Optalis Health And Rehabilitation Of Sterling Heig
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling Heights, Michigan.
- Location
- 38200 Schoenherr Road, Sterling Heights, Michigan 48312
- CMS Provider Number
- 235665
- Inspections on file
- 33
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Sterling Heig during CMS and state inspections, most recent first.
A resident with impaired cognition, cervical fracture, and muscle wasting was care planned and coded on the MDS as dependent for bed mobility and requiring a two-person assist. Despite this, a CNA provided perineal care alone and repositioned the resident, during which the resident moved and rolled out of bed. The resident subsequently complained of right leg pain and was later found to have a right femur fracture requiring surgery. The DOR confirmed the ongoing need for two-person assistance for safety, and the DON stated the expectation that two staff be present when a resident is care planned as a two-person assist, which did not occur in this incident.
A resident with Alzheimer's disease, severe cognitive impairment, restlessness, agitation, and aggression toward staff was admitted on a scheduled antipsychotic (Olanzapine) with physician orders for a psych consult related to aggressive behaviors. However, consent for psychiatric services was not obtained until about three months after admission, and no psych visit notes were available in the record or provided to surveyors. Social work staff reported that the standard process is to obtain psych consent at admission for residents on regular antipsychotics and to send a referral, but they could not explain why this was not done. This was inconsistent with the facility’s Behavioral Health and Management policy requiring necessary behavioral health care and services in accordance with the resident’s plan of care.
Surveyors identified several deficiencies in food service safety, including mold-like buildup and leaking equipment in the kitchen, undated and expired food items in storage, dishwashing equipment failing to reach required sanitization temperatures, expired ice machine filters, and a staff member failing to perform hand hygiene before handling food. These issues were confirmed by facility staff and were not in accordance with professional standards.
The facility did not keep the exterior dumpster area clean, as the ground was observed to be soiled with grease, sludge, and a milky liquid, along with a foul odor. Staff interviews confirmed that maintenance was responsible for cleaning the area, which had not been cleaned recently.
Surveyors identified that the facility did not maintain an active water management program, with required team members uninvolved and key monitoring activities, such as disinfectant checks and fixture flushing, not completed or documented. Additionally, staff failed to use required PPE, specifically gowns, during high-contact care for a resident on Enhanced Barrier Precautions, and did not perform hand hygiene during medication administration. The facility also lacked documentation of monthly infection control surveillance as required by policy.
Several residents with intact cognition reported that food was frequently cold and unpalatable, a concern also reflected in resident council meeting minutes. Food temperature testing confirmed that meals were served below the preferred temperature, and the use of foam containers due to a broken dishwasher contributed to the issue. The dietary manager and survey team acknowledged that the food was cold and not appetizing, failing to meet facility standards.
A resident with severe cognitive and physical impairments was initially placed on Contact Isolation for C. difficile and later required Enhanced Barrier Precautions (EBP) due to tube feeding. The care plan was not updated to reflect the change from Contact Isolation to EBP, despite physician orders and ongoing EBP signage, resulting in the care plan containing outdated information.
Three dependent residents with severe cognitive and physical impairments were not provided timely assistance with ADLs, including repositioning and brief changes, and did not have consistent access to their call lights. Observations showed residents left in bed for extended periods, call lights placed out of reach, and care needs unmet despite facility policy and staff awareness of required standards.
Two residents with severe cognitive impairment and high dependency were not provided with meaningful activities, despite documented preferences and care plans indicating the importance of such engagement. Both were observed in bed without any form of stimulation, and activity records showed no evidence of independent, intellectual, physical, social, or spiritual activities being offered or documented. Facility staff confirmed the lack of activity provision and documentation, contrary to facility policy.
A resident with a history of paraplegia and hypertension experienced ongoing post-menopausal vaginal bleeding, which was repeatedly documented by staff and reported by the resident. Despite recommendations for GYN follow-up, delays in arranging specialist care occurred due to transportation issues, scheduling difficulties, and unclear staff responsibilities. The resident's symptoms persisted and worsened over several months before a diagnosis of endometrial carcinoma was made following a delayed surgical procedure.
