Optalis Health & Rehabilitation At Kent-crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Rapids, Michigan.
- Location
- 2320 E Beltline Se, Grand Rapids, Michigan 49546
- CMS Provider Number
- 235103
- Inspections on file
- 37
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation At Kent-crossing during CMS and state inspections, most recent first.
The facility failed to prevent significant medication errors when an antipsychotic injection order for a resident with schizophrenia was mis-transcribed in the EMR, causing multiple haloperidol decanoate injections to be given within a short period instead of once every 21 days, despite an LPN questioning the order and being instructed by a supervisor to administer it as written; the resident’s family and therapy staff later observed increased tremors, confusion, and functional decline. Another resident with schizoaffective disorder had a scheduled haloperidol decanoate injection documented as refused, but the LPN did not notify the SW, DON, or provider as required, and the injection was never re-offered, coinciding with documented behavioral decompensation, increased delusions, refusals of care, and falls. On a separate occasion, an agency LPN left mid-shift without notice and failed to pass HS medications, resulting in several residents not receiving ordered doses of antipsychotics, anti-seizure medications, opioids, a beta-blocker, and a diuretic, which the facility categorized as significant medication errors due to the potential to jeopardize health and safety.
An LPN left mid‑shift without notifying anyone, locking medication cart keys in the med room and resulting in multiple residents not receiving their scheduled HS medications. Staff discovered the abandoned keys around midnight and contacted the on‑call nurse, and a replacement RN later confirmed that no HS medications had been administered for a group of rooms and that it was too late to give them. Despite facility records documenting the missed medications and the event being identified as potential neglect related to medication administration delay, facility leadership determined it did not meet criteria for reportable neglect and did not make the required reports to the State Survey Agency or nurse licensing authorities as outlined in the facility’s abuse and neglect reporting policy.
Surveyors found widespread failures in medication administration, documentation, and post‑fall monitoring. An LPN documented giving multiple medications and a daily weight to a cognitively intact resident with renal disease that were not actually provided, and later did not return with a held dose as requested. The same resident received midodrine without vital signs being taken or any BP parameters in the order. Another resident with diabetes missed a scheduled Ozempic injection when the nurse could not locate the drug and did not notify the provider or reorder it. Required neuro checks after unwitnessed falls were incompletely documented for a resident who had multiple falls with head involvement. An RN charted psychosocial observations and dialysis‑site assessments for a resident who was off‑site at dialysis for the entire shift. In a separate event, an agency LPN left mid‑shift without notice, resulting in numerous residents not receiving scheduled HS medications. Another resident with conjunctivitis had persistent eye drainage and redness after multiple missed or undocumented doses of ordered antibiotic eye drops, with no evidence that the provider was informed of the missed doses or ongoing infection.
Surveyors observed multiple environmental and sanitation deficiencies throughout the facility, including damaged walls and cabinetry, deteriorated wall junctures, and evidence of water damage and possible pest access points in soiled utility rooms and pantries. A mop sink in a soiled utility room emitted sewer gas due to an evaporated p-trap and was connected to a chemical pre-dispense unit with faucet handles left on, creating undue back pressure on the internal vacuum breaker. Spa and shower areas contained unclean equipment, such as shower chairs with matted hair or brown and yellow staining, a shower bed with black staining under the mat, and a spa tub with wet linens and toilet paper left inside. Additional findings included bubbling and chipping paint and drywall from routine roof leaks in an activity room, a leaking valve in a converted linen room, a leaking hopper in a soiled utility room, and accumulated debris and black spots on furniture and HVAC units in a lounge.
Oxygen not provided at ordered flow rates. Two residents with significant respiratory conditions were observed receiving oxygen inconsistently with physician orders. One resident with severe cognitive impairment and respiratory failure was repeatedly found with her concentrator set below the ordered continuous flow rate, and at times had no oxygen tubing on while away from her room with an empty portable tank. Another resident with multiple chronic cardiopulmonary conditions was observed with her concentrator set above the ordered 2 LPM, and an agency RN confirmed the setting was incorrect.
A cognitively intact resident with end stage renal disease and chronic pain repeatedly called for help with the call light on while an LPN at the nearby med cart told her to wait, loudly sighed at her calls, and referred to her as a drug addict and drug seeking within earshot. The LPN entered the room without knocking or identifying herself, interrupted the resident’s 911 call for help by telling the dispatcher the resident was fine, offered only Tylenol for reported pain without assessing it or providing non-pharmacologic interventions, and left despite the resident stating she still needed help. The resident later reported feeling ignored, overhearing staff label her a drug addict, and feeling she was treated like “ghetto trash,” contrary to the facility’s dignity policy requiring residents be treated with dignity and respect at all times.
Surveyors found that the facility failed to obtain proper consent and provide adequate notification to resident representatives for care and treatment involving two residents. One resident with schizoaffective disorder and documented inability to make medical decisions received antipsychotic and antianxiety medications based on consent recorded as obtained from the resident, even though the resident’s representative did not consent. Another resident with paranoid schizophrenia and co-guardians was sent to offsite medical and mental health appointments without the co-guardians being informed or present, and in one instance the resident attended alone. The staff member responsible for scheduling appointments described informal and undocumented methods of notifying the guardian, and could not provide evidence that the guardian had been properly informed.
A resident with paranoid schizophrenia and cognitive deficits received multiple incorrect doses of Haloperidol Decanoate after an LPN transcribed the order as a daily IM injection over several days instead of a single injection every 21 days. The error was first uncovered when an outside mental health nurse reviewed the resident’s medications and learned from an LPN that the order was wrong and multiple doses had been given. Although the LPN admitted he had questioned the order and later became aware of the medication error during this review, he did not promptly notify the provider, the resident’s guardians, or nurse managers. The family learned of the error from the outside mental health provider before the facility contacted them, and the NP was not informed until days later, resulting in a lack of timely assessment and monitoring following the significant medication error.
Surveyors found that the facility failed to maintain clean, organized, and dignified room environments for multiple residents. One resident who was bedbound and cognitively intact had a dresser repeatedly observed over several days with dust, debris, scattered ostomy and wound supplies, scissors, and food items left in disarray. Another resident with severe cognitive impairment and a feeding tube had a room with dried enteral feeding splattered on the pump, pole, floor, and chair, scattered personal belongings on the floor, persistent dirt and dust along floorboards, and a wheelchair with missing rubber on a rear wheel; a family member also reported ongoing concerns about poor hygiene, unchanged linens, and soiled items left in the room. A third resident with significant mobility limitations had a crowded room with no clear path to the bathroom, items such as a commode lid, hanger, and food wrapper left on the floor for days, a broken picture frame on the floor, and visible dirt and debris along the floorboards.
A resident with PTSD, anemia, diabetes, and cirrhosis, who was cognitively intact but had a Kinyarwanda language barrier and care-planned communication needs, reported that a CNA refused to provide a second cup of water, pushed at her when she reached for a cup, and called her profane names, leaving her scared and unable to sleep. One CNA stated she overheard the involved CNA say, “This Bitch got me messed up,” and believed it was about the resident but did not intervene or check on the resident. The RN on duty described a conflict over water in which the resident grabbed the CNA and the CNA told her not to touch her, while the accused CNA denied using profanity and cited a language barrier and lack of knowledge of interpretation tools. These events show that the resident was subjected to verbal abuse and that staff did not consistently follow care-planned interventions for communication and behavior management.
A resident with a neurocognitive disorder had a pre‑loaded credit card, managed by his guardian, whose image was sent to the business office and then forwarded to an AIT so it could be formatted and printed for billing. The AIT thereby gained access to the card information and, according to the guardian and facility records, used it to make an unauthorized phone purchase of a motorcycle battery that was billed under the facility’s name and shipped to the facility’s address, later reimbursing the guardian in cash without reporting the incident internally. The facility’s routine Advocate Rounds tool, used by concierge staff, did not include questions about the safety or security of belongings or personal funds, and staff interviews confirmed that only the business office and the AIT should have had access to the card image, establishing that the facility failed to adequately safeguard the resident’s financial information, resulting in misappropriation.
A cognitively intact resident with a language barrier and history of trauma reported, via interpreter, that a CNA used hostile language, curse words, and insults, leaving the resident very scared and unable to sleep. An RN witnessed part of the interaction involving refusal of a second cup of water and physical contact but did not promptly report it to the Abuse Coordinator. Another CNA heard the abusive language, did not check on the resident, delayed informing the RN until the next morning, and could not recall when the incident was reported to the Administrator, despite prior training on reporting abuse. These staff actions and delays resulted in a failure to follow the abuse policy and a delay in reporting alleged verbal abuse to the state agency.
Two residents receiving enteral feeding experienced failures in labeling, timing, and cleanliness of tube feeding equipment. One resident with severe cognitive impairment and malnutrition had a feeding ordered to be off by a specific time, yet the feeding continued running with pump alarms sounding, while the pump, pole, floor, and nearby chair and belongings were splattered with dried tube feeding residue that staff did not address. Multiple staff walked past the alarm without intervening, and a family member reported visible feeding drippings on the visitor chair from the prior day. Another cognitively intact resident receiving nightly tube feeding for duodenal obstruction had an enteral feeding container and IV fluids hung without any labeling of name, date, or time, despite leadership stating such labeling was required, and repeated observations showed partially full, unlabeled feedings with residual in the tubing and soiled pumps, poles, and floors covered in dried feeding residue.
A resident with paranoid schizophrenia and a cognitive communication deficit was admitted on a regimen of Haloperidol Decanoate injections every 21 days, but an LPN incorrectly transcribed the order as daily injections over several consecutive days each month. The consulting pharmacist completed monthly medication regimen reviews and noted no irregularities, despite observing that the Haldol injection was scheduled on multiple consecutive days and not reporting or questioning the order. Under this incorrect order, nurses administered multiple Haldol injections within the same week, even after one LPN expressed concern to a supervisor and was told to give the medication as written, resulting in unnecessary antipsychotic administration.
A resident with bipolar disorder and intact cognition had an active order allowing unsupervised self-administration of medications, but agency nurses repeatedly refused to let her take her own meds. She reported feeling frustrated and nervous when staff stood over her, while a CNA and LPN confirmed agency staff were not following her care preference and the unit worksheet did not document her right to self-administer.
Inconsistent code status and advance directive documentation: A cognitively intact resident had signed DNR paperwork and told staff she did not want CPR, but the chart also contained Full Code physician orders and conflicting physician, psychiatry, and SW notes. The facility’s code status records were not consistent with the resident’s stated wishes and advance directive documents.
Failure to provide SNF ABN forms for 2 residents with Medicare Part A coverage ending and payer source changes. One resident had multiple chronic conditions including a muscle disorder, cognitive communication deficit, DM, HTN, and depression; the other had ESRD, aphasia, CHF, heart disease, DM, depression, and anxiety. SNF beneficiary review forms showed Part A skilled episodes ended before benefit days were exhausted, but the ABN question was left unanswered. The BOM stated the forms were not provided, and Social Services reported they only issue NOMNC forms, not SNF ABNs.
A resident with dementia with psychotic disturbance and hospice services was started on PRN Ativan for anxiety/restlessness after hospice input, with non-pharmacologic interventions documented before administration. The PRN order was later extended to 90 days, but the record lacked documentation supporting use beyond the initial 14-day period; staff later gave additional doses for wandering/restlessness, and an NP reported re-evaluations of the medication.
A resident with dementia was admitted to hospice, but the facility did not complete a significant change MDS when hospice services began. The MDS showed the resident was not on hospice during the look-back period, while a later MDS reflected hospice services. The MDSC said the assessment may have been missed because the payor had not been changed, and the BOM said the hospice paperwork was in the chart but the account was not updated until later.
