Shorepointe Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in St. Clair Shores, Michigan.
- Location
- 26001 East Jefferson Avenue, St. Clair Shores, Michigan 48081
- CMS Provider Number
- 235443
- Inspections on file
- 34
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Shorepointe Nursing Center during CMS and state inspections, most recent first.
A resident with quadriplegia and moderate cognitive impairment, who required two-person assistance for bed mobility, fell and sustained injuries when only one CNA was present during care. The resident became anxious, attempted to hold onto the bed sheet, and rolled off the bed. Documentation and interviews confirmed that the care plan requiring two-person assistance was not followed, and the facility's policy did not address fall prevention procedures.
The facility failed to provide adequate meal portion sizes, potentially affecting residents' nutritional intake. A dietary staff member used a 6-ounce ladle instead of the required 8-ounce portion for chili, confirmed by the Certified Food Manager. Residents also reported insufficient food portions, such as receiving only one rib or one slice of pizza during meals.
The facility was found deficient in food safety practices, with issues such as black debris in the ice scoop holder, dusty ice machine filter, and soiled microwaves. The dish machine's sanitization log was incomplete, and chlorine sanitizer was not detected. Unlabeled spray bottles and mold-like substances were also observed, indicating a failure to maintain cleanliness and proper labeling.
The facility failed to provide person-centered care plans for two residents, one with PTSD and Vascular Dementia, and another with moderate cognitive impairment and non-compliance issues. The first resident's care plan lacked provisions for their specific diagnoses, while the second resident, who often refused care and dietary restrictions, had no care plan addressing their non-compliance. Staff acknowledged these deficiencies, which were not in line with the facility's Behavioral Care Services policy.
A resident experienced delays in receiving ADL care, with their call light out of reach and ignored by staff. The resident, dependent on staff for toileting due to respiratory failure and COPD, waited over an hour for assistance. Multiple staff members failed to respond to the call light, and a group of residents reported similar issues when agency staff were on duty.
A resident received inappropriate medication administration via a PEG tube, with an LPN failing to follow the facility's policy on water flush amounts and medication combination. The resident reported feeling full and nauseous after the administration. Interviews with staff revealed inconsistencies in understanding and applying the facility's policy.
A facility failed to maintain a medication error rate below five percent, resulting in a 12.82% error rate. An LPN administered nine crushed medications via a PEG tube to a resident, combining the last five medications despite no order to do so. The resident felt full and nauseous, and residual medication was left in the syringe. Facility policy mandates separate administration of each medication.
A resident with a history of stroke and heart disease did not receive blood pressure medication, Clonidine, as needed according to physician orders. Despite multiple elevated blood pressure readings, the facility failed to administer the medication and notify the physician, as required. The resident's MAR showed only two administrations of the PRN Clonidine, and the Unit Manager confirmed the expectation to follow orders and report elevated readings.
The facility failed to properly label and discard expired medications, as observed in several medication carts and a medication room. Items such as dorzolamide eye drops, insulin vials, and inhalers were found without proper labeling or were expired. The DON confirmed the need for proper labeling and discarding of expired medications.
A resident's tube feeding pole was observed with a thick layer of dried tube feed and missing labeling on the feeding bag. Used gloves and wet fluid were found on the floor. The Infection Control Preventionist indicated the pole should be cleaned when soiled, but this was not done, violating the facility's cleaning policy.
The facility failed to ensure call lights were accessible to residents, as observed in three cases where call lights were found on the floor, out of reach. One resident with intact cognition required substantial assistance for ADLs, while another with moderately impaired cognition needed moderate assistance. A third resident, also with moderately impaired cognition, was dependent on staff for toileting. The facility's policy requires call lights to be within reach, but this was not consistently adhered to.
Two residents were found to lack required care plans: one with PTSD and Vascular Dementia had no care plan addressing these diagnoses, and another, dependent for most ADLs and with a history of non-compliance, had no care plan for refusal of care or dietary non-adherence. Staff confirmed the omissions, despite facility policy requiring care plan development based on assessment.
A resident with respiratory failure, muscle weakness, and moderately impaired cognition was twice observed to have their call light on the floor and out of reach. During one observation, an LPN was present and placed the call light within reach after being questioned. Another LPN confirmed that call lights should be accessible to residents at all times.
A call light was found on the floor and out of reach for a resident with impaired cognition, incontinence, and dependence on staff for toileting, despite facility policy and administrative expectations that call lights be accessible at bedside.
Surveyors found that multiple emergency exit doors, which were labeled as having a 15-second delayed-egress with alarm, opened freely without resistance or alarm activation when tested. This failure to maintain the required delayed-egress locking and alarm systems was confirmed with the Maintenance Director.
Multiple ceiling-mounted exit signs on the 2nd and 3rd floors were found to be inoperative, lacking the required continuous illumination and emergency lighting backup. This deficiency was confirmed by the Maintenance Director during surveyor observations.
The facility did not provide evidence of required semi-annual servicing or monthly owner inspections for its range hood suppression system, with the last documented service occurring over a year ago. These documentation lapses were confirmed during record review with the Maintenance Director.
