Riverside Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in St. Louis, Michigan.
- Location
- 1149 West Monroe Road, St. Louis, Michigan 48880
- CMS Provider Number
- 235324
- Inspections on file
- 23
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Riverside Healthcare Center during CMS and state inspections, most recent first.
A resident with paranoid schizophrenia and anxiety, who was cognitively intact per a recent MDS/BIMS, reported that staff cleaned and organized her room without her permission while she was out of the facility, and that this bothered her. The NHA/DON acknowledged that staff cleaned the room due to its condition and stated she believed she had the guardian’s permission, but the guardian denied being consulted or giving consent and noted the resident’s delusions and paranoia. Review of the EMR showed no documentation of any rationale for cleaning the room without the resident’s permission or of any discussion with the guardian, despite facility policy requiring explanation of care before activities and respect for the resident’s living space and possessions.
A resident with intact cognition and mental health diagnoses reported that staff cleaned and organized her room without permission while she was out, after which she discovered missing personal items including blankets, a doll, a stuffed rabbit, and clothing. She stated she reported this concern to multiple staff members without resolution and felt the NHA/DON did not care. The NHA/DON acknowledged knowing about the complaint and discussing it with the ombudsman and guardian but did not complete a grievance form, did not document the concern in the EMR, and could not verify any follow-up with the resident, contrary to the facility’s written grievance policy requiring documentation and a written decision.
A resident with severe cognitive impairment and incontinence did not receive care planned interventions or physician-ordered Calmoseptine ointment for pressure ulcer prevention. Staff failed to check and change the resident every two hours as required, and there was confusion among CNAs and nurses regarding responsibility for applying the ointment. Documentation indicated the ointment was administered when it was not, and staff were unaware of the specific order to apply it after each incontinence episode.
The facility failed to maintain cleanliness in food service equipment, affecting 38 residents. Observations revealed unclean conditions, including soiled pots, pans, and kitchen appliances. The Dietary Manager acknowledged the issues and missing cleaning records.
The facility failed to maintain accurate advanced directive information for two residents, leading to potential non-compliance with their medical care preferences. One resident's directive was improperly witnessed after the guardian and doctor signed, while another resident's directive was signed by witnesses a day after the resident, indicating they did not witness the signing. These procedural errors could result in the facility not following the residents' medical care preferences.
The facility failed to provide timely and accurate Medicare coverage notices to three residents. A resident was not informed of the end date of services, and two residents did not receive proper notification 48 hours prior to the end of skilled services. Additionally, the SNFABNs lacked necessary details such as reasons for non-coverage and estimated costs. The Business Office Manager confirmed these deficiencies but could not explain the omissions.
A facility failed to include a Foley catheter in a resident's Baseline Care Plan within 48 hours of admission, despite the resident having quadriplegia and an indwelling urinary catheter. Observations confirmed the presence of the catheter, but it was not documented in the initial care plan, and interventions were only created weeks later. Staff acknowledged the omission during interviews.
A resident with severe cognitive impairment and a history of constipation experienced ongoing issues with constipation that were not adequately addressed by the facility. Despite having multiple physician's orders for constipation management, some orders lacked specific dosing and route instructions. The resident did not have a recorded bowel movement for several days, and no as-needed medications were administered, indicating a failure in the facility's protocol to manage the resident's condition effectively.
The facility failed to ensure a safe environment for two residents regarding smoking and bedrail use. A resident was allowed to smoke independently without a completed risk assessment, posing a safety risk. Another resident had a bedrail without a physician's order or care plan, and no assessments or measurements for entrapment were conducted, indicating a lack of proper safety procedures.
A facility failed to ensure recommended laboratory monitoring for a diabetic resident, who was on insulin and Metformin. Despite a pharmacy review recommending A1C and Lipid Panel tests, and the physician's agreement, the resident refused the tests in June. By October, the resident's lab results still lacked an A1C test. An RN confirmed the absence of A1C results since February, highlighting a failure in monitoring the resident's drug regimen.
A facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate. An RN did not wash her hands before preparing medications and failed to administer Lexapro and Betamethasone as ordered. The RN left medications unattended at the bedside, and the medication administration record confirmed the omissions. Interviews indicated that nurses are expected to wash hands and not leave medications at the bedside.
