Mission Point Nursing & Physical Rehabilitation Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Springs, Michigan.
- Location
- 400 Jeffrey, Cedar Springs, Michigan 49319
- CMS Provider Number
- 235294
- Inspections on file
- 24
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Mission Point Nursing & Physical Rehabilitation Ce during CMS and state inspections, most recent first.
A resident with a central venous port and dependence on renal dialysis was placed on enhanced barrier precautions (EBP) per physician order and care plan, requiring PPE use during high-contact care such as hygiene and repositioning. During care, a CNA scratched the resident’s bare back and repositioned her in bed without wearing gloves or a gown, despite acknowledging awareness of the EBP requirement, and the ICP confirmed PPE should have been used. Separately, the Maintenance Director reported the water management plan was still in progress, with no active disinfection sampling and only intermittent flushing of some fixtures. Surveyors observed unflushed fixtures, including a hopper, hose sprayer, and over-hopper sink that produced brown, discolored water when turned on, as well as capped water lines in a shower room that had not been flushed or removed, despite facility policies calling for defined control measures, testing protocols, and monthly disinfectant residual testing.
A resident experienced mental anguish and fear due to another resident's aggressive and inappropriate behavior, which the facility failed to adequately address. Despite staff observations and reports, the administration did not conduct a thorough investigation or implement sufficient protective measures, resulting in a deficiency in ensuring a safe environment.
A resident with a history of falls and severe cognitive impairment fell and sustained injuries due to inadequate supervision in an LTC facility. The resident required maximal assistance and was placed in a room far from the nurses' station, limiting staff's ability to monitor him closely. Despite known risks and family warnings, the facility did not provide sufficient supervision, resulting in the resident's fall and injury.
A facility failed to notify a resident's family member and DPOA of changes in the resident's condition, including an open area on the ankle and localized edema. The family member only learned of these issues by asking the nurse during a visit, despite the facility's policy to inform the DPOA of acute health changes.
The facility failed to follow its abuse policy for three residents, leading to unreported and uninvestigated incidents of resident-to-resident abuse. A resident with a history of aggressive behavior approached another resident aggressively, causing fear and distress. Staff intervened but did not report the incidents immediately, and the NHA did not conduct an investigation. Additionally, concerns about potential sexual abuse involving another resident were not investigated or reported to the state agency.
The facility failed to report allegations of abuse involving three residents to the State Agency in a timely manner. A resident with a history of aggressive behavior approached another resident aggressively, causing fear and distress, but the incidents were not reported as required. Additionally, an allegation of potential sexual abuse involving a severely cognitively impaired resident was not reported or investigated. The facility's staff, including the NHA and DON, did not follow the policy for reporting and investigating abuse allegations.
The facility failed to investigate allegations of abuse involving three residents, including aggressive behavior by a resident with dementia and potential sexual abuse concerns. Despite staff intervention and reports, the incidents were not thoroughly investigated, and the state agency was not notified, violating the facility's policy on abuse, neglect, and exploitation.
A facility failed to refer a resident for a Level II PASARR evaluation despite the resident exhibiting significant mental health issues, including verbal and sexual behaviors, and receiving antipsychotic medication. The resident's care plan addressed these behaviors, but no referral was made to the state mental health authority, as confirmed by interviews with the LMSW and DON.
A resident's aggressive behavior towards another resident was not documented by an LPN, despite being witnessed during two separate incidents. The LPN reported the incident to the NHA, who advised against documentation due to concerns about transfer referrals. This lack of documentation left the PA unaware of the incidents, hindering the evaluation and management of the resident's behavior.
A resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate behavior. Despite interventions in place, inadequate staffing levels during meals allowed the incident to occur without immediate intervention, resulting in the resident being unable to protect herself.
The facility failed to maintain a safe and sanitary environment, with issues such as raw wood shelving for clean supplies, deteriorating storage areas, and stained privacy curtains. A resident with COPD had a dusty fan, soiled curtain, and dusty windowsill, despite cleaning protocols. Housekeepers acknowledged the oversight, but deficiencies persisted.
The facility failed to provide palatable and appropriately heated food to several residents, leading to dissatisfaction and potential nutritional decline. Residents reported cold meals, unappetizing food, and inadequate seasoning, with meal trays transported in non-insulated carts. This issue affected residents with various health conditions, including stroke, diabetes, and dysphagia, highlighting a significant deficiency in meal service.