A resident requiring one to two-person assist for transfers and bed mobility fell from bed during incontinence care when a CNA, working alone, rolled the resident away from herself, resulting in injury and prolonged time on the floor. The facility's policy did not address fall prevention interventions.
A resident with severe cognitive impairment and total dependence on staff was observed receiving tube feeding at a rate lower than the physician-ordered amount, with no documentation to support the change. The tube feeding formula bag in use was also not changed within the required 24-hour period, contrary to facility policy. Nursing staff and the DON confirmed the expectation to follow physician orders and change bags as directed.
A resident with a history of cerebral infarction, hypertension, and muscle weakness was found with a medication cup containing two pills left on their overbed table, with no awareness of how long the medications had been there. An LPN had provided the medications but did not ensure they were taken, and there was no assessment for self-administration in the medical record. The DON confirmed that medications should not be left at the bedside, and the facility's policy did not address this issue.
Two CNAs did not have documentation of completing the required 12 hours of annual in-service training, including dementia care and abuse prevention. The facility's records were incomplete, and the staffing policy did not address the annual training requirement.
A resident with impaired cognition and severe malnutrition was admitted without pressure ulcers and placed on preventative measures. Later, an open area was discovered on the coccyx and groin, but the wound was not timely assessed, staged, or measured by the wound care team or licensed nurse, as required by facility policy. The wound care nurse awaited the weekly visit from the wound care nurse practitioner, who did not assess the wound before the resident's hospital transfer.
A resident who required extensive assistance for incontinence care experienced a delay of approximately one hour in being changed after having a soiled brief. The resident, who was cognitively intact, documented the incident and reported similar past issues. A grievance was filed by the resident's representative, and the CNA involved received a written warning for failing to complete the assigned task. The facility's policy required timely assistance based on resident needs, which was not followed.
A resident at high risk for pressure ulcers developed a Stage III ulcer due to the facility's failure to implement timely and effective preventative measures. Despite being identified as very high risk, the facility did not consistently follow prescribed skin care treatments, and necessary pressure-reducing support surfaces were not provided until after the ulcer worsened. Interviews with staff highlighted a lack of adequate preventative measures and support surfaces, and the facility's guidelines did not address necessary interventions.
The facility failed to provide and document adequate assistance with ADLs for two dependent residents. One resident with dementia and other health issues received minimal bathing assistance, while another with multiple sclerosis reported not knowing their shower schedule and expressed hygiene concerns. Both residents require significant assistance, and the facility acknowledged the need for improvement in documentation.
The facility failed to ensure safe food storage and maintain sanitary conditions in the kitchen. Observations included improperly cooled pork roasts, raw meat stored next to cooked meat, a soiled microwave, and expired food items in nourishment room refrigerators. The Certified Dietary Manager confirmed these issues.
A resident with Parkinson's Disease and Dementia had a peripheral intravenous line (PIV) that was not labeled, dated, or removed after completing IV therapy. The resident expressed discomfort and requested its removal. The facility's policy required the PIV to be removed if not used for 24 hours and the dressing to be labeled, which was not followed.
The facility failed to identify and document targeted behaviors, non-pharmacological interventions, and monitor side effects of a prescribed psychotropic medication for a resident. The resident was excessively sedated, often lethargic, and not consuming meals, with inadequate documentation and attempts of non-pharmacological interventions prior to medication increases.
