated they did not perform restorative tasks due to lack of time and that only a restorative aide, unavailable on weekends and currently off work, handled such care. Observations and interviews also showed residents waiting in soiled briefs until after meals for morning care, meal trays piling up due to insufficient staff to pass them, and activities being rescheduled because dependent residents were not assisted out of bed in time to attend. Facility documentation showed that the facility assessment set a maximum census of 78 residents, yet census data revealed 90 days in which the census exceeded this number, reaching up to 87 residents, with a high proportion of admissions and discharges occurring Friday through Sunday. Night shift schedules for multiple weekend days showed only 3.5 to 4 CNAs on duty for 73–82 residents. Complaints and Quality Assistance Forms from residents and families described residents sitting in stool and urine for hours, long call light waits (often 45 minutes to over an hour), residents not being toileted or put to bed when requested, residents not being gotten out of bed for days, and staff telling residents that there were not enough staff to honor their preferences for getting in and out of bed. Responses on these forms frequently cited staff education or asserted that staffing was adequate, and several forms lacked documented resolution, while concerns about staffing, call light response, and late meals recurred month after month in Resident Council minutes.
Failure to Provide Timely Incontinence Care and Response to Call Light
Penalty
Summary
The facility failed to provide routine incontinence care and timely assistance to a resident with severe cognitive impairment, frequent urinary incontinence, and occasional bowel incontinence. On multiple observations, a strong odor of urine and feces was noted from the hallway outside the resident’s room. The resident was found lying in bed in a fetal position with the bottom sheet pulled off the mattress and gathered around her, and a top sheet draped over her torso and lower body. Feces was observed on the pillowcase, sheets, fitted sheet, and mattress, as well as on the resident’s hands and under her fingernails. The resident repeatedly stated she was cold, soaking wet, and needed to be cleaned up, and reported she had not gotten out of bed that day. The resident activated her call light, which was confirmed to be functioning as indicated by the illuminated light above the door. An unidentified male staff member entered the room, was informed by the resident of her need for cleaning and warmth, turned off the call light, stated he would try to get an aide, and then left without providing care. No staff entered the room for at least 29 minutes after the call light was activated, during which time the resident continued to call out for help. Later observations showed the resident still soiled and shivering, yelling for help with no staff visible in the hallway. An LPN/Unit Manager briefly entered and exited the room, verbally noting the resident wanted to get up, but did not return to assist. A CNA could not state when the resident last received care. The resident expressed anger, frustration, helplessness, sadness, and a desire to leave the facility due to not being cared for. The facility’s abuse, neglect, and exploitation policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress.
Systemic Infection Control Failures Including Delayed EBP, Poor PPE Use, and Unsanitary Practices
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control program, including delayed implementation of Enhanced Barrier Precautions (EBP), improper use of personal protective equipment (PPE), lack of annual policy review, unsanitary medication and treatment carts, inadequate hand hygiene during feeding, and improper separation of clean and soiled meal trays. Surveyors observed a medication cart on B Hall with an open coffee and an energy drink on top, and the RN interviewed acknowledged that open drinks should not be on the cart. A treatment cart on D Hall was observed with dark rings resembling coffee stains and visible dust and debris under glove boxes, and another treatment cart on B Hall had disposable cups and straws on top with food crumbs and debris in and around the glove rack; an RN stated CNAs used the cart as an extra surface when passing meals, even though it housed wound care supplies. The facility failed to timely initiate EBP for several residents who met criteria under the facility’s own EBP policy. Residents with surgical wounds, pressure ulcers, dialysis catheters, and indwelling urinary catheters had EBP orders initiated days to weeks after admission or after the condition was present. One resident admitted with a right tibia/fibula fracture and a surgical incision to the right leg had no EBP signage or PPE cart outside the room, and the EBP order was not entered until three days after admission. Another resident with a left tibia/fibula fracture, diabetes, chronic kidney disease, and a dialysis port had no EBP signage or PPE cart outside the room, and the EBP order was also delayed until 12 days after admission. Additional residents with a stage 2 pressure ulcer present on admission, a neck surgical incision, acute kidney failure with an indwelling catheter, and a right femur fracture requiring surgery all had EBP orders initiated between 3 and 14 days after admission or after the qualifying condition was documented. Surveyors also observed staff not properly donning PPE when providing care to residents under EBP. An occupational therapist provided physical therapy to a resident with a surgical incision without wearing a gown, and an LPN removed a leg brace from another EBP resident without a gown, later stating he did not realize the resident was on EBP. In another instance, a CNA was seen pushing PPE carts into two residents’ rooms while a unit manager placed EBP signs on their doors, indicating EBP implementation was occurring well after the presence of surgical wounds and ongoing dressing changes documented in the medical record. Hand hygiene and food service practices were also deficient. During a lunch meal, a CNA assisted three different residents with feeding, moving between them, handling different utensils, cups, plates, trays, and clothing protectors without performing hand hygiene at any time; when questioned, the CNA was unsure if hand hygiene was required between residents. During meal service on two different halls, food carts were observed containing both unserved meal trays and soiled trays together, with some soiled trays placed above or directly next to unserved trays, blocking service. CNAs who opened the carts acknowledged that dirty trays were not supposed to be placed with new trays. The facility’s hand hygiene policy required all staff to perform proper hand hygiene to prevent the spread of infection, and the FDA Food Code cited in the report requires food to be protected from cross contamination by proper arrangement and separation. The facility’s infection prevention and control program policies, including the Infection Prevention and Control Program Policy and Procedures, Antibiotic Stewardship Program Policy, Influenza Vaccine Policy, and Pneumococcal Vaccine Policy, were reviewed/revised in late 2023, and the Infection Prevention and Control Program policy required an annual review of the program and associated policies. The infection preventionist acknowledged that delayed EBP implementation often occurred when she was out of the facility because there was no designated backup to oversee the process, and confirmed that the provided infection prevention and control policies were the most up-to-date versions available. These findings collectively demonstrate failures to implement and operationalize the infection prevention and control program as written, including timely EBP initiation, consistent PPE use, maintenance of sanitary carts, adherence to hand hygiene, and proper separation of clean and soiled food trays.
Failure to Maintain Cleanliness and Repair of Resident and Common Areas
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain general cleanliness and repair of the environment, affecting resident, staff, and public areas. In the front entrance foyer across from the front door, a pink “Caution Wet Floor” sign was observed on the floor next to a waste container that contained a couple of inches of water, and the ceiling around the skylight above this area showed visible water damage. During an interview, the Maintenance Director stated he had attempted to repair the roof several times but was instructed to stop further repairs due to concerns about voiding the roof warranty. Additional observations on the D hall included a soiled bathroom floor shared between rooms D14 and D16, with chipped and worn paint along the bottom of the bathroom door and door frame, damaged walls and missing paint in room D11 exposing bare plaster, missing wall paint in room D9, and cove base molding peeled away from the wall in room D5. These conditions collectively demonstrated a lack of adequate upkeep and cleanliness of the physical environment in multiple resident-use areas within the facility.
Inaccurate Daily Nurse Staffing Form Posting
Penalty
Summary
The facility failed to ensure that the Daily Nurse Staffing Form was accurately posted each day. On initial entry to the facility on 2/8/2026, the form posted at the end of E-Hall near the nurses’ station was dated 2/6/2026 and listed a resident census of 84, while the Nursing Home Administrator stated the current census was 86. This showed the posted staffing information was not current when surveyors observed it. During interview, the facility scheduler stated she was responsible for posting the Daily Nurse Staffing Form during her Monday through Friday work week and that she provided pre-filled forms for nursing staff to complete and post on Saturdays and Sundays. She explained that nursing staff were instructed to adjust the form if the census changed or if staffing needs changed based on resident acuity and care needs. When the 2/8/2026 form was reviewed, it did not include a census number, and the scheduler confirmed the facility had new admissions since 2/6/2026, increasing the census from 84 to 86. She also stated the 2/8/2026 staffing form did not accurately reflect the needs of the facility for that day and was unsure why nursing had not adjusted and posted it. The NHA later confirmed the Daily Nurse Staffing Form should be completed and posted daily to reflect the current census and staffing needs of the facility.