Surveyors observed that the fire alarm remote panel in the vestibule to Physical Therapy was displaying incorrect date and time information, indicating the system was not properly tested and maintained according to NFPA 70 and NFPA 72 requirements. This issue was confirmed by the Maintenance Director and could impact all residents in the event of a fire.
Multiple deficiencies were identified in the maintenance and testing of the facility's automatic sprinkler system, including missing or damaged ceiling tiles, absent or incomplete sprinkler components, dirty sprinkler heads, and improper storage near sprinkler heads. Required documentation for quarterly flow tests was also not provided, with these issues confirmed by the Maintenance Director.
Surveyors identified that combustible items were stored too close to electrical panels and a transformer, and that an electrical panel cover was disassembled and open blanks were present in another panel. These deficiencies were confirmed by the Maintenance Director and could affect all residents in the event of an electrical fire.
Surveyors found that the facility did not provide documentation of the required quadrennial fire damper inspection, with the last recorded servicing over four years ago. This deficiency was confirmed with the Maintenance Director and could impact all residents in the event of a fire.
Nursing staff on an upper floor reported not receiving training on evacuation procedures for moving residents to the ground level when elevators are unavailable or during a fire. This was confirmed by the Maintenance Director, indicating a lack of compliance with required emergency preparedness training.
The facility did not conduct required fire drills at unexpected times or under varying conditions, instead holding them at similar, predictable times for both 1st and 2nd shifts. This deficiency was confirmed by record review and interview with the Maintenance Director, and could affect all residents in the event of a fire.
Surveyors found that emergency backup power generators had unsecured access panels and lacked required handle locks, and the facility could not provide documentation for annual servicing, load bank testing, monthly load tests, or annual fuel analysis. These deficiencies were confirmed with the Maintenance Director.
An observation revealed that the electronic stairway path interrupter on the 2nd floor egress by the elevators was not functioning, which could cause individuals to miss the correct exit during an emergency. This issue was confirmed with the Maintenance Director and could affect a significant number of residents during a fire.
A fire extinguisher in the Physical Therapy Charting Room was found obstructed by combustible stock items, preventing proper access and maintenance as required by NFPA 10. This deficiency was confirmed by the Maintenance Director and could have affected multiple residents in the event of a fire.
Surveyors found that several smoke barrier doors, including those at the 2nd floor storage room, Physical Therapy, and sitting room, failed to positively latch when tested, and some lacked required self-closure devices. These deficiencies were confirmed with the Maintenance Director during the inspection.
Oxygen cylinders were found stored within five feet of combustible items in a clean linen room, in violation of NFPA 99 requirements for gas storage. This improper storage was confirmed by the Maintenance Director and could impact a significant number of residents in the event of a fire emergency.
A resident experienced fear and distress after a staff member misappropriated funds from their bank account and confronted them aggressively during an abuse investigation. Despite being suspended, the staff member was able to enter the resident's room, causing further intimidation. The facility failed to implement its abuse prevention policy effectively, resulting in the resident feeling unsafe.
A staff member at an LTC facility misappropriated a resident's funds by linking a gambling app to a joint bank account, resulting in unauthorized withdrawals of $18,368. The resident discovered the issue after noticing declined transactions and reported it to their family, who then involved the police. Despite being suspended, the staff member confronted the resident, causing fear and distress. The facility's failure to prevent this incident highlights a deficiency in protecting residents from financial exploitation.
The facility failed to notify two residents of room changes as required by policy. One resident's responsible party was informed two days after the move, while another resident was told just before the change without a chance to preview the new room. Both residents, with diagnoses including dementia, were dissatisfied with the changes, and there was no documentation of prior notification.
A resident with a history of falls and medical conditions was left unattended on a mechanical lift sling in a wheelchair, contrary to their care plan which included an anti-slip pad. The CNA realized the sling was the wrong size and left to get the correct one, during which the resident fell. The DON acknowledged the resident should not have been left unattended, and the facility lacked specific policy documentation for such situations.
A resident with severe cognitive impairment and a history of shoulder dislocations was improperly transferred using a sit to stand lift instead of the prescribed mechanical lift with two-person assistance. This led to a shoulder dislocation, as staff failed to review the Kardex for correct transfer instructions.
The facility failed to provide scheduled grooming and showering for two residents, leading to a deficiency in ADL care. One resident, with intact cognition, only received bed baths despite needing showers, which were not documented as a preference. Another resident, with impaired cognition, was unable to shave and reported staff unavailability for assistance, despite a care plan indicating the need for help with personal hygiene.
A resident with an indwelling catheter required a follow-up urology appointment after hospital discharge, which the facility failed to schedule. Despite attempts by the DON and Unit Clerk to arrange the appointment, there was no documentation of the efforts or physician notification. The facility's policy on scheduling external consultations was not followed.
The facility failed to provide palatable and properly heated meals, as residents reported receiving cold or barely warm food. Observations showed meals left uncovered on a steam table, and a test tray revealed food was not hot and lacked taste. The Tray Delivery Schedule was not followed, with delays in meal delivery. The Dietary Manager confirmed food temperatures were checked before plating but could not explain the delay.