A resident with schizoaffective disorder, bipolar type had an incorrect PASARR Level I screening that listed only anxiety, and no updated Level I or Level II PASARR evaluation was completed after the diagnosis was identified. Staff interviews confirmed the diagnosis was omitted from the screening, and the RSSC delayed submitting a new screening because she believed guardian consent was needed.
Failure to Track and Administer Pneumococcal Vaccines: Two residents who had consented to pneumococcal immunization did not receive the vaccines as intended. One resident with CHF had Prevnar 20 ordered but not administered, with no documentation explaining why. Another resident with severe cognitive impairment and a CVA diagnosis had no order or MAR entry for PCV-20 and was not offered the follow-up PCV-23 dose. The DON and ICP stated the facility did not have a process to track immunizations.
Following a change in facility ownership, multiple residents were unable to access their personal funds held by the facility due to an unsigned and uncashed check transferring funds from the previous owner. This resulted in frustration and grievances from several residents, as the facility ran out of petty cash and could not fulfill withdrawal requests, contrary to its own policy requiring timely access to resident funds.
Multiple residents with cognitive impairment and trauma histories were subjected to sexual and verbal abuse by another resident, including unwanted kissing and derogatory language. Staff witnessed and reported these incidents to the administrator, but no incident reports were filed and the events were not reported to the State Agency, contrary to facility policy. The administrator assessed the incidents as welcome contact, despite staff statements to the contrary, and failed to implement required protective measures or documentation.
Staff witnessed and reported multiple incidents where a male resident with a history of boundary issues kissed two female residents with cognitive impairments who could not consent, and made inappropriate statements to another resident. Despite staff notifying the administrator and recognizing these as potential abuse, the administrator did not report the allegations to the State Agency as required, resulting in the potential for incomplete investigations and further unreported abuse.
A significant staffing shortage led to delayed call light responses, late medication administration, and unmet ADL needs for multiple residents. Residents and families reported increased wait times, emotional distress, and a decline in care quality following a change in ownership, with agency staff unfamiliar with resident needs. Staff confirmed that the facility operated with only half the required nurses on certain days, resulting in residents not being assisted out of bed, not receiving timely wound care, and experiencing late or missed medications.
A resident with multiple chronic conditions was transferred to the hospital due to altered mental status and shortness of breath, but her emergency contact was not notified by staff. The LPN responsible for the transfer did not inform the family, assuming the resident could do so herself, despite facility policy requiring notification. The family only learned of the hospitalization from the hospital social worker.
A resident dependent on staff for bathing, grooming, and dressing did not consistently receive scheduled showers or assistance with personal hygiene, particularly during periods of low staffing. The resident remained in bed, was not dressed or groomed as scheduled, and experienced back pain and emotional distress as a result. Staff and family interviews confirmed that these lapses were due to insufficient staffing, and facility policy requiring assistance with ADLs was not consistently followed.
The facility failed to employ a qualified Activities Director for nearly a year, allowing an unqualified Activity Assistant to assume the role without the necessary certification or supervision. This resulted in the potential for unmet psychosocial needs and a lack of person-centered activities for all 126 residents. The facility's policy regarding the activities program was not provided during the survey.
The facility failed to adhere to food safety and sanitation standards, with issues such as improperly stored and labeled food, unclean equipment, and a non-functional kitchen exhaust system. Observations included opened and unsecured food items, buildup of grime and debris in storage areas, and expired food in pantries. The ice machines had significant lime and slime buildup, and the kitchen was excessively hot due to a broken HVAC unit. These deficiencies could potentially lead to foodborne illness among residents.
The facility failed to maintain proper infection control practices and lacked an effective water management plan. An LPN did not change gloves during care for a resident with a tracheostomy, and a housekeeping aide did not follow droplet precaution protocols. Additionally, the facility's water management plan was insufficient, with stagnant water lines and discolored water observed, increasing the risk of waterborne pathogens.
The facility failed to maintain resident dignity, as evidenced by staff speaking negatively about residents, delayed responses to call lights, and lack of interaction during care. Cognitively intact residents reported feeling reluctant to ask for help, while severely impaired residents were ignored or startled by staff actions. A resident's concerns about delayed restroom assistance were not adequately addressed by the administration.
The facility failed to provide individualized activities for several residents, leading to feelings of boredom and potential decline in well-being. A resident expressed loneliness due to lack of group activities and support for independent interests. Another resident, moderately cognitively impaired, lacked support in pursuing leisure activities, spending most time in bed. A severely cognitively impaired resident was observed in bed with little engagement, expressing a desire for social interaction and use of a tablet. Another resident with Huntington's disease was restless, with insufficient activities provided.
The facility failed to ensure timely weight measurements and follow-up for residents at risk for altered nutrition status, affecting four residents. A resident experienced significant weight loss without a reweight, another high-risk resident did not receive ongoing nutritional assessments, and a newly admitted resident missed weight checks. The RD admitted to being unable to manage the workload, resulting in missed assessments, which was communicated to management but not addressed.
The facility failed to maintain a sanitary and comfortable environment, with issues such as dust, dirt, and dead ants in rooms, hot and humid spa conditions, and improper storage of linens and chemicals. Maintenance issues included holes in walls, missing vinyl coving, and non-functional exhaust ventilation. Resident rooms had peeling paint and dusty personal fans, with residents reporting discomfort. Housekeeping staff acknowledged the need for more frequent cleaning.
A facility failed to ensure a resident's call light was within reach, leading to potential unmet care needs. The resident, with a diagnosis of unsteadiness of feet, was observed with the call light on the floor and out of reach. Staff interviews confirmed the resident used the call light when it was accessible. The facility's policy mandates call lights be within reach for residents who can use them, which was not followed in this case.
The facility failed to report abuse allegations to the State Agency in a timely manner for two residents. One resident, cognitively intact, reported being assaulted by an LPN during medication administration, resulting in scratches. Another resident, with severe cognitive impairment, was observed by a hospice nurse being held down during medication administration. Despite internal investigations, neither incident was reported to the State Agency, violating the facility's policy.
A facility failed to accurately complete an MDS assessment for a resident with a tracheostomy, resulting in an inaccurate reflection of the resident's status. The resident was not documented as receiving tracheostomy services in the MDS assessment, despite physician orders and observations confirming the presence of a tracheostomy tube and related care supplies. An MDS RN acknowledged the inaccuracy, highlighting the importance of accurate documentation for appropriate care.
A facility failed to complete a Level II PASARR evaluation for a resident with a psychotic disorder and dementia, resulting in potential unmet mental health needs. The Social Services Director could not locate the necessary screening, which was found incomplete in the physician's portal.
The facility failed to implement comprehensive care plans for three residents, leading to potential unmet needs. A resident with pressure ulcers was observed without a required heel protector, another with paralysis lacked a prescribed hand splint in their care plan, and a third resident with dementia had no care plan focus for their condition. These deficiencies indicate a lack of coordination and communication among the care team.
The facility failed to follow professional standards for wound care and documentation, affecting three residents. A resident with wounds on her feet and leg did not receive timely dressing changes, and documentation was missing for several days. Two other residents also had missing documentation for wound care and meal intake. Staff interviews confirmed the expectation for daily care and documentation, but no explanations were provided for the omissions.
A resident with a history of falls and metastatic cancer to the bone fell from a wheelchair. Two LPNs moved the resident back to the wheelchair without conducting a proper assessment for injuries, contrary to facility policy. No vital signs or post-fall monitoring were documented, highlighting a deficiency in care.
A facility failed to provide trauma-informed care for a resident with a history of sexual abuse, leading to a potential risk of re-traumatization. The resident, diagnosed with major depressive disorder, anxiety disorder, and dementia, did not have a care plan addressing trauma-related needs. The Social Services Director was unaware of the resident's trauma history, and the facility lacked a policy on trauma-informed care.
A resident with severe periodontal disease did not receive timely dental services due to a lack of coordination and communication among facility staff. Despite consent from the resident's guardian for dental extractions, the facility failed to arrange the necessary care, resulting in prolonged poor dental condition and potential risk for infection. Staff interviews revealed confusion about responsibility for scheduling appointments and a lack of awareness about the resident's dental needs.
The facility failed to provide written notification of the bed hold policy to two residents upon their transfer to a hospital. One resident, admitted with muscle weakness, and another with insomnia, were transferred without receiving the necessary documentation. The Nursing Home Administrator and DON confirmed the oversight, acknowledging that the facility nurses missed providing the bed hold policy forms, leading to potential unanticipated expenses or loss of room placement.
A resident with a history of strokes experienced symptoms indicative of a stroke and DVT, including lethargy, weakness, and facial asymmetry. Despite these signs, the facility delayed notifying a physician and sending the resident to the hospital. Interviews revealed that staff had concerns about the resident's condition, but these were not acted upon promptly, leading to a delay in diagnosis and treatment.
A resident with dysphagia and aphasia was at risk of choking due to staff not following prescribed feeding protocols. Despite orders for liquids to be given via teaspoon only, staff used sip cups and straws, contrary to the resident's care plan. The SLP had communicated these precautions, but observations showed non-compliance, with sip cups and straws present in the resident's room. The facility had not updated the resident's eating assistance orders, leading to a potential safety hazard.
A resident with severe cognitive impairment and a history of wandering was able to exit the facility due to inadequate supervision. Despite wearing a functioning Wander Alert device, the front desk receptionist mistook the resident for a visitor and allowed him to leave, ignoring the alarm. The resident was found in the parking lot and safely returned to the facility by nursing staff.
A resident with dementia and a history of wandering attempted to elope from the facility, crossing a busy street before being redirected by staff. Despite the incident, staff failed to document the event in the resident's medical records or complete an incident report. The lack of documentation was due to a misunderstanding that no further action was needed if the resident remained in visual sight, resulting in incomplete and inaccurate medical records.
The facility failed to implement proper transmission-based precautions for COVID-19 positive residents. Staff, including a CNA, LPN, and Activity Director, entered rooms with Special Droplet/Contact Precautions without the required PPE, such as N-95 masks and eye protection. Signage indicating PPE requirements was either unnoticed or misunderstood, and necessary PPE was not always available.
The facility failed to assess and ensure the safe self-administration of medication for a resident who was observed with medications at his bedside. The resident, who was cognitively intact, had not been evaluated for self-administration, and there was no care plan in place to reflect this status. Interviews with staff confirmed the oversight.