Unqualified Dietary Director
Penalty
Summary
The facility failed to provide a qualified dietitian, other clinically qualified nutrition professional, and/or director of food and nutrition services who met the required qualifications within the allowed timeframe. During an interview on 2/8/2026, Dietary Director C stated that he was working on his Dietary Manager certificate but was not currently certified, and he also stated that he was not a Certified Professional Food Manager through a nationally accredited program. He reported having many years of experience. During a later interview on 2/9/2026, the Nursing Home Administrator stated that the dietary manager was not a certified dietary manager or a Certified Professional Food Manager and was unable to produce any certificates showing certification in a nationally recognized food manager program. The NHA stated that Dietary Director C was supposed to have submitted these after hiring.
Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Food service practices were not maintained in accordance with professional standards when soiled meal trays were placed in food carts with unserved trays during meal service on B Hall and D Hall. During lunch, a CNA was observed moving soiled meal trays back to the food cart for transport to the kitchen, and the cart was later seen containing six unserved trays along with soiled trays, including trays placed above and next to the unserved trays and touching and blocking service. During breakfast the next day, the food cart again contained one tray still to be served and eight soiled trays returned from resident rooms, and a CNA stated the dirty trays should not have been placed with the resident's meal. Additional food service sanitation concerns were observed in the kitchen. Hood filters above the cooking equipment were soiled with dust and debris, and stainless steel steam table pans were stored on a lower shelf beneath the steam table on a surface that was partially covered with peeled, soiled protective plastic sheeting and food debris. The pans were turned upside down on the soiled surface and had food debris on them. A garbage disposal was also observed backed up with the bowl half full of wastewater, and a dietary aide stated it had been broken for a while and a work order had been placed. Hand hygiene and storage practices were also deficient. A dietary cook was observed drinking from a bottle on the prep line, placing the bottle back on the prep table, and then handling cleaned parts of a food processor without washing hands after drinking. In the dry storage room, a large box of single-serve Styrofoam cups, two boxes of insulated bowls, and a box of single-serve lids were observed sitting on the floor rather than stored above the floor in a clean, dry location.
Incomplete Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to maintain a comprehensive and accurate facility assessment to determine the resources needed to care for residents competently during day-to-day operations and emergencies. Review of the revised facility assessment showed an average daily census of 72 residents, with a minimum of 64 and a maximum of 78, but census records from 10/1/25 through 2/11/26 showed 90 days when the census exceeded that maximum, including a high of 87 residents on 2/6/26. The assessment also listed resident acuity levels showing substantial percentages of residents requiring maximum assistance or total dependency for self-care, bed mobility, transfers, walking, and wheelchair/scooter use. The staffing plan in the assessment stated that the scheduler used a staffing ladder based on the facility budget to determine baseline staffing requirements, with day, afternoon, and midnight shifts each listed at 5-7 CNAs and 2-3 nurses on day and afternoon shifts and 3-5 CNAs and 2-3 nurses on midnight shift. The assessment also referenced contingency planning for staffing shortages and use of staff from other facilities, but the contingency planning section was left blank except for staff signatures. During interview, the NHA stated the facility did not have a staffing problem but a call-in problem, said no retention or recruiting efforts or meetings occurred, and did not explain why the assessment lacked a staffing contingency plan. The NHA also did not respond when asked whether 3 CNAs were sufficient to safely and adequately cover a census of 79 or greater with the documented mobility acuity levels.
QAPI Program Failed to Identify and Address Systemic Quality Deficiencies
Penalty
Summary
The facility failed to develop and maintain a QAPI program that identified and prioritized quality deficiencies, systematically analyzed the underlying causes of systemic quality deficiencies, and implemented effective corrective action or performance improvement activities to address those deficiencies. During interview, the Nursing Home Administrator stated that low staffing levels had not been identified as a concern and said the facility was fully staffed, with only a couple open nurse positions and CNA staffing fully staffed. When asked about excessively low weekend staffing identified on the PBJ report for Quarter 4, 2025, the NHA acknowledged the survey process had identified it but stated the facility did not have a staffing problem, only a call-in problem, and said the facility had not discussed a contingency staffing plan in QAPI. The NHA also stated the facility had been enforcing attendance expectations and using its attendance and disciplinary policies, but did not respond when asked whether that approach was effective. Review of the facility's performance improvement projects did not show staffing concerns or other systemic issues had been appropriately identified and addressed through the QAPI process. The Regional Director of Operations stated, "Our QAPI program needs work." The facility policy stated that QAPI should systematically collect data, address all systems of care and management practices, include clinical care, quality of life, and resident choice, and that identified problems should be addressed and prioritized through root cause analysis and appropriate corrective action.
Failure to Use QAPI to Address Repeated Staffing Concerns
Penalty
Summary
The facility failed to incorporate high-risk, high-volume, and high-priority quality concerns from direct care staff, residents, and resident representatives into its QAPI program. Review of Quality Assistance Forms submitted to the NHA showed 15 grievances from staff, residents, and/or resident representatives related to low staffing concerns since June 2025. Resident Council Meeting Minutes since March 2025 repeatedly documented staffing concerns, including excessively late mealtimes, for 9 of the previous 11 months. During a confidential group interview on 2/9/26, 8 of 9 residents stated the facility still had ongoing low-staffing concerns that were directly affecting resident outcomes. During the recertification process, staff from activities, dietary, and housekeeping each described ongoing staffing-related problems. The Activities Director stated concerns about staffing, call lights, and untimely meal service were brought to management through Quality Assistance Forms after every Resident Council meeting, but management responded that staffing guidelines were met. The Dietary Manager stated food was prepared on time but there were not enough staff to deliver trays in a timely manner, and that the issue went nowhere when raised with management. A housekeeper stated CNAs were short staffed and got to call lights when they could. The NHA stated low staffing had not been identified in QAPI because the facility was fully staffed, and said staffing was being addressed through write-ups and attendance policy, despite the repeated concerns documented in grievances, council minutes, and staff interviews.
Failure to Provide Homelike Dining Environment Due to Use of Plastic Utensils
Penalty
Summary
Surveyors identified that the facility failed to provide a homelike dining environment when serving meals with disposable plastic utensils instead of standard silverware. During a lunch observation on 2/8/2026, meals on A Hall and B Hall were delivered on trays from food carts, and each tray included only disposable plastic utensils. CNA R reported that disposable plastic utensils often came on the trays and explained that sometimes meal trays sat near the kitchen door in the dining room and did not get washed in time for the next meal. During a breakfast observation on 2/9/2026, meals were again delivered on trays from food carts, and on A Hall each tray included regular forks and spoons but plastic disposable knives. In an interview on 2/11/2026, the Food Service Manager (Staff C) stated that trays went down the hall and did not come back in time to be washed for the next meal, and he believed residents were keeping the silverware. Staff C acknowledged he was aware disposable plastic utensils were being used and that he had not ordered any more silver utensils. In a confidential group interview on 2/9/2026, five residents expressed frustration with the plastic cutlery used at mealtimes, with one resident stating that a plastic knife would not cut the meat. A complaint submitted to the State Agency on 12/29/2025 also reported that meals were never adequately served due to limited utensils. The facility’s policy on Residents’ Rights and Quality of Life, reviewed 1/1/2022, stated that all residents have the right to a dignified existence.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure meals were palatable and served at preferred and appetizing temperatures, as evidenced by resident interviews, resident council minutes, and direct observation of food temperatures. In a confidential group interview, six of nine residents reported that food delivered at mealtimes was often cold, with one resident stating it was sometimes cold and other times lukewarm. Residents reported that meal trays sat in the serving window or in delivery carts for extended periods, contributing to cold food temperatures. One resident described purchasing hairnets online in an attempt to help deliver trays due to ongoing staffing problems and expressed distress that the facility would not allow this, noting that trays frequently stacked up in the serving window because there were not enough staff to deliver them promptly. Resident council meeting minutes over multiple months documented ongoing, unresolved complaints about cold or lukewarm food and beverages, including room trays, dining room meals, and coffee that was sometimes pre-poured and served lukewarm or cold. A cognitively intact resident with a history of left tibia/fibula fractures, who required staff assistance for bathing and toileting, reported that both breakfast and lunch were cold and that this occurred frequently because staff were late checking blood sugar. During observation of a lunch meal service on A Hall, surveyors measured the temperatures of items on the last tray from a food cart and found milk and juice at 59 degrees Fahrenheit and hot items (chicken breast and sliced cooked carrots) at 106–107 degrees Fahrenheit, which did not meet the FDA Food Code standards for hot and cold holding. The facility’s own policy required prompt meal service with resident preferences accommodated, but the observations and interviews showed this was not consistently achieved.
