Optalis Health & Rehabilitation Of Wyoming
Inspection history, citations, penalties and survey trends for this long-term care facility in Wyoming, Michigan.
- Location
- 625 36th Street Sw, Wyoming, Michigan 49509
- CMS Provider Number
- 235441
- Inspections on file
- 25
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 41
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation Of Wyoming during CMS and state inspections, most recent first.
A resident with dementia, chronic respiratory failure, and severe protein-calorie malnutrition did not receive timely and thorough assessment and care for a coccyx Stage 2 pressure ulcer. Required weekly skin assessments were not documented for a two-week period, the pressure ulcer was identified without notifying the legal guardian, and a specific care plan was delayed and lacked clear offloading and repositioning interventions. Recommendations for an alternating pressure mattress (APM) and offloading were not promptly implemented, the APM order was significantly delayed, and documentation indicating a turning/repositioning program and pressure-reducing devices did not result in actual interventions. The care plan was not updated when the wound was documented as resolved, and when a subsequent open coccyx area was found, there was no evidence of guardian notification or care plan revision.
A resident with Type 1 DM had a low BG identified, was told by an LPN to eat cookies, and was left without a timely BG recheck or documented ongoing assessment, contrary to the facility’s hypoglycemia policy. Later, the resident was found unresponsive with critically low BG and low O2 saturation, with no documentation that ordered glucagon or supplemental O2 were provided before EMS arrival, despite existing hypoglycemia treatment orders. Two additional residents with Type 2 DM had orders for nightly Lantus with parameters to hold if BG was below a specified level, yet BG checks were either not ordered routinely or not performed and documented on multiple days, while Lantus was still administered without recorded BG values or documented refusals.
Surveyors identified multiple food service and sanitation failures, including lack of hand towels at the only kitchen handwashing sink, a leaking dining room hand sink, and a non-operational cookline hood with filters removed for several days. Resident food in the pantry refrigerator was held beyond the facility’s stated 3-day limit for TCS items, and an expired therapeutic nutrition supplement product was stored with other supplements. Kitchen staff were observed handling clean dishes and resuming food preparation after other tasks or leaving the kitchen without required handwashing, and changing gloves without washing hands. The dish machine’s sanitizing rinse did not reach required temperatures for hot water sanitization, failing to achieve the minimum plate surface temperature needed for effective sanitization.
A resident with an infected hip replacement and impaired mobility reported that a CNA told her to stop using her call light, stated they would not return, then manipulated the bed controls and call light before leaving the room. The resident later awoke needing the bathroom, could not locate the call light, and subsequently had a bowel movement and urinated in bed, leaving her devastated and embarrassed. Another CNA entering after shift change found the resident upset, the bed saturated with urine and feces, and the call light wrapped with the bed remote on the floor, out of the resident’s sight and reach.
Two residents experienced significant clinical changes without provider notification. One resident with type 1 DM had multiple blood glucose readings in the 400–551 range despite an order to notify the physician for values above 200, and there was no documentation that the provider was informed. Another resident with heart disease and a pacemaker reported left-sided chest pain, received nitroglycerin, and had elevated BP and reduced O2 sats documented, but only the spouse was notified and there was no record of provider notification or entry in the provider communication log. The DON confirmed the absence of documentation in both cases.
The facility failed to prevent and monitor misappropriation of medications for two residents when an RN accepted and retained a GLP-1 (Ozempic) from the pharmacy that later could not be located, and only one LPN dispensed all PRN Norco doses to a cognitively intact resident whose pain was controlled with scheduled Tylenol and who reported not requesting the narcotic. Controlled drug records showed a missing Norco tablet that could not be accounted for, and the DON acknowledged that a single nurse exclusively dispensing a narcotic over time appeared suspicious for diversion.