Significant Medication Errors from Mis-transcribed Antipsychotic Orders and Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, including incorrect transcription and administration of antipsychotic injections and omission of ordered medications. One resident with paranoid schizophrenia and a cognitive communication deficit was admitted with an order for haloperidol decanoate 250 mg IM every 21 days. An LPN entered the order into the electronic record incorrectly as 2.5 mL IM "one time a day starting on the 16th and ending on the 21st every month," which resulted in multiple injections being scheduled and administered within a short period instead of a single injection every 21 days. The MAR showed that the resident received haloperidol decanoate injections on multiple days in February, and the facility’s own investigation confirmed that the order was transcribed incorrectly. The resident’s family member reported noticing a decline in the resident’s condition after these multiple injections, including decreased participation in therapy, increased tremors, and confusion. Therapy documentation from the last two weeks of February noted downgraded tasks due to difficulty with fine motor tasks, poor sequencing, increased confusion, and lethargy. The same resident’s outside mental health provider discovered the error when the resident presented for her usual monthly medication review and reported she had already received the injection at the facility. The mental health nurse requested medication records and later called the facility to review the orders. During that call, an LPN at the facility read the incorrect haloperidol order and acknowledged that the resident had received multiple doses within a week. The mental health nurse documented that the LPN stated he thought the order looked unusual, had asked a supervisor for clarification, and was told to administer the medication as written. The LPN later documented in a progress note that the order in the electronic record was incorrect and that he had administered two doses, but he did not clearly recall when he reported the incident internally or whether the physician was notified at the time. The facility pharmacist stated that the resident’s total monthly dose exceeded the typical effective range and described specific clinical risks associated with excessive haloperidol dosing. Another resident with schizoaffective disorder, depressive type, had a care plan intervention to administer medications as ordered and monitor for side effects and effectiveness. This resident had an order for haloperidol decanoate 2 mL IM every 28 days with instructions to inform the social worker, DON, and provider if the injection was refused. The MAR showed the injection was documented as refused by an LPN, but there was no documentation that the social worker, DON, or provider were notified, and the injection was not subsequently administered. Staff interviews indicated that this resident experienced increased behaviors, including more frequent screaming out, attempts at self-transfer, refusals of care, verbal aggression, and falls during the following weeks. Progress notes documented refusals of care, self-transfers, delusional statements, and an IDT note referenced recent falls and delusional statements, with a psychiatry follow-up note explicitly stating that the resident had not received the scheduled haloperidol injection and that this was likely contributing to her current decompensation. Additional residents experienced omitted medications when an agency LPN left mid-shift without notice and failed to complete assigned medication administration duties. The facility’s investigation summary and medication error log for that date showed that multiple residents did not receive scheduled HS medications. One resident did not receive doses of Seroquel, Keppra, and Topamax; another did not receive a dose of oxycodone; another missed doses of metoprolol and Norco; another did not receive a dose of Lasix; another did not receive risperidone; and another did not receive olanzapine. These omissions were identified as significant medication errors based on the potential to jeopardize residents’ health and safety. The facility’s medication administration policy required medications to be administered according to physician orders and standards of practice, and required documentation of refusals and physician notification as clinically indicated, but the documented events show that medications were either administered contrary to the prescribed frequency or not administered or followed up as ordered.
Failure to Report Nurse Abandonment and Missed HS Medications to Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse and neglect to the State Survey Agency and other required officials after an agency LPN left mid‑shift without notice, resulting in missed medication administration for 13 residents. On the evening in question, the LPN worked approximately the first two hours of a 7 PM to 7 AM shift, then left the building without informing leadership or giving report to another nurse, locking the medication cart keys in the medication room. Certified nurse aides later noticed the keys in the medication room and, around midnight, notified the on‑call nurse. A replacement RN from the agency arrived around 3:30 AM and confirmed that none of the HS medications for a group of rooms had been administered and that, by the time of review after 4 AM, it was too late to give the medications. Facility records, including the Summary of Medication Errors and individual medication error reports, documented that 13 identified residents did not receive their scheduled HS medications due to the LPN’s failure to pass medications and subsequent departure. The facility’s Investigation Summary categorized the event as potential neglect related to medication administration delay but concluded it did not meet criteria for reportable neglect, and therefore did not report the allegation to the State Survey Agency or to the State’s nurse licensing department at the time of the incident. The Nursing Home Administrator confirmed during interview that the LPN left mid‑shift without notice, that 13 residents did not receive their HS medications, and that the facility did not notify the State Survey Agency or the nurse licensing department as required by its abuse policy. The facility’s abuse policy required all allegations involving abuse or neglect to be reported immediately (within two hours if involving abuse or serious bodily injury, and within 24 hours if not) to the State Survey Agency and other officials. Despite this policy and the documented missed medications for multiple residents, the facility determined the event was not reportable and did not make timely reports to the appropriate authorities.
Widespread Medication Errors, Inaccurate Documentation, and Missed Neuro Checks
Penalty
Summary
Surveyors identified multiple failures to provide treatment and care according to orders, resident preferences, and professional standards, resulting in missed medications, inaccurate documentation, administration of medications without appropriate parameters, and incomplete neurological assessments after unwitnessed falls. One cognitively intact resident with end stage renal disease and chronic pain was observed during a morning medication pass where an LPN documented administration of several medications and a daily weight that had not actually been given, including a lidocaine patch, Lokelma, sevelamer, and Colace. The resident declined sevelamer until after breakfast, and the LPN removed the tablets and stored them in the cart but still documented them as administered and later confirmed she never returned to give the dose or corrected the record. The same resident reported not receiving the lidocaine patch or her daily weight, and record review showed daily weights had not been documented for over a week. The same resident had an order for midodrine for hypotension, including a scheduled dose and a PRN dose, but the order lacked blood pressure parameters. During observation, the LPN administered midodrine without first assessing or documenting vital signs and later stated she believed she had taken them but could not locate documentation. The LPN acknowledged that midodrine requires a blood pressure assessment and that there were no parameters in the order, while the nurse who transcribed the order and the NP both confirmed that parameters should have been included but were missing. Another resident with type 2 diabetes and obstructive sleep apnea had a weekly Ozempic injection documented as not given because the LPN could not find the medication; there was no documentation that the provider was notified or that the medication was reordered, and pharmacy records showed no refill request had been received. For residents who experienced unwitnessed falls, required neurological assessments were not fully documented according to the facility’s protocol. One resident had an unwitnessed fall with initiation of neuro checks, but the neuro assessment form showed missing documentation for a specified shift several days later. The same resident had another unwitnessed fall with head impact reported, and the neuro assessment record showed multiple missing entries at required times over subsequent days. Staff, including LPNs and the DON, stated that neuro checks were required after unwitnessed falls and should be documented on the neurological assessment sheet, but review confirmed missing documentation that could not verify completion of all required assessments. Another cognitively intact resident who went to dialysis three times weekly had treatment documentation completed by an RN for a shift when the resident was not in the building. The RN documented that the resident had no episodes of sadness or loneliness, that the dialysis site and port were monitored and intact, and that enhanced barrier precautions were maintained throughout the shift, even though the resident had left for dialysis before the RN’s shift began and did not return until midday. In a separate incident, an agency LPN left mid‑shift without notifying leadership, locking medication cart keys in the med room and failing to administer scheduled HS medications to multiple residents. A subsequent review showed that numerous residents each missed several scheduled nighttime medications, and a replacement nurse arriving hours later confirmed that none of the HS medications for a group of rooms had been given and that it was too late to administer them. Another cognitively intact resident with conjunctivitis had ongoing eye infection signs, including green drainage and red, irritated sclera in both eyes, observed on multiple days. The resident did not have a current antibiotic order despite visible symptoms. Record review with the unit manager and infection preventionist showed that the resident had been ordered gentamycin eye drops twice in recent weeks, but doses were missed on days when the resident was at dialysis and on at least one other occasion, with refusal or missed doses not consistently documented in progress notes. There was no evidence that the physician was notified of missed antibiotic doses, no orders obtained for late administration after dialysis, and no documentation that the provider was informed that the infection persisted. The unit manager acknowledged that progress notes and follow‑up documentation were not completed as expected and that the resident continued to have conjunctivitis because the full antibiotic course was not received.
Environmental Sanitation and Maintenance Deficiencies in Multiple Facility Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas used by residents, staff, and the public. Surveyor observations identified a volleyball-sized hole in the wall under a three-compartment sink, dilapidated and water-damaged cabinetry under sinks in soiled utility rooms, and deteriorating wall junctures with holes that could be used by pests. Pantries at two nurse stations had undersink cabinetry and areas under an ice machine with accumulated debris, black spots, and water damage. A 500-hall soiled utility room had a strong odor, with a mop sink that appeared dry and emitted hot air from the floor drain, indicating an evaporated p-trap and sewer gas entering the room. The mop sink was connected to a chemical pre-dispense unit with faucet handles left on, creating undue back pressure on the internal vacuum breaker. A converted shower room used as a clean linen room contained multiple water fixtures, including a leaking valve serving a commode that left a puddle on the floor, and a 600-hall soiled utility room hopper was observed leaking from the wall. Additional observations showed unclean and poorly maintained resident care and common areas. In the 500-hall spa room, large tufts of matted hair were present in the wheels of each shower chair. In the 600-hall spa tub room, soaking wet washcloths, towels, and pieces of toilet paper were left in the tub, and a shower chair had brown and yellow staining and streaking down its legs. The garden activity room’s greenhouse area had bubbling and chipping paint and drywall due to routine roof leaks that caused deterioration at the wall juncture under the roof. In the 700-hall lounge, a cushioned chair had accumulated debris and trash under the seat cushion, and there was increased trash and debris on top of a vending machine, along with black spots and accumulation in and on the wall-mounted heating and cooling unit above it. A 300-hall shower room contained a shower bed with black staining underneath the mat.
Oxygen not provided at ordered flow rates
Penalty
Summary
The facility failed to provide oxygen consistently per physician orders for two residents who required respiratory support. Resident #25 had severe cognitive impairment and a diagnosis of respiratory failure. Her order, dated 1/13/2026, directed continuous oxygen via nasal cannula at 3 liters per minute. During multiple observations on 3/17/2026 and 3/18/2026, her oxygen concentrator was repeatedly found set at 1.5 liters per minute instead of 3 liters per minute, and at times she was out of her room without oxygen tubing in place and with an empty portable oxygen tank on her wheelchair. When observed away from her concentrator, she was not receiving continuous oxygen as ordered. Resident #25 was also observed with no oxygen on while seated in her wheelchair in the hallway and at a dining table, despite the active order for continuous oxygen. The Interim DON confirmed the order remained 3 liters per minute continuous and stated that if the resident was out of her room and away from the concentrator, she should still be receiving oxygen. Later on 3/18/2026, the oxygen order was revised to 3 liters per minute PRN beginning at 7:00 PM, but at the time of the observations the resident was still being found with oxygen set below the ordered rate or not in use while away from her room. Resident #130 had diagnoses including end stage renal disease, heart failure, pulmonary hypertension, anemia, hypertension, diabetes, obstructive lung disease, and chronic respiratory failure. Her active order directed oxygen via nasal cannula at 2 liters per minute continuously every shift for difficulty breathing/hypoxia, and her care plan noted she sometimes refused to wear oxygen. During observations, her oxygen concentrator was found set at 4 liters per minute, and an agency RN verified the concentrator was set above the ordered rate and stated it should have been set at 2 liters per minute.
Failure to Maintain Resident Dignity and Respect During Pain and Help Requests
Penalty
Summary
The deficiency involves the facility’s failure to provide care that promoted and enhanced a resident’s dignity and sense of well-being. Resident #130, who had end stage renal disease, chronic pain syndrome, and was cognitively intact with a BIMS score of 14/15, was observed lying in bed with her call light on, crying out for help. An LPN at the medication cart outside the resident’s open door yelled to the resident that she would have to wait and then told the surveyor that the resident was a drug addict who would yell nonstop. The LPN was positioned close enough that the resident could hear this comment. As the resident continued to call out, the LPN loudly sighed each time and repeatedly told the resident she had to wait, while continuing to prepare medications. After preparing the medications, the LPN entered the resident’s room without knocking or identifying herself and asked, “What is wrong with you?” The resident was on her personal cell phone with 911, stating she was calling because nobody helped her while she yelled out, and she was noted to be tearful. The LPN yelled to the 911 operator that the resident was fine and did not need assistance, and the dispatcher ended the call. When the resident reported she was in pain, the LPN stated she had Tylenol for her, administered the medications, and left the room despite the resident stating she still needed help. The LPN did not assess the resident’s pain or offer non-pharmacological interventions and, after exiting, again referred to the resident as drug seeking and probably withdrawing, while continuing to ignore her ongoing calls for help. In a later interview, the resident reported feeling very frustrated, stated she had to yell to get help because staff ignored her, reported overhearing the LPN call her a drug addict, and said she often heard staff complain about her and felt they treated her like “ghetto trash.” The facility’s dignity policy stated residents would be treated with dignity and respect at all times.