Failure to Honor Food Preferences, Standing Orders, and Always Available Menu Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to honor resident food preferences, standing diet orders, and to offer substitutes or alternative menu items as ordered or documented. During meal observations, multiple residents did not receive the type or amount of juice specified on their tray cards, including residents whose cards called for 8 fl oz of assorted or apple juice but who received only 4 fl oz, and one resident whose card specified certain acceptable vegetables but who was served carrots without an alternative vegetable. Another resident whose tray card allowed deli meat and specified an alternative meal of ham or turkey sandwich instead received a peanut butter and jelly sandwich. A resident who was supposed to receive two bowls of soup when no selective menu was filled out did not receive any soup, and several residents who requested hot dogs from the Always Available menu instead received hamburgers. Additional observations showed that condiments and beverage additions documented as standing orders were not provided. One resident’s tray card specified cream and sugar substitute, but the tray arrived without cream, sugar substitute, salt, or pepper, despite staff acknowledging the resident would want these items. Several residents with tray cards indicating “extra sauces or gravy” or “sauce/gravy on all meats” received dry ground or chopped meat without sauce or gravy; one of these residents reported the meat was too dry, did not like it, and ate only a sip of milk and part of a muffin. At breakfast, a resident who had handwritten yogurt on a selective menu did not receive yogurt and stated this had happened before, and another resident whose standing orders included a daily banana did not receive one, although other residents had bananas and the resident stated he would like one. Surveyors also noted failures to offer substitutes when meals were not eaten and ongoing, unresolved food availability issues. One resident with malnutrition and severe cognitive impairment had a breakfast tray placed out of reach and did not eat any of the food before a hospitality aide removed the tray without offering any substitutes or alternatives. Another cognitively intact resident had a meal tray removed by an LPN without being offered any food or beverage substitutes or alternative menu items. In a confidential group interview, four residents reported the facility frequently ran out of preferred items listed on the Always Available menu, including ice cream, yogurt, pudding, cookies, hamburgers, and hot dogs; one resident requiring a gluten-free diet reported being served salad for two meals a day, five days per week and expressed frustration, stating they wanted anything other than salad. Resident council minutes over several months documented repeated, unresolved complaints that residents continued to receive foods listed as dislikes on their meal tickets and that the kitchen repeatedly ran out of requested items such as hamburgers, hot dogs, tomato juice, hot chocolate, ice cream, creamer, sweetener, and cottage cheese.
Meals Left Out of Reach or Not Set Up for Residents Needing Assistance
Penalty
Summary
The facility failed to reasonably accommodate residents’ needs and preferences by not assisting with, setting up, or placing meals within reach for four residents. For Resident #4, the record showed admission with malnutrition, depression, anxiety disorder, and severe cognitive impairment. On observation, the resident’s lunch and later breakfast tray were left on the bedside table out of reach with food and beverage covers in place, and a hospitality aide removed the breakfast tray without offering any food or beverage. The resident’s menu card indicated regular diet, thin liquids, and “Independent, offer set up assistance (for meals).” For Resident #47, the record showed admission with diabetes mellitus and hip fracture, with intact cognition. On observation, the resident was lying in bed with a tray of food covered and out of reach, and the menu card showed the resident had been given another resident’s meal tray. A LPN removed the tray from the bedside but did not offer any food or beverage. Facility policy stated staff were to check trays for correct diets before serving residents, and the resident’s menu card indicated “Independent offer set up assistance (for meals).” For Resident #69, the record showed diagnoses including demyelinating disease of the central nervous system, osteoporosis, arthritis, generalized weakness, and frequent falls, with mild cognitive impairment and care plan directions to provide assistance with meals as needed. On two observations, the resident’s breakfast tray was left across the room and not set up, and the resident could not rise to retrieve it. A CNA stated the resident had declined in recent weeks and required assistance to set up meals, and later stated she left the tray without setting it up so she could pass the remaining trays. For Resident #83, the record showed quadriplegia, anoxic brain damage, and total dependence for bed mobility. On observation, the resident’s untouched breakfast tray was placed 2 to 3 feet from the bed and out of reach; the resident stated she did not see it, was hungry, and needed help because she could not reach the tray. The tray card stated the resident needed assistance with meals, and the care plan included 1-person assist and set-up assistance.
Unsecured medications and unlocked medication/treatment carts
Penalty
Summary
The facility failed to secure medications and maintain locked storage for medications and treatment supplies. On 2/8/26, a full cup of medications was observed sitting on the bedside table of Resident #64 while the resident was asleep, and a full cup of morning medications was observed on the bedside table of Resident #91, along with an albuterol rescue inhaler. On 2/9/26, Resident #93 was observed with mupirocin ointment on the bedside table, and record review found no order, assessment, care plan, or interdisciplinary note showing the resident could self-administer medications. The medication administration record showed that R91 and R64 had received multiple scheduled medications earlier that day. The facility also failed to keep medication and treatment carts secured. An A Hall treatment cart was observed unlocked with diclofenac sodium topical gel 1% and an opened can of soda pop on top of the cart, and RN Q stated the treatment carts should be locked when licensed staff are not using them. Later observations found an unlocked medication cart near the nurses' station with no staff present, treatment carts unlocked on A Hall, E Hall, and D Hall, and the B Hall medication cart unlocked and unattended while RN N was away from the cart. LPN SS stated lancets were not supposed to be left unattended on the medication cart. The facility policy stated medications must be stored in locked compartments and, during medication pass, must be under direct observation or locked in the medication storage area/cart.
Failure to Provide Ordered Adaptive Dining Equipment
Penalty
Summary
Provide special eating equipment and utensils for residents who need them and appropriate assistance. During a lunch meal observation, four of five residents reviewed for dining assistive devices did not receive the adaptive equipment listed on their meal tray cards. Resident #6 had a tray card indicating adaptive equipment of a 2-handle cup, built-up utensil handles, and a red plate, but received plastic silverware and did not receive the built-up utensil handles or the specialty red plate. Resident #23 had a tray card indicating adaptive equipment including straws, but no straws were observed on the tray. Resident #30 had a tray card indicating adaptive equipment including a 2-handled cup and straw, but the tray did not include a straw or beverage in a 2-handled cup. During a breakfast meal observation, Resident #48 had a tray card indicating adaptive equipment including a 2-handled cup, with an alert on the side of the card stating "2 handled cup FLAT LID," but the resident's beverage was not served in a 2-handled cup with a flat lid. The facility policy stated that assistive devices include eating utensils and that the facility will provide assistive devices for residents who need them. The resident meal service policy also stated that each resident shall receive the correct diet, with preferences accommodated as feasible, and that assistive devices will be made available to residents who need them.
Failure to Protect Resident’s Personal Narcotic Medication From Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s belongings, specifically prescription pain medication, from misappropriation. A cognitively intact resident with a left tibia/fibula fracture was admitted with personal belongings, and later reported that four hydrocodone/acetaminophen tablets she had brought in her purse from home were missing when she wanted to take one for increased pain. The resident’s admission inventory sheet did not list any medications, and the facility’s own summary documented that the resident told the administrator she had a bottle in her purse with four hydrocodone tablets that were now gone, stating that a “skinny little nurse probably took them last night.” The facility’s abuse, neglect, and exploitation policy required protections against misappropriation of resident property, but the DON stated she was unsure whether nurses asked about medications during admission, indicating that medications brought from home were not consistently inventoried. Multiple staff interviews described a nurse (RN AA) working on the same unit who appeared to be under the influence while on duty, raising concerns about medication handling and resident safety. Staff reported that this nurse was not passing medications as expected, was weaving and wobbling, had uncontrolled facial movements, was found asleep at the medication cart, and required other staff to notify the NHA and remove her medication cart keys. CNAs and another nurse stated that residents commented the nurse was “cooked” and “wiped out,” and one staff member reported that another resident received the wrong medications. A confidential resident also described the nurse as being “higher than a [NAME]” and “F**ked up,” hiding in an alcove. The NHA confirmed that the nurse was behaving out of the ordinary and was terminated after refusing a drug test. The facility’s internal summary of the missing narcotic documented that the resident’s admission inventory did not reflect any medications from home, despite the resident’s report that she had brought hydrocodone in her purse. When the administrator later examined the purse, an empty hydrocodone bottle and other medications (gabapentin and ondansetron) were found and counted, and a subsequent room search with the resident’s permission revealed marijuana gummies, cigarettes, and a lighter. These findings, combined with the lack of documented medication inventory at admission and the presence of a nurse suspected by multiple staff and a resident of being under the influence while having access to medications, demonstrate the facility’s failure to protect the resident’s property from potential misappropriation as required by its abuse, neglect, and exploitation policy.