Failure to Provide Required Supervision and Assistance During Resident Care Resulting in Fall
Penalty
Summary
A resident with quadriplegia, anxiety, muscle wasting, and moderate cognitive impairment, who required two-person assistance for bed mobility and transfers, experienced a fall while being cared for by a single CNA. The resident became anxious during care, attempted to hold onto the bed sheet, and subsequently rolled off the bed, resulting in a laceration above the right eyebrow and additional injuries. The resident was transported to the hospital for evaluation and treatment following the incident. Review of the resident's care plan and ADL documentation confirmed the need for two-person assistance during bed mobility and toileting. However, at the time of the fall, only one CNA was present and providing care. The facility's Accident and Injury policy, provided upon request, did not address specific procedures for fall prevention. Interviews with staff and the DON confirmed the circumstances of the fall and the lack of adherence to the resident's care plan requirements.
Inadequate Meal Portion Sizes in Facility
Penalty
Summary
The facility failed to ensure that meal portion sizes met the nutritional needs of the residents, which could potentially lead to inadequate protein intake, weight loss, and decreased meal enjoyment. During an observation, a dietary staff member was seen serving chili using a 6-ounce ladle, despite the production sheet indicating that the portion size should be 8 ounces. When questioned, the dietary staff member was unaware of the correct portion size, and the Certified Food Manager confirmed the error. Additionally, during a group meeting with eight residents, all participants expressed that the food portions were insufficient, citing examples such as being served only one rib or one slice of pizza during meals.
Plan Of Correction
Element 1: Cited Residents The facility failed to ensure meal portion sizes meet the nutritional needs of the residents. No specific residents were affected by these practices. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified practice. The facility audited the serving ladles to ensure they are the proper size. Element 3: Education Dietary Director and Dietary staff will be educated on the acceptable ladle size of 8 oz. to ensure the serving size meets the nutritional needs of the residents. Element 4: Audits The administrator or designee will complete random audits on the kitchen tray line 5 meals a week for 4 weeks to ensure the acceptable ladle size of 8 oz. is being used to meet the nutritional needs of the residents. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.
Deficient Food Safety Practices in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The ice scoop holder was found with black debris, and the ice scoop was resting in it. The ice machine filter was dusty, and the interior of the microwave had dried food debris. The walk-in cooler's floor was soiled with black stains and dried milk. In the chemical room, two unlabeled spray bottles were found, and the floor drain cover under the dish machine was obstructed with debris. The dish machine's sanitization log had not been completed since breakfast on 4/11, and the chlorine sanitizer was not detected during testing. Additionally, the 2nd floor nourishment room had a microwave with peeling paint and mold-like stains on towels under the sink. The 3rd floor nourishment room's microwave was rusty, and the shelf under the sink was water-damaged and soiled with a mold-like substance. These observations indicate a failure to maintain cleanliness and proper labeling, which are essential for preventing foodborne illnesses.
Plan Of Correction
Element 1: Cited Residents The facility failed to prepare food in accordance with professional standards for food service safety. No specific residents were affected by these practices. Element 2: Like Residents Residents who reside at the facility have the potential to be impacted by the identified practice. - FDS or designee will ensure that the ice scoop holder is free of debris. - FDS or designee will ensure the ice machine filter is clean and free from debris. - FDS or designee will ensure the interior of the microwave is clean and free from debris. - FDS or designee will ensure the flooring of the walk-in cooler is clean and free from debris. - FDS or designee will ensure spray bottles are appropriately labeled. - FDS or designee will ensure the floor drain cover underneath the dish machine is clean and free from debris. - FDS or designee will ensure to properly test and document the dish machine. - Housekeeping Supervisor or designee will ensure the nourishment rooms on 2nd and 3rd floor are clean and free from debris. Element 3: Education Dietary staff and Housekeeping staff will be educated on the importance of appropriate and effective methods of cleaning in all areas and the sanitation policy. Element 4: Audits The FDS or designee will complete a random audit 5 times a week for 4 weeks for cleanliness compliance. The Housekeeping Supervisor will complete a random audit 3 times a week for 4 weeks for nourishment room cleanliness. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.
Deficiencies in Person-Centered Care Plans
Penalty
Summary
The facility failed to provide person-centered care plans for two residents, leading to deficiencies in addressing their specific medical and psychosocial needs. One resident, who was cognitively intact, was admitted with diagnoses including Post-Traumatic Stress Disorder (PTSD) and Vascular Dementia. However, their care plan did not include provisions for these conditions. The social worker acknowledged the absence of a care plan for these diagnoses after being questioned by the surveyor, and the Nursing Home Administrator confirmed that appropriate care plans and psych services should have been in place. Another resident, who had moderate cognitive impairment and was dependent on assistance for most activities of daily living, was observed without heel protectors despite having a pressure ulcer on the right heel. This resident often refused care and did not adhere to their Renal Diet, leading to elevated potassium and phosphorous levels. Despite these issues, there was no care plan addressing the resident's non-compliance. Interviews with staff and family confirmed the resident's frequent refusal of care and dietary non-adherence, yet the facility's Behavioral Care Services policy, which includes care plan development, was not followed.