The facility failed to store medication securely and monitor refrigerator temperatures properly. Unlocked medication carts were observed on multiple occasions, and temperature logs for a medication refrigerator were found to be incomplete for several dates. The facility's policies on medication storage and temperature monitoring were not adhered to.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow the resident’s care plan requiring two-person assistance for bed mobility, which resulted in a fall and subsequent right femur fracture. The resident was admitted with cervical fracture and muscle wasting/atrophy and had a BIMS score of 3/15, indicating impaired cognition. The most recent MDS documented the resident as dependent for bed mobility, and the ADL care plan dated 11/14/2025 specified a two-person assist for bed mobility. The Director of Rehabilitation confirmed that this resident required two staff during care for safety and remained a two-person assist for bed mobility. On 12/31/2025, during perineal care, a CNA provided care alone and repositioned the resident toward themselves. During this care, the resident, described by the LPN as very antsy, moved and rolled out of bed. An incident report documented that the resident complained of right leg pain, could not move the right lower leg, and was assisted back to bed by two staff, with vital signs taken and a STAT X-ray ordered. A subsequent physician readmission note dated 1/15/2026 documented that the resident was sent back to the hospital for possible trauma and was found to have a right femur fracture requiring surgery in the OR. The DON stated that the expectation is that when a resident is care planned as a two-person assist, there should be two people in the room, indicating that this expectation was not met at the time of the fall.
Failure to Timely Initiate Psychiatric Services for Resident on Antipsychotic Therapy
Penalty
Summary
The facility failed to provide necessary behavioral health care and services by not timely initiating psychiatric services for a resident admitted with significant behavioral and cognitive issues. The resident was admitted with Alzheimer's disease, restlessness, and agitation, and had a Brief Interview for Mental Status score of 0/15, indicating severely impaired cognition. The resident required staff assistance with bed mobility and transfers. Physician orders at admission included scheduled Olanzapine 5 mg orally every 12 hours as an antipsychotic and a psychiatric consult related to aggression toward staff, including throwing water at staff and refusing care, with consult start dates documented as 9/9/2024 and 10/13/2024. Despite these orders and the resident’s behavioral concerns, the medical record showed that consent to receive psychiatric services was not obtained until 12/12/2024, approximately three months after admission. No psychiatric visit notes were available in the record and were not provided to surveyors upon request. Social work staff interviewed during the survey stated that the usual process is to obtain consent for psychiatric services upon admission for residents on regular antipsychotic medications and to send a referral to the psychiatric provider, but they were unable to explain why this did not occur for this resident. The facility’s Behavioral Health and Management policy states that it is the policy of the facility to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents in accordance with their plan of care, which was not followed in this case.
Multiple Food Service Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in food service safety and sanitation within the facility's kitchen. There was a buildup of a black, mold-like substance on the backsplash of the dish machine, and the faucet assembly for the hose sprayer was leaking water. In the walk-in cooler, opened containers of ranch and Greek dressing were found undated, and a container of cut carrots and celery was dated beyond the acceptable range and appeared dried out. The Dietary Manager confirmed that the dressings should have been dated and the vegetables discarded. The dish machine was tested and found not to reach the required sanitization temperature, with the Dietary Manager acknowledging ongoing issues and a pending replacement. Additionally, ice machine filters in several locations were observed with expired dates, and the Maintenance Supervisor confirmed they were overdue for replacement. Further, a dietary staff member was observed entering the kitchen and beginning work on the lunch trayline without performing required handwashing. The Dietary Manager confirmed that handwashing should have occurred before handling food items. These observations were all in direct violation of specific sections of the 2022 FDA Food Code regarding cleanliness, equipment maintenance, food labeling and dating, temperature requirements for dishwashing, and hand hygiene.