A resident with dementia, anxiety, and bipolar disorder, but assessed as cognitively intact, reported that a CNA yelled at him during a dispute about a roommate’s urinal, and a CNA witness documented that the resident described the aide screaming at him and that he appeared fearful. Although the incident was reported internally and an investigation file and risk management forms were created, the resident’s EHR contained no documentation of the allegation, the verbal altercation, or any related behavioral episodes or psychosocial assessments during the period in question. The DON and NHA confirmed that such allegations were recorded only in internal incident and risk management systems, not in the resident’s medical record, resulting in incomplete and inaccurate documentation contrary to accepted professional standards.
A resident with esophageal cancer and obstruction, receiving enteral nutrition, had their tube feeding paused and restarted by a CNA who was not trained or authorized to perform this task. Interviews with the DON and an LPN confirmed that only trained staff should handle tube feedings, but it was reported that CNAs regularly performed this action, contrary to facility policy.
The facility failed to ensure call lights were within reach for residents, compromising their ability to alert staff for assistance. A resident with dementia and mobility issues was repeatedly observed with her call light on the floor, out of reach. Another resident was unaware of the call light's location due to it being hooked through the bed frame. A CNA confirmed that staff should check call light placement, indicating a lapse in protocol adherence.
A facility failed to adhere to professional standards for medication administration for a resident with a seizure disorder. The resident was prescribed Vimpat 50 mg twice daily, but the medication ran out on January 12, 2025, and was not available until January 16, 2025. Despite this, the Emar showed a dose was given on January 14, 2025, which was not accounted for in the Control Substance Record. The Unit Manager confirmed the medication was not available, indicating a failure to maintain accurate documentation.
The facility failed to implement Enhanced Barrier Precautions and Contact-Based Precautions for three residents, leading to infection control deficiencies. Nurses did not follow gown requirements, and Contact Precautions were delayed for two residents. Additionally, IV administration protocols were not followed for a resident, risking infection. The facility also neglected its water management plan, failing to address abnormal legionella levels, potentially affecting all residents.
A resident self-administered a nebulizer treatment without proper assessment or supervision, as the facility failed to perform necessary assessments and obtain a physician order for self-administration. The resident had diagnoses including pneumonitis and COPD, and the facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted. An LPN acknowledged the need for supervision during treatments but cited time constraints as a barrier.
A facility failed to monitor and assess the use of psychotropic medications for a resident with schizoaffective disorder, bipolar disorder, and PTSD. Despite a care plan requiring medication monitoring, there was no documentation of monitoring for side effects or effectiveness. An LPN confirmed the absence of documentation, highlighting a failure to follow the facility's policy on psychoactive drug use.
The facility failed to label and date medications, dispose of expired medications, and secure medication carts. An insulin pen was improperly stored, and several medications lacked proper labeling. Personal belongings were found in a medication room, and medication carts were left unlocked and unattended. These issues indicate deficiencies in medication management practices.
The facility failed to provide coordinated hospice care for two residents, resulting in a lack of collaborative care. One resident with multiple sclerosis was unaware of the hospice staff's visit schedule, and there was no documentation of hospice participation in care conferences. Another resident with hemiplegia reported severe pain, and the RN was unaware of the hospice staff's visit schedule. The facility's social worker could not locate documentation of hospice participation in care conferences, and the last hospice records were dated over a week prior.
A resident with heart disease and hypertension was not administered the pneumococcal vaccine PCV20 upon admission, despite being due and having consented. The resident's immunization status remained pending, and the DON acknowledged the oversight, noting a lack of process to ensure timely vaccination. Facility policy required offering the vaccine upon admission unless contraindicated or previously vaccinated.