A facility failed to follow infection control protocols during wound care for a resident with Alzheimer's and pressure ulcers, as a nurse did not change gloves or clean scissors between handling soiled and new dressings. Additionally, the facility did not obtain proper consent for a COVID-19 immunization for a resident with Huntington's disease, as the guardian signed the declination section of the consent form, and verbal consent was not documented.
The facility did not post daily nurse staffing information for 38 residents and visitors. During facility tours, the postings were not observed, and HR reported that the information had not been completed or posted for about two months, believing it was no longer required.
The facility did not provide documentation of the required bi-annual Sensitivity Test for its fire alarm system, as required by NFPA 70 and NFPA 72. This was confirmed during a record review and interview with Facility Maintenance.
The facility did not provide a smoke barrier map showing complete compartmentalization by smoke barriers throughout the building, as required by code. The map lacked details of smoke barriers separating compartments from outside wall to outside wall, and this was confirmed by Facility Maintenance during record review.
Surveyors found that more than 100 cigarette butts were discarded on the ground in shrubbery and leaves in front of all emergency exits, rather than being placed in noncombustible containers as required by smoking regulations. This was confirmed by Facility Maintenance during the inspection.
A hasp latching mechanism with a padlock was found on the kitchen storage cooler door, allowing it to be locked from the outside and preventing egress from within. This arrangement did not meet required standards for egress doors and was confirmed by Facility Maintenance during the survey.
Staff were unable to provide access to a supply storage room in the service hall, preventing surveyors from verifying that the hazardous area was properly protected by required fire barriers or an automatic extinguishing system. This deficiency was confirmed by Facility Maintenance and could affect 20 occupants in a fire emergency.
A smoke detector was found installed within three feet of direct airflow from an air return or supply near an exit door, contrary to NFPA 70 and NFPA 72 requirements. This installation issue was confirmed by Facility Maintenance and could impact 30 occupants during a fire emergency.
A gap was found in the med supply room door handle, preventing the door from effectively resisting the passage of smoke as required by NFPA standards. This deficiency was confirmed by maintenance staff and could impact the safety of up to 20 occupants during a fire emergency.
A receptacle box with exposed live electric wires was found hanging off the wall behind the kitchen garbage disposal, creating a risk of unintentional electrical exposure. This noncompliance with NFPA 70 was confirmed by Facility Maintenance during the survey.
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of insects, including winged ants and spiders, in various areas. Staff were seen stepping on and killing the insects, but no formal pest control measures were observed. Additionally, the dining room was found to be unsanitary, with soiled tables and overflowing trashcans. Two residents, both moderately cognitively impaired, reported dissatisfaction with the cleanliness and presence of insects.
The facility failed to follow professional standards of nursing practice for medication administration, resulting in multiple medication errors and mismanagement of controlled substances for four residents. Issues included administering medication despite contraindicated vital signs, failing to document controlled substances properly, and not notifying providers of missed doses.
The facility failed to secure smoking materials per protocol. An observation revealed an open closet door in the shower room containing a plastic box with 7 packs of cigarettes and 2 lighters. Although the box had a padlock, it was not secured. The Administrator confirmed that smoking materials were supposed to be double locked but were not.
Failure to Obtain Consent Before Cleaning Cognitively Intact Resident’s Room
Penalty
Summary
The facility failed to ensure dignified care for a resident when staff cleaned and organized the resident’s room without obtaining the resident’s permission. The resident had been admitted with diagnoses including paranoid schizophrenia and anxiety, and a recent MDS with a BIMS score of 15/15 indicated the resident was cognitively intact. While the resident was out of the facility, staff entered the room and cleaned and organized it because they believed it was a mess and contained wet and dirty boxes. The resident later reported that this was done without her permission and that it bothered her. The Nursing Home Administrator/DON stated that staff cleaned the room and that she believed she had permission from the resident’s guardian to do so. However, the guardian reported that the facility had not discussed cleaning the room with her and that she had not given permission, further stating that due to the resident’s delusions and paranoia it did not make sense to clean the room when the resident was gone. The NHA/DON reviewed the electronic medical record and was unable to find any documentation of the rationale for cleaning the room without the resident’s permission or any documentation that this had been discussed with the guardian. The facility’s Promoting/Maintaining Resident Dignity policy required staff to explain care or procedures before initiating activities and to respect the resident’s living space and personal possessions, including not searching a resident’s personal possessions without consent from the resident or, if applicable, the resident’s representative.