Plan Of Correction
Element 1: It is the practice of the facility to provide person-centered interventions and care plans for patients with Vascular Dementia, PTSD, and ESRD. R78 and R46 care plans have been reviewed and updated. Element 2: Residents that have been diagnosed with Vascular Dementia, PTSD, and ESRD have the potential to be affected by this cited practice. Those residents' care plans have been reviewed and updated. Element 3: The Interdisciplinary Team reviewed the policy and procedure to Develop/Implement Comprehensive Care Plan and deemed it appropriate. The Social Services and dietician have been educated on the policy of Develop/Implement interventions and care plans with focus on to provide person-centered interventions and care plans. Element 4: S.W./Designee will audit new admissions with diagnoses of Vascular Dementia, PTSD to ensure care plans are in weekly x4 then monthly x3. Dietician/Designee will audit renal patients to ensure non-compliance diet care plans are in place and will do random audits on renal patients for compliance with diet weekly x4 weeks then monthly x3 months. Results of audits will be taken through QA for further review and recommendations. The Administrator will be responsible for sustaining compliance.
Failure to Respond to Call Lights and Provide Timely ADL Care
Penalty
Summary
The facility failed to respond to call lights and provide activities of daily living (ADL) care in a timely manner for one resident and a group of eight confidential residents. Specifically, a resident was observed waiting for over an hour to have their brief changed, with their call light out of reach on the floor. Staff entered the resident's room to deliver a breakfast tray but did not address the resident's care needs. On a follow-up visit, the resident activated their call light due to a wet brief, but multiple staff members walked by without responding. A staff member deactivated the call light without providing assistance, and the resident had to reactivate it before the Director of Nursing (DON) responded. The resident's electronic medical record indicated they were admitted with respiratory failure and COPD, had moderately impaired cognition, and were dependent on staff for toileting. Resident council meeting notes from December 2024 to March 2025 highlighted concerns about delayed ADL care and long call light wait times. A group of eight residents reported that when agency staff were on duty, call lights were often ignored, and care was delayed. The facility's policy stated that staff should respond to call lights regardless of assignment and only turn off the light once the resident's request is met.
Plan Of Correction
Element 1: Cited Residents Resident R152 currently resides in the facility. The Facility failed to respond to call lights and provide activities of daily living care in a timely manner. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified deficiency. The facility completed baseline audit to ensure residents call lights are being answered in a timely manner based on resident interviews and observation. Element 3: Education Staff will be educated on the facility call light policy to ensure call lights are answered in a timely manner. Element 4: Audit Administrator or designee will complete a random audit 7x a week for 4 weeks to ensure the call lights are answered in a timely manner according to facility policy based on resident interviews and observation. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.
Inappropriate Medication Administration via PEG Tube
Penalty
Summary
The facility failed to ensure the appropriate administration of medications via a percutaneous endoscopic gastrostomy (PEG) tube for a resident, identified as R73. During an observation of medication administration, an LPN was seen preparing and administering nine crushed medications through R73's PEG tube. The process involved an initial water flush of 30-40 milliliters, followed by the administration of medications with varying amounts of water flushes between them. The orders indicated a flush amount of 20-30 milliliters, but the facility's policy required a flush of 15 milliliters between medications. The LPN combined the last five medications, which was not ordered for R73, and administered them together, leading to the resident feeling full and nauseous. Interviews with facility staff, including another LPN, the Unit Manager, and the Director of Nursing (DON), revealed inconsistencies in the understanding and application of the facility's policy on PEG tube medication administration. The staff reported different practices regarding the amount of water used for flushing between medications and the combining of medications, which contradicted the facility's policy. The facility's policy required medications to be diluted with at least 30 milliliters of water and flushed with 15 milliliters of water between medications unless otherwise prescribed. This inconsistency in practice and deviation from the policy led to the deficiency in the care provided to R73.
Plan Of Correction
Element 1: It is the practice of the facility to ensure an appropriate amount of water flush is provided between administration of individual medications via peg tube. Element 2: Residents that receive medications via peg tube have the potential to be affected by this cited practice. R73 stated she was fine and that she always feels full. R73 was offered to take her medications by mouth and stated she prefers her medication via peg. LPN E was educated on medication administration via peg tube. Element 3: The Interdisciplinary Team reviewed the policy and procedure on Enteral Tube Medication Administration and deemed it to be appropriate. Nursing was educated on Enteral Tube Medication Administration. Element 4: Nurse Educator/Designee will audit random nurses weekly x4 for proper medication administration via peg, then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5: The Administrator will be responsible for sustaining compliance.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12.82% error rate for a resident. During a medication administration observation, an LPN prepared and administered nine crushed medications via a PEG tube for a resident. The LPN initially flushed the tube with 30 to 40 mls of water, followed by four medications with an additional 20-30 mls of water. The resident reported feeling full and nauseous, prompting the LPN to pause. The LPN then combined the remaining five medications into 30 mls of water and flushed with another 20-30 mls of water, leaving residual medication in the syringe. The LPN admitted to combining medications for some residents, although this was not ordered for the resident in question. The facility's policy requires each medication to be administered separately, diluted with at least 30 ml of water.