The facility did not ensure an effective training program for abuse prevention, leading to potential resident safety risks. The DON reported the absence of a staff development role and that she monitored online training completion. The facility lacked an on-site HR employee, with records kept at the corporate level. A former administrator noted annual online abuse education, last completed in the summer. A review showed 11 out of 66 employees had not started the required module, and the DON and a Unit Manager were still in progress. The facility failed to provide documentation of completed abuse training for all employees.
The facility failed to ensure timely meal service and call light response, affecting residents' dignity and care. Observations showed inconsistent meal service, with some residents waiting longer than others, contrary to the expected practice of serving one table at a time. A resident with Alzheimer's and another cognitively intact resident expressed dissatisfaction with the meal service order. Additionally, a resident reported long call light wait times, sometimes up to an hour, despite the facility's standard of a 3-minute response time.
A facility failed to update a care plan for a resident after a new diagnosis of dementia. The resident, who was cognitively intact, was diagnosed with dementia, but the care plan did not reflect this change. The Unit Manager confirmed the oversight during an interview.
A facility failed to consistently apply a brace for a resident with limited ROM, potentially leading to decreased ROM and contractures. The resident, with a history of stroke and paralysis, had a care plan requiring PROM exercises and a brace application, but observations showed the brace was often not used or improperly applied. The Rehab Director had to intervene to adjust the brace and perform ROM exercises, highlighting a lapse in following the facility's restorative nursing policy.
The facility failed to ensure proper PPE usage during a COVID-19 outbreak, with staff observed not wearing required masks and eye protection. A resident with COVID-19 was under droplet/contact precautions, but staff did not adhere to PPE requirements. Another resident on Enhanced Barrier Precautions due to a pressure ulcer received care without staff donning gowns, indicating a lack of awareness of EBP protocols.
A resident with multiple health conditions experienced issues with the call light system, which was not within reach and malfunctioned, leading to delayed staff response. The facility provided a doorbell pendant as an alternative, but it was ineffective due to its single ding and potential confusion with the front doorbell. Staff interviews and observations confirmed ongoing issues with the call light system, attributed to electrical problems within the wall.
The facility failed to protect residents from sexual abuse, involving three residents with cognitive impairments. A resident was found with another resident's hand up her shorts, and two other residents engaged in inappropriate sexual interactions despite guardians' consent for limited contact. Staff were unclear about boundaries, leading to multiple incidents of inappropriate contact. The facility's policies failed to prevent these incidents, resulting in a deficiency.
A cognitively impaired resident was allegedly abused by another resident in a LTC facility. The incident was witnessed by a CNA, who intervened and reported it. The facility's response included 15-minute checks and moving the victim, but staff reported these measures were insufficient, especially during short staffing. The facility did not conduct a thorough investigation or implement adequate interventions, leading to further abuse allegations.
The facility failed to maintain accurate medical records for two residents with cognitive impairments, leading to incomplete documentation of observed sexual interactions. Staff, including CNAs and an RN-UM, witnessed these interactions but did not document them in the EHR, believing existing care plans sufficed. A Social Services Manager also failed to document a conversation with a guardian about consent boundaries. This lack of documentation could impact the facility's ability to provide appropriate care.
Failure to Implement Enhanced Barrier Precautions and Maintain Water Management Controls
Penalty
Summary
The deficiency involves failure to properly implement enhanced barrier precautions (EBP) for a resident and failure to maintain an active, ongoing water management program to reduce the risk of Legionella and other opportunistic premise plumbing pathogens. A female resident with dependence on renal dialysis and a central venous port was under physician orders and care plan directives for EBP during high-contact care activities, including dressing, bathing, transferring, hygiene, linen changes, toileting/brief changes, and device or wound care. During observation, a CNA was seen scratching and rubbing the resident’s bare back and then repositioning her in bed without wearing gloves or a gown, despite acknowledging that the resident was on EBP and that PPE should have been used for this type of care. The Infection Control Preventionist confirmed that the resident was on EBP due to the central line and that PPE was required during such high-contact care activities. The deficiency also includes lack of a fully implemented water management program consistent with the facility’s own policy. The Maintenance Director reported that the water management plan was still a work in progress and that there were no established control measures and control limits in active use to reduce the risk of Legionella or OPPP, including no current sampling for disinfection levels. He stated that he maintained ice machines, cleaned the fountain in the summer, and flushed some taps every few days, but had not been flushing certain fixtures. Observation of a soiled utility room revealed a hopper with an attached hose sprayer and an over-hopper sink that had not been fully flushed; when the water was turned on, brown and discolored water came from both hot and cold lines and the sprayer. In a shower room, capped water lines extended several feet from the main water line and had not been flushed or removed. Review of the facility’s written Water Management Program and related documents showed that control measures, testing protocols, and control limits, including monthly disinfectant residual testing of hand sinks, showers, and whirlpool baths, were required but not being carried out as described.