Improper Maintenance of Exterior Dumpster Area
Penalty
Summary
The facility failed to maintain the exterior trash refuse area in a clean and sanitary condition. During observation, the ground around both dumpsters was found to be soiled with grease and sludge, and a milky liquid was pooled on the ground, accompanied by a foul, sour odor. The Dietary Manager indicated that Maintenance was responsible for cleaning the dumpster area, while the Maintenance Supervisor stated that the area is typically cleaned monthly and acknowledged it was likely due for cleaning again. These findings were confirmed through observation, staff interviews, and reference to the 2022 FDA Food Code requirements for refuse area maintenance. No specific residents were directly involved or affected at the time of the deficiency, but the condition of the refuse area had the potential to impact all residents, staff, and visitors.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to maintain an active and ongoing Water Management Program Plan (WMPP) to reduce the risk of Legionella and other opportunistic pathogens in the plumbing system. The WMPP required the establishment of a Water Management Team, including the Administrator, Maintenance Director, and Infection Preventionist, to implement policies, monitor performance, and review the program annually. However, interviews revealed that the Infection Preventionist and Administrator were not actively involved, with responsibilities deferred entirely to the Maintenance Supervisor. The plan had not been updated since 4/29/23, and required monitoring activities such as Point of Use Residual Disinfectant checks and fixture flushing logs were not being completed or documented, as confirmed by the Maintenance Supervisor. The facility also failed to ensure proper use of Personal Protective Equipment (PPE) during isolation precautions and did not complete departmental infection control surveillance. Observations showed that staff providing care to a resident on Enhanced Barrier Precautions (EBP) wore only gloves, not gowns as required by signage and physician orders, during high-contact activities such as bathing, brief changes, and PEG tube care. Additionally, a nurse was observed failing to perform hand hygiene during a medication pass. The Infection Control Preventionist confirmed that the required PPE was not used and that there was no documentation of monthly departmental infection control surveillance. The resident involved in the PPE deficiency had significant medical needs, including non-traumatic brain dysfunction, stroke, high blood pressure, severely impaired cognition, impaired range of motion, and total dependence on staff for activities of daily living. The resident was on EBP due to a PEG tube and had previously been on contact precautions for a stool-borne pathogen. The facility's infection surveillance policy required monthly data analysis and presentation to the QAPI committee, but no such documentation was available at the time of the survey.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food was served in a palatable manner and at a safe, appetizing temperature for several residents. Multiple residents with intact cognition reported that the food did not taste good and was frequently cold when served. These concerns were echoed by five residents during a group interview and were also documented in resident council meeting minutes over several months, which noted that meals were cold and the overall quality of food needed improvement. Specific residents interviewed had medical conditions such as cellulitis, heart disease, fracture of the right lower leg, muscle weakness, spondylolisthesis, heart failure, and depressive disorder. During an observation, a breakfast tray was tested for temperature and found to be below the preferred standard, with pancakes at 105°F and turkey sausage at 103°F, while the dietary manager indicated the desired temperature was 130°F or greater. The food was served in white foam containers due to a broken dishwasher, and the dietary manager acknowledged that these containers did not maintain food temperature well. Survey team members confirmed that the food tasted cold, which negatively impacted its palatability. The administrator confirmed that the expectation was for food to meet all temperature standards.
Failure to Update Care Plan Following Change in Isolation Precautions
Penalty
Summary
A resident with diagnoses including non-traumatic brain dysfunction, stroke, and high blood pressure was admitted to the facility and assessed as having severely impaired cognition, impaired range of motion, and total dependence on staff for all activities of daily living. The resident was initially placed on Contact Isolation Precautions for C. difficile shortly after admission, and later, a physician's order directed that Enhanced Barrier Precautions (EBP) be implemented every shift due to tube feeding. Despite these changes, the resident's care plan, last revised on the date of the initial isolation, was not updated to reflect the new EBP order. Observations during the survey confirmed that EBP signage was present on the resident's door, and interviews with the Infection Preventionist and DON revealed that the care plan should have been updated immediately to reflect the change from Contact Isolation to EBP. The care plan continued to reference the discontinued C. difficile precautions and did not include the current EBP requirements, indicating a failure to revise the care plan in accordance with the resident's updated care needs and physician's orders.