Failure to Provide Timely and Effective Pressure Ulcer Assessment and Care
Penalty
Summary
The deficiency involves the facility’s failure to provide thorough and effective quality care to treat and prevent recurrence of a pressure sore for one resident. The resident was admitted with chronic respiratory failure, dementia, and severe protein-calorie malnutrition, and was assessed as moderately cognitively impaired with a legal guardian for medical decisions. Although an RN stated that weekly full-body skin assessments were conducted on all residents, the EMR showed no skin assessments for this resident over a two-week period. A Stage 2 pressure sore on the coccyx was first documented on 3/10/2026, but the note did not show that the legal guardian was notified. When a medical provider evaluated the resident two days later, the wound had increased in size, and recommendations were made for an alternating pressure mattress (APM) and offloading. A care plan specific to the Stage 2 pressure ulcer was not initiated until nine days after the wound was identified, and the plan lacked actionable interventions for offloading or a defined repositioning regimen. The care plan referenced a prior refusal of an APM in 2024 and a plan to reattempt, but there was no documentation of when or whether this reattempt occurred. A 3/19/2026 progress note, generated from a check-box form, indicated a turning/repositioning program and pressure-reducing devices for bed and chair, but the DON reported this documentation did not translate into implemented actions. A physician order for an APM was not entered until twelve days after the provider’s recommendation. The EMR later documented that the skin issue was resolved, but the care plan was not updated to reflect resolution, and there was no documentation of assessments or care plan changes to prevent recurrence. A subsequent total body skin evaluation documented another open, measurable coccyx area without evidence that the guardian was notified or that the care plan was revised as of 4/7/2026.
Failure to Competently Manage Hypoglycemia and Follow Insulin Parameters for Diabetic Residents
Penalty
Summary
The deficiency involves failures in recognizing and managing hypoglycemia and in administering insulin according to physician orders for three diabetic residents. One resident with Type 1 diabetes had orders for blood glucose (BG) checks before meals and at bedtime, with specific hypoglycemia treatment orders including oral glucose tablets and glucagon nasal spray. On the morning in question, an LPN obtained a BG of 69 mg/dL, documented only in a nursing note, encouraged the resident to eat cookies, and then left the room without rechecking the BG or reassessing the resident as required by the facility’s hypoglycemia policy. There was no documentation of a repeat BG within approximately 15 minutes, no documentation that the resident’s clinical status was monitored during this period, and no documentation that the resident was medically stable until vital signs were taken about 1 hour and 45 minutes later. When the resident was next assessed, vital signs showed an oxygen saturation of 84% on room air and a BG of 46 mg/dL. Documentation and interviews indicate the resident was unresponsive at that time, with a critically low BG and elevated blood pressure. Staff did not document application of supplemental oxygen after the low oxygen saturation was identified, and there is no documentation that ordered emergency hypoglycemia treatments (glucagon) were administered by facility staff prior to EMS arrival. EMS and hospital records reflect that staff reported the resident’s sugar had been found low earlier, that the resident had been told to eat and left alone, and that staff stated they did not have glucagon or glucose to give, despite existing orders for oral glucose tablets and glucagon nasal spray. EMS found the resident unresponsive, hypoxic, and with a BG of 24 mg/dL, and administered glucagon. The deficiency also includes failures to follow physician orders for insulin administration parameters for two other residents with diabetes. One resident with Type 2 diabetes had an order for nightly Lantus insulin with instructions to hold the dose if BG was less than 100 mg/dL, and to obtain a BG prior to administration. Review of records showed multiple dates on which no BG was assessed in the evening, yet all Lantus doses were documented as given, with no rationale or documentation of BG refusals. Another resident with Type 2 diabetes had an order for nightly Lantus with instructions to hold if BG was less than 100 mg/dL, but there was no corresponding order for routine BG assessments. Over a several-week period, only four BG readings were documented, while Lantus was administered on most nights, including nights without a recorded BG. The DON confirmed that BGs were not consistently obtained prior to insulin administration and that nurses were expected to review full order summaries to follow provider-ordered parameters.