Failure to Document and Address Resident Grievance About Missing Personal Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to address a cognitively intact resident’s complaint about missing personal belongings. The resident, who had diagnoses including paranoid schizophrenia and anxiety, was admitted on a specified date and had a BIMS score of 15/15, indicating intact cognition. The resident reported that while she was out of the facility, staff cleaned and organized her room without her permission, and upon her return she discovered that personal items, including blankets, a doll, a stuffed rabbit, and several pieces of clothing, were missing. She stated that she had discussed this concern with multiple staff members, but nothing was done to resolve her complaint, and she felt that the NHA/DON did not care about her concern. The NHA/DON acknowledged awareness of the resident’s concern about missing items and confirmed that staff had cleaned and organized the room while the resident was out. The NHA/DON reported having discussions with the ombudsman and the resident’s guardian about the missing items but admitted that she did not complete a resident concern/grievance form or document the concern in the EMR. She was unable to verify that she had followed up with the resident regarding the missing items and stated that, in hindsight, she should have documented the concerns on a grievance form and in a progress note. This inaction was inconsistent with the facility’s written “Resident and Family Grievances” policy, which requires staff receiving a grievance to record the nature and specifics on the designated grievance form or assist the resident/family to complete it, and requires the Grievance Official to issue a written decision at the conclusion of the investigation.
Failure to Implement Care Plan and Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified regarding the facility's failure to implement care planned interventions and physician-ordered treatments for pressure ulcer prevention for one resident. The resident in question was admitted with diagnoses including cerebral infarction and hemiplegia, was severely cognitively impaired, and was dependent on staff for toileting and personal hygiene. The care plan directed staff to keep the resident's skin clean and dry, minimize exposure to moisture, provide incontinence care after each episode, and use a moisture barrier product as needed. There was also a physician's order for Calmoseptine ointment to be applied to the buttocks after each episode of incontinence. Observations on two consecutive days revealed that the resident was left in a soaked brief and clothing for several hours after being placed in a chair by the previous shift. During incontinence care, there was no evidence of barrier cream or Calmoseptine ointment on the resident's skin, and staff did not apply these products at the time of care. Interviews with CNAs indicated that the resident had not been checked or changed for several hours, despite the expectation that incontinent residents be checked and changed every two hours. CNAs also expressed confusion about who was responsible for applying Calmoseptine ointment, with some believing it was a nursing responsibility and others stating they would apply it only if it was available in the room. Further interviews with nursing staff and the Director of Nursing confirmed that Calmoseptine ointment was considered medicated, stored in the treatment cart, and should be administered by a nurse. Documentation in the Medication Administration Record indicated that the ointment had been administered, but the nurse later admitted this was not the case and that CNAs typically performed this task. There was also a lack of awareness among staff regarding the specific order for Calmoseptine ointment to be applied after each incontinence episode. These findings demonstrate a failure to follow care plan interventions and physician orders for pressure ulcer prevention.
Deficient Cleaning and Maintenance of Food Service Equipment
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 38 residents. During an initial tour of the food services, several deficiencies were observed. A cardboard box containing dinex cup lids was found on the floor in the dry storage room, and the baseboards along the wall had a black substance on them. The door jam of the dry storage room was rusted along the floor. In the freezer, referred to as the vegetable freezer, the bottom shelf was soiled with what appeared to be a dried liquid film. Additionally, seven pots and pans were found with a dark-colored substance inside, resembling baked-on food that could not be removed. Further observations revealed that the toaster grill had baked-on substances and burnt toast crumbs on the grates. The grill, oven, and gas grills were soiled, with the upper portion of the grill covered in a dark black substance. The oven door handle was greasy, and the oven racks were discolored with food substances. The bottom of the oven was covered with burnt grease and food substances, and the side of the oven door had old yellow dark grease. During an interview, the Dietary Manager acknowledged the unclean state of the equipment and noted that cleaning records were missing for two days prior to the inspection.
Failure to Ensure Accurate Advanced Directives
Penalty
Summary
The facility failed to ensure updated and accurate advanced directive information was in place for two residents, resulting in the potential for a resident's preferences for medical care to not be followed. Resident #7, who was cognitively intact, had an advanced directive signed by a guardian on 09/24/24, but the witnessing process was not correctly followed. The social worker signed the document after the guardian and doctor, contrary to the instructions that required witnessing the guardian or resident's signature at the time of signing. This discrepancy was due to the social worker following incorrect procedures taught to her when she started working at the facility. Resident #39, who was cognitively impaired, signed his advanced directive on 01/28/25, with the provider also signing on the same day. However, the witnesses signed the document on the following day, 01/29/25, which means they did not witness the resident's signature as required. This procedural error in handling advanced directives could lead to the facility not adhering to the residents' medical care preferences.