Failure to Protect Resident from Mental and Psychosocial Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from mental and psychosocial abuse, specifically involving resident-to-resident interactions. Resident #106, who was cognitively intact with a BIMS score of 15/15, experienced mental anguish and fear due to the behavior of Resident #105. Resident #105, who also had a BIMS score of 15/15, exhibited behaviors such as staring, aggressive verbal interactions, and inappropriate sexual conduct, which were not adequately addressed by the facility. Staff members, including a registered nurse, a certified nursing assistant, and a licensed practical nurse, observed and reported Resident #105's behavior towards Resident #106. Despite these observations and reports, the facility's administration, including the Nursing Home Administrator, did not conduct a thorough investigation or implement sufficient measures to protect Resident #106. The facility's inaction led to Resident #106 feeling unsafe and fearful, impacting her ability to move freely within the facility. The facility's policies on abuse prevention and response were not effectively implemented, as evidenced by the lack of immediate action following the incidents. The Interdisciplinary Team discussed potential interventions, such as increased supervision and door alarms, but these were not promptly executed. The failure to address Resident #105's behavior and protect Resident #106 from mental and psychosocial abuse constitutes a deficiency in the facility's duty to ensure a safe environment for all residents.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement effective interventions to prevent falls for a resident with a history of multiple falls. The resident, who was severely cognitively impaired and required maximal assistance to stand and transfer, was admitted with diagnoses including unsteadiness on feet and repeated falls. Despite these known risks, the resident was placed in a room far from the common areas and nurses' station, limiting the ability of staff to provide close supervision. On the night of the incident, the staffing on the resident's hall was limited to one nurse and one CNA for 21 residents, which was insufficient to meet the resident's needs for close supervision. The resident was found on the floor after an unwitnessed fall, having sustained a fracture to the right humerus and thoracic vertebrae. Prior to the fall, the resident exhibited increased agitation, poor safety awareness, and attempted to transfer without assistance, indicating a need for more frequent monitoring than was provided. Interviews with staff and family members revealed that the resident was known to be confused and restless, particularly at night, and required immediate response to his needs. Despite this, the facility did not implement additional measures to ensure the resident's safety, such as increased supervision or frequent checks, leading to the fall and subsequent injury.
Plan Of Correction
Element 1: Resident #100 no longer resides at the facility. Element 2: All residents have the potential to be affected by this deficient practice. A 100% audit of current residents with falls in the last 30 days was completed on 3/24/25 to ensure residents' current needs, have appropriate notification and care plans were updated as needed. Element 3: NHA and DON reviewed the Fall prevention policy on 3/17/25 and deemed it appropriate. The DON/designee will re-educate all licensed nurses on fall prevention policy prior to 3/24/2025. Any licensed nurses not re-educated by 3/24/25 will not work until re-education is completed. An Ad-Hoc QAPI meeting will be held on 3/20/25 to review fall reduction policies and the plan of correction. Medical Director reviewed. Element 4: DON/Designee will review newly admitted residents and residents with falls weekly during clinical meetings for three (3) months to ensure interventions were implemented and appropriate, and notifications completed. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. DON is responsible for achieving and sustaining compliance.
Failure to Notify Responsible Party of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the responsible party of a change in care or condition for one of the residents reviewed for notification of change. This deficiency involved a resident with a history of Huntington's disease, dementia, and adult failure to thrive, who was found to have an open area on the right ankle and was diagnosed with localized edema. Despite these changes in the resident's condition, the family member and Durable Power of Attorney (DPOA) reported not being informed by the facility since the resident's admission. The family member expressed frustration over the lack of communication, stating that she only became aware of the resident's new health issues when she inquired with the resident's nurse during a visit to the facility. The Director of Nursing confirmed that it is the facility's policy to inform a resident's DPOA of any acute changes in health, which was not adhered to in this case.