Failure to Timely Report Alleged Misappropriation of Controlled Pain Medication
Penalty
Summary
The facility failed to implement its policies and procedures for timely reporting of a reasonable suspicion of a crime related to misappropriation of a resident’s controlled pain medication. A cognitively intact resident, admitted with a left tibia/fibula fracture and prescribed hydrocodone/acetaminophen for pain, reported that a night shift nurse had taken four of her hydrocodone 10 mg/325 mg tablets, which she had brought from home in her purse. The resident stated this concern to staff at approximately 5:30 PM on a Saturday, and the DON documented in a progress note that the administrator and a nurse spoke with the resident about the missing Norco. Despite this allegation of misappropriation of narcotic medication, the NHA acknowledged in an interview that the allegation was not reported to the state agency at that time. The deficiency was further supported by the timing of the report to the state agency compared with when the allegation was known to facility staff. The state agency report, dated 2/8/26 at 4:47 PM, listed the misappropriation incident as discovered on 2/7/26 at 5:26 PM, indicating late reporting. The resident had already reported the missing medication to the surveyor on 2/7/26 at 2:15 PM, and the surveyor alerted the DON at 2:20 PM that same day. Facility policy on Abuse, Neglect, and Exploitation required reporting all violations to the administrator, state agency, adult protective services, and other required agencies within specified timeframes, including not later than 24 hours for events that do not involve abuse and do not result in serious bodily injury. The facility did not follow this policy or the requirements of section 1150B of the Act in reporting the reasonable suspicion of a crime involving misappropriation of the resident’s property.
Failure to Investigate Alleged Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy requiring immediate and thorough investigation of alleged misappropriation of resident property, specifically narcotic medication. A cognitively intact resident, admitted with a left tibia/fibula fracture, reported that a night shift nurse took four hydrocodone/acetaminophen tablets that the resident stated she had brought from the hospital and kept in her purse. The resident reported increased pain and a desire to take one of the missing pills. A progress note by the DON documented that the resident had raised the concern about four missing Norco tablets in her purse. The facility’s written policy required immediate investigation of suspected abuse, neglect, exploitation, or misappropriation, including investigating different types of alleged violations, identifying and interviewing all involved persons and potential witnesses, and providing complete and thorough documentation of the investigation. Surveyor review and interviews showed that these investigative steps were not carried out as required. When asked on multiple occasions, the DON could not initially provide documentation of an investigation into the alleged misappropriation of narcotics. Later, a summary of the event was produced by the RDO, but review of staff interviews and staffing schedules revealed that 16 staff members who could have relevant information were not interviewed regarding the allegation. Additionally, the DON stated she was unsure whether nurses asked about medications during the admission process and only knew that care assistants inventoried clothing, indicating that resident medications were not consistently inventoried on admission. This lack of comprehensive interviews, incomplete documentation, and absence of a clear process for identifying and accounting for resident medications on admission demonstrated the facility’s failure to follow its own policies and procedures for investigating alleged misappropriation of resident property.
Failure to Provide Individualized ADL Care and Personal Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide individualized ADL care, including repositioning, grooming, toileting, and bathing, in accordance with residents’ assessed needs and preferences. One resident with depression, anxiety, malnutrition, osteoporosis, and identified as at risk for pressure ulcers had an MDS indicating a need for supervision/touching assistance with turning and repositioning in bed. During a two-hour observation period, this resident remained lying on her back with the head of the bed slightly elevated, and no staff entered the room to assist or encourage her to turn or reposition. Another resident with diabetes mellitus and a hip fracture, who was cognitively intact, was observed lying in bed with long facial hair. He reported he had not been shaved in a long time and could not recall when he was last shaved, and stated that long facial hair made him feel dirty. A CNA stated residents were supposed to be shaved on admission, on shower days, or upon request, while another CNA reported that at times residents did not receive the care they deserved due to insufficient staffing and that residents were neglected. A third cognitively intact resident with a left tibia/fibula fracture, diabetes mellitus, and chronic kidney disease requiring dialysis was dependent on staff for bathing and required staff assistance for toileting. This resident reported having been left wet and soiled in urine and fecal matter for over two hours one morning, describing the experience as mortifying and nasty. She also reported not having received a shower during her two-week stay and that staff hardly got her up into a chair; at the time of observation, her hair was disheveled. Her documented preferences indicated it was very important to her to choose her bathing method and that she preferred showers, but her ADL care plan did not include bathing interventions. Review of her shower task list showed missed showers on multiple scheduled days, and a CNA confirmed she had not received any showers since admission, citing lack of shower sheets and frequent call-ins on scheduled shower days. These findings occurred despite facility policies stating that residents would be treated with dignity and receive necessary services to maintain grooming and personal hygiene.
Failure to Complete Timely Admission Assessment and Initiate Bowel Protocols
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessments and care according to orders and residents’ needs, including failure to complete an admission assessment and to initiate bowel protocols for constipation. One resident was admitted in the evening and reported that upon arrival staff briefly entered and left the room without explanation, and no vital signs, blood pressure, or head-to-toe assessment were performed at the time of admission. The resident, who was cognitively intact with a BIMS score of 15/15 and had a recent leg fracture limiting mobility, documented in a notebook that she lay in bed without understanding what was happening, needed pillows to elevate her legs, and did not receive dinner when told it was on the way. She also reported using the call light during the first night, which remained on for a long period without response, leading her to call the facility’s main phone number, which was answered first by one resident and then handed to another resident before staff eventually came to her room. Record review for this resident showed she was admitted on one date and that the nursing assessment was not started until nearly six hours later and was not completed. Facility policy on admission orders required that a physician or other qualified practitioner provide orders for immediate care needs, including diet and other care-related orders, to allow staff to provide essential care. In interviews, an RN stated that on admission nurses are expected to settle the resident in the room, add a diet order, perform a head-to-toe assessment, obtain vital signs, complete a skin assessment, notify the physician, and write an admission note when the resident first arrives. The DON confirmed that nursing staff are expected to complete an assessment within the first hour of admission and obtain vital signs immediately, which did not occur for this resident. The facility also failed to initiate bowel protocols in a timely manner for two residents with documented constipation and available PRN and scheduled bowel medications. One resident with diagnoses including diabetes, a Stage 2 sacral pressure ulcer, left hip fracture, mesenteric artery stenosis, and constipation reported not having a bowel movement for four days and expressed concern that no treatment had been provided, while a family member confirmed they had alerted nursing the previous day. The following day, the resident continued to report no bowel movement, nausea, and abdominal discomfort, and the family member stated a nurse had been informed and said she would call the physician. EMR review showed no bowel movement documented from admission through several days later, despite frequent administration of opioid pain medication. PRN Milk of Magnesia ordered for no bowel movement in three days was not given until day five without documented use of subsequent PRN Dulcolax suppository or Fleet enema, and scheduled daily laxative and stool softener orders were not started until more than five days after admission. Another resident with demyelinating disease of the CNS, osteoporosis, arthritis, generalized weakness, and frequent falls, and with mild cognitive impairment (BIMS 13/15), was observed nauseated, declining breakfast and lunch, and unsure of the date of the last bowel movement. Bowel elimination documentation showed the last bowel movement occurred five days earlier, with repeated entries of no bowel movement through the date of review. There was no documented bowel assessment corresponding to the resident’s nausea or the prolonged absence of a bowel movement. Although multiple PRN bowel medications (Milk of Magnesia, Metamucil, Dulcolax suppository, Fleet enema) were ordered, none were documented as administered during the review period. The DON reported that night shift was supposed to pull bowel elimination reports and pass information to oncoming staff, but acknowledged the reports were not consistently provided and that a nurse did not receive a bowel protocol list due to staff being busy with multiple new admissions, and also stated there was no facility policy related to bowel protocol.