Multiple Food Service Sanitation and Hand Hygiene Failures in Kitchen and Dining Areas
Penalty
Summary
The deficiency involves multiple failures in kitchen sanitation and food handling practices observed during a survey. Surveyors observed that the only designated handwashing sink in the dishwashing room did not have hand towels readily available, contrary to FDA Food Code requirements for hand drying provisions. In the dining room, the hand sink was leaking cold water, and the dietitian reported that the faucet had been repaired the prior week for the same issue, indicating the plumbing system was not maintained in good repair. Additional observations showed that the ventilation hood system over the cookline was not properly maintained. Filters were missing from the face of the hood ventilation system, and the dietitian stated the filters had been out for cleaning since several days prior and that the hood was not operational, then turned the hood off. This condition did not meet FDA Food Code requirements that ventilation hood systems be sufficient in number and capacity to prevent grease or condensation from collecting on walls and ceilings. Surveyors also identified improper food storage, expired products, and inadequate hand hygiene and dish sanitization practices. Resident food stored in the pantry refrigerator included a foam takeout container with an orange/brown sauce dated beyond the facility’s stated 3-day holding policy for time/temperature controlled for safety food. A Vital therapeutic nutrition supplement with an expiration date already passed was found on shelving with other therapeutic nutrition products. Kitchen personnel were observed handling clean dishes after other tasks without washing their hands, removing gloves and donning new ones without handwashing, and leaving and re-entering the kitchen to resume food preparation without washing hands, contrary to FDA Food Code handwashing requirements. The dish machine’s sanitizing rinse failed to reach the required 180°F at the gauge and 160°F plate surface temperature, with a DishTemp plate registering only 146°F, which did not meet FDA Food Code standards for hot water sanitization temperatures.
Failure to Maintain Resident Dignity and Access to Call Light
Penalty
Summary
The deficiency involves the facility’s failure to treat a resident in a dignified manner and to honor her rights to self-determination and communication. The resident was an adult female admitted with an infected right hip replacement and difficulty walking. In an interview, she reported that very early one morning a CNA entered her room and told her to stop using her call light, stating that the CNA had already been in the room multiple times and would not be coming back again. The resident stated that the CNA then manipulated her bed controls and call light and left the room. The resident later awoke around 5:00 AM needing to use the bathroom and was unable to locate her call light to request assistance. According to the resident, because she could not find the call light, she had a bowel movement and urinated in her undergarments, which left her feeling devastated and embarrassed. Another CNA, who entered the room after shift change that morning, reported smelling feces, finding the resident very upset, and observing that the sheets were saturated with urine and feces. This CNA also reported that the call light was wrapped together with the bed remote, on the floor, out of the resident’s sight and reach. The CNA implicated in the incident was no longer employed at the facility and was not available for interview.
Failure to Notify Providers of Significant Changes and Abnormal Clinical Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify providers of significant changes in condition and abnormal clinical findings for two residents. One resident with type 1 diabetes mellitus and an order to obtain blood sugars before meals and at bedtime, with instructions to notify the physician for blood glucose levels less than 60 or greater than 200, had multiple documented blood sugar readings far above the ordered threshold. These included values in the 400–551 range on numerous dates. Review of the electronic medical record showed no documentation that the provider was notified of any of these elevated blood sugar results. When surveyors requested evidence of provider notification, the Nursing Home Administrator acknowledged there was no documentation, and the DON stated that the expectation was for licensed nurses to notify the provider of elevated blood sugars, typically when readings were greater than 450. The second resident, who had heart disease and a cardiac pacemaker, experienced an episode of left-sided chest pain for which nitroglycerin was administered. Vital signs at that time included a blood pressure of 158/90, pulse 73, respirations 18, temperature 97.3, and oxygen saturation of 93% on room air. Nursing documentation indicated that the nurse notified the resident’s wife of the condition and that she advised continued monitoring and possible hospital transfer if the condition worsened. However, there was no documentation in the electronic medical record or provider communication log that the provider was notified of this chest pain episode, despite the resident’s complex cardiac history. The DON confirmed there was no documentation of provider notification. The report cites a nursing textbook outlining failure to communicate abnormal assessment data or significant changes in status as a common negligent act.