Plan Of Correction
Element 1: It is the practice of the facility to be free of medication error rates of 5%. Element 2: Residents that receive medications via PEG tube have the potential to be affected by this cited practice. R73 stated she was fine and that she always feels full. R73 was offered to take her medications by mouth and stated she prefers her medication via PEG. LPN E was educated on medication administration via PEG tube. Element 3: The Interdisciplinary Team reviewed the policy and procedure on medication error and deemed it to be appropriate. Nursing was educated on medication errors and medication administration via PEG. Element 4: Nurse Educator/Designee will audit random nurses weekly x4 for proper medication administration via PEG, then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5: The Administrator will be responsible for sustaining compliance.
Failure to Administer Blood Pressure Medication as Ordered
Penalty
Summary
The facility failed to ensure the proper administration of blood pressure medication, Clonidine, for a resident as per the physician's order. During a medication pass observation, it was noted that the resident had a blood pressure of 197/96, which required the administration of Clonidine and notification to the physician as per the order. However, the previous blood pressure reading of 196/88 at 5:00 AM was not reported to the physician, and there was no documentation of this notification in the progress notes. The resident's Medication Administration Record (MAR) showed only two previous administrations of the PRN Clonidine, despite multiple instances of elevated blood pressure readings that met the criteria for administration. The resident, who was admitted with diagnoses including stroke, heart disease, chronic kidney disease, and malnutrition, had a history of moderately impaired cognition and required assistance with daily activities. The facility's failure to administer the medication as needed and to notify the physician of elevated blood pressure readings was confirmed by the Unit Manager, who acknowledged that the expectation was to follow the physician's orders and report out-of-parameter blood pressures. The resident's electronic medical record documented ten or more instances of systolic blood pressures greater than 160 since the order was initiated, indicating a pattern of non-compliance with the prescribed medication regimen.
Plan Of Correction
Element 1 It is the practice of the facility that Residents are Free of Significant Medication Errors and to ensure the PRN blood pressure medication (Clonidine) is administered as needed per physician orders. Element 2 Residents that receive PRN Clonidine have the potential to be affected by this cited practice. R73 was seen and evaluated at bedside on 4/11/25 & 4/14/25 by physician for hypertension and refusal of medication. Element 3 The Interdisciplinary Team reviewed the policy and procedure on Medication Administration and deemed it to be appropriate. Nursing was educated on PRN blood pressure medication administration and to recheck blood pressure within 1 hour. If SBP is greater than 160 to call the physician. Element 4 UM/Designee will audit residents who have PRN blood pressure medication to ensure they are given appropriately weekly x4 then monthly x3. Results of audits will be taken through QA for further review and recommendations. Element 5 The Administrator will be responsible for sustaining compliance.
Failure to Properly Label and Discard Expired Medications
Penalty
Summary
The facility failed to properly label and discard expired drugs and biologicals in accordance with accepted professional principles. During observations, it was noted that several medication carts and a medication room contained items that were either expired or lacked proper labeling. Specifically, a dorzolamide eye drop vial was found without a resident identifier or date opened, glucose strips were not dated when opened, and insulin aspart vials were expired. Additionally, a Basalgar insulin pen, Trelegy inhalers, and an Arnuity inhaler were not dated when opened, and some lacked resident identifiers. Further observations revealed that a tuberculin vial in a medication room was open but not dated, and Latanoprost eye drops and Prednisone Acetate bottles were found without identifying labels or open dates. The Director of Nursing confirmed that expired medications should be discarded and that medications requiring them should have a date opened and an identifier. The facility's Prescription Dating/Storage Guidelines and manufacturer's information were reviewed, highlighting the specific storage and expiration requirements for these medications.
Plan Of Correction
Element 1: It is the practice of the facility to ensure proper labeling of drugs and biologicals. The glucose strips, insulins, and inhalers that were not dated and that did not have patient identifiers on them were removed from the med carts and discarded. Element 2: Residents who have eye drops, insulins, and inhalers have the potential to be affected by this cited practice. Those residents' inhalers, insulins, and eye drops—the medication carts were checked for proper label and dating. No other issues were found. Element 3: The Interdisciplinary Team reviewed the policy and procedure titled: Storage and Expiration Dating of Medications/Biologicals, and deemed it appropriate. The nurses and Nurse Managers were inserviced on the proper labeling and dating of medications and biologicals. Element 4: U.M./or designee will audit all medication carts weekly for 4 weeks to ensure eye drops, inhalers, and insulins are properly labeled and dated as needed, then monthly for 3 months. Results of audits will be taken through QA for further review and recommendations. The Administrator will be responsible for sustaining compliance.
Inadequate Sanitation of Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain a tube feeding pole in a sanitary manner for a resident who was dependent on enteral feeding due to severe cognitive impairment and medical conditions including Hemiplegia, Hemiparesis, Dysphagia, and Diabetes. Observations revealed that the tube feeding pole and base had a thick layer of brown dried tube feed stuck to it, and a bag of Isosource 1.5 cal was missing the resident's name, date, time, or order. Additionally, used gloves were found on the floor, and a pool of wet fluid was observed on the floor. The Infection Control Preventionist stated that the expectation was for the pole to be cleaned when soiled, but this was not adhered to, as evidenced by multiple observations of the soiled pole over several days. The facility's policy on cleaning and disinfection of resident-care equipment was not followed, as the tube feeding equipment was not stored in the soiled utility room as required.