Failure to Implement Fall Interventions and Enforce Safe Smoking Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain required fall-prevention interventions for one resident and to ensure safe smoking practices for another resident. One resident with a seizure disorder, fracture history, anxiety disorder, and moderate cognitive impairment had a care plan focus identifying risk for falls and injury, with an intervention specifying fall mats on both sides of the bed initiated months earlier. During observation, the resident’s bed was in a high position and the two floor mats were found folded behind a chair in another resident’s room, not on the floor beside the bed as ordered. A CNA who had been on duty since early morning reported the floor mats were not in place at the start of the shift, stated that the mats were supposed to be on both sides of the bed due to a previous fall, and noted she could not view the care plan on the computer. An RN confirmed the mats were required per the care plan and acknowledged the intervention was not set up as a CNA task, which was described as concerning given the number of new staff unfamiliar with the residents. The NHA also acknowledged concern about the missing floor mat intervention. The facility’s fall prevention policy required assessment of fall risk, development of a comprehensive plan of care including environmental hazards, and monitoring of interventions for effectiveness. The deficiency also includes failure to ensure safe smoking practices for a resident with difficulty walking, need for assistance with personal care, tobacco use, and moderate cognitive impairment. The resident was observed returning from outside in very cold, snowy conditions, wearing a heavy coat and gloves with snow on them, after going out to smoke. A CNA stated the resident went out to smoke, was “his own person,” and was supposed to go off premises, though acknowledged that in winter the resident could not traverse the deep snow and instead smoked just outside the door. Staff reported the resident smoked as often as possible, approximately every two to four hours, and that he had his own cigarettes and lighter. They also stated he was supposed to sign himself out in a lobby sign-out book, which was not present in the lobby at the time of observation. Later, the NHA was found holding the sign-out book along with the resident’s lighter and cigarettes, confirmed the items belonged to the resident, and stated the campus was non-smoking and residents could smoke off premises using the sign-out process. Review of the sign-out book showed only a few entries, all by this resident, despite staff reports that he smoked many times daily. The facility’s smoking policy stated that smoking was not permitted on facility property and that residents with smoking privileges may not retain smoking articles on their person or in their living or sleeping area at any time.
Failure to Honor Resident Preferences for Sleep and Care Timing
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for three residents. Resident #10 was admitted with spastic quadriplegic cerebral palsy, need for assistance with personal care, major depressive disorder, and chronic pain syndrome, and was cognitively intact with a BIMS score of 15. The care plan documented a preference to go to bed at 4 a.m. and wake between 1 p.m. and 2 p.m., yet on observation the resident was still in bed and awake after 2:35 p.m. with a sign on the door stating, "Please wake up by 1 PM." The resident stated no one had come in yet and reported repeated delays in getting up, including being left in bed until as late as 4 p.m. or after 2 p.m. because staff were busy or wanted to go to lunch. A CNA confirmed the resident was supposed to get up by 1:00 p.m. but did not get up until 3:00 p.m. because there were not enough staff to provide care, and the workload showed four CNAs were responsible for 85 residents, with one CNA assigned to monitor one resident at all times. Resident #12, admitted with diabetes mellitus and PVD/PAD and scored 11 on the BIMS, reported having a wound on the bottom of the foot and said the nurse came during the night or very early in the morning, waking the resident and preventing return to sleep. The resident stated a preference for the treatment to be done during the day when awake. Resident #30, admitted with cancer and arthritis and also scoring 11 on the BIMS, reported that the nurse came in the middle of the night for a roommate's dressing change and turned on all the lights, making it impossible to sleep afterward. The unit manager stated she had not asked Resident #12 what time the dressing change was preferred and scheduled them at night, while Resident #12 stated the nurse had been told not to change the dressing in the middle of the night but continued to do so. The facility policy stated resident goals and preferences would be included in the plan of care and that former lifestyle and personal choices would be considered when providing care and services.
Inaccurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure accurate advance directive information was in place for one resident, who was admitted with a primary diagnosis of autistic disorder. The resident’s MDS indicated the BIMS could not be completed because the resident was rarely or never understood. The EMR contained physician orders for Full Resuscitation dated 8/17/2022, and the chart banner on each page also identified the resident’s code status as Full Resuscitate. At the same time, the EMR also contained a form titled DO NOT RESUSCITATE (DNR) ORDER GUARDIAN CONSENT COURT APPOINTED GUARDIAN MAKING DECISIONS, signed by the legal guardian and physician on 12/12/2025, with the witness signature lines left blank. Additional documents dated 11/12/2024, signed by the legal guardian and physician, indicated the box checked for wanting efforts made to prolong life and to provide life sustaining treatment. During interviews, the Social Service Designee stated he was not sure whether the resident was full code or DNR, and an LPN stated the resident was full code based on the banner but then said she did not know what the directive should be after reviewing the DNR form.
Unsecured Resident Health Information on Open Laptop
Penalty
Summary
The facility failed to protect the privacy of medical records for one resident when a medication cart at the beginning of C Hall was observed with a facility laptop computer open and the resident’s personal health information displayed on the screen while no staff were present near the cart. During an interview shortly after the observation, the LPN stated that the screen should not have been left open with resident information available for anyone to access. The NHA later acknowledged that the medical record information was not secured when the LPN walked away from the medication cart.
Failure to Obtain Immediate Admission Diet Orders
Penalty
Summary
The facility failed to obtain physician dietary orders for the immediate care of two residents at the time of admission. Resident #94 was admitted to the facility at 5:31 PM, but the physician diet order in the EMR was not dated until 3:27 PM on 2/8/2026, and the diet notification/transmittal to dietary was also dated 2/8/2026. During interview, the resident stated he had arrived on Friday and had not received breakfast or lunch that day, reporting that he had only had coffee and donut holes brought by a visitor. His roommate stated he had gone to tell the kitchen that the resident had not received any food that day. The Dietary Manager stated, "I guess he got here yesterday. I will deliver it." Resident #91 was originally admitted on 2/6/26 and was cognitively intact with a BIMS score of 15/15. During interview, the resident stated she had not received lunch on Saturday and had not received breakfast on 2/8/26, saying it was already lunchtime and she was unsure if she would get lunch. The EMR showed the resident was admitted at approximately 5:25 PM, but the physician diet order was not dated until 3:29 PM on 2/8/2026, and the diet notification/transmittal to dietary was also dated 2/8/2026. Facility documentation titled admission Check Off indicated nursing was to add a diet order upon admission, and both the RN and DON acknowledged that a diet order should be written upon admission and dietary should be alerted.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative therapy services for two residents who had documented needs for range of motion, splinting, and mobility support. One resident with quadriplegia and anoxic brain damage was observed sitting reclined in bed after lunch and stated staff did not work with her left contracted hand and that her brace was not being applied. She later said she had not been receiving restorative therapy for a long time and that the splint was not being put on enough. CNAs stated restorative care was done by the Restorative Aide and that they did not do restorative unless they had time, while the DON stated no one covered restorative tasks on weekends or when the Restorative Aide was unavailable. The resident’s record showed intact cognition, total dependence for rolling, sitting, and lying down, and impairment in both upper and lower extremity ROM. The care plan included restorative PROM to the shoulders, left elbow, fingers, and bilateral lower extremities, as well as a restorative splinting program for a palm protector splint to the left hand for 3 to 4 hours of wear time. However, the most recent 14-day task review showed brace toleration documented on only two days, with all other days marked did not occur. The current physician orders contained no restorative therapy order and no order for splint or brace use. A second resident with paraplegia and intact cognition reported that he used to receive ROM exercises from restorative nursing but no longer did so. He stated his ability to use his arms and hands to feed himself was becoming more difficult and that he was having trouble holding a spoon and bringing it to his mouth. The facility policy stated restorative nursing programs are intended to improve or maintain independence in ADLs and mobility, and the report identified that restorative services were not being provided as planned for the two residents reviewed.
Failure to Document Non-Pharmacological Pain Interventions Before PRN Opioids
Penalty
Summary
The facility failed to ensure that PRN opioid pain medications were preceded by documented non-pharmacological interventions for two residents reviewed for unnecessary medications. Resident #8 had diagnoses including Alzheimer's disease, adjustment disorder with mixed anxiety and depressed mood, spinal stenosis, muscle weakness, and a history of falling. The resident was ordered oxycodone-acetaminophen 5-325 mg every six hours as needed for pain and received multiple doses in February 2026, but the MAR and EMR contained no documentation of the location of pain or any non-pharmacological interventions attempted and failed before those doses were given. The care plan stated that non-pharmacological interventions should be offered to relieve pain and their effectiveness observed. Resident #15 had diagnoses including cervical disc disorder, schizophrenia, constipation, pain, and a history of substance abuse disorder. The resident was ordered oxycodone-acetaminophen 10-325 mg every four hours as needed for pain and received repeated doses throughout February 2026, but the MAR and EMR contained no documentation of the location of pain or non-pharmacological interventions attempted and failed before administration. The care plan directed staff to offer non-pharmacological interventions to relieve pain and observe for effectiveness, and to explore alternative methods of coping and offer emotional support as needed. During interview, the DON stated that non-pharmacological interventions should be attempted and documented in the EMR along with their effectiveness before PRN opioids are administered, and that the lesser means should be utilized for treating pain.