Failure to Provide Timely and Accurate Medicare Coverage Notices
Penalty
Summary
The facility failed to provide accurate and timely notifications regarding Medicare coverage and potential liability for services not covered to three residents. Resident #5 was not given a Notice of Medicare Non-Coverage (NOMNC) indicating when services would end, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) did not specify the last covered day of services. Resident #8 was not notified 48 hours prior to the end of skilled services, and the SNFABN did not include the estimated cost of services. Resident #35's NOMNC did not indicate when services would end, and the SNFABN lacked the reason for non-coverage and estimated costs. The Business Office Manager (BOM) confirmed these deficiencies during an interview, acknowledging the failure to provide necessary information on the NOMNC and SNFABN forms. The BOM could not explain why the required information was missing or why notifications were not completed in a timely manner. These oversights affected the residents' understanding of their Medicare coverage and potential financial responsibilities.
Failure to Include Foley Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a Baseline Care Plan with necessary healthcare information for a resident (R37) within 48 hours of admission. The resident was admitted with diagnoses including quadriplegia and neuromuscular dysfunction of the bladder, and had an indwelling urinary catheter. However, the Baseline Care Plan initiated on the date of admission did not reflect the presence of the Foley catheter, which is a critical component of the resident's care needs. Observations and interviews revealed that the resident was cognitively intact and had a Foley catheter, as confirmed by the resident and observed by surveyors. Despite this, the Baseline Care Plan did not include the catheter, and the approaches/interventions related to the catheter were only created weeks after admission. Staff interviews indicated that the Care Plan is used to identify resident care needs, and the omission of the catheter from the Baseline Care Plan was acknowledged by the Nursing Home Administrator/Director of Nursing.
Failure to Prevent Constipation and Ensure Proper Medication Orders
Penalty
Summary
The facility failed to prevent constipation and ensure proper medication orders for a resident with severe cognitive impairment and a history of constipation, diabetes, and hemiplegia. The resident reported ongoing issues with constipation since admission, which they felt were not adequately addressed by the staff. The medical record showed multiple physician's orders for constipation management, including Metamucil, Senna Plus, and other medications, but some orders lacked specific dosing and route instructions. Observations and interviews revealed that the resident did not have a recorded bowel movement for several consecutive days, and the Medication Administration Record did not reflect the administration of any as-needed medications for constipation. A registered nurse acknowledged the lack of bowel movements over a significant period and the absence of action to address the issue, indicating a failure in the facility's protocol to manage the resident's constipation effectively.
Failure to Ensure Safety in Smoking and Bedrail Use
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision for two residents regarding smoking and the use of bedrails. Resident #2 was observed to have burn marks on his hoodie and stated he could smoke independently, yet there was no completed smoking risk assessment on file since his admission. This lack of assessment and supervision poses a potential safety risk, as the resident mentioned having access to a lighter and marijuana outside, which was not addressed by the facility. Resident #5 was found to have a bedrail on the right side of his bed without a physician's order or a care plan in place. The resident explained that the bedrail was used to prevent falls, but there was no documentation of an assessment for its use, nor were any alternative interventions attempted. Additionally, the facility did not conduct measurements for possible entrapment when the bedrail was applied or on a quarterly basis, as confirmed by the Director of Nursing. This oversight indicates a failure to follow proper procedures for bedrail use and safety assessments.