Failure to Obtain Representative Consent for Psychotropics and Notify Guardians of Offsite Appointments
Penalty
Summary
The deficiency involves the facility’s failure to properly inform and obtain consent from resident representatives for care and treatment, including psychotropic medications and offsite medical appointments, for two residents. One resident with schizoaffective disorder, bipolar type, had documentation indicating moderate cognitive impairment and an inability to process and understand medical information or make informed medical treatment decisions. A probate court physician report and a Determination of Inability to Participate in Complex Decision Making form, signed by two physicians, stated that this resident was not able to make or participate in medical treatment decisions. Despite this, psychotropic medication consent forms for an antipsychotic (Perphenazine) and an antianxiety medication (Alprazolam) documented that education was provided to and consent was obtained from the resident himself. The facility’s own Psychotropic Medication Use policy required that consent for each psychotropic medication be obtained from the resident or authorized representative, with education on risks versus benefits. Social Services staff confirmed that when a resident is deemed unable to make medical decisions, informed consent must be obtained from the legal guardian or authorized representative. They further confirmed that this resident could not make medical decisions, did not yet have a legal guardian when Alprazolam and Perphenazine were initially prescribed, and that the authorized resident representative did not provide consent for these medications. As a result, the resident received psychotropic medications without consent from the appropriate representative, contrary to the facility’s policy and the documented incapacity determinations. The second resident had paranoid schizophrenia and a cognitive communication deficit and had two co-guardians appointed by court order. A family member co-guardian reported that she and her sister had always made the resident’s medical treatment decisions and routinely attended all medical appointments, including those with a local mental health authority that managed the resident’s monthly Haldol injections. The co-guardian stated that the facility sent the resident to an outside medical appointment with a staff member on one occasion and to a mental health authority appointment alone on another occasion, without notifying either co-guardian. The mental health authority nurse confirmed that it was unusual for the resident to attend without the co-guardian, who had historically been present and served as a resource and advocate. The unit clerk, who was responsible for scheduling outside medical appointments, reported that when a resident has a guardian, she is supposed to ensure the guardian is aware of outside appointments and that, if the guardian cannot attend, the facility would send a staff member. She stated she scheduled one of the resident’s appointments and attempted to notify the co-guardian by preparing a written slip with appointment information. She said she waited to hand it to the co-guardian but, not wanting to interrupt a conversation, instead placed the slip on the resident’s meal tray in the room. The unit clerk gave inconsistent accounts about whether she later spoke with the co-guardian by phone and could not recall the date or details of any such conversation. She was unable to provide documentation verifying that the co-guardian had been informed of the appointment. As a result, the resident attended at least one offsite appointment without representation from her co-guardian, despite the facility’s awareness that the co-guardian expected to be notified and typically accompanied the resident.
Failure to Notify Practitioner and Family After Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of a significant medication error to the resident’s practitioner and family, which resulted in a lack of assessments and monitoring. A resident with paranoid schizophrenia and a cognitive communication deficit was admitted with a care plan that included administration of medications per physician orders. An LPN entered an incorrect order for Haloperidol Decanoate, transcribing it as a daily intramuscular injection over several days each month instead of a single injection every 21 days. This transcription error led to multiple Haldol injections being administered within a short period, as documented on the MAR and confirmed by staff interviews and records. The error was first identified externally when the resident’s Local Mental Health Authority (LMHA) nurse attempted to administer the monthly Haldol injection and was told by the resident that she had already received it at the facility. The LMHA nurse requested medication records and later called the facility to review the resident’s medications. During that call, the LMHA nurse learned from an LPN that the order had been written incorrectly and that multiple doses had been given within a week. The LPN acknowledged that the order “looked weird,” stated he had asked a supervisor for clarification, and reported he was instructed to give the medication as written. The LMHA nurse documented that the resident had received multiple doses and that the LPN believed she had received at least two doses from him. Despite becoming aware of the medication discrepancy during the medication review with the LMHA nurse, the LPN did not promptly notify the facility’s provider, the resident’s guardians, or nurse managers. The LPN later documented the conversation and discrepancy in a progress note several days after the LMHA call, and he could not recall if he had contacted the physician about the error. The resident’s family member reported learning of the multiple Haldol doses from the LMHA and stated that the facility did not contact her until days later, after she had already been informed by the LMHA. The nurse practitioner reported she was not notified of the medication errors until a later date, by which time the resident was planning discharge. The nursing home administrator confirmed that the facility discovered the medication error days after the LPN had been informed by the LMHA nurse, and that the LPN had not notified the provider, guardians, or nurse managers when he first became aware of the errors.
Failure to Maintain Clean, Organized, and Dignified Resident Room Environments
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, orderly, and comfortable environment in multiple resident rooms, as well as failure to ensure safe and appropriate management of resident belongings and care-related supplies. One resident, R8, was cognitively intact but dependent on staff for transfers and unable to get out of bed independently. Over three consecutive days of observation, surveyors noted that a dresser behind this resident’s bed had dust and debris under a bottle of stoma powder lying on its side, along with a jar of chicken bouillon, various wound and ostomy supplies, and scissors with plastic wrap hanging from the blades. These items remained in the same disorganized and unclean condition across all three days, with visible dirt, dust, and debris and supplies piled on top of each other. The resident stated that staff took care of things in his room because he could not get out of bed on his own. Another resident, R108, was severely cognitively impaired, dependent on staff for all ADLs, and had a feeding tube with a resident-specific treatment plan for enteral feeding. Observations on three separate days showed that her room remained in a persistently unclean and cluttered state. Under the heat register was a purple container of deodorant that was not removed. A chair next to the enteral feeding pole held a wadded-up fleece jacket and a tube of ointment, all splattered with a dried sticky substance resembling enteral feeding, which also covered the pump, pole, pole base, floor underneath, and the chair. Dirt, dust, and debris were noted along the floorboards and dressers, and the resident’s personal belongings were partially in tote bags and partially spilled out onto the floor, as if someone had gone through them and left items scattered. The resident’s high-backed wheelchair had the rubber missing completely around the right rear wheel. These conditions were observed repeatedly without change over the three days. Family concerns further highlighted the issues in R108’s environment and hygiene. Her family member reported ongoing concerns about the resident’s personal hygiene and room condition, stating that despite staff-provided showers, the resident complained of still feeling unclean and having body odor. The family member described that linens were not consistently changed with bed baths, that she often had to change the sheets herself, and that the resident’s hair and skin showed signs of inadequate hygiene care, including dry, flaky skin and buildup of hair oil. She also reported finding used gloves on the floor, dirty wipes in drawers, spilled hair conditioner under the bed, and enteral feeding drippings on the visitor chair and floor, which she had previously observed and addressed. The unit manager later confirmed that floors were the responsibility of housekeeping, while aides and nursing staff were responsible for keeping rooms and belongings neat and tidy and for reporting equipment issues. A third resident, R12, was cognitively intact but dependent on staff for bed-to-chair transfers and had limited physical mobility related to bilateral total shoulder arthroplasties and removal of the right shoulder. Over three consecutive days, surveyors observed that his room was crowded with a bedside dresser, walker, wheelchair, bedside commode, and dresser against the wall, leaving no clear path to the bathroom and little space to move around. Under the bedside commode, there was a cookie in a wrapper, a plastic hanger, and the lid from the bedside commode, which remained in the same place on subsequent days. A broken picture frame was also observed on the floor, and along the floorboards there was an accumulation of dirt and debris that persisted across all three days. The only noted change was that the packaged cookie that had been on the floor appeared to have been moved to the bedside table, while the rest of the clutter and dirt remained unchanged.
Failure to Protect Resident From Verbal Abuse During Water Pass
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by staff. The resident was cognitively intact, scored 15/15 on the BIMS, spoke Kinyarwanda, and required an interpreter to communicate with health care staff. Her care plan identified communication concerns, a language barrier, and a history of trauma/PTSD, with interventions including use of interpretation services, simple questions, open-ended questions, and calm communication to promote positive interactions and prevent behavior problems. Despite these identified needs and interventions, staff interactions during the incident did not reflect the care-planned approaches. According to a progress note, the resident reported to the Social Services Coordinator, using a translation device, that a CNA had a hostile attitude and used curse words and insults toward her, leaving her very scared and unable to sleep the rest of the night. The Social Services Coordinator recalled the incident as centering around a CNA pulling something away from the resident. An RN who was present on the night of the incident stated that the CNA was passing water, the resident requested two cups, and when the CNA refused and said she would return later with another cup, the resident grabbed a cup and then grabbed the CNA by the back of the neck. The RN reported that the CNA told the resident not to touch her and that no other staff were around at that time, and also stated that the Administrator did not interview her about the incident. Another CNA reported overhearing the involved CNA say, “This Bitch got me messed up,” while wearing earbuds and talking, and believed the CNA was talking about the resident, but did not intervene or check on the resident because she felt the CNA had been a bully. The CNA accused of verbal abuse stated she refused to give the resident a second cup of water immediately, that the resident followed her speaking in Kinyarwanda, snatched a cup of water, and grabbed her shirt, and that she told the resident not to grab her but denied calling the resident any names. The resident, interviewed with a translator, stated that when she requested two cups of water, the CNA refused without explanation, pushed at her when she reached for a cup, and said, “Fuck, Fuck Bitch,” which made her feel very bad. These accounts demonstrate that the resident was subjected to hostile and profane language by staff, contrary to her right to be free from verbal abuse and to the care-planned interventions for communication and behavior related to her trauma history and language barrier.
Failure to Safeguard Resident Credit Card Information Resulting in Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to safeguard a resident’s credit card information, which led to an unauthorized purchase by a staff member. The resident involved had a diagnosis that included frontotemporal neurocognitive disorder, and his brother/guardian managed his financial transactions. The guardian provided a copy or image of the resident’s pre‑loaded credit card, which contained the resident’s Social Security funds, to the Business Office Manager (BOM O) for payment of the resident’s bills. Because the card image could not be opened, BOM O forwarded it to the Administrator in Training (AIT R) at the direction of the former Nursing Home Administrator so that AIT R could format and print it. BOM O reported that, aside from herself, AIT R was the only other employee who would have had access to the resident’s credit card information. Subsequently, the resident’s guardian noticed an unauthorized charge on the card for a motorcycle battery purchased over the phone and shipped to the facility’s address. Store staff confirmed to the guardian that the purchase had been made via a phone order from someone at the facility, using the resident’s credit card. The guardian went to the facility intending to speak with BOM O about the charge but was instead approached by AIT R, who stated he could assist and took the information about the credit card transaction, telling the guardian he would follow up. According to the guardian, about a week or two later, AIT R contacted him and arranged to meet at a gas station, where AIT R reimbursed him in cash for the amount of the unauthorized charge, stating that the money came from a special fund and that such things happened all the time. No details of this situation were reported by AIT R to anyone else at the facility. When the resident’s August payment did not process, BOM O contacted the guardian, who explained that he had locked the card after discovering the unauthorized charge and described the reimbursement by AIT R. BOM O then reported the concern to the current Nursing Home Administrator (NHA A). Review of the credit card statement and an invoice from the store showed a phone purchase of a motorcycle battery using the resident’s Mastercard, billed under the facility’s name and shipped to the facility’s address. NHA A attempted to question AIT R, who had already resigned, but he declined to provide substantive answers, repeatedly stating he did not recall or did not know. The facility’s Advocate Rounds tool, which was used to ask residents about their experiences, did not include any questions about the safety or security of belongings or personal funds, and the Concierge reported they were instructed to ask the questions exactly as written. The new Business Office Manager (BOM M), who started later, had no knowledge of the credit card issue. The evidence gathered by the facility and surveyors supported that misappropriation of the resident’s funds occurred after the facility failed to adequately safeguard the resident’s credit card information. The facility’s internal interviews and documentation further established that the resident’s credit card image was handled in a way that allowed access beyond the business office. BOM O stated that normally they did not receive images of credit cards, but in this case, due to Medicaid application requirements and the unusual card type, an image was obtained and then forwarded to AIT R for printing. This process created an opportunity for misuse of the resident’s financial information. Additionally, the Advocate Rounds process, as described by NHA A and Concierge BB, did not include any structured inquiry into residents’ perceptions of the safety and security of their belongings or personal funds, limiting the facility’s ability to detect or prevent such misappropriation through routine resident interviews. These actions and omissions collectively led to the misappropriation of the resident’s credit card for a personal purchase by a staff member.