Missing Hospice Follow-Up and Communication
Penalty
Summary
The facility failed to ensure implementation of physician orders for hospice services for one resident and failed to ensure communication with hospice providers and receipt of hospice documentation for another resident. For Resident #8, the EMR showed a physician order for a hospice consultation dated 1/21/26, and a Social Services Progress Note dated 1/28/26 stated that the guardian consented to hospice consultation and a referral was issued. However, no hospice consultation follow-up was found in the EMR. When surveyors requested the consultation results, the DON stated there was no documentation of the hospice consult and did not know when hospice visited, and Social Services Designee Staff P stated he did not know when hospice was in the building and was waiting for an email with the results. For Resident #4, the MDS showed severe cognitive impairment with a BIMS score of 3 out of 15 and indicated the resident was receiving hospice services. The Hospice Certification and Plan of Care listed weekly SN visits, one MSW evaluation, and weekly HHA services, but the DON acknowledged there was no documentation from hospice regarding the weekly visits. Review of the hospice binder found no communication from the MSW or HHA, no communication regarding SN visits from 12/28/25 to 1/8/26, and no communication regarding SN visits between 1/10/26 and 1/21/26. The SSA stated the hospice SW should have left an evaluation in the binder and that the SN should have placed communication to staff in the binder, and acknowledged the SN did not make weekly visits.
Failure to Implement Timely Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement timely and appropriate pressure ulcer prevention and treatment interventions for two residents, resulting in the development and worsening of pressure injuries. One resident was admitted with diagnoses including Alzheimer’s disease, adult failure to thrive, weakness, and cognitive communication deficit, and was identified on admission as having bilateral lower leg wounds, scabs/bruising on both arms, bowel incontinence, and being at risk for skin impairment. A Braden Scale score of 15 indicated risk for pressure ulcers, and the admission evaluation identified the need for a pressure redistribution mattress to the bed. Initially, a physician note documented no open wounds, but within days, moisture-associated skin damage (MASD) was identified on the bilateral buttocks, with red, eroded skin and loose stools. Nursing documentation over subsequent days repeatedly described shearing and deterioration of the buttocks, including purple areas and scattered open superficial areas, while the resident continued to have very loose stools. Despite ongoing documentation of worsening buttock skin breakdown and the resident’s high risk factors (failure to thrive, incontinence, limited mobility), there was no timely implementation of a low air loss mattress. The facility’s own policy stated that evidence-based interventions, including moisture management and appropriate pressure-redistributing support surfaces, should be implemented for residents at risk or with existing pressure injuries. The low air loss mattress was not ordered until mid-October, after documentation that the buttocks were deteriorating, and the order required maintenance to place the mattress. Maintenance staff reported that work orders are generally completed within 48 hours and that there is no retrievable record once completed. The DON acknowledged that moisture from bowel incontinence increases pressure ulcer risk and that failure to thrive is an indication for a low air loss mattress, and confirmed that a physician order was required before placement. However, review of MARs, TARs, and POC documentation showed no order, application, or monitoring of a low air loss mattress during the period when the wounds were progressing from MASD to suspected deep tissue injury and then to unstageable pressure ulcers. Physician progress notes documented that the resident’s buttock wounds progressed from MASD to suspected deep tissue wounds with slough/eschar, and then to unstageable pressure ulcers with nearly 100% black necrotic tissue, purulence, erythema, and induration concerning for wound infection or necrotizing fasciitis. The resident was transferred to the hospital, where an emergency department exam found a necrotizing, foul-smelling sacral and bilateral buttock wound, with imaging and labs consistent with a severe infected decubitus ulcer. The resident required urgent surgical incision and debridement, ICU admission, IV antibiotics, and had a large surgical dressing with wound VAC at discharge. Facility work order records later showed that the low air loss mattress ordered in mid-October was not documented as placed until early November, after the resident had been hospitalized and surgically treated, indicating a significant delay between identification of worsening wounds and implementation of this pressure-redistributing support surface. The second resident was admitted with diagnoses including diabetes, adult failure to thrive, dehydration, difficulty walking, and osteoarthritis, and was documented on admission as having a right buttock rash, a left buttock blister, and pressure wounds on the right rear thigh and left gluteus. The admission nursing evaluation identified the need for a pressure redistribution mattress to the bed as an intervention. An MDS assessment showed the resident required substantial/maximal assistance with bed mobility, was dependent for transfers, had a stage 2 pressure ulcer, and was at risk for developing pressure injuries. However, review of physician orders from admission through the survey date revealed no order for a low air loss mattress, and observations on multiple occasions showed the resident in bed without a low air loss mattress, seated directly on the buttocks without a wedge or positioning device for offloading, and with heels resting directly on the mattress. During observations, heel protection boots were seen on the nightstand rather than on the resident’s feet, and the resident reported that staff did not put the boots on because they bothered her and that a pillow was used instead. The resident also reported having an open wound on the left outer thigh. Nursing staff confirmed that the resident was fearful of turning and repositioning, had significant left knee pain, could not consistently move or reposition herself in bed, did not like to wear heel boots, and was at risk for further pressure injuries. The unit manager stated she was unaware of the resident’s refusal to wear heel protection boots but acknowledged that the resident’s admission with pressure injuries placed her at higher risk for future wounds. Across both residents, the facility did not consistently translate identified risk factors, documented skin breakdown, and care plan recommendations (such as pressure redistribution mattress and heel protection) into timely, ordered, and implemented interventions to prevent the development and worsening of pressure ulcers. The facility’s pressure injury prevention policy defined avoidable pressure injuries as those occurring when the facility fails to evaluate clinical condition and risk factors, and to define and implement interventions consistent with resident needs, goals, and professional standards of practice. The policy specified that interventions should be based on risk and skin assessments and that evidence-based interventions, including minimizing moisture exposure and providing appropriate pressure-redistributing support surfaces, should be implemented for all residents at risk or with existing pressure injuries. In the cases of these two residents, the documented sequence of assessments, nursing notes, physician notes, and observations showed that the facility did not timely implement or consistently use pressure-redistributing mattresses, offloading devices, and moisture management strategies in accordance with the residents’ identified risks and existing wounds, leading to the cited deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Provide Timely Wound Care and Communication for Post-Operative Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and appropriate wound care, accurate documentation, and effective communication regarding a post-operative surgical site for a resident admitted with multiple complex medical conditions, including a recent lumbar fusion, right hip fracture, diabetes, and adrenal insufficiency. Upon admission, the initial skin assessment did not document the resident's post-operative back incision, despite its presence and the need for ongoing care. Physician orders for wound care to the central lower back were not implemented until the third day after admission, and there were missed dressing changes on subsequent days, with no corresponding nursing notes to explain the omissions. The resident reported increased pain and drainage from the back incision, and there was evidence of wound dehiscence documented in progress notes. However, the facility failed to notify the physician or nurse practitioner of the change in the wound's condition, and the provider was not made aware of the dehiscence. The resident and her family had to advocate for wound assessment and care, and ultimately, the back surgeon's office instructed the resident to seek emergency care after reviewing a photo of the wound. The lack of timely wound care, incomplete documentation, and failure to communicate changes in the wound's condition resulted in the resident developing a surgical site infection that required hospital admission, surgical washout, intravenous antibiotics, and an extended course of oral antibiotics. Facility policy required wound treatments to be provided according to physician orders and for nurses to notify the physician in the absence of orders, but these procedures were not followed in this case.
Failure to Maintain Sanitary Shower Room Due to Mold
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the D-hall community shower room, as evidenced by the presence of mold along the base of the shower and around the drain. A complainant who recently stayed at the facility reported seeing mold in the shower area, describing it as 'disgusting' and expressing discomfort with the cleanliness. The complainant stated they were relieved to use a shower chair to avoid direct contact with the floor. Direct observation confirmed the presence of mold in the specified areas of the shower room. Interviews with staff revealed that the shower room was reportedly cleaned daily and deep cleaned monthly, with documentation showing the last deep cleaning occurred six days prior to the observation. However, the housekeeper responsible for the deep cleaning did not notice the mold, and was unable to articulate the appropriate response if mold was found. The maintenance director and regional director of operations both confirmed they had not received any notifications or work orders regarding mold in the shower rooms. The nursing home administrator acknowledged the presence of mold and stated that the shower rooms should not have mold and require re-caulking.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from abuse, specifically sexual abuse, involving four residents. The incidents involved a resident with moderate cognitive impairment who engaged in inappropriate touching of other residents, including kissing one resident on the cheek, touching another on the thigh, and touching the breast of a third resident. These actions were reported to the State Agency as abuse. The residents involved had varying levels of cognitive impairment, with some having severe cognitive deficits, making them unable to consent to such interactions. Staff members, including CNAs, witnessed these incidents and reported them to the Nursing Home Administrator. Despite these reports, there was no evaluation conducted to determine the capacity of the affected residents to consent to the advances. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents and lack of immediate intervention to prevent further occurrences. The facility's failure to establish a safe environment and adequately address the inappropriate behavior led to the deficiency.