Plan Of Correction
Element 1: Resident #102 resides in the facility and has a FM / DPOA who was notified of resident's condition on 3/17/2025. Element 2: All residents reviewed in Clinical stand-up meeting on 3/19/25 to identify any change of condition in real time. DPOA notified of any changes identified. Element 3: All Nursing staff will be re-educated by the QAPI Development Coordinator on the Change in Condition policy by 3/24/2025. Any staff member that has not been re-educated by 3/24/2025 will be removed from the schedule until re-education is completed. Element 4: DON / designee will review the clinical dashboard daily, Monday-Friday to identify changes of condition and ensure notifications are completed appropriately. The Director of Nursing is responsible for achieving and maintaining compliance.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to operationalize its abuse policy and procedure for three residents, resulting in staff not reporting resident-to-resident observations of abuse to the Nursing Home Administrator (NHA) immediately, the facility not initiating a thorough investigation, and the facility not reporting allegations of abuse to the state agency. This deficiency involved Resident #105, who had a history of inappropriate physical touching and aggressive verbal behaviors, and Resident #106, who was the target of Resident #105's aggressive actions. Despite staff interventions during incidents where Resident #105 approached Resident #106 aggressively, the incidents were not reported immediately, and no investigation was initiated. Resident #105, who was cognitively intact, exhibited aggressive verbal behaviors towards Resident #106, causing fear and distress. Staff members, including an LPN and a Physical Therapy Assistant, witnessed these incidents and intervened to redirect Resident #105. However, the incidents were not documented or reported to the NHA immediately. The NHA did not conduct an abuse investigation, believing the staff's reactions were overly reactive and that Resident #106 was not significantly affected. This inaction led to a failure in addressing the potential abuse and ensuring the safety of Resident #106. Additionally, concerns were raised about potential sexual abuse involving Resident #107, who was severely cognitively impaired. A family member reported these concerns to a Unit Manager, but the facility did not investigate further or report the allegations to the state agency. The Director of Nursing confirmed that the facility's abuse policy was not followed, as there were no obvious signs of injury, and the resident stated they felt safe. This lack of action and failure to follow the facility's abuse policy resulted in the deficiency noted in the report.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Report Allegations of Abuse Timely
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner for three residents, resulting in the potential for additional allegations to go unreported and delayed investigation. Resident #105, who has a history of inappropriate physical behavior and aggressive tendencies, was involved in two incidents with Resident #106. During these incidents, Resident #105 approached Resident #106 aggressively, causing fear and distress. Despite staff intervention, the incidents were not reported immediately as required by the facility's policy. Resident #106, who was the victim of Resident #105's aggressive behavior, reported feeling scared and harassed. The facility's Unit Manager and Nursing Home Administrator were aware of the incidents but did not conduct an abuse investigation or report the incidents to the state agency. The Nursing Home Administrator believed that staff were overreacting to Resident #105's behavior and did not consider the incidents as abuse. Additionally, there was an allegation of potential sexual abuse involving Resident #107, who is severely cognitively impaired. A family member reported concerns about a male staff member to the Unit Manager, but the facility did not report the allegation to the state agency or conduct a further investigation. The Director of Nursing confirmed that the facility did not report the allegation, which was a violation of the facility's policy to protect residents and report all alleged violations immediately.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/2025 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving three residents, leading to a potential risk of further abuse. Resident #105, who had diagnoses including depression, paraphilia, unspecified dementia with psychotic disturbance, and anxiety, was involved in an incident with Resident #106. Resident #106 reported feeling harassed and fearful after Resident #105 approached her aggressively on two occasions, despite staff intervention. LPN H, who witnessed the incidents, did not report them immediately but later informed the Nursing Home Administrator (NHA) A, who decided against documenting the incident to avoid affecting admission referrals for Resident #105. Additionally, a family member of Resident #107's roommate reported concerns of potential sexual abuse by a male staff member. Unit Manager (UM) E was informed of these concerns but did not conduct a full investigation, as it was determined there was no immediate concern due to limited male staff presence. The Director of Nursing (DON) B confirmed that a full investigation was not completed for the sexual abuse concerns involving Resident #107. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of all alleged violations to the facility administrator and state agency. However, in these cases, the facility did not adhere to its policy, as the allegations were not thoroughly investigated, and the state agency was not notified. This failure to act according to policy resulted in a deficiency citation for the facility.