Failure to Prevent and Monitor Misappropriation of Medications
Penalty
Summary
The facility failed to prevent misappropriation of a resident’s medication when a nurse accepted and retained possession of a GLP-1 medication (Ozempic) for a male resident with type 2 diabetes and the medication subsequently could not be located. According to the facility-reported incident, the RN accepted the Ozempic from the pharmacy late at night and had it in her possession, then attempted to obtain a co-signature from an LPN after she already had the medication. The LPN found this concerning and reported it to the DON early the next morning. When first shift staff arrived, the Ozempic could not be found, and the packing slips for all medications delivered were recovered except for the Ozempic. Multiple co-workers reported that the RN frequently communicated or inquired about medications for weight loss. The facility also failed to adequately monitor and investigate potential or ongoing misappropriation of a resident’s narcotic medication when only one LPN dispensed all doses of a PRN narcotic (Norco) to a cognitively intact female resident over an extended period, and a missing tablet was documented without resolution. Review of the controlled drug records showed that from late October to early January, only one nurse dispensed the Norco, and an entry indicated a correct count had been completed but one tablet was missing and could not be accounted for. The resident reported that her pain was effectively controlled with scheduled Tylenol at night and that she did not request the PRN Norco. The DON confirmed that the pattern of only one nurse dispensing the narcotic appeared suspicious for diversion, and the NHA confirmed the resident’s report that she did not require the PRN Norco for pain control.
Failure to Document Resident Abuse Allegation and Related Assessments in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a cognitively intact resident with multiple psychiatric diagnoses, including dementia with agitation and psychotic disturbance, anxiety, and bipolar disorder. The resident’s admission record and MDS showed he was cognitively intact, with a BIMS score of 15. On or around late September, the resident reported to staff that a CNA had yelled at him when he complained about his roommate’s urinal being left in the bathroom, and he stated that the interaction was upsetting to him. In a typed interview statement, the resident reported that the aide spoke to him in a way he did not like, but he did not remember the aide’s name and stated he was not scared and felt safe in the facility. A CNA’s written statement documented that the resident described arguing with a specific CNA about the urinal being left in the bathroom, that he had removed it and thrown it on the floor, and that the CNA was screaming at him until an RN intervened. The CNA also documented that the resident appeared fearful and stated he would protect himself from the aide if necessary, and that she immediately reported the incident to the facility abuse coordinator. Despite these reports and the internal investigation, a review of the resident’s electronic medical record for the period surrounding the alleged incident showed no documentation of the resident’s complaint, the alleged verbal altercation, or any related behavioral episodes such as yelling or verbal aggression by either the resident or staff. Interviews with the DON and NHA confirmed that allegations of staff yelling or swearing at residents were documented only in the facility’s incident reporting system and on internal risk management forms, which are not part of the resident’s medical record. The DON stated she was unsure whether such accusations would be documented in the resident’s progress notes and indicated that staff would definitely document if a resident yelled or swore at staff, but not necessarily if staff were accused of yelling at a resident. The NHA stated that the facility did not document the resident’s initial accusation in the medical record and that related information was kept in an investigative file separate from the record. This practice resulted in the absence of any documentation in the resident’s electronic medical record regarding the allegation, the resident’s psychosocial status, or any follow-up assessments during the relevant time frame, contrary to accepted professional standards for nursing documentation as described by the American Nurses Association.
Untrained Staff Paused and Restarted Enteral Feeding
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) paused and restarted enteral tube feeding for a resident diagnosed with esophageal cancer and esophageal obstruction, who was receiving enteral nutrition per physician's orders. The CNA reported pausing the tube feeding prior to providing care and then restarting it afterward, despite not being trained or authorized to perform this task. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that only trained staff, such as licensed nurses and med techs, were permitted to pause and restart tube feedings. Additional staff interviews revealed that CNAs regularly performed this action, indicating a lack of adherence to facility policy regarding tube feeding management.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents, which is a critical aspect of accommodating their needs and preferences. Resident #305, a female with dementia, unsteadiness, cognitive communication deficit, and lack of coordination, was observed multiple times with her call light on the floor, out of sight and reach. Despite requiring assistance for daily activities, she stated she would manage on her own, indicating a lack of awareness or ability to use the call light effectively. Observations on consecutive days showed the call light consistently out of reach, whether she was in bed or in a wheelchair. Another resident in bed 104-A was also found with the call light cord hooked through the bed frame, leaving the call light on the floor and inaccessible. This resident was awake and watching television but was unaware of the call light's location when asked. A CNA confirmed that staff are expected to check call light placement each time they enter a room, suggesting a lapse in adherence to this protocol. These observations highlight a failure in ensuring residents can alert staff when needed, compromising their ability to receive timely assistance.