Failure to Ensure Laboratory Monitoring for Diabetic Resident
Penalty
Summary
The facility failed to ensure that recommended laboratory monitoring was in place for a resident, identified as R15, who was admitted with diagnoses including diabetes, constipation, hemiplegia, and hemiparesis following a nontraumatic intracranial hemorrhage. R15's medical record included physician's orders for insulin and Metformin to manage diabetes, with instructions for fasting blood sugar checks on specific days. A pharmacy medication regimen review recommended ordering current labs, including A1C levels and a Lipid Panel, which the physician agreed to. However, R15 refused to have these tests collected in June 2024. Despite the refusal in June, the medical record showed laboratory test results from October 2024, which included fasting lipids and glucose but did not include an A1C test. During an interview, RN B confirmed that A1C tests are generally conducted every three months for diabetic residents and acknowledged that there were no A1C results for R15 dating back to February 2024. This oversight indicates a failure to ensure the resident's drug regimen was free from unnecessary drugs due to the lack of appropriate laboratory monitoring.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate for a resident. During an observation, RN C prepared several medications for the resident but did not wash her hands or use hand sanitizer before setting up the medications. Additionally, RN C did not administer or apply Lexapro 5 mg and Betamethasone cream as ordered. RN C left the medication cup and MiraLAX mixture on the over-the-bed table and walked away to wash her hands, failing to ensure the resident took the medications. The medication administration record confirmed that Lexapro and Betamethasone were not administered or signed out. Interviews with LNA/DON A and MDS/RN B revealed that nurses are expected to wash their hands before entering and leaving the room and should not leave medications at the bedside.
Infection Control and Consent Deficiencies
Penalty
Summary
The facility failed to adhere to accepted infection control protocols during wound care for a resident with multiple health issues, including Alzheimer's Disease, legal blindness, and pressure ulcers. During an observation, a registered nurse (RN) did not change gloves or clean scissors between handling soiled and new dressings for the resident's wounds. The RN also reused a disposable gown that was hung inside the resident's room, which is against infection control expectations. The wound care orders specified the use of alginate dressing only on the wound bed, but the RN applied it over healthy tissue as well. Additionally, the facility did not obtain proper consent before administering a COVID-19 immunization to a resident with Huntington's disease and memory impairments, who had a legal guardian. The resident's medical record showed that the guardian had signed the declination section of the vaccine consent form, but the facility reported that verbal consent had been given. However, this verbal consent was not documented in the resident's medical record. These deficiencies highlight lapses in infection control practices and consent procedures, which are critical for ensuring resident safety and compliance with regulatory standards. The facility's failure to follow proper protocols and documentation requirements led to these findings during the survey.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted for 38 residents and visitors. During a tour of the facility on two separate occasions, the daily nurse staffing posting was not observed. In an interview, the Human Resources/Scheduler (HR) reported that the daily nurse staffing information had not been completed or posted for approximately two months. HR believed they had been informed that posting the daily nurse staffing information was no longer necessary.
Failure to Document Bi-Annual Fire Alarm Sensitivity Test
Penalty
Summary
The facility failed to provide documentation of the required bi-annual Sensitivity Test for the installed fire alarm system, as mandated by NFPA 70 and NFPA 72. During a record review on 03/25/2025, surveyors found that no documentation of this test was available, and this was confirmed through an interview with Facility Maintenance at the time of the review. The absence of this documentation indicates that the fire alarm system was not tested and maintained in accordance with the approved program requirements. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K345 - Fire alarm System The Facility failed to have the bi-annual Sensitivity Test for the installed fire system completed, putting the whole facility and all occupants at risk. The maintenance director scheduled the Smoke Detector Sensitivity Test with DeLau Fire services, this was completed on 4-14-25 with all smoker detectors passing inspection; no repair or follow-up needed. He also scheduled our next bi-annual Sensitivity Test to ensure sustained compliance. The Maintenance Director was educated on the requirements and importance of having the Sensitivity Test completed and other scheduled maintenance. The Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. The Administrator is responsible for maintaining compliance.
Failure to Provide Complete Smoke Compartmentalization
Penalty
Summary
The facility failed to ensure that smoke barriers were provided to form at least two smoke compartments on every floor as required by applicable codes. During a record review, it was found that the facility did not provide a smoke barrier map that demonstrated complete compartmentalization by smoke barriers throughout the building. The map provided did not show smoke barriers separating smoke compartments from outside wall to outside wall in each compartment, as required. This finding was confirmed during an interview with Facility Maintenance at the time of the record review. No information about specific patients, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
K 371 Facility floor plan was reviewed and revised to include smoke compartments. Floor plans in the facility will be replaced to meet requirements. Maintenance Director was educated on K371 tag that floor plan must identify smoke barrier walls. Maintenance Director will review floor plans with any changes to ensure compliance with updates. Concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Improper Disposal of Smoking Materials at Emergency Exits
Penalty
Summary
During an outside perimeter walk of the building, surveyors observed over 100 cigarette butts discarded on the ground in the tree shrubbery and leaves in front of all emergency exits. These cigarette butts were not disposed of in noncombustible containers as required by facility smoking regulations. The observation was confirmed through an interview with Facility Maintenance at the time of the finding. The report notes that the facility failed to ensure smoking regulations were adopted and implemented to meet all required provisions, specifically regarding the proper disposal of smoking materials.