Plan Of Correction
Element 1: Resident 106 remains in the facility. Resident's care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Resident 105 no longer resides in the facility. Resident 107 no longer resides in the facility. Element 2: All residents have the potential to be affected by this practice. Alert and Oriented residents with BIMS eight (8) and above were interviewed by Guardian Angels to ensure no unreported allegations of abuse exist. Residents with a BIMS score of less than eight (8) had a skin assessment completed, no other concerns identified. Element 3: The RDO re-educated the NHA on the abuse policy on 3/17/25. The NHA reviewed the abuse policy on 3/17/25 and deemed it appropriate. All staff will be re-educated by the SDC/Designee on the abuse policy by 3/24/2025. Any staff member not re-educated by 3/24/25 will be removed from the schedule until re-education is complete. Element 4: The NHA / designee will audit/interview five (5) staff members regarding abuse/neglect knowledge and reporting guidelines per week for four (4) weeks and then monthly for three (3) months. All findings will be reported to the QAPI committee monthly. The NHA is responsible for achieving and sustaining compliance.
Failure to Refer Resident for Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a referral was made for a Level II PASARR evaluation for a resident who exhibited significant mental health issues. The resident, who was admitted with diagnoses of depression and anxiety, was cognitively intact but displayed verbal behaviors such as threatening, screaming, and cursing at others. The resident was also receiving antipsychotic medication. Despite these behaviors and the initiation of antipsychotic medication, the facility did not refer the resident for a Level II PASARR evaluation, which is required when a resident exhibits a newly evident or possible serious mental disorder. The resident's care plan included interventions for inappropriate physical and verbal behaviors, and the resident was diagnosed with paraphilia. A behavioral health provider noted episodes of sexual behaviors, auditory hallucinations, and delusional thinking. Despite these significant changes, the facility did not report them to the state mental health authority for a Level II PASARR assessment. Interviews with the Licensed Medical Social Worker and the Director of Nursing confirmed that no referral had been made, indicating a failure to address the resident's psychosocial needs adequately.
Plan Of Correction
Element 1: Resident #105's change in condition was submitted to OBRA on 3/17/25. Element 2: A facility-wide audit was completed by the regional social worker on 3/13/25 to ensure that no significant diagnosis or medications have been changed. Any changes identified were corrected. Element 3: The resident assessment/coordination with PASARR program policy was reviewed by the NHA and deemed appropriate on 3/17/25. The social services director/designee was re-educated regarding the resident assessment/coordination with PASARR program policy on 3/17/25. Element 4: All residents reviewed in daily clinical meeting for any new significant mental illness diagnosis or medications weekly x4 weeks and monthly 3 months. Any diagnosis or medications requiring a Level II assessment will be submitted to OBRA by social services director/designee. The NHA is responsible for achieving and sustaining compliance.
Failure to Document Resident Altercations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of the residents reviewed, specifically regarding the documentation of abusive behaviors. On February 26, 2025, Resident #105 was involved in two separate incidents where they aggressively confronted another resident, Resident #106, in the hallway and later in the therapy gym. Despite witnessing these altercations, LPN H did not document the incidents in Resident #105's medical records. LPN H reported the incident to the Nursing Home Administrator (NHA) the following day but was instructed not to document it due to concerns about the impact on Resident #105's transfer referrals. The lack of documentation meant that the Physician's Assistant (PA) responsible for managing Resident #105's behaviors was unaware of the incidents and could not evaluate or adjust interventions accordingly. The Director of Nursing (DON) confirmed that staff are expected to report and document any potential abuse immediately, but this protocol was not followed. The failure to document these incidents resulted in a lack of proper evaluation and monitoring of Resident #105's behaviors, potentially compromising the safety and well-being of other residents.