Failure to Implement Abuse Policy and Timely Report Staff-to-Resident Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy by not ensuring timely reporting of staff-to-resident verbal abuse to the state agency for one resident. The resident was cognitively intact with a BIMS score of 15/15, had a preferred language of Kinyarwanda, required an interpreter to communicate with health care staff, and was independent with ADLs. Her care plan identified communication concerns, a language barrier, and a history of trauma with a goal of no behavior problems, and included interventions such as interpretation services, use of simple and open-ended questions, and calm caregiver interactions. A progress note documented that the resident reported to the Social Services Coordinator, via a translation device, that a CNA had a hostile attitude and used curse words and insults toward her, and that she became very scared and could not sleep the rest of the night. Interviews revealed that the Nursing Home Administrator served as the Abuse Coordinator and expected staff to report any type of abuse at any time. An RN reported witnessing an interaction in which the CNA refused to immediately provide a second cup of water, the resident took a cup anyway, and then grabbed the CNA by the back of the neck; the RN acknowledged she did not report the incident to the Abuse Coordinator in a timely manner and believed she should have. A CNA stated she heard the involved CNA say, “This B**** got me messed up,” did not know to whom it was directed, and walked away without checking on the resident, later telling the RN the next morning that the CNA was “fussing” at the resident. This CNA also reported that she eventually informed the Administrator but could not recall when, despite having been trained on to whom to report such incidents. These actions and inactions by staff led to a delay in reporting the alleged verbal abuse to the state agency, in violation of the facility’s abuse policy.
Failure to Label and Maintain Clean Enteral Feeding Equipment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate labeling, dating/timing, and cleanliness of enteral feeding equipment for two residents receiving tube feedings. One resident had severe cognitive impairment, a history of CVA, and calorie-deficient malnutrition, and had physician orders for enteral feeding to be turned off at 9:00 AM. During observation late in the morning, this resident’s tube feeding was still running, and the pump alarm was sounding with an error message. An LPN who did not normally work on that hall silenced the alarm without knowing when the feeding had been started or how long it was supposed to run, and did not address the visibly dirty condition of the pump, pole, base, floor, and nearby chair and belongings, all splattered with a dried, sticky substance resembling tube feeding. Further observations showed that the same resident’s pump alarm continued to sound with an error code while the pump was not running, and multiple staff, including an RN, walked past the open room without responding to the alarm. The resident appeared frustrated, waving a hand with an angry expression. The order summary still indicated the enteral feeding was to be off at 9:00 AM, yet the feeding equipment remained in use and visibly soiled. A family member later reported that the visitor chair next to the bed had been covered with feeding tube drippings the previous day, which they stated had been dripping from the bottle. On a subsequent day, the resident’s enteral feeding and a bag of clear fluids were again observed hung on a pole and attached to the pump, with the pump, pole, base, floor, and a chair with a fleece jacket and ointment tube all splattered with a dried, sticky substance resembling enteral feeding. The second resident, who was cognitively intact and received nightly enteral feeding for duodenal obstruction and chronic vascular intestinal disorders, was observed with an enteral feeding container and a bag of clear fluids hung on a pole and connected through a pump. Neither the feeding nor the fluids were labeled with the resident’s name or with the date and time they were hung, despite the DON’s statement that tube feedings and fluids should be labeled with name, date, and time so staff would not reuse them and would know when they were hung. Later observation showed the feeding and fluids still partially full, with residual feeding in the tubing, and the pump, pole, base, and floor splattered with a dried, sticky substance resembling enteral feeding. On another day, the same resident’s pump, pole, base, and floor were again observed splattered with a sticky substance resembling enteral feeding. A unit manager confirmed that tube feeding and fluid should be dated and labeled to know when they were hung and if they were fresh, and that enteral feeding equipment should be kept clean for infection control.
Failure to Identify Incorrect Antipsychotic Order During Monthly Drug Regimen Review
Penalty
Summary
The deficiency involves the facility’s failure to identify and correct an inaccurately transcribed antipsychotic medication order during the monthly medication regimen review for one resident. The resident had diagnoses including paranoid schizophrenia and a cognitive communication deficit and was admitted with an existing regimen of Haloperidol Decanoate injections every 21 days. On admission, an LPN entered the Haldol order into the electronic medical record incorrectly as an intramuscular injection to be given daily from the 16th through the 21st of each month, with additional directions stating every 21 days. This transcription error resulted in the order appearing as multiple consecutive daily doses instead of a single dose every 21 days. The consulting pharmacist completed medication regimen reviews on two occasions and documented that there were no new irregularities in the resident’s medication regimen. During interview, the pharmacist acknowledged noticing that the Haldol injection was scheduled for multiple days in a row but assumed this was to allow nurses flexibility if the medication did not arrive on time, and therefore did not report or question the order. As a result, the incorrect order remained in place and was not identified as an irregularity during the monthly drug regimen review, despite the conflicting directions and the unusual frequency for a long-acting antipsychotic injection. According to the medication administration record, the resident received multiple doses of Haloperidol Decanoate under the incorrect order, with injections documented on several days within the same week. One LPN reported administering two doses and stated that he had questioned the order and asked his unit manager for clarification but was instructed to administer the medication as written. The resident’s family member later reported being informed by the local mental health authority that the resident had received three doses of her monthly Haldol injection in error at the facility. The mental health authority nurse documented a telephone conversation with the LPN in which he confirmed that the resident had received multiple doses within a week based on the written order. The facility’s failure to detect and correct the erroneous order during the pharmacist’s monthly medication regimen review led to the unnecessary administration of an antipsychotic medication.
Failure to Honor Resident Medication Self-Administration Preference
Penalty
Summary
The facility failed to ensure Resident #5’s right to self-determination and resident choice was honored when agency nurses did not allow her to self-administer her medications despite an active physician’s order permitting unsupervised self-administration. Resident #5 was admitted with bipolar disorder and had a BIMS score of 15/15, indicating she was cognitively intact. Her care plan included a focus on supporting psychosocial well-being related to risk for loss of independence and included opportunities for her to participate in care, as well as a goal for safe self-administration of prescribed medications. During interviews, Resident #5 stated she felt frustrated and nervous when nurses stood over her and watched her take her pills, and she reported that agency nurses frequently refused to let her administer her own medications. An agency RN stated she relied on verbal report from the off-going shift and said none of the residents on the unit were able to self-administer medications. A CNA reported that every time an agency nurse worked, they did not allow Resident #5 to take her own medications, and an LPN acknowledged ongoing difficulties with agency nurses not following resident care preferences. The assignment/worksheet for the unit did not document Resident #5’s preference to self-administer medications.
Inconsistent Code Status and Advance Directive Documentation
Penalty
Summary
The facility failed to maintain accurate and consistent code status documentation and advance directive information for one resident who was cognitively intact with a BIMS score of 15. The resident reported that she had told the facility her wishes for emergency medical treatment on admission and stated that if her heart stopped, she did not want chest compressions and did not want to live if she was going to be in pain. Her admission evaluation documented DNR, and her advance directive and DNR order were both signed by the resident, witnesses, and the physician, indicating no CPR. Despite this documentation, the resident’s current physician orders listed Adv Directive: Full Cardiopulmonary Resuscitation (CPR), and there were discontinued Full Code orders in the chart that did not match the resident’s advance directive or interview statements. The facility’s code status binder at the nurse’s station contained the resident’s DNR paperwork in a red sleeve, while other records in the chart reflected both DNR and Full Code entries. Notes from different disciplines also conflicted, including physician notes documenting DNR per discussion with the patient, a psychiatry note listing Full CPR, and a social work note stating the resident wished to remain full code at that time and wanted to speak with her husband before signing DNR paperwork.
Failure to Provide SNF ABN Forms for Medicare Part A Coverage Changes
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form for 2 of 3 residents reviewed for timely provision of notifications, including Resident #4 and Resident #13. Resident #4 was a male with diagnoses including a muscle disorder, lack of coordination, cognitive communication deficit, diabetes, high blood pressure, and depression, and he was not his own responsible party. His Medicare Part A coverage ended on 12/22/25, after which he remained in the facility and his payer source changed to Medicaid Pending on 12/23/25. The SNF Beneficiary Notification Review form documented the start and end of his Part A skilled services episode and that the facility/provider initiated discharge from Medicare Part A services when benefit days were not exhausted, but the question asking whether a SNF ABN, Form CMS-10055, was provided was unanswered. Resident #13 was a male with diagnoses including end stage renal disease, muscle disorder, lack of coordination, aphasia, diabetes, cognitive communication deficit, heart disease, heart failure, depression, and anxiety, and he was not his own responsible party. His Medicare Part A coverage ended on 12/6/25, after which he remained in the facility and his payer source changed to Medicaid on 12/7/25. The SNF Beneficiary Notification Review form for this resident also documented the start and end of the Part A skilled services episode and that the facility/provider initiated discharge from Medicare Part A services when benefit days were not exhausted, but the question asking whether a SNF ABN, Form CMS-10055, was provided was unanswered. In interview, the Business Office Manager stated SNF ABN forms were not provided for either resident and was unaware of the facility process related to SNF ABN forms. The Social Services Coordinator stated social workers currently provide Notice of Medicare Non-Coverage forms prior to discharge from Medicare Part A services, but they do not currently provide SNF ABN forms.
PRN Ativan Continued Beyond 14 Days Without Documented Medical Necessity
Penalty
Summary
The facility failed to ensure that a resident was not prescribed a PRN psychotropic medication for longer than 14 days without documented medical necessity to extend its use. Resident #18 was admitted with dementia with psychotic disturbance and was noted to have restlessness and to prefer walking independently on the unit while receiving hospice services. After a hospice-related recommendation, the resident was started on Ativan 0.5 mg PRN for anxiety/restlessness on 2/10/26 for 14 days, with documentation that non-pharmacologic interventions should be attempted before administration. The MAR showed one dose was given after redirection, reduced stimulation, and reorientation were attempted. A physician note on 2/23/26 documented that Ativan had been evaluated and that it improved the resident’s quality of life, with benefits outweighing risks, and the order was changed to PRN for 90 days. The record did not include documentation supporting why the PRN psychotropic medication should continue beyond the initial 14-day period. Subsequent MAR entries showed additional doses were administered for wandering or restlessness, and nursing interviews indicated the resident had been wandering around the building and was considered a fall risk. The NP reported re-evaluating the resident on 3/5/26 and again on 3/18/26.