Plan Of Correction
K 741 Facility moved free standing smoking ash tray pole and picnic table to required distance from building. No smoking signs were placed in areas of concern to ward off smoking near building. Staff was educated on smoking away from the building or smoking privileges would be reviewed and possibly revoked. Maintenance director was educated on K741 smoking regulation. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Improper Egress Door Locking Mechanism in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless compliant with special locking arrangements for clinical needs. Specifically, during an inspection, it was found that the cooler door for kitchen storage was equipped with a hasp latching mechanism and a padlock, which could allow the door to be locked from the outside. This hardware arrangement created a situation where someone inside the cooler could be locked in without a means to exit, as the locking mechanism did not meet the required standards for egress doors. The finding was confirmed through an interview with Facility Maintenance at the time of observation. The deficiency was noted to potentially affect 15 occupants in the event of an egress emergency.
Plan Of Correction
Maintenance Director adjusted the cooler door in the kitchen to ensure proper functioning. All other doors were checked and corrected as identified. The Maintenance Director was educated on K222 tag to ensure proper means of egress in the event of an emergency. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Inaccessible Hazardous Area Prevents Fire Safety Verification
Penalty
Summary
Staff were unable to provide access to a supply storage room located in the service hall between storage rooms 11 and 12 during an observation on 03/25/2025 at approximately 12:20 PM. This prevented a full inspection of the area to verify whether it was properly protected by a fire barrier with a 1-hour fire resistance rating, equipped with 3/4 hour fire rated doors, or safeguarded by an automatic fire extinguishing system as required by regulation. The inability to access the room meant that surveyors could not confirm compliance with fire safety standards for hazardous areas. This deficiency was confirmed through an interview with Facility Maintenance at the time of observation. The report specifically notes that this practice could affect 20 occupants in the event of a fire emergency, as the lack of access hindered the ability to ensure the hazardous area was adequately protected.
Plan Of Correction
Rounds being conducted during the Annual State Survey, the Maintenance director was unable to make entry into the supply closet located between rooms 11 and 12 in the service hallway, in turn not being able to ensure the automatic-closing door or the presence of an automatic fire extinguishing system, which put 20 occupants at risk. The maintenance director adjusted the door to the supply closet between rooms 11 and 12 to ensure the door would open freely with key access. The Maintenance director confirmed that the door was an automatic-closing door and was functioning properly, and there was an automatic fire extinguishing system present inside the closet. The maintenance director did a complete facility round to ensure safeguards were in place. The maintenance director was educated on K321 tag to ensure proper access to the facility, to ensure areas are protected with a fire-rated door or an automatic fire extinguishing system, and to ensure all safeguards are in place. The Maintenance director will complete bi-weekly facility rounds to ensure safeguards are in place and that all doors are functioning properly. Concerns will be addressed at the time of observation. Results of the facility rounds will be reported in QAPI monthly for 3 months. The Administrator is responsible for maintaining compliance.
Improper Smoke Detector Placement Near Airflow Source
Penalty
Summary
A deficiency was identified when a smoke detector was observed to be installed within three feet of direct airflow from an air return or supply on the ceiling near Exit Door H. This installation does not comply with the requirements of NFPA 70 and NFPA 72, which govern the proper placement and installation of fire alarm system components. The issue was confirmed during an interview with Facility Maintenance at the time of observation. The deficient practice could affect 30 occupants in the event of a fire emergency.
Plan Of Correction
Maintenance Director moved the smoke detector to an area more than 3 feet away from the air/return supply on the ceiling. All other areas were reviewed with no concerns noted. Maintenance Director was educated on K341 tag to ensure proper placement of smoke detectors from direct airflow to an air return/supply. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance of K345.
Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
During an inspection, it was observed that the door handle of the medication supply room had a gap measuring approximately 2 inches long by 1/4 inch wide at the handle cover. This gap was identified during a walkthrough and was confirmed by the facility's maintenance staff at the time of observation. The deficiency pertains to the requirement that doors protecting corridor openings must be capable of resisting the passage of smoke, as outlined in NFPA 19.3.6.3. The presence of the gap in the door handle area means the door does not meet the standard for smoke resistance, which could affect the safety of up to 20 occupants in the event of a fire emergency.