Medication Administration Discrepancy for Resident with Seizure Disorder
Penalty
Summary
The facility failed to adhere to professional standards for medication administration for a resident with a seizure disorder. The resident, a male with a history of seizure disorder, frequent falls, weakness, and unsteadiness, was prescribed Vimpat (Lacosamide) 50 mg twice daily. A review of the Control Substance Record indicated that the medication was last administered on the morning of January 12, 2025, and had run out, with no additional pills available until January 16, 2025. Despite this, the Electronic Medication Administration Record (Emar) showed that the resident was given a dose of Vimpat on the evening of January 14, 2025, which was not accounted for in the Control Substance Record. During an interview, the Unit Manager confirmed that the Vimpat was not available in the facility on the evening of January 14, 2025, and could not explain why it was recorded as administered. This discrepancy indicates a failure to maintain accurate and complete documentation of medication administration, as required by professional standards. The report highlights the importance of ensuring that medication records are truthful and complete to maintain the quality of care for residents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and Contact-Based Precautions for three residents, leading to deficiencies in infection control. One resident, who was cognitively intact and required extensive assistance, had a sign on their door indicating the need for EBP, including wearing gloves and a gown. However, two nurses entered the room with only gloves, disregarding the gown requirement. Another resident, admitted with a wound infection and paraplegia, was placed on EBP but did not have Contact Precautions implemented until over six weeks later, despite a physician's order. Similarly, a third resident with sepsis was not placed on Contact Precautions until 25 days after admission, despite being on EBP. The facility also failed to follow policies and procedures for IV administration for one resident. During an observation, a nurse was seen using undated tubing for an IV antibiotic and did not disinfect the port before reconnecting the tubing. The nurse admitted to not having an answer for why the port was not cleaned and mentioned a lack of tubing as a reason for the improper practice. This failure to adhere to IV administration protocols posed a risk of infection for the resident. Additionally, the facility did not implement its water management plan to reduce the risk of legionella and other pathogens, potentially affecting all residents. A water analysis revealed abnormal levels of legionella, but the facility did not take the required remedial actions, such as enhanced monitoring or notifying the Regional Director of Maintenance. The Director of Maintenance admitted to not being familiar with the entire water management plan, and housekeeping staff were not properly instructed to flush sinks, as required by the plan.