Plan Of Correction
Element 1 It is the practice of the facility to ensure appropriate infection control practices are used for equipment cleaning. The Nursing and Housekeeping staff were educated on cleaning of the tube feed pole and spills on the floor. Element 2 Residents that have a peg tube pole in the facility have the potential to be affected by this cited practice. Residents' rooms with a tube feeding pole were audited and cleaned. Element 3 The Interdisciplinary Team reviewed the policy and procedure titled: Cleaning and Disinfection of Resident-Care Equipment was reviewed and deemed the policies to be appropriate. Nursing and Housekeeping will continue to be educated on this policy. Element 4 Environmental Manager/designee will randomly audit on residents with tube feeding poles to ensure there are no spills on the floor or pole itself for 4 weeks and then monthly x 3 months. Results of audits will be taken through QA for further review and recommendations. The Administrator will be responsible for sustaining compliance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents, as observed in the cases of three residents. For one resident, the call light was found on the floor by the side of the bed, out of reach, on two separate occasions. This resident, who had intact cognition but required substantial assistance for activities of daily living (ADLs), was unaware of the call light's location. Another resident's call light was observed on the floor under the bed and later next to the bed, both times out of reach. This resident had moderately impaired cognition and required moderate assistance for ADLs. A Licensed Practical Nurse (LPN) was observed picking up the call light from the floor and clipping it to the resident, indicating a lack of consistent adherence to call light placement protocols. A third resident's call light was also found on the floor by the bed, out of reach. This resident had moderately impaired cognition, was frequently incontinent of urine, and was dependent on staff for toileting. The facility's policy on call light accessibility, issued in August 2023, mandates that staff ensure call lights are within reach of residents. However, interviews with staff and the Nursing Home Administrator (NHA) revealed that the expectation for call light placement was not consistently met, as evidenced by the observations made during the survey.
Plan Of Correction
Residents R57, R106, and R152 currently reside in the facility. The facility failed to ensure that call lights are in reach. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified deficiency. The facility completed a baseline audit to ensure residents had call lights in place. Element 3: Education Staff will be educated on the importance of ensuring the call lights are within reach for residents. Element 4: Audit An administrator or designee will complete a random audit on 10 residents a week for 4 weeks to ensure their call light is in place. Element 5: Compliance The facility Administrator will be responsible for assuring substance compliance is attained through this plan of correction by 5/13/25 and for sustained compliance thereafter.
Failure to Develop and Implement Required Care Plans for Diagnoses and Non-Compliance
Penalty
Summary
A review of one resident's medical record revealed that, despite diagnoses of Post-Traumatic Stress Disorder (PTSD) and Vascular Dementia, there was no care plan in place addressing these conditions. The resident was cognitively intact and required assistance with activities of daily living. When questioned, the social worker confirmed the absence of care plans for these diagnoses, and the nursing home administrator acknowledged that appropriate care plans should be in place for such conditions. Another resident, who was dependent for all activities of daily living except eating and had a history of encephalopathy, diabetes with neuropathy, kidney disease requiring dialysis, and a pressure ulcer, was observed not using prescribed heel protectors and was known to frequently refuse care, including dietary restrictions. Multiple staff interviews confirmed the resident's pattern of non-compliance, yet there was no care plan addressing this behavior. The facility's own policy requires care plan development and implementation based on comprehensive assessment, which was not followed in these cases.
Call Light Not Accessible to Resident with Impaired Cognition and Mobility
Penalty
Summary
On two separate occasions, a resident's call light was observed to be on the floor and out of the resident's reach, first under the bed and later next to the bed. During one of these observations, an LPN entered the room and was questioned about the proper placement of the call light, at which point the LPN picked up the call light and clipped it to the resident. Another LPN confirmed in an interview that the expectation is for the call light to be clipped to or located beside the resident within their reach. The resident involved had a history of respiratory failure and muscle weakness, with moderately impaired cognition and required moderate to total assistance for all activities of daily living except eating, as documented in the most recent MDS assessment.
Call Light Inaccessible to Dependent Resident
Penalty
Summary
A call light was observed on the floor by the bed, out of reach of a resident who had been admitted with respiratory failure and COPD. The resident's most recent MDS indicated moderately impaired cognition, frequent urinary incontinence, and dependence on staff for toileting. Facility policy requires staff to ensure call lights are accessible to residents at bedside, and the administrator confirmed that staff are expected to check call light placement and accessibility for all residents. Despite these requirements, the call light was not within the resident's reach at the time of observation.
Failure to Maintain Delayed-Egress Door Alarms and Locking Systems
Penalty
Summary
Surveyors observed that several emergency exit egress doors, specifically those leading to stairways on the 2nd and 3rd floors, were signed as having a 15-second delay with an alarm to sound upon opening. However, when these doors were tested, they opened freely without any resistance or alarm activation. This was confirmed during observations at multiple locations and times within the facility. The lack of functioning delayed-egress locking systems and alarms on these doors means that the doors did not operate as indicated by their signage. The facility failed to ensure that doors in a required means of egress were equipped and maintained in accordance with the special locking arrangements for clinical needs, as required by regulation. These findings were confirmed with the facility Maintenance Director at the time of observation.