Inadequate Investigation of Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of sexual abuse involving a resident, identified as R20, who was reported to have inappropriate physical interactions with other residents. The incidents included R20 kissing a resident on the cheek, touching another resident on the thigh, and further inappropriate touching of other residents. Despite these reports, the facility's investigation was incomplete, lacking detailed witness statements and failing to document the specifics of the incidents, such as the date, time, and location. Witness statements were inconsistent, with some lacking signatures and others not being included in the investigation file. The Nursing Home Administrator (NHA) acknowledged the deficiencies in the investigation process, including the absence of detailed documentation and the inability to recall specific details about the incidents. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and thorough documentation, which was not adhered to in this case. This failure to properly investigate and document the incidents resulted in a potential risk for additional exposure to sexual abuse for other cognitively impaired residents.
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to maintain sufficient nursing staff, as evidenced by interviews with residents, family members, and staff, as well as a review of payroll data. The Payroll-Based Journal (PBJ) report indicated low staffing levels and a one-star staffing rating for the fourth quarter. The facility's Facility Assessment Tool outlined specific staffing requirements based on resident acuity, but these were not met on multiple occasions. For instance, on several dates, the number of Certified Nursing Assistants (CNAs) scheduled was below the required levels, with instances of no call no shows and staff not being available, leading to inadequate coverage for the four halls in the facility. Interviews with staff and residents highlighted the impact of the staffing deficiencies. A CNA reported that the facility was short-staffed 85% of the time, particularly on weekends, and noted that monetary incentives to cover shifts were not typically offered. Residents expressed concerns about delayed responses to call lights and unmet care needs, with one resident stating they sometimes had no choice but to soil themselves due to long wait times. Family members also reported similar issues, with one noting that their relative had been left in the same clothes for four days and experienced a stomachache without receiving timely assistance. These findings indicate that the facility's staffing levels did not adequately account for resident acuity or care needs, resulting in unmet resident needs and distress.
Failure to Maintain Safe and Sanitary Conditions for Personal Refrigerators
Penalty
Summary
The facility failed to provide a safe and sanitary environment for six residents who had personal refrigerators in their rooms. During an observation, it was noted that these refrigerators stored both perishable and non-perishable foods, but none were equipped with thermometers, and no temperature logs were maintained. The internal temperatures of these refrigerators varied between 37 F and 54 F, which could lead to food spoilage. The facility did not have a comprehensive list of residents with personal refrigerators, as only three out of the six rooms with refrigerators were identified by the facility. The facility had a policy in place for the use of personal refrigerators, which included requirements for maintenance inspections, temperature monitoring, and safe food handling practices. However, these policies were not being followed. Housekeeping staff were supposed to record refrigerator temperatures daily and clean the refrigerators, but the housekeeping supervisor confirmed that this was not being done. This lack of adherence to the policy contributed to the unsanitary conditions observed in the residents' rooms.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as evidenced by improper storage and labeling of respiratory equipment, failure to provide supplemental oxygen as per physician's orders, and lack of documentation for CPAP therapy. Resident #31 was observed with a nasal cannula dated 12/25/24, and the oxygen concentrator was set incorrectly at 3 liters per minute instead of the ordered 2 liters per minute. The resident was unaware of who changed the flow rate, and the oxygen tubing was not changed weekly as ordered. Resident #46 had a CPAP machine without a physician's order or documentation for its use and maintenance. The CPAP mask was not stored properly, lacking a bag or barrier. The only record of the CPAP was a progress note from 9/13/24, with no further documentation on settings or maintenance. Similarly, Resident #7 had a CPAP without a physician's order or care plan, and the mask was improperly stored. Resident #57 was observed using a nasal cannula with an oxygen concentrator set at 10 liters per minute, but the bubbler reservoir was empty, causing discomfort. There were no physician's orders for oxygen use or maintenance, and the resident had been using oxygen since admission. The facility's policies required physician orders for oxygen and CPAP use, and the Director of Nursing confirmed these expectations were not met, leading to deficiencies in respiratory care for these residents.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to secure medications properly, as observed during a survey. An unlocked and unattended treatment cart was found on the A-hall, containing eight topical medication creams and various wound care supplies, including an opened bottle of normal saline without a date of opening. Additionally, a topical medication cream, Nystatin, was found in a resident's bathroom, despite the resident's quarterly nursing assessment indicating that she did not wish to self-administer medications. This resident was cognitively impaired and sitting in her wheelchair at the time of the observation. Further observations revealed issues with the D-hall medication cart, which contained a medication cup of crushed medications unlabeled for an unidentified resident, and several loose pills identified as escitalopram, sucralfate, nifedipine, and aspirin. Additionally, a water bottle with a red substance, identified as the floor nurse's beverage, was stored in the bottom drawer of the medication cart. The facility's policy on medication storage requires all drugs and biologicals to be stored in locked compartments, which was not adhered to in these instances.
Failure to Update Care Plans Appropriately
Penalty
Summary
The facility failed to ensure care plans were updated promptly and revised appropriately for four residents, leading to care plans that did not reflect the residents' needs. For Resident 15, a care plan was updated two months after an altercation with another resident, but the update was unclear to staff, as they could not identify the resident to be avoided. The Regional Clinical RN admitted to not updating the care plan at the time of the incident. Resident 24's care plan was not updated following multiple hospitalizations due to catheter issues. Despite a hospitalization for continuous bleeding around the catheter, the care plan lacked updated interventions to prevent further dislodging and rehospitalization. The RN acknowledged the absence of updated interventions in the care plan. Resident 25's care plan did not include interventions to prevent further decline of contractures or negative outcomes due to contractures. The DON confirmed the lack of care plan details for managing the resident's contractures. Additionally, Resident 36's care plan was not updated following an altercation with another resident, despite the DON's initial claim that it had been updated. The DON later acknowledged the oversight.
Verbal Abuse Incident Involving a Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, resulting in mental distress and anguish. The incident involved a resident with a history of cerebral infarction, dementia, muscle weakness, and difficulty walking, who required assistance with personal care. The resident, identified as having moderate cognitive impairment, was subjected to verbal abuse by a Certified Nursing Assistant (CNA N) who yelled and used inappropriate language after the resident had an accident in their pants. This incident was reported by another CNA (CNA M) who intervened after being informed by two non-certified aides who overheard the altercation. Interviews conducted with the resident and multiple staff members confirmed the details of the incident. The resident expressed feeling bad about the situation, and staff members corroborated the use of vulgar language by CNA N. The facility's policy on abuse, neglect, and exploitation, which aims to protect residents' health, welfare, and rights, was not adhered to in this instance, leading to the deficiency. The Nursing Home Administrator acknowledged the unacceptable behavior of CNA N, which was verified by other staff members, including a Regional Clinical Nurse.
Failure to Provide Appropriate ROM Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion for a resident with severe cognitive impairment and contractures. The resident, who was admitted with diagnoses including cerebral palsy, contractures, lack of coordination, and dementia, was observed on multiple occasions without any protective devices in place to prevent skin breakdown in his contracted fists. Despite being on the facility's case load for contracture treatment until September 2, 2024, the resident had not received any treatment since that date, and no interventions were documented in the care plan to prevent further decline. Interviews with facility staff revealed that the resident was supposed to be included in a restorative program, but it had not yet been implemented. The Director of Rehabilitation acknowledged the lack of ongoing treatment and the need for restorative therapy, while the Regional Clinical RN confirmed that the facility was in the process of developing a restorative program. The facility's policy on Restorative Nursing Programs, last reviewed in January 2022, indicated that residents with contractures could benefit from such programs, yet no actions had been taken to address the resident's needs.