Plan Of Correction
Element 1: Resident #105 no longer resides at the facility. Resident #106 care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Element 2: All residents have the potential to be affected by this practice. IDT team reviewed 24-hour on 3/19/2025 to review all residents and ensure information was not missing from medical record. Element 3: Clinical staff have been re-educated by the DON/designee on Nursing documentation of healthcare data from Perry and Potter 10th edition pg 51- 53; Legal guidelines for documenting and reporting and recording. to include timely documentation of resident condition variances. Those not receiving the education prior to date of allegation of compliance 3/24/25 will complete the education prior to their next scheduled shift. Element 4: Facility IDT will review the electronic health record during facility daily clinical meeting Monday through Friday with a lookback review done on Monday for any weekend documentation. The DON/designee will follow up on any identified missing or incomplete documentation. Any incomplete documentation will be resolved upon identification. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. The Administrator is responsible for achieving and sustaining compliance.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident. The incident involved a resident with severe cognitive impairment due to dementia and anxiety, who was unable to effectively communicate or understand situations. This resident was found outside the south cafe door when another male resident, who was cognitively intact, was seen with his hand in her pants. Despite attempts to roll away, the male resident grabbed her hair and pulled her back. Witnesses reported the female resident was crying and appeared helpless during the incident. The male resident had a documented history of inappropriate sexual behavior, including making sexual requests to staff and other residents, exposing himself, and masturbating in public areas. Despite these behaviors, the facility's care plan for him included interventions such as having two staff members present during personal care and informing him that his behavior was inappropriate. However, these measures were insufficient to prevent the incident with the female resident. Staffing levels during the incident were inadequate, with only one CNA and one nurse present on the unit, as the second CNA was assisting in the dining room. This lack of supervision contributed to the male resident's ability to engage in inappropriate behavior without immediate intervention. Interviews with staff and witnesses confirmed that the male resident's behavior was escalating, and the facility's response was insufficient to protect the female resident from harm.
Environmental and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During a tour of the central supply storage, raw wood shelving was used for storing clean and sanitary supplies, which were stained, chipped, and pitted. The outside storage barn had openings and rusted areas that could allow pest entry, and the outside storage shed had a deteriorating roof dropping debris onto stored equipment. In the main hall soiled utility room, brown water was discharged from old water lines, and privacy curtains in the west hall spa room were stained. The east hall spa room had a shower chair with crusty debris, and the south hall spa room had a shower chair with a smeared disposable wipe. Additionally, the microwave in the cafe had pitting and scuffing, and brown-tinged water was observed in the south hall soiled utility room. Resident #22, who was cognitively intact and had chronic obstructive pulmonary disease, was found to have a personal fan caked with dust and debris, a soiled privacy curtain, and a dusty windowsill in his room. Despite the facility's cleaning protocol, these issues persisted over multiple days. Housekeepers reported that resident rooms were cleaned daily, including wiping down surfaces and inspecting privacy curtains, but the deficiencies in Resident #22's room were not addressed. The facility's Room Clean / Deep Clean / Discharge Check Off Sheet indicated that staff should clean and dust various areas, but these tasks were not completed in Resident #22's room.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable food products to five out of seven residents reviewed for food palatability, resulting in dissatisfaction with meals and the potential for nutritional decline. The Resident Council Minutes from late November and early December 2024 revealed ongoing concerns about cold food and lack of flavor. Interviews with residents confirmed these issues, with reports of cold meals, unappetizing food, and inadequate seasoning. Residents expressed dissatisfaction with the temperature and taste of the food, noting that the meal trays were transported in non-insulated carts, contributing to the problem. Resident #8, who is cognitively intact and has a history of stroke, protein-calorie malnutrition, and diabetes, reported that the food was often cold and unpalatable, with specific complaints about the coffee and certain meals being dry or hard. Resident #9, also cognitively intact, mentioned that the quality of food varied depending on the kitchen staff and that meals were sometimes cold when served in her room. Resident #4, with cognitive communication deficits and other health issues, expressed that her food was unappealing and cold, and the lack of seasoning did not improve the taste. Resident #12, with Parkinson's disease and dysphagia, had family members report that the food was cold and lacked options for softer foods, leading to her refusal to eat. Resident #22, who is cognitively intact and has Type 2 Diabetes Mellitus, reported that the food was not consistently served at a palatable temperature, with meat often being tough. These consistent reports from residents highlight a significant deficiency in the facility's ability to provide meals that meet the residents' expectations for temperature and taste, potentially impacting their nutritional intake.
Deficiency in Staff Training for Abuse Prevention
Penalty
Summary
The facility failed to maintain and monitor an effective training program for abuse prevention for all staff, which resulted in the potential for decreased resident safety. During an interview, the Director of Nursing (DON) reported that the facility lacked a staff development role and that she was responsible for monitoring the completion of assigned online trainings. The facility also did not have an on-site human resources employee, with training records being maintained at the corporate level. A former Nursing Home Administrator indicated that abuse education was completed online annually, with the last session occurring in the summer. A review of the Course Completion History for the Abuse, Neglect, and Exploitation module revealed that it was due on July 31, 2024, and out of 66 employees, 11 had not started the module, while the DON and a Unit Manager were still in progress. The facility was unable to provide documentation confirming the completion of abuse training by all employees by the time of the survey exit.