Failure to Provide Timely ADL Care and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide timely care and assistance with activities of daily living (ADLs), including repositioning, brief changes, and ensuring call light accessibility, for three dependent residents. Observations revealed that residents with severe cognitive impairment and physical limitations, such as those with diagnoses of non-traumatic brain dysfunction, stroke, high blood pressure, Alzheimer's, anxiety, depression, and dementia, were left in bed for extended periods without being repositioned or assisted out of bed. In multiple instances, residents' call lights were found out of reach, placed in closed drawers, and not accessible to the residents, despite facility policy requiring call lights to be within reach and functioning. One resident was observed multiple times over several days lying supine in bed, dressed in a hospital gown, with their breakfast tray untouched and the call light inaccessible. The resident expressed a desire to be out of bed but was not observed to have been assisted with transfers or repositioning, and staff confirmed the resident required a Hoyer lift and two-person assistance. Another resident was observed with long, dirty fingernails, a saturated brief, and reported not having been changed or repositioned recently. Staff interviews confirmed knowledge of the facility's two-hour repositioning and brief change policy, but observations indicated these standards were not consistently met. Additionally, a third resident was observed repeatedly activating their call light to request a brief change, but staff deactivated the call light without providing care and left the room. Agency staff admitted to not knowing the call light policy. Resident council meeting minutes documented ongoing concerns about untimely call light responses and lack of care. Interviews with nursing leadership confirmed expectations for timely call light response and care provision, but these were not consistently followed as evidenced by the observations and resident reports.
Failure to Provide Meaningful Activities for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate and meaningful activities for two residents with severe cognitive impairment and high dependency for activities of daily living. Both residents were observed in their rooms, in bed, without any form of engagement such as television, music, or other devices during multiple days and times. Record reviews indicated that both residents had documented preferences for activities such as listening to music, keeping up on the news, participating in group activities, and going outside. Care plans for both residents included encouragement to attend activities of their choice and assistance with attending special events or going off the unit. However, activity task documentation showed no evidence that any independent, intellectual, physical, social, or spiritual activities were provided to either resident during the reviewed period. Interviews with the Activities Director confirmed that room visits are intended for residents who are bedbound or do not leave their rooms, but there was no documentation of any such activities for the two residents in question. The Director of Nursing also confirmed that care activities should be provided and documented. Facility policies require an ongoing program of activities to meet the interests, choices, and preferences of each resident, supporting their physical, mental, and psychosocial well-being, as well as their right to participate in activities programs of their choice. Despite these policies, the facility did not provide or document activities for the two residents reviewed.
Failure to Provide Timely Gynecological Care for Resident with Abnormal Uterine Bleeding
Penalty
Summary
A deficiency occurred when the facility failed to provide timely gynecological care for a resident experiencing post-menopausal vaginal bleeding. The resident, who had a history of paraplegia, adjustment disorder, and hypertension, reported intermittent vaginal bleeding beginning in June 2024. Despite multiple progress notes documenting the resident's ongoing symptoms and requests for gynecological evaluation, there were significant delays in arranging appropriate specialist care. The initial assessment by the facility's nurse practitioner ruled out a urinary tract infection, but no further investigation was pursued for several months, even as the resident's symptoms persisted and sometimes worsened to heavy and painful bleeding. The resident's medical record showed repeated documentation of abnormal uterine bleeding, with recommendations for gynecological follow-up made by both the primary care provider and facility staff. However, logistical challenges, such as the need for stretcher transportation and difficulties in scheduling with a gynecologist who could accommodate the resident's bedbound status, led to multiple missed and rescheduled appointments. Interviews with staff revealed a lack of clarity regarding responsibility for scheduling these appointments, with the unit clerk unaware of the need for gynecological care until several months after the initial symptoms were reported. Social work staff indicated their role was limited to ancillary services, and the director of nursing was not familiar with the concern. Throughout this period, the resident continued to experience vaginal bleeding, which was observed by direct care staff and reported to nursing. The resident ultimately received a diagnosis of mixed high-grade endometrial carcinoma after a significant delay, following a surgical procedure performed under anesthesia. The facility's failure to ensure timely specialist evaluation and coordination of care, despite ongoing symptoms and repeated documentation of the need for follow-up, resulted in a delay in diagnosis and treatment of a serious medical condition.