Failure to Provide Adequate Social Services After Resident Altercation
Penalty
Summary
The facility failed to provide adequate medically related social services for a resident with severe cognitive impairment, as evidenced by an incident involving resident-to-resident aggression. The resident, who has diagnoses including dementia and a cognitive communication deficit, was involved in an altercation where they scratched another resident. Despite the incident being reported and documented, the resident's care plan was not updated to address the behavior, and there was no evidence of follow-up by social services. Interviews with the Director of Nursing and the Social Services Director revealed that the expected follow-up actions, such as updating the care plan and documenting social services interventions, were not completed. The facility's policy on behavior management requires the identification of target behaviors and the development of an individualized plan of care, which was not adhered to in this case. The lack of documentation and follow-up indicates a deficiency in providing necessary social services to ensure the resident's psychosocial stability and prevent further altercations.
Medication Administration Errors Result in 11.54% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54%. This was identified during a medication administration observation involving a resident with diagnoses including diabetes mellitus, heart disease, sleep apnea, and hypertension. The resident had a BIMS score indicating intact cognition. During the medication pass, a registered nurse (RN) administered two types of insulin and a carvedilol tablet. However, the RN did not hold the insulin pen needles in place for the recommended time, leading to leakage from the injection sites. Additionally, the RN administered carvedilol despite the resident's blood pressure being below the prescribed parameters. The RN was unaware of the blood pressure parameters for the carvedilol and expressed surprise that the computer system allowed the medication to be administered outside the specified range. The facility's policy on medication administration requires adherence to physician orders and manufacturer specifications, including holding medications for vital signs outside prescribed parameters. The RN's actions resulted in three medication errors: two related to improper insulin administration and one related to administering carvedilol outside the prescribed blood pressure parameters.
Inadequate Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to ensure effective infection control practices and the appropriate use of personal protective equipment (PPE) for two residents, resulting in the potential transmission of communicable diseases to all 74 residents. Observations revealed that rooms of residents with COVID-19 had open doors despite signage indicating the need for closed doors under airborne precautions. The signage did not specify which resident required which type of isolation, leading to confusion among staff, particularly those unfamiliar with the residents. Certified Nurse Aide (CNA) D, who was not usually assigned to the D-hall, was not informed about the specific precautions needed for residents with COVID-19, and Licensed Practical Nurse (LPN) F admitted that the CNA would not know unless informed by a nurse. The Director of Nursing (DON) and Regional Nurse K acknowledged the lack of clarity in the signage and the need for better processes to inform staff about isolation precautions. The care plans for the residents did not include interventions to keep the doors open, which was necessary for some residents requiring supervision. Additionally, PPE was not available inside the rooms, and staff were observed wearing PPE from one resident's room into the hallway, contrary to the facility's policy and CDC guidelines. CNA S was seen placing a meal tray on a dirty bin and using the same PPE for multiple residents, further indicating lapses in infection control practices. Housekeeper R was observed placing garbage bags on the floor in the hallway, which was against the facility's policy. The DON confirmed that refuse bags should be placed in larger containers and that PPE should be removed before exiting a resident's room. The facility's policies on COVID-19 prevention and transmission-based precautions were not adequately followed, as evidenced by the improper use of PPE and the failure to maintain closed doors for residents under airborne precautions.
Failure to Post Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure that the contact information for the Office of the State Long-Term Care Ombudsman was posted in a manner accessible to residents and their representatives. This deficiency affected all 74 residents residing in the facility. During a confidential group meeting with eight residents, it was revealed that they were unfamiliar with the Ombudsman and did not know how to contact the office. Subsequent observations confirmed that the contact information for the Ombudsman was not posted. Interviews with the Nursing Home Administrator and the Assistant NHA revealed that there was no policy in place for posting this information.
Inaccurate Staffing Information Posted
Penalty
Summary
The facility failed to accurately reflect the actual hours worked by nursing staff, including nurses and certified nursing assistants, on their daily staffing postings. This deficiency was identified during a record review of the facility's daily staffing postings for specific dates, which revealed that the postings did not indicate the actual hours worked by staff for both day and night shifts. The postings were supposed to be updated 2 hours prior to the shift start but lacked adjustments for any changes, such as a nurse calling in sick. During an interview, the Director of Nursing (DON) acknowledged that the daily staffing posting included all staff present with hours worked, but it did not reflect adjustments for a nurse who was absent due to illness. This oversight resulted in necessary staffing information not being available to residents and visitors, potentially affecting all 74 residents within the facility.
Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
The facility failed to prevent, detect, and respond to an elopement involving two residents, resulting in the likelihood of serious harm. On the evening of 7/13/24, two residents, one with severe cognitive impairment and the other with intact cognition, eloped from the facility undetected. They were later found on a roadway by a facility visitor. The residents were wearing Wanderguard bracelets, which were intended to prevent such incidents, but the bracelets were removed by one of the residents, and the facility's alarm system did not alert staff due to a visitor holding the door open. The incident was compounded by staff inaction and a lack of proper response to the alarm system. A Licensed Practical Nurse (LPN) and a Registered Nurse (RN) were notified by a visitor about the residents being outside, but they did not hear the alarm due to frequent alarm activations caused by visitors entering and exiting the facility. The alarm had become a normal background noise, leading to complacency among staff. Additionally, a Certified Nursing Assistant (CNA) turned off the door alarm without checking for residents, as it was common practice to silence the alarm without verifying the situation. The facility's documentation and reporting of the incident were also flawed. The Director of Nursing (DON) and the Regional Director of Operations initially reported inaccurate information regarding the residents' location and the alarm's status. The Regional Director of Operations admitted to not reviewing the video footage until much later and acknowledged assumptions made in the initial report. This lack of accurate reporting and investigation further highlights the facility's failure to adequately address and prevent the elopement incident.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent two separate incidents of resident-to-resident sexual abuse involving four residents. In the first incident, a resident with quadriplegia and PTSD was inappropriately touched by another resident with severe cognitive impairment in the dining room. Despite the resident's request to stop, the inappropriate behavior continued, causing the resident to feel embarrassed and anxious. The incident was reported to the police, and it was noted that the resident had a history of being a victim of sexual assault, which exacerbated the psychological harm experienced. The second incident involved a resident with Alzheimer's Disease and another resident with vascular dementia. A CNA discovered one resident with exposed genitalia and the other standing nearby, possibly performing peri-care. The CNA reported the incident to the floor nurse and the Regional Director of Clinical Services, but there was no documentation of the event in the residents' medical records. The floor nurse admitted to not documenting the incident due to being overwhelmed with responsibilities. The facility's policies on abuse prevention and trauma-informed care were not effectively implemented, as evidenced by the lack of updated care plans and interventions for residents with known behavioral issues. The resident involved in the first incident had a care plan that prohibited dining room presence, yet this was not enforced. Additionally, the facility's communication methods for alerting staff to residents' behavioral histories were inadequate, relying on word-of-mouth rather than documented protocols.
Failure to Report Employee's Criminal Conviction
Penalty
Summary
The facility failed to report an employee's criminal conviction to the State Agency, which could potentially jeopardize the safety and welfare of all 69 residents. The issue was identified during a complaint investigation related to an employee, referred to as Confidential Staff R, who had a criminal conviction for brandishing a firearm in public. This information was unknown to the facility administration at the time of the survey. A confidential staff member expressed concerns about the safety of the residents due to this conviction. During interviews, the Nursing Home Administrator and Regional Directors of Clinical Services stated they were unaware of the conviction, believing the charges had been dropped. Confidential Staff R confirmed the conviction and claimed that previous administration had been notified, but no evidence of such notification was provided. The facility's employee handbook requires employees to notify the Facility Administrator of any arrests or convictions, and the facility's policy mandates reporting any court actions indicating an employee is unfit for service to the state nurse aide registry or licensing authorities.
Staffing Deficiency Leads to Unmet Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care, needs, and safety of its residents, resulting in unmet care needs and potential safety issues for all 69 residents. On a specific night shift, only one LPN and three CNAs were available to care for 80 residents, with the Director of Nursing aware of the situation but failing to provide assistance. Timecard reviews confirmed that one LPN was the sole nurse on duty for 4.5 hours with a census of 77 residents, contrary to the facility's staffing plan that required three licensed nurses on the midnight shift. Interviews with staff and residents revealed ongoing concerns with understaffing, particularly during night shifts. Residents reported delays in receiving incontinence care, daily hygiene, and skin and wound treatments. One resident frequently waited a week or more for a shower, while another had to wait extended periods for incontinence care. Additionally, a resident experienced a 14-day delay in surgical staple removal due to communication errors and low staffing. The Regional Director of Clinical Services acknowledged the staffing ratio was unacceptable and not in line with facility standards.
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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