Failure to Complete Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change MDS assessment for a resident who was admitted to hospice, resulting in the resident’s hospice status not being reflected in the MDS during the applicable look-back period. Resident #18 was admitted to the facility with a diagnosis of dementia, and the hospice election contract showed hospice services were to begin on 12/31/25. The resident’s care plan also identified hospice/palliative care related to dementia, with the hospice intervention initiated on 12/31/25. Review of the MDS record showed that the assessment with a reference date of 12/17/25 indicated the resident was not receiving hospice services during the 7-day look-back period, and there was no significant change MDS completed for the hospice admission. The next MDS, with a reference date of 3/5/26, reflected that the resident had been receiving hospice services during the 7-day look-back period. During interviews, the MDS Coordinator stated the significant change MDS was not completed when the resident signed onto hospice and said it may have been missed because the payor had not been changed to hospice by the business office. The Business Office Manager stated the hospice paperwork had been scanned into the record on 1/6/26, but the payor was not changed until later when she found the paperwork. The MDS Coordinator later stated she received clarification that the significant change MDS could have been completed without the account being changed to a hospice payor and that she should have relied on the charting and orders in the resident’s record.
PASARR Screening Not Updated for Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure that a significant change PASARR Level I screening was submitted and that a Level II PASARR evaluation was completed for a resident with schizoaffective disorder, bipolar type. The resident’s record showed diagnoses including schizoaffective disorder, bipolar type, and a care plan identified the resident as being at risk for fluctuations in mood related to that diagnosis. The MDS assessment documented that the resident was cognitively intact, was receiving an antipsychotic and an antianxiety medication, and had a legal guardian. The facility’s PASARR Level I screening identified only anxiety as the mental illness, and the OBRA PASARR correspondence stated that the resident did not meet criteria for serious mental illness unless a significant change was reported. Review of the diagnosis list showed schizoaffective disorder/bipolar type, and interviews confirmed the diagnosis was not included on the Level I screening. The Social Services Coordinator reported the screening tool was incorrect, the Regional Social Services Consultant said she had not submitted a new Level I screening because she believed guardian consent was needed, and the OBRA LMSW stated the facility should have submitted a new Level I screening once the diagnosis was known. The LMSW confirmed the screening was not submitted as required.
Failure to Track and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide requested pneumococcal immunizations to 2 residents who had consented to receive them. One resident was cognitively intact with a BIMS score of 15/15 and had diagnoses including debility and cardiorespiratory conditions such as congestive heart failure. His MDS indicated his pneumococcal vaccination was up to date, but the immunization record showed the vaccine was refused, and the order summary did not contain an order for the pneumococcal vaccine. During interview and record review, the DON and Regional ICP stated that consent for Prevnar 20 had been received, an order was written, but the vaccine was never administered and there was no documentation explaining why it was not given. The second resident was severely cognitively impaired, unable to complete the BIMS, dependent on staff for all ADLs, and had a diagnosis of cerebrovascular accident. Her immunization record showed the PCV-20 vaccine was refused, but the DON and Regional ICP stated she had received the pneumonia PCV-20 vaccine in January 2026; later review showed there was no order for the vaccine and it was not in the MAR. They also stated she was not offered the PCV-23 vaccine eight weeks later. The ICP stated the facility did not have a process to track immunizations, and review of the facility's pneumococcal vaccine policy showed residents would be evaluated for eligibility and offered the vaccine series under physician-approved standing orders.
Residents Denied Access to Personal Funds Following Ownership Change
Penalty
Summary
The facility failed to ensure that residents' personal funds held by the facility were accessible to them, affecting 40 residents. After a change in facility ownership, residents were unable to access their personal funds, as confirmed by interviews with residents, the Administrator in Training, and the Business Office Manager (BOM). The BOM reported that since the week following the ownership change, the facility ran out of petty cash and was unable to fulfill resident fund requests. A check containing the combined personal funds of 40 residents, totaling $21,594.90, had not been signed or cashed, preventing the transfer of funds from the previous to the new ownership. As a result, residents could not access their money for personal purchases or needs. Multiple residents expressed frustration and filed grievances due to their inability to access their funds. One resident was visibly upset and reported not having access to his money since the new company took over. Grievance forms from two other residents indicated dissatisfaction and distress over the lack of access to their funds. Facility policy requires that resident fund withdrawals be distributed within a reasonable timeframe, but this was not followed due to the unresolved transfer of funds and lack of available petty cash.
Failure to Protect Residents from Sexual and Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect multiple residents from sexual and verbal abuse by another resident, resulting in several incidents of resident-to-resident abuse. Specifically, a male resident with a history of schizoaffective disorder, cognitive communication deficits, and boundary issues was observed kissing two female residents who were unable to consent due to severe and moderate cognitive impairment. Staff members, including an LPN, CNA, and PA, directly witnessed these incidents and reported them to the facility administrator. Despite these reports, no incident or accident reports were completed for the involved residents, and the administrator determined that the incidents did not require reporting to the State Agency, citing his own assessment that the contact was welcome, which was not supported by staff witness statements. The affected residents included individuals with significant cognitive impairments and trauma histories, making them particularly vulnerable. One resident had a BIMS score indicating severe cognitive impairment and a care plan noting risks related to mood and behavioral disturbances. Another resident had a moderate cognitive impairment, a history of trauma, and a care plan specifying a preference for female-only caregivers. Both were unable to recall or report the incidents, and social work notes indicated the need for ongoing monitoring due to their vulnerability. Additionally, another cognitively intact resident reported feeling uncomfortable and altering her dining habits due to the perpetrator's behavior, while another resident reported being verbally abused and emotionally distressed by the same individual. The facility's abuse prevention policy required immediate reporting, investigation, and protection of residents from abuse, including resident-to-resident incidents. However, the facility did not follow these procedures, as evidenced by the lack of documentation, failure to report to the State Agency, and insufficient protective interventions. Staff interviews revealed concerns about the administrator's handling of the situation, including the removal of a social work note describing the incident as sexual assault and the lack of appropriate response to repeated abusive behaviors. The failure to act in accordance with policy and regulatory requirements resulted in unaddressed abuse and the potential for emotional distress among vulnerable residents.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual and verbal abuse to the State Agency in a timely manner for five residents. Multiple staff members, including an LPN, CNA, and Social Worker, witnessed or were informed of incidents where a male resident, who was cognitively intact but had a history of boundary issues, kissed two female residents with cognitive impairments who could not legally consent. These incidents were reported internally to the facility's administrator, who was made aware of the potential abuse but chose not to report the allegations to the State Agency, contrary to facility policy and regulatory requirements. The administrator assessed the residents himself and determined that the contact was welcome, despite staff statements and documentation indicating otherwise. The residents involved included individuals with significant cognitive impairments and histories of trauma, making them particularly vulnerable. One female resident had a BIMS score indicating severe cognitive impairment, while another had moderate impairment and a history of trauma. Both were unable to consent to the contact. Staff notes and interviews revealed that the incidents were not welcomed by the residents, and in at least one case, a resident was visibly in shock and did not respond to the incident. Another resident, who was cognitively intact, reported feeling uncomfortable and changed her dining habits to avoid the male resident after a separate incident involving inappropriate verbal and physical behavior. Despite multiple staff members recognizing these incidents as potential abuse and expressing concern that failure to report could lead to further incidents, the administrator did not initiate the required reports to the State Agency. Facility policy required immediate reporting of any abuse allegations, including those involving residents who could not consent, but no incident or accident reports were found for the affected residents. The lack of timely reporting resulted in the potential for incomplete investigations and further unreported abuse.
Failure to Provide Sufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents, as evidenced by multiple reports of delayed responses to call lights, late medication administration, and unmet activities of daily living (ADL) needs. Several residents reported waiting 30 minutes to over an hour for staff to respond to call lights, resulting in discomfort, emotional distress, and, in some cases, incontinence episodes. Residents and their families noted a decline in staffing levels and care quality following a recent change in facility ownership, with an increased reliance on agency staff unfamiliar with residents' needs. Documentation and interviews revealed that on specific days, the facility operated with only half the required number of licensed nurses and was also short on certified nursing assistants (CNAs). This staffing shortage led to residents not being assisted out of bed, not being dressed, not receiving timely wound care, and not having their bed linens changed. Medication administration records showed that medications were given several hours late, and some residents did not receive necessary blood sugar checks or insulin as scheduled. Staff interviews confirmed that the facility was aware of impending staffing shortages but was unable to secure adequate coverage, and that the situation caused significant frustration among both staff and residents. Residents with complex medical needs, such as those with pressure ulcers, diabetes, and cognitive impairments, were particularly affected. Family members reported concerns about late medications and unmet care needs, leading to at least one resident being discharged to another facility. Staff, including LPNs and the nursing staff coordinator, described the situation as "horrible" and "hellish," with some staff responsible for an unmanageable number of residents and medication carts. The facility's own policies and facility assessment indicated that staffing should be based on resident acuity and care plans, but these standards were not met during the period in question.
Failure to Notify Family of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's designated representative of a significant change in condition that resulted in hospitalization. Specifically, a female resident with a history of kidney disease, diabetes, and high blood pressure experienced altered mental status and shortness of breath, leading to her transfer to the hospital. Documentation showed that the resident's emergency contact was not notified of the transfer, and the transfer form indicated that notification had not occurred. The family member only learned of the resident's hospitalization and unresponsive state from the hospital social worker, not from the facility. Interviews revealed that the LPN responsible for the transfer did not contact the resident's emergency contact, believing the resident was alert and able to notify her family herself. However, facility policy required that the resident's representative be notified of significant changes in condition and transfers, regardless of the resident's alertness. The interim DON confirmed that family notification should occur in all such cases. The failure to notify the family resulted in them being unaware of the resident's decline and subsequent hospitalization.
Failure to Provide Consistent ADL Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely and consistent assistance with activities of daily living (ADLs) for a resident who was dependent on staff for bathing, grooming, and dressing due to impaired mobility from multiple fractures and moderate cognitive impairment. The resident was scheduled to receive showers twice weekly, but records showed that she was not offered a shower for 3 out of 7 scheduled opportunities within a specified period, and did not receive any unscheduled showers. Interviews with family, staff, and the resident confirmed that she often remained in bed, was not dressed or groomed, and missed scheduled showers, particularly during periods of low staffing, especially on weekends. The resident expressed frustration and embarrassment about her appearance when not assisted with bathing and grooming, and reported back pain from remaining in bed too long. Family members and staff corroborated that the resident's personal hygiene and grooming needs were not consistently met, and that these lapses were linked to staffing shortages. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain hygiene and dignity, but this was not consistently implemented for the resident in question.