Plan Of Correction
K 363: The med supply door handle was corrected related to a gap that would allow smoke to pass and addressed to remedy this concern. Like areas were reviewed for areas of concern with no concerns noted at this time. Maintenance Director was educated on K363. Tag to ensure corridors openings are capable of resisting the passage of smoke. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Noncompliance with Electrical Safety Standards in Kitchen Area
Penalty
Summary
During an observation in the facility's kitchen dish tank area, a receptacle box with electrical wiring was found hanging off the wall behind the garbage disposal. The box was electrically tapped and exposed live electric wires to water, creating a situation where unintentional exposure to electricity could occur. This condition was directly observed and confirmed through an interview with Facility Maintenance at the time of the survey. The installation did not comply with NFPA 70, National Electric Code, as required, and presented a hazard to occupants in the area. No information was provided regarding specific residents or their medical conditions at the time of the deficiency.
Plan Of Correction
K511 Live wires in kitchen were addressed. Like areas were reviewed and no concerns were noted at this time. Maintenance director was educated on K511 electrical equipment complies with NFPA 70 NEC Code for unintentional exposure to electricity. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of insects, including winged ants and spiders, in various areas of the facility. On several occasions, staff members were seen stepping on and killing the insects, but no formal pest control measures were observed. The Maintenance Director was not informed of the pest issue, indicating a breakdown in communication and protocol for addressing such problems. Additionally, the dining room was found to be in an unsanitary condition, with tables visibly soiled with dried food and drink spills, and trashcans overflowing with garbage. This was corroborated by resident interviews, who expressed dissatisfaction with the cleanliness of the dining room and the presence of insects. Two residents, one with hypertension and multiple sclerosis and another with Type 2 diabetes mellitus with diabetic neuropathy, were directly affected by these conditions. Both residents were moderately cognitively impaired, as indicated by their Brief Interview for Mental Status (BIMS) scores. One resident reported seeing bugs crawling around and pointed out insects near his feet, while the other resident complained about the filthy condition of the dining room in the mornings. These observations and resident reports highlight the facility's failure to provide a safe, clean, and comfortable environment for its residents.
Medication Administration Errors and Mismanagement of Controlled Substances
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for four residents, resulting in multiple medication errors and mismanagement of controlled substances. For Resident #18, the facility administered midodrine despite blood pressure readings exceeding the physician-ordered parameters and failed to properly document the administration of gabapentin on two occasions. Resident #6 did not receive a scheduled dose of morphine, and there was no documentation indicating that the provider was notified or any follow-up actions were taken. Resident #16 had multiple instances where gabapentin and clonazepam were not signed out or administered as required, and there was a lack of proper documentation for the disposal of refused medication. Resident #88 had discrepancies in the administration and documentation of Lyrica, including missing doses and an additional dose being administered without proper documentation. The report highlights that the facility's medication administration process did not ensure that vital signs were checked and recorded before administering medications with specific parameters. Additionally, there were multiple instances where controlled substances were not properly signed out or documented, leading to potential medication errors. The facility's policy on medication administration was not consistently followed, resulting in inaccurate documentation and potential risks to resident safety. Interviews with staff, including a Registered Nurse and the Nursing Home Administrator/Director of Nursing, confirmed the medication errors and the lack of proper documentation. The facility's policy on medication administration and the fundamentals of nursing practice emphasize the importance of accurate documentation and adherence to physician orders, which were not followed in these cases. The deficiencies identified in the report indicate a need for immediate action to address the medication administration process and ensure compliance with professional standards of nursing practice.
Failure to Secure Smoking Materials
Penalty
Summary
The facility failed to secure smoking materials per protocol. During an observation, it was noted that the door to the shower room behind the nurses' desk was open. Inside the shower room, there were two separate closets. The closet on the left had an open door and contained a plastic box with 7 packs of cigarettes and 2 lighters. Although the plastic box had a small padlock attached to its lid, the lid was not secured. During an interview, the Administrator stated that resident smoking materials were supposed to be kept in a plastic box that was double locked, with the cigarettes and lighters stored in a locked closet in the shower room. However, the closet door was not locked, and the lid of the plastic box was not secured, leading to the deficiency.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