Failure to Assess and Supervise Self-Administration of Medication
Penalty
Summary
The facility failed to perform a resident assessment and obtain a physician order for the self-administration of a breathing treatment for a resident, resulting in the resident self-administering a nebulizer treatment without appropriate supervision and assessments. The resident, identified as R225, was admitted to the facility with diagnoses including pneumonitis, heart disease, lack of coordination, and blindness in one eye. During an observation, it was noted that R225 was in his room starting a breathing treatment without being assessed by the registered nurse (RN) present, who also did not perform a post-assessment after the treatment was completed. The Medication Administration Record (MAR) indicated an order for Arformoterol Tartrate Inhalation Nebulization Solution to be administered twice daily for COPD. However, there were no orders, assessments, or care plans for the self-administration of medications in the resident's electronic medical record. The facility's policy on self-administration of medications requires an interdisciplinary team assessment and periodic re-evaluation, which was not conducted for R225. Additionally, a Licensed Practical Nurse (LPN) admitted that nurses are supposed to stay with residents during nebulizer treatments but cited time constraints as a reason for not doing so.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and assess the use of psychotropic medications for a resident identified as R19. The resident, who was admitted with diagnoses of schizoaffective disorder, bipolar disorder, and PTSD, was observed to be tearful and intermittently crying during an interview. The care plan for R19 included administering medications as ordered and monitoring for side effects and effectiveness, yet there was no documentation of such monitoring in the medical records. A behavioral health document indicated that hydroxyzine was discontinued, and the plan was to monitor for changes in mood or behaviors for 14 days, but this monitoring was not documented. During an interview, an LPN confirmed that there was no documentation in the MAR for monitoring R19's behaviors or side effects of psychotropic medications, although such monitoring was documented for another resident. This lack of documentation and monitoring represents a failure to adhere to the facility's policy on psychoactive drug use, which aims to prevent excessive dosing, duration, and ensure adequate monitoring and indications for use.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly label and date mark opened medications, dispose of expired medications, and secure medication carts. During an observation of a medication cart on the 100 hall, it was found that a Flex Touch 1000 insulin pen, which should have been refrigerated until opened, was improperly stored in the cart. Additionally, a vial of Lantus insulin, two bottles of Systane eye drops, Polymyxin antibiotic eye drops, and Dorzolamide/Timol eye drops were not labeled with the resident's name or the date they were opened. A registered nurse confirmed these labeling issues and acknowledged that the insulin pen should have been refrigerated. Furthermore, a personal belonging, specifically a large black purse, was found stored in a medication room, which was confirmed by the unit manager to be inappropriate. The facility's Medication Access and Storage Policy, adopted on 7/11/2018, did not address the labeling of medications, which contributed to the deficiencies observed. Additionally, during separate observations, two medication carts were found unlocked and unattended in the hallways. In one instance, an LPN admitted to forgetting to lock the cart, and in another, a medication treatment cart was left unlocked with no nurses in view. The LPN responsible for the cart confirmed that it should have been locked when unattended. These lapses in securing medication carts and improper labeling and storage of medications highlight significant deficiencies in the facility's medication management practices.
Lack of Coordinated Hospice Care for Two Residents
Penalty
Summary
The facility failed to provide coordinated hospice care for two residents, resulting in a lack of collaborative care. Resident R16, a female with multiple sclerosis and neuromuscular dysfunction, was observed to be unaware of the hospice staff's visit schedule, except for a hospice aide who visited on Wednesdays without a set time. The facility's social worker could not find documentation confirming hospice participation in R16's care conferences, and there was no record of weekly hospice visits in her electronic medical records. An email request for hospice records revealed that the hospice aide provided weekly showers, but it was unclear if other services were provided. Resident R41, a female with hemiplegia, dysphagia, and chronic kidney disease, reported severe stomach pain and was receiving Tylenol for pain management. The RN was unaware of the hospice staff's visit schedule for R41. The facility's social worker could not locate documentation of hospice participation in R41's care conferences, and the last hospice records were dated over a week prior. Progress notes indicated that R41 experienced severe pain and nausea, but there was no indication of hospice notification regarding her condition change. The facility's NHA found documentation that R41 refused hospice nurse aide services, but there was no explanation for the lack of hospice nurse documentation in her medical record.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident, identified as Resident #29, who was reviewed for immunizations. Upon admission, the resident had pertinent diagnoses including heart disease and hypertension and was due for the pneumococcal vaccine PCV20. The Michigan Care Improvement Registry indicated that the resident was due for this vaccine since admission, and the resident had consented to receive it. However, the resident's electronic health record showed the pneumococcal status as pending. The Director of Nursing acknowledged that the vaccine was due upon admission and should have been scheduled by the unit manager, but this did not occur. Additionally, there was uncertainty about whether the Infection Preventionist had a process to ensure timely offering of pneumococcal vaccines to residents. The facility's policy stated that all residents should be offered pneumococcal vaccines upon admission unless contraindicated or previously vaccinated.
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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