Plan Of Correction
K222 Egress Doors 1. The facility failed to ensure doors in a required means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress unless meeting the special locking arrangements for clinical needs in accordance with 19.2.2.2.5.1 and 19.2.2.2.6. a. Emergency exit to egress door to Stairway "A" 3rd floor was assessed and serviced. b. Emergency exit egress door on 3rd floor by sitting was assessed and serviced. c. Emergency exit egress door to stairway "A" 2nd floor was assessed and serviced. 2. The maintenance director and staff will be educated on checking and maintaining any breaches in egress doors with a latch or lock throughout the facility. 3. To ensure continued compliance is maintained with the emergency fire exits, the Maintenance Director/designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Inoperative Exit Signage and Noncompliance with Emergency Lighting Requirements
Penalty
Summary
The facility failed to ensure that exit and directional signs were displayed in accordance with regulatory requirements, specifically 7.10 and 19.2.10.1, which mandate continuous illumination and connection to the emergency lighting system. During observations on April 14, 2025, multiple ceiling-mounted exit signs were found to be inoperative: one on the 3rd floor Lakeland Hall by stairway "C," several in the 3rd floor corridor at the Jefferson Central Stairway door and the remainder of the 3rd floor, and one on the 2nd floor Jefferson Hall. These deficiencies were confirmed by the facility Maintenance Director at the time of observation. All 175 residents in the facility could be affected by the lack of properly functioning exit signage in the event of a fire, as the required continuous illumination and emergency lighting backup were not provided for these exit signs.
Plan Of Correction
K293 - Exit Sign 1. The Facility failed to ensure exit and directional signs are displayed in accordance with 7.10, continuously illuminated and served by the emergency lighting system as required by 19.2.10.1. a. Ceiling mounted exit sign 3rd floor Lakeland Hall by stairway "C" is now operative. b. Ceiling mounted exit signs 3rd floor in the corridor at Jefferson Central Stairway door and the remainder of the 3rd floor are now operative. c. Ceiling mounted exit sign 2nd Floor Jefferson Hall is now operative. 2. The maintenance director and staff will be educated on the importance of exit signs/emergency lighting to be continuously activated and working properly. 3. To ensure continued compliance is maintained with the exit sign lighting/emergency lighting, the Maintenance Director/Designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Maintain Required Range Hood Suppression System Inspections
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Specifically, there was no evidence provided of the required semi-annual service dates for the installed range hood suppression system from 2023 to the present, with the last recorded service date being 2/15/2023. Additionally, the facility did not provide documentation of the required owner's monthly hood suppression system inspections for 2024 to the present. These deficiencies were confirmed during record review with the Maintenance Director and no supporting compliance documentation was presented to the surveyor by the time of exit. All 175 residents in the facility could be affected by these lapses in fire protection system maintenance, as identified during the survey process.
Plan Of Correction
K324 - Cooking Facilities 1. The facility failed to ensure cooking facilities are protected in accordance with NFPA 96. a. The facility conducted monthly hood suppression system inspections for the range hood with proper documentation. b. The facility conducted semi-annual service for the installed range hood suppression system with proper documentation. 2. The Maintenance Director and Food Service Director were educated on the importance of monthly and semi-annual testing and the proper documentation to maintain compliance. 3. To ensure continued compliance of the Hood Suppression System is maintained, the Maintenance Director/Designee will report monthly and semi-annually. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72. During an observation, the fire alarm remote panel located in the vestibule to Physical Therapy (new) was found to be displaying incorrect date and time information, specifically showing '0506 on 06/03/2059.' This issue was confirmed by the facility Maintenance Director at the time of observation. This deficiency could potentially affect all 175 residents in the facility in the event of a fire situation, as the fire alarm system may not function as required due to improper maintenance or testing.
Plan Of Correction
K345- Fire Alarm System- Maintenance and Testing 1. The facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72. a. The Fire alarm remote panel date and time in the vestibule to Physical Therapy is correct. 2. The Maintenance director and staff will be educated on the importance of rounding and ensuring the time and date on the fire alarm remote panels have the correct date and time. 3. To ensure compliance is maintained, the Maintenance Director/designee will complete a random audit 3x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Deficient Sprinkler System Maintenance and Testing
Penalty
Summary
The facility failed to maintain and test its automatic sprinkler and standpipe systems in accordance with NFPA 25 requirements. Observations on multiple occasions revealed several deficiencies, including ceiling tile penetrations in the IT/Telecom Room and storage room, missing ceiling tiles in the Maintenance Office and laundry area, and missing or incomplete sprinkler components such as escutcheon rings and concealed covers in various rooms including a resident bathroom, Dietary Rest Room, Dialysis Treatment Room, and Conference Room. Additionally, dirty sprinkler heads were found behind the dryers in the laundry, and stock items were stored within 18 inches of a sprinkler head in the vestibule for dialysis storage. These issues were confirmed by the Maintenance Director during the survey. Further review of facility records showed a lack of documentation for the required quarterly flow tests for the automatic fire suppression system for two consecutive quarters. No evidence of these tests was provided to the surveyor by the time of exit. The combination of physical deficiencies and missing compliance documentation affected all 175 residents in the facility, as confirmed through interviews and record reviews with the Maintenance Director.