Failure to Prevent Resident Fall During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a history of nontraumatic intracerebral hemorrhage, diabetes, and heart failure, who was cognitively intact and required assistance from one to two staff for transfers and bed mobility, sustained a fall during incontinence care. The resident was being assisted by a single CNA, despite requiring up to two-person assistance, and the CNA rolled the resident away from herself, resulting in the resident falling out of bed onto the floor. The resident reported pain to the right upper and lower extremities and remained on the floor for approximately 30-45 minutes while staff located a mechanical lift to return them to bed. Documentation and interviews confirmed that the CNA was working alone and did not follow proper transfer technique, which was acknowledged by both the ADON and DON. Further review revealed that the facility's provided policy, titled "Accident and Incident Report," did not address fall interventions or prevention measures. The incident was witnessed by staff who responded to a loud noise and found the resident on the floor. The resident expressed concerns about the adequacy of assistance during transfers and bed mobility, and the lack of a comprehensive fall prevention policy contributed to the failure to prevent the accident.
Failure to Properly Label, Date, and Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to properly label, date, and administer tube feeding as ordered for a resident with significant medical needs. The resident, who had diagnoses including non-traumatic brain dysfunction, stroke, and high blood pressure, was assessed as having severely impaired cognition and was dependent on staff for all activities of daily living, including eating. Observations over two days showed the resident receiving tube feeding at a rate of 40 ml/hr, while the physician's order specified a rate of 45 ml/hr. There was no documentation in the progress notes or orders to justify the deviation from the prescribed rate. Additionally, the tube feeding formula bag in use was observed to be dated from the previous day, exceeding the facility's policy to change the bag every 24 hours. Interviews with nursing staff and the DON confirmed that the policy requires tube feeding bags to be changed and dated every 24 hours and that physician orders should be followed precisely. The facility's own policy also mandates that tube feedings be administered according to current clinical standards and physician orders, including specific instructions for feeding type, rate, and bag changes.
Medications Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a medication cup containing two pills was observed on a resident's overbed table, with the resident unaware of their presence or how long they had been there. The resident, who was cognitively intact and required minimal assistance for activities of daily living, had been admitted with diagnoses including cerebral infarction, hypertension, and muscle weakness. There was no assessment in the medical record for the resident's ability to self-administer medications. The assigned LPN reported having provided the medications to the resident while attending to the resident's roommate but did not ensure the medications were taken at that time. The LPN was unaware of why the medications had not been taken and only observed the resident take them after being prompted. The facility's Director of Nursing confirmed that medications should not be left at the bedside and that nurses are expected to watch residents take their medications. The facility's policy on medication storage did not address the issue of medications being left at the bedside.
Failure to Ensure Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) completed the required 12 hours of annual in-service training, including education in dementia care and abuse prevention. Documentation for one CNA only included a skills competency checklist, which did not specify the number of training hours or confirm that dementia management and abuse prevention topics were covered. No training documentation was provided for the second CNA by the end of the survey. The facility relies on a vendor to provide training for agency CNAs through an app, and ongoing education is reportedly provided during work shifts. Additionally, a review of the facility's staffing policy revealed it did not address the requirement for 12 hours of annual in-service training for CNAs.