Facility Lacks Qualified Activities Director
Penalty
Summary
The facility failed to employ a qualified Activity Director, which resulted in the potential for unmet psychosocial needs and a lack of person-centered activities for all 126 residents. The facility had been without a qualified Activities Director for nearly a year, during which time an Activity Assistant was allowed to assume the role without the necessary qualifications. This individual, identified as AD NN, did not possess the required certification and was not supervised by a qualified individual. The facility's job description for the Activities Director position required eligibility for certification as a therapeutic recreation specialist or activities professional, or completion of a state-approved training course. However, AD NN had not been in the director role long enough to take the certification test. The facility's policy regarding the overall activities program and the role of the director was requested but not provided during the survey. Interviews with staff, including the Nursing Home Administrator, confirmed the lack of a qualified Activities Director and the absence of proper supervision for the individual in the role.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards for food service safety, as observed during a kitchen/food service tour. In the freezer, opened cases of hamburger patties, Salisbury steaks, and egg patties were not securely closed, posing a risk of contamination. The freezer floor had a buildup of dirt, grime, and debris, and a broken plastic cover from a sprinkler head was found on the floor. In the reach-in cooler, a rack with trays of prepared food had a buildup of dried food product and debris. In the storeroom, opened boxes of chocolate cake mix and flaked coconut were not securely closed, and the floor was soiled with debris and dust. In the 600-hall nourishment room, there was significant lime buildup on the ice machine, and the refrigerator had dried spillage. A condiment tray contained spilled sugar packets, and a CNA's lunchbox was improperly stored in the refrigerator. In the 300-hall nourishment room, a lunchbox was not labeled or dated, and opened beverages lacked discard dates. The beef broth was not discarded after 7 days, and there was dried spillage in the freezer. The kitchen was hot and humid due to a non-functional exhaust system, and the floor mixer had dried debris. A black hose connected to the dish machine lacked an atmospheric vacuum breaker, and the 500-hall pantry had expired food and slime debris in the ice machine. The 100-hall pantry contained commercially prepared salsa and hummus with incorrect discard dates, and condiments were at risk of contamination. The 600-hall pantry's ice machine had slime debris, and the facility's maintenance director confirmed that a vendor services the ice machines quarterly. The report cites several sections of the 2022 FDA Food Code, highlighting the facility's failure to maintain cleanliness, proper food storage, and equipment maintenance, which could lead to foodborne illness among residents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to maintain safe infection control practices, as observed in the care of two residents. For one resident with a tracheostomy and gastrostomy, an LPN did not change gloves after touching potentially contaminated surfaces and before performing tracheostomy care. This oversight occurred despite the resident being highly susceptible to infections due to their medical conditions. The LPN admitted to not changing gloves during the procedure, which could lead to cross-contamination and the spread of bacteria. In another instance, a housekeeping aide did not adhere to droplet precaution protocols while entering a resident's room. The aide failed to wear eye protection and did not change gloves or wash hands after exiting the room. The facility's policy required staff to don eye protection, gloves, gown, and mask before entering rooms with droplet precautions, but these measures were not consistently followed. Additionally, the facility lacked an active and ongoing plan to reduce the risk of Legionella and other opportunistic pathogens in the plumbing system. Observations revealed stagnant water lines, discolored water, and infrequent flushing of unused fixtures. The maintenance director was unaware of some stagnant water lines and admitted that the facility's water management plan was not fully implemented, increasing the risk of waterborne pathogens spreading within the facility.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of several residents, as evidenced by multiple observations and interviews. Resident #26, who was cognitively intact, reported overhearing staff speaking negatively about residents, which made her feel reluctant to ask for help. This was corroborated by a Registered Nurse who confirmed that staff often spoke disrespectfully about residents. Additionally, during a confidential meeting, several residents reported long wait times for call light responses and overheard staff socializing instead of attending to their needs, leading to feelings of frustration and decreased self-worth. Resident #55, who was severely cognitively impaired, was observed being moved by a CNA without any verbal interaction, causing the resident to appear startled. Similarly, Resident #57, also severely cognitively impaired, was assisted with eating by a CNA who engaged in a loud personal conversation with another CNA, ignoring the resident. These actions likely contributed to a decreased sense of self-worth and frustration for the residents involved. Resident #112, who was cognitively intact, reported an incident where a CNA delayed assistance for restroom use, citing other duties, and later ignored the resident's call light while using a cell phone. The resident's concerns were reported to a social worker, who confirmed overhearing disrespectful interactions and reported them to the administration. However, the Nursing Home Administrator was unaware of these issues, indicating a lack of communication and follow-up within the facility. Disciplinary records for the CNA involved showed previous warnings for disrespectful behavior, highlighting ongoing issues with staff conduct.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide individualized activities for several residents, leading to feelings of boredom and a potential decline in their well-being. Resident #26, who was cognitively intact, expressed feelings of boredom and loneliness due to the lack of group activities and support for independent leisure interests. Despite the resident's preferences for reading materials, religious activities, and being around pets, the facility did not facilitate these activities, especially during periods when group activities were suspended due to infection control measures. Resident #39, who was moderately cognitively impaired, also experienced a lack of support in pursuing leisure activities. The resident's family member reported that the facility did not assist with the resident's interest in music and social activities. Observations showed that the resident spent most of the time in bed with little engagement in activities, despite having a care plan that included interests in music, socializing, and religious activities. The facility's activity participation records indicated extended periods without any activity involvement for the resident. Resident #42, who was severely cognitively impaired, was observed spending all his time in bed, with little engagement in activities. The resident expressed a desire for social interaction and the use of a computer tablet, which was no longer available to him. The facility had tablets available for residents, but the activity assistant was unaware of the resident's needs. Similarly, Resident #55, who had Huntington's disease and was severely cognitively impaired, was observed to be restless and spent most of the time sitting in a geri chair near the nurse's station. The facility did not provide enough activities for the resident, and there was a lack of communication with the resident's family to understand his interests and preferences.
Failure in Nutritional Monitoring and Assessment
Penalty
Summary
The facility failed to ensure timely and consistent weight measurements and follow-up for residents at risk for altered nutrition status, affecting four residents. Resident #59 experienced a significant weight loss of 13.7% in one month, but a reweight was not obtained despite multiple requests from the Registered Dietitian (RD). The RD reported that reweights should be obtained within a day or two to implement new nutritional interventions if needed, but the Certified Nurse Aides (CNAs) responsible for obtaining reweights did not fulfill this requirement. Resident #111, who was at high risk for nutritional status alteration due to tube feeding and a stage IV pressure ulcer, did not receive ongoing nutritional assessments. The RD acknowledged that only one dietary evaluation was completed since admission, and no subsequent nutrition/weight progress notes were documented. The RD admitted to being unable to keep up with the workload, which resulted in missed assessments for high-risk residents like Resident #111. Resident #121, a newly admitted resident with a gastrostomy, missed several weight checks despite being at risk for malnutrition. The RD reported that new admissions should be weighed weekly, but this was not done. Similarly, Resident #89, diagnosed with unspecified protein-calorie malnutrition, had not received a dietary evaluation since June 2024, despite significant weight loss. The RD admitted to being behind on assessments due to an unmanageable workload, which was communicated to facility management but not addressed. The Director of Nursing was unaware of the missed assessments and the RD's workload issues.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During a tour, several deficiencies were observed, including an accumulation of dust, dirt, sand, and dead ants in various rooms. The 600 hall spa room was found to be hot and humid, with moisture dripping down the windowsills and black debris on the window frame. Open and exposed linens were laid out on a shower bed, and urine remover and personal hygiene products were stored together on the same shelf. Additionally, holes in the concrete wall of the 600 linen closet allowed air to enter the room, and the 100 hall clean utility room had a gap between the floor and wall due to missing vinyl coving. In the 500 hall spa, a cloth-backed chair was found near the shower area, and a used brief was half hanging out of the trash receptacle. The alarm cord was stained, and there was dried brown debris on the wall near the commode. The 400 hall spa room had a roll of toilet paper on the ground, and a plastic cart with gloves and briefs was stored next to the sink and commode. The facility's maintenance director acknowledged that some exhaust ventilation was down, contributing to a foul odor in the 600 hall soiled utility room. The janitor's closet in the 200 hall had a chemical pre-dispense with water left on under constant back pressure, which was not approved for the fixture. Several resident rooms had issues with peeling and chipped paint, and personal fans were found to be caked with dust and debris. Residents reported that the dust from the fans blew into their eyes, and despite requests for cleaning, the fans remained uncleaned. Housekeeping staff confirmed that resident fans should be dusted multiple times a week, but the housekeeping account manager admitted that audits were only conducted once a month. These observations indicate a lack of regular maintenance and cleaning, leading to an unsanitary and uncomfortable environment for residents.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, resulting in the inability to call for staff assistance and potential unmet care needs. Resident #27, who was admitted with a diagnosis of unsteadiness of feet and had a care plan indicating a need for a safe environment with the call light in reach, was observed with the call light on the floor and out of reach. The resident reported using the call light when staff remembered to place it within reach. Interviews with a registered nurse and a certified nursing assistant confirmed that the resident used the call light when needing assistance. The facility's policy requires call lights to be within reach of residents who can use them, but this was not adhered to in this instance.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency in a timely manner for two residents, resulting in the potential for additional allegations of abuse to go unreported and delayed investigation. Resident #115, a cognitively intact female with adjustment disorder, reported being assaulted by a nurse during medication administration, resulting in scratches to her chest. Despite the resident's grievance and the involvement of multiple staff members in the investigation, the allegation was not reported to the State Agency. Resident #127, a male with severe cognitive impairment and multiple diagnoses, was involved in an incident where a hospice nurse observed him being held down by staff during medication administration. The hospice nurse reported care concerns to the facility, leading to the suspension of the involved LPN pending investigation. However, the allegation was not reported to the State Agency, despite the facility's awareness of the hospice nurse's concerns and the subsequent internal investigation. The facility's policy requires all allegations of abuse to be reported immediately to the appropriate State Agencies, but this was not adhered to in the cases of Resident #115 and Resident #127. The failure to report these allegations in a timely manner resulted in a deficiency citation, highlighting the potential for further unreported incidents and delayed investigations.
Inaccurate MDS Assessment for Resident with Tracheostomy
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, resulting in an inaccurate reflection of the resident's status. The resident, who was admitted with a tracheostomy, was not documented as receiving tracheostomy services in the MDS assessment dated 12/18/24. This discrepancy was identified through a review of the resident's physician orders, which included instructions for regular tracheostomy care, and an observation that confirmed the presence of a tracheostomy tube and related supplies in the resident's room. An interview with the MDS Registered Nurse revealed that the resident had a tracheostomy upon admission, and the MDS record was acknowledged as inaccurate. The Long-Term Care Facility Resident Assessment Instrument Manual specifies the importance of accurately coding special treatments, such as tracheostomy care, to ensure the appropriateness of care provided. The failure to accurately document the resident's tracheostomy care in the MDS assessment could lead to an inaccurate understanding of the resident's needs and care requirements.
Failure to Complete Level II PASARR Evaluation
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for a resident, resulting in the potential for unmet mental health and psychiatric care needs. The resident was admitted with a diagnosis of psychotic disorder with delusions and had a Preadmission Screening (PAS) Annual Resident Review (ARR) Level I Screening that indicated the presence of mental illness and dementia. The screening also noted that the resident had received treatment for mental illness, was on antipsychotic or antidepressant medications, and exhibited significant disturbances in thought, conduct, emotions, or judgment. Despite these indicators, the Social Services Director (SSD) responsible for coordinating the facility's PASARR screenings was unable to locate the resident's Level II screening. Upon further investigation, it was discovered that the Level II screening had not been completed in a timely manner, as it was found in the facility's physician's online portal awaiting completion. This oversight highlights a lapse in the facility's process for ensuring necessary evaluations are conducted to address the mental health needs of its residents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential unmet medical, physical, mental, and psychosocial needs. Resident #73, who had a history of stroke, dementia, pressure ulcers, and reduced mobility, was observed without a padded boot on her right foot despite having a pressure wound on her right heel. The care plan for Resident #73 included the use of heel protectors, but observations revealed non-compliance with this intervention, as her right heel was resting directly on the mattress. Resident #97, with a diagnosis of right-side paralysis following a stroke, was observed without a splint device on his right hand, which was prescribed to prevent contractures. The care plan for Resident #97 did not include orders for the hand splint, and the Therapy Director confirmed that the resident was prescribed a splint in May 2023. However, there was no record of the splint in the resident's care plan or therapy notes, indicating a lack of coordination and communication among the care team. Resident #27, diagnosed with dementia, did not have a care plan focus related to this diagnosis. The Social Services Director and Registered Nurse Unit Manager confirmed that all residents with dementia should have a care plan addressing their condition, but Resident #27's care plan lacked this essential component. This oversight highlights a failure in the facility's process for developing and implementing comprehensive care plans tailored to each resident's needs.