Plan Of Correction
K353 - Sprinkler System Maintenance and Testing 1. The facility failed to provide sprinkler system maintenance and testing as required by NFPA 25. a. The ceiling tile penetration on 2nd floor new side by IT/Telecom room has been replaced. b. The ceiling penetration in 2nd floor storage room with roof access has been replaced. c. Escutcheon plate in the 2nd floor room #235 has been replaced. d. The ceiling tile penetration in Maintenance Office by the IT equipment rack has been replaced. e. Dirty sprinkler heads behind the dryers have been cleaned. f. Missing sprinkler head in the Dietary restroom has been replaced. g. Escutcheon plate in the Dialysis den has been replaced. h. Missing sprinkler in the 1st floor conference room has been replaced. i. All combustibles and stock items within 18" have been removed from dialysis storage room. j. Missing ceiling tile above the washers in the laundry room has been replaced. 2. The maintenance director and staff will be educated on the importance of routine rounding to ensure the sprinkler heads have escutcheon plates and are clean, ceiling tiles maintain no breaches, and combustible/stock items maintain 18" from the ceiling. 3. To ensure continued compliance, the Maintenance director/designee will complete random audits 5 times a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Improper Storage of Combustibles and Electrical Panel Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's compliance with NFPA 54 and NFPA 70 standards for gas and electrical equipment. Specifically, combustible stock items were found stored within three feet of electrical panels in both the Physical Therapy storage area and the first floor mechanical room. Additionally, the electrical panel in the second floor electrical closet near Room #263 was found with its cover disassembled and resting on the floor. Two open blanks were identified in the electrical panel for the first floor auxiliary kitchen located in the first floor mechanical room. Furthermore, combustible items were stored on top of and within three feet of a transformer in the first floor mechanical room. These findings were confirmed by the facility Maintenance Director at the time of observation. All 175 residents of the facility could be affected by these deficiencies, as the improper storage of combustibles and unsecured electrical panels present a risk in the event of a fire caused by electrical sparks, arcing, or overheating.
Plan Of Correction
K511 – Utility's-Gas and Electric 1. The facility failed to ensure equipment using gas or gas related piping complies with NFPA 54 and electrical wiring and equipment complies with NFPA 70. a. The combustible stock items stored within 3' of the electrical panels in the Physical Therapy Storage have been removed. b. The electrical panel in the 2nd floor electrical closet by room #263 has been reassembled. c. The Electrical Panel for the 1st floor auxiliary kitchen in the 1st floor mechanical room with 2 open blanks has been corrected. d. The combustibles stored within 3' of the electrical panel in the 1st floor mechanical room have been removed. e. The combustibles stored on top of the transformer in the 1st floor mechanical room have been removed. 2. The maintenance director and staff will be educated on maintaining clearance of 3' of electrical panels and transformers, and the panels are properly assembled and maintained within the requirements of NFPA 54 and 70. 3. To ensure compliance is maintained, the maintenance director/designee will complete a random audit 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Provide Timely Fire Damper Inspection Documentation
Penalty
Summary
The facility failed to provide evidence of the required quadrennial (every four years) servicing and inspection of their installed fire dampers, as mandated by regulatory standards. During a record review on April 15, 2025, it was found that the last recorded servicing of the fire dampers was dated June 16, 2020, and no documentation supporting compliance with the current inspection requirement was available for review. This deficiency was confirmed with the facility Maintenance Director at the time of the record review. The lack of current inspection documentation could affect all 175 residents in the event of a fire, as noted in the findings.
Plan Of Correction
K521 - HVAC 1. The facility failed to ensure heating, ventilation, and air conditioning in compliance with 9.2. a. The facility scheduled the required quadrennial serving and inspection of the installed Fire Dampers. 2. The Maintenance Director was educated on the required quadrennial serving and inspection of the installed fire dampers and proper documentation following required fire drills. 3. To ensure compliance is maintained, the Maintenance Director/designee will complete an audit monthly following each fire drill with proper documentation. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Train Staff on Emergency Evacuation Procedures
Penalty
Summary
The facility failed to ensure that there was a written plan for the protection and evacuation of all residents in the event of an emergency, as required by regulatory standards. During an interview, nursing staff on the second floor reported that they had not received periodic training on procedures for removing residents from elevated floors to the ground level if elevators were not operable or during a fire situation. This lack of training was confirmed by the Maintenance Director at the time of observation. The deficiency was identified through direct questioning of staff and was based on their statements regarding the absence of such training since their employment at the facility. No specific residents or their medical conditions were mentioned in the report, and the findings were based solely on staff interviews and confirmation by facility leadership.
Plan Of Correction
K711 - Evacuation and Relocation Plan. 1. The facility failed to ensure there is a written plan for the protection of all residents and for their evacuation in the event of an emergency, employees are periodically instructed in their duties under the plan as required by 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3. a. The facility will schedule annual education and drill for the evacuation of residents from elevated floors to the ground level. 2. The Administrator/safety