Failure to Timely Assess and Document Pressure Ulcer
Penalty
Summary
A resident with severe protein-calorie malnutrition and impaired cognition was admitted to the facility without any open pressure ulcers, as confirmed by an initial skin assessment conducted by the wound care team. Preventative measures, including a pressure-reducing mattress and repositioning protocols, were implemented due to the resident's decreased mobility. However, the resident later developed an open area on the coccyx and groin, which was first identified by a CNA and subsequently treated by nursing staff with cleansing, application of Medihoney, and a foam dressing. The medical doctor was notified, and a wound care consult was requested. Despite the development of the pressure ulcer, there was no evidence in the medical record that the wound was timely assessed, staged, or measured by the wound care team or licensed nurse, as required by facility policy. The wound care nurse stated that they were waiting for the wound care nurse practitioner, who visits weekly, but the practitioner did not assess the wound before the resident was transferred to the hospital. Wound care notes were requested but not provided by the end of the survey.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R702, who was cognitively intact and required extensive assistance from two persons for incontinence care. On a specific day, R702 experienced a delay in being changed after having a soiled brief. The resident reported waiting approximately one hour before being attended to by their assigned CNA, despite being told they would be changed sooner. This delay was documented by the resident in a notepad, which included dates, assigned staff, and wait times for care. The resident also expressed that they had experienced similar issues in the past and had attempted to plan their bowel movements around staff shifts due to long call light wait times. The incident was further corroborated by a grievance filed by the resident's representative, expressing concerns about the timeliness of incontinence care. The facility's records showed that the CNA involved received a written warning for failing to complete the assigned task and for carelessness in performing their job duties. The Director of Nursing acknowledged the incident but did not provide additional comments. The facility's policy on incontinence care stated that residents should receive assistance based on their requests or needs, which was not adhered to in this case.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to implement timely and effective interventions to prevent the development of a pressure ulcer for a resident identified as R701. Initially admitted without skin integrity issues, R701 had multiple diagnoses, including Vascular Dementia and Acute Kidney Disorder, and required extensive assistance for mobility and toileting. After a hospital transfer, R701 returned with a Stage II pressure ulcer, which later healed. However, the resident was at very high risk for pressure ulcers, as indicated by the Braden Scale, and the facility's treatment records showed lapses in the prescribed skin care regimen. Despite the high risk, the facility did not consistently follow the physician's orders for skin care, as evidenced by missed treatments on several dates. Additionally, the facility's documentation failed to identify any skin abnormalities in weekly evaluations, even as the resident's condition deteriorated to a Stage III pressure ulcer. The facility's interventions, such as the use of a custom care mattress, were not sufficient, and a low air loss mattress was not provided until after the ulcer worsened. Interviews with facility staff, including the Wound Care Nurse and Director of Nursing, revealed a lack of adequate preventative measures and support surfaces for R701. The facility's Skin and Wound Guidelines did not address the implementation of preventative interventions, contributing to the deficiency. The resident's care plan and physician orders were not updated to include necessary pressure-reducing support surfaces until the pressure ulcer had progressed to a more severe stage.
Failure to Provide and Document ADLs for Dependent Residents
Penalty
Summary
The facility failed to document and provide adequate assistance with Activities of Daily Living (ADLs) for two dependent residents, R902 and R903. R902, who has diagnoses including Dementia, Diabetes, and Heart Failure, was observed to have received only a bed bath on one occasion and a shower on another within a 30-day period, with other dates marked as Not Applicable. The resident's family expressed concerns about the lack of showers and assistance in getting out of bed. R902 is significantly cognitively impaired and requires 1-2-person assistance for bed mobility, transfers, and toileting. Similarly, R903, who has Multiple Sclerosis, Hypotension, and Bi-Polar Disorder, reported being unaware of their shower schedule and expressed concern about personal hygiene. A review of R903's records showed no documentation of showers or resident refusals, with all entries marked as Not Applicable. R903 also has significantly impaired cognition and requires assistance for transfers, toilet use, and personal hygiene. The Director of Nursing and a corporate employee acknowledged the need for improvement in documentation after reviewing the electronic medical records.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was safely stored and maintained sanitary conditions in the kitchen, as observed during an initial tour. In the walk-in cooler, two foil-covered pans with cooked whole pork roasts dated 5/13 were found with internal temperatures between 56-58 degrees Fahrenheit, which did not comply with the FDA Food Code requirements for cooling potentially hazardous food. The Certified Dietary Manager (CDM) was unable to locate the cooling logs used by kitchen staff. Additionally, raw ground beef was stored next to cooked beef patties and chopped beef, and a box of raw bacon was stored directly above the cooked beef, which violates the FDA Food Code's guidelines for preventing cross-contamination of food items. The CDM confirmed these storage issues during the inspection. Furthermore, the second-floor kitchenette had a microwave with dried, encrusted food debris, and the nourishment room refrigerators contained undated and expired food items, including containers with unknown substances and food items dated as far back as 4/7, which were not discarded as per the facility's Outside Food Policy dated 10/2/23.