Deficiency in Meal Service and Call Light Response Times
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity during meal times for three residents. Observations revealed that during lunch service in the main dining room, residents were not served in a consistent order, leading to some residents waiting longer for their meals. For instance, Resident #14, who has Alzheimer's disease and moderate cognitive impairment, was observed waiting longer than others at her table to be served. Resident #17, who is cognitively intact, expressed frustration about the lack of a specific pattern in meal service, noting that it was bothersome to see others served while she had to wait. The Unit Manager confirmed that staff are supposed to serve one table at a time, but this was not being followed. Additionally, Resident #60 reported long wait times for call light responses, sometimes up to an hour, which was corroborated by Resident Council Minutes and staff interviews. The expectation set by the facility was for call lights to be answered within 3 minutes or as soon as possible. The Director of Nursing confirmed this standard, but residents had complained about the delays, indicating a failure to meet the expected response times.
Failure to Update Care Plan Following Dementia Diagnosis
Penalty
Summary
The facility failed to update the care plan for a resident following a new diagnosis of dementia. The resident, who was cognitively intact with a BIMS score of 15/15, was diagnosed with dementia on 10/8/24. However, a review of the resident's care plan revealed no documentation of this diagnosis. During an interview, the Unit Manager confirmed the omission and acknowledged that the care plan should have been updated to reflect the resident's new diagnosis.
Inconsistent Application of Brace for Resident with Limited ROM
Penalty
Summary
The facility failed to consistently apply a positioning device, specifically a brace, for a resident with limited range of motion (ROM), which could potentially lead to decreased ROM, contractures, and pain. The resident, who was admitted with diagnoses including stroke, paralysis, and muscle weakness, had a care plan that required passive range of motion (PROM) exercises to the right hand and wrist before applying a right resting hand splint. Observations revealed that the resident was often without the brace or it was improperly applied, despite orders to monitor for skin breakdown and apply the brace every shift. During observations, the resident was seen without the brace or with it improperly applied, and the Rehab Director had to intervene to adjust the brace and perform ROM exercises. The Rehab Director noted that the brace was to be applied by CNAs each day, and there was no record of the resident refusing the brace. The facility's policy on restorative nursing emphasized maintaining or improving residents' abilities, including the use of assistive devices and ROM exercises, but these were not consistently implemented for the resident in question.
Inadequate PPE Usage During COVID-19 Outbreak and EBP Non-Compliance
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was utilized as required during a COVID-19 outbreak, leading to potential infection control deficiencies. During observations, multiple staff members were seen without surgical masks, despite the requirement due to the outbreak. Specifically, a CNA was observed entering a COVID-positive resident's room without proper eye protection, and a Registered Dietician entered the same room without any PPE, despite clear signage indicating droplet precautions were necessary. The Director of Nursing reported that staff were informed of PPE requirements through a messaging system, but compliance was not observed. Resident #40, who was COVID-positive, was under droplet/contact precautions, requiring staff to wear gowns, N95 masks, eye protection, and gloves. However, staff were observed not adhering to these requirements. For instance, a CNA was seen wearing an N95 mask over a surgical mask but did not use eye protection. Additionally, a Licensed Practical Nurse was observed with an N95 mask that did not cover her nose, and a Registered Dietician entered the resident's room without donning any PPE, despite the resident still being under isolation precautions. Resident #17 was on Enhanced Barrier Precautions (EBP) due to a stage two sacral pressure ulcer, requiring gowns and gloves for direct care. However, during an observation, an LPN and a CNA provided care without donning gowns, indicating a lack of awareness of the EBP requirements. Interviews with staff revealed confusion and lack of awareness regarding the current precautions for Resident #17, despite the presence of a sign on the door and a care plan indicating the need for EBP. The Unit Manager confirmed that EBP was initiated for the resident due to the new wound, but staff failed to comply with the necessary precautions.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to maintain a functioning call light system for a resident, which could potentially result in delayed response and negative outcomes. The resident, who had a history of fracture, unsteadiness, chronic pain, muscle weakness, osteoporosis, hearing difficulties, and other conditions, was observed with a call light system that was not within reach. The resident expressed concerns about staff not responding promptly to her call light, and it was noted that the call light system only emitted a single ding, which could be confused with the front doorbell, and did not illuminate the light above the door. Interviews with staff revealed that the call light system had been malfunctioning, with reports of a short in the system and issues with the electrical wiring within the wall. The facility had provided the resident with a doorbell pendant as an alternative alert system, but this was not effective as it only dinged once and could be easily missed. Observations confirmed that the call light was not consistently working, and staff had to repeatedly plug and unplug the system to get it to function. A work order had been submitted to address the issue, but it had not been resolved by the due date.