Deficiencies in Wound Care and Documentation
Penalty
Summary
The facility failed to adhere to professional standards of practice for wound care and documentation, affecting three residents. Resident #230, who was cognitively intact, had wounds on her bilateral feet and left lower leg. Despite physician orders for daily dressing changes, observations revealed that her dressings had not been changed for two days, with visible wound drainage present. The Treatment Administration Record (TAR) showed missed documentation for wound care on specific dates, and there was no progress note explaining the missed treatments. Resident #27 also experienced lapses in wound care documentation. The TAR indicated missing entries for wound care on multiple dates for different wound sites, including the left buttock, right toes, and an old suprapubic catheter site. Interviews with staff confirmed the expectation for daily wound care and documentation, yet there was no explanation for the missed entries in the resident's records. Resident #89's meal intake documentation was incomplete on several dates, despite the facility's policy requiring documentation of all services provided to residents. Interviews with a CNA and the DON confirmed the expectation for documenting meal intake to monitor nutritional status. The DON reviewed the electronic health records and confirmed the missing documentation for both wound care and meal intake, with no further documentation explaining the omissions.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to properly assess a resident after a fall, which was identified during a review of Resident #48's care. Resident #48, who was admitted with a diagnosis of unsteadiness on feet and had a history of falls, experienced a fall from his wheelchair. Despite the resident's medical history of metastatic cancer to the bone, which increased his risk of fractures, the Licensed Practical Nurses (LPNs) involved did not conduct a thorough assessment before moving him. The LPNs lifted the resident back into his wheelchair without checking for potential injuries, such as deformities or pain, and did not document any vital signs or initiate post-fall monitoring. Interviews with the Unit Manager and LPNs confirmed that the facility's policy, which requires a full assessment before moving a resident post-fall, was not followed. The Unit Manager acknowledged that a proper assessment, including range of motion and vital signs, could not be completed in less than a minute, and that the resident's condition warranted careful evaluation due to his increased risk of fractures. The lack of documented vital signs and post-fall monitoring further highlighted the deficiency in care provided to Resident #48 after his fall.
Failure to Provide Trauma-Informed Care for Resident
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who was a trauma survivor, resulting in a potential for re-traumatization. The resident, who had a history of sexual abuse at age 10, was admitted with diagnoses including major depressive disorder, anxiety disorder, and dementia. Despite this history, the facility did not have a care plan in place to address the resident's trauma-related needs. The Social Services Director (SSD) was unaware of the resident's trauma history, as it was not assessed during the initial social work assessments for residents admitted more than a few years ago. The deficiency was identified during an interview with the SSD, who confirmed that the resident had not been assessed for any trauma-related triggers. The SSD acknowledged the importance of knowing a resident's trauma history to prevent re-traumatization during care. Additionally, the Nursing Home Administrator reported that the facility lacked a policy related to trauma-informed care, further contributing to the oversight in addressing the resident's psychosocial needs.
Failure to Facilitate Timely Dental Services for Resident
Penalty
Summary
The facility failed to facilitate timely dental services for a resident with severe periodontal disease, resulting in prolonged poor dental condition and potential risk for life-threatening infection. The resident, who was severely cognitively impaired due to Huntington's disease, had a history of dental infections requiring antibiotics and hospitalization. Despite consent from the resident's guardian for dental extractions, the facility did not successfully arrange for the necessary dental services. The resident's medical records indicated multiple attempts by the Nurse Practitioner to coordinate dental care, including referrals for extractions and the need for sedation due to the resident's inability to cooperate during dental exams. However, there was a lack of communication and coordination among facility staff, leading to confusion about who was responsible for scheduling the dental appointments. The Medical Records Coordinator and Unit Secretary were unaware of the referral, and the Director of Nursing was not informed that consent had been obtained. Interviews with facility staff revealed a breakdown in communication and responsibility, with staff members unsure of the status of the resident's dental care and referrals. The Director of Nursing and other staff members were unaware of the resident's need for dental extractions and the consent that had been obtained. This lack of coordination and follow-through resulted in the resident not receiving the necessary dental care, despite the known risks and previous recommendations for extractions.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents upon their transfer to an acute care hospital. This deficiency was identified for two residents who were reviewed for emergency hospital transfers. Resident #102, who was admitted with a diagnosis of muscle weakness, was transferred to a hospital on 10/18/24. Although the transfer note indicated that a medication list and facesheet were sent with the resident, there was no documentation to confirm that the bed hold policy was provided. Similarly, Resident #103, admitted with insomnia, was sent to a local hospital following a medical specialty appointment, but there was no documentation indicating that the bed hold policy was provided upon discharge. During the survey, the Nursing Home Administrator and the Director of Nursing confirmed that the facility could not provide the bed hold policy forms for these residents. The Director of Nursing acknowledged that the facility nurses were expected to provide the bed hold policy form to residents when they were transferred to the hospital, but this was missed in the cases of Resident #102 and Resident #103. This oversight resulted in the potential for unanticipated expenses or the loss of desired room placement for the residents.
Failure to Address Acute Change in Condition
Penalty
Summary
The facility failed to address an acute change in condition for a resident, resulting in a delay in treatment for a subacute cerebral vascular accident (CVA) and an acute right lower extremity deep vein thrombosis (DVT). The resident, who had a history of strokes, exhibited symptoms such as increased lethargy, right upper extremity weakness, facial asymmetry, decreased grip strength, and increased pain, warmth, and swelling in the right knee. Despite these symptoms, the facility did not notify the physician promptly or send the resident to the hospital for evaluation. The resident was initially assessed after a fall, and subsequent evaluations noted a decline in mentation and increased pain in the right hip and knee. However, the facility's medical staff, including a nurse practitioner and physician assistant, did not recognize the neurological changes as indicative of a stroke. The resident's guardian was not informed of the neurological symptoms, which contributed to the delay in seeking emergency medical care. Interviews with facility staff revealed that there were concerns about the resident's condition, but these were not acted upon in a timely manner. The medical director was not informed of the potential stroke symptoms, and the nurse practitioner believed the resident's condition was at baseline. It was only after persistent concerns from nursing staff and the resident's guardian that the resident was eventually sent to the hospital, where a stroke and DVT were diagnosed.
Failure to Follow Prescribed Feeding Protocols for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure the safety of a resident with specific dietary needs, leading to a potential risk of choking. The resident, who had a history of aphasia and dysphagia following a stroke, was prescribed a pureed diet with thin liquids to be administered via teaspoon only, with no straws or sip cups allowed. Despite these clear orders, observations and interviews revealed that the resident was provided with liquids using sip cups and straws, contrary to the prescribed method. This was observed on multiple occasions, and staff members, including CNAs, were found to be using sip cups and straws, believing it was easier for the resident, despite the risk of choking due to the resident's impaired cognition and need for frequent swallowing cues. The Speech Language Pathologist (SLP) had communicated the specific feeding precautions to the staff, and these were documented in the resident's orders and Kardex. However, there was a disconnect between the prescribed care and the actual care provided, as evidenced by the presence of sip cups and straws in the resident's room. Interviews with staff, including the Kitchen Manager and LPN, confirmed that the orders were not being followed, and there was a lack of adherence to the feeding assistance orders. The Director of Nursing acknowledged that the facility had not updated the resident's eating assistance orders, despite the SLP's recommendations, indicating a lapse in communication and implementation of care protocols.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as high risk for wandering. The resident, who had severe cognitive impairment and a history of wandering and exit-seeking behavior, was able to exit the facility without staff knowledge. The resident was wearing a Wander Alert electronic monitoring device, which was functioning properly and sounded an alarm when the resident approached the exit. Despite the alarm sounding, the front desk receptionist did not respond appropriately. The receptionist mistook the resident for a visitor and allowed him to exit the building without verifying his status or ensuring he had permission to leave. The receptionist admitted to turning off the alarm, which she claimed made noise frequently, and did not check if the resident was authorized to leave. This inaction allowed the resident to reach the parking lot before being noticed by another resident, who alerted the nursing staff. The nursing staff responded promptly once informed by another resident, redirecting the eloped resident back into the facility. The incident highlighted a lapse in the facility's protocol for responding to door alarms and ensuring residents at risk of elopement are adequately supervised. The resident was found unharmed and was placed under 1:1 supervision following the incident.
Failure to Document Elopement Incident for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as Resident #107, who was at risk for wandering and elopement. The resident, diagnosed with dementia and other conditions, had a history of wandering behaviors and wore a WANDER ALERT bracelet as a preventive measure. On the day of the incident, the resident attempted to elope from the facility, successfully leaving the premises and crossing a four-lane street before being redirected back by staff. Despite the seriousness of the event, there was no documentation of the incident in the resident's medical records, nor were there any incident reports filed. Interviews with staff revealed that the resident had removed his WANDER ALERT bracelet prior to the elopement attempt, and staff members were aware of the incident as it unfolded. However, the staff did not document the event in the resident's progress notes or complete any standard assessments on the day of the incident. The lack of documentation was attributed to a misunderstanding among staff that no further action was needed if the resident remained in visual sight. This oversight resulted in an incomplete and inaccurate medical record for the resident, failing to provide an accurate picture of the resident's status and condition. The Director of Nursing (DON) acknowledged being informed of the incident shortly after it occurred but admitted to not ensuring that the necessary documentation and incident report were completed. The failure to document the resident's behavior escalation, the removal of the WANDER ALERT bracelet, and the attempted elopement highlights a significant deficiency in maintaining accurate medical records, which is crucial for effective resident care and safety.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to implement proper transmission-based precautions and ensure the use of required Personal Protective Equipment (PPE) when entering rooms of COVID-19 positive residents. Observations revealed that staff members, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), entered rooms with Special Droplet/Contact Precautions without donning the necessary PPE, such as N-95 masks, gloves, and eye protection. The signage on the doors clearly indicated the need for these precautions, yet staff either did not notice the signs or did not have access to the required PPE. In one instance, a CNA entered a room with an open door, responding to a call light while wearing only a surgical mask, despite the posted requirement for an N-95 mask and other PPE. The CNA was unaware of the additional precautions due to the open door and lack of visible signage. Similarly, an LPN entered the same room with only a surgical mask and gown, citing the absence of N-95 masks in the PPE bin as a reason for not following the protocol. Further observations showed that an Activity Director also entered a COVID-19 positive resident's room wearing only a surgical mask, misunderstanding the PPE requirements as applicable only during direct care or potential contact with body fluids. The Director of Nursing/Infection Preventionist confirmed that both COVID-19 positive and negative residents in shared rooms should be under the same Special Droplet/Contact Precautions, requiring full PPE for all staff entering these rooms.
Failure to Assess and Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to assess and ensure the safe self-administration of medication for Resident #105. Resident #105, who was cognitively intact with a BIMS score of 15, was observed with a medication cup containing two tablets on his bedside table. The resident reported that the tablets were Vitamin B12 and Folic Acid, which he intended to take with his lunch. However, a review of the physician's orders revealed that the medications were Folic Acid and Thiamine HCl (Vitamin B1), not Vitamin B12. The resident had not been assessed for the ability to self-administer medications, and there was no care plan in place to reflect self-administration status. Interviews with the Director of Nursing (DON) and the Registered Nurse Unit Manager (RNUM) confirmed that an assessment should have been completed to ensure the resident's safety in self-administering medications. Both the DON and RNUM acknowledged that the resident had not been evaluated for self-administration and should not have had medications at his bedside. A review of the resident's care plan also showed no documentation regarding self-administration of medications.
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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