Failure to Label, Date, and Remove Peripheral Intravenous Line
Penalty
Summary
The facility failed to label, date, and remove a peripheral intravenous line (PIV) for a resident who had completed their IV therapy. On 5/14/2024, the resident was observed with a PIV in their left wrist that was not labeled or dated, and an IV pump was present in the room. The resident, who had Parkinson's Disease and Dementia, stated they were not receiving any fluids through the PIV and expressed discomfort, requesting its removal. The medical record indicated that the resident had completed their IV therapy on 5/8/2024, but the PIV was still in place as of 5/14/2024. An interview with the Infection Control Preventionist (ICP) revealed that the PIV might have been left in due to the resident's hypotension, but the dressing should have been labeled and dated. The facility's policy on catheter insertion and care stated that the peripheral catheter should be removed if it has not been used for 24 hours or if the therapy is discontinued, and the dressing should be labeled with the date, time, and initials. The failure to follow these policies led to the deficiency observed during the survey.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to identify and document targeted behaviors, non-pharmacological interventions for behaviors, and monitor side effects of a prescribed psychotropic medication for one resident. The resident, who was admitted with diagnoses including Cerebral Infarction, Adjustment Disorder, Diabetes Type II, and Hypertension, was observed to be excessively sleeping and not consuming meals. Despite being severely cognitively impaired and requiring assistance for bed mobility and transfers, the resident's excessive sedation was not adequately addressed or documented in their care plan. The resident was prescribed Quetiapine upon discharge from the hospital, with the dosage being increased twice within a short period. Despite recommendations from a Medication Regimen Review to consider discontinuation or adding a supporting diagnosis, the resident continued to receive the medication. Observations and interviews with staff indicated that the resident was often lethargic, drowsy, and unresponsive, with multiple instances of the resident not participating in therapy and refusing meals. Interviews with the Nurse Practitioner and Director of Nursing revealed that non-pharmacological interventions were not adequately attempted or documented prior to the medication increases. The resident's care plan included interventions for psychotropic medication use, but there was no evidence of targeted or documented non-pharmacological attempts for behavior management. The facility's policy for unnecessary medications was not provided by the end of the survey.
Medication Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store medication in a safe and secure manner for two of the nine medication/treatment carts. On multiple occasions, medication carts were observed to be unlocked and unattended, allowing residents and staff to pass by them. Specifically, on 5/14/24, a treatment cart near room 152 was found unlocked, and on 5/15/24, a medication cart on the second floor was also observed to be unlocked. The unit manager, LPN C, was informed about the unlocked cart and instructed the assigned nurse to ensure it was locked. The Nursing Home Administrator confirmed that the facility's expectation is to lock the medication cart when not in use. The facility's policy on medication and treatment storage mandates that all medications and biologicals be stored in locked compartments under proper temperature controls, which was not adhered to in these instances. The facility also failed to monitor the temperatures of a medication refrigerator that stored drugs and biologicals. During an observation on 5/16/24, the One [NAME] Unit medication refrigerator's temperature log was found to have incomplete documentation for several dates in February, March, April, and May 2024. LPN B explained that the day shift nurse is responsible for completing the temperature log on the day shift, and the afternoon nurse is responsible for its completion on the afternoon shift. Both the Nursing Home Administrator and the Director of Nursing confirmed that the expectation is for the temperature logs to be completed daily. The facility's policy requires that logs be kept on each refrigerator and temperature levels be recorded daily by the charge nurse or other designee, which was not followed in this case.
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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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