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, involving three residents with varying degrees of cognitive impairment. Resident #101, who was severely cognitively impaired, was found in a situation where another resident, Resident #102, who was cognitively intact, had his hand up her shorts. This incident was witnessed by a CNA who immediately intervened and reported it to the Director of Nursing. Resident #101 appeared confused and unaware of the situation, and the facility's response was to separate the residents and instruct Resident #102 to stay away from Resident #101. Additionally, the facility did not adequately manage the interactions between Resident #103 and Resident #104, both of whom had cognitive impairments and guardianship. Despite the guardians' consent for limited physical contact, the facility allowed these residents to engage in sexual interactions, including fondling and being found in compromising situations. Staff members were unclear about the boundaries set by the guardians and often allowed the residents to be alone in private rooms, believing they were permitted to have sexual interactions. This lack of clear communication and documentation regarding the guardians' consent led to multiple incidents of inappropriate contact between the residents. The facility's policies and procedures failed to prevent these incidents, as there was no clear documentation or communication regarding the boundaries of the residents' interactions. Staff members were not adequately informed or trained on how to handle the situation, leading to confusion and inappropriate actions. The facility's abuse policy, which was supposed to prevent non-consensual sexual contact, was not effectively implemented, resulting in the failure to protect the residents' rights to be free from abuse.
Inadequate Investigation and Prevention of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of resident-to-resident sexual abuse and prevent further potential abuse. The incident involved a cognitively impaired resident who was allegedly abused by another resident who was cognitively intact. The incident was witnessed by a CNA who immediately intervened and reported it to the Director of Nursing (DON). Initial interventions included separating the residents, placing them on 15-minute checks, and moving the victim to another room. However, the facility did not conduct a comprehensive investigation or implement sufficient measures to prevent further incidents. Interviews with staff revealed that the only intervention consistently reported was the 15-minute checks on the alleged perpetrator. Staff expressed concerns about the effectiveness of these checks, especially during times of short staffing. The facility did not assess the alleged perpetrator for underlying behaviors or triggers, nor did they update the care plan to address the potential for further incidents. The Social Services Manager and other staff confirmed that no additional interventions were considered to prevent the alleged perpetrator from targeting other residents. The facility's investigation was deemed inadequate as it did not substantiate the abuse, and no further assessments or interventions were conducted. The DON and former Nursing Home Administrator (NHA) acknowledged the lack of documentation and assessment of the alleged perpetrator's behaviors. The facility's failure to implement comprehensive interventions and conduct a thorough investigation resulted in additional allegations of abuse by the same resident, highlighting a significant deficiency in the facility's response to the initial incident.
Failure to Document Resident Interactions and Update Care Plans
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in the potential for staff and providers not having all pertinent information to care for them. Resident #103, diagnosed with Alzheimer's disease, and Resident #104, diagnosed with cognitive communication deficit and Wernicke's encephalopathy, both had care plans indicating a potential for behaviors that sound or appear sexual in nature. Despite these care plans, multiple incidents of sexual interactions between the two residents were observed by staff but not documented in their electronic health records (EHR). Certified Nursing Assistants (CNAs) and a Registered Nurse Unit Manager (RN-UM) reported witnessing sexual interactions between the two residents in the facility's courtyard. These incidents were reported verbally to supervisors but were not documented in the residents' EHRs. The RN-UM believed documentation was unnecessary due to the existing care plans that required redirection of such behaviors. Additionally, a Social Services Manager discussed consent boundaries with Resident #104's guardian but failed to document the conversation or update the care plans accordingly. The Nursing Home Administrator (NHA) became aware of an alert in the EHR regarding an incident involving the two residents, but upon investigation, found the documentation to be inaccurate. The lack of documentation and communication among staff members led to incomplete medical records, which could hinder the facility's ability to provide appropriate care and interventions for the residents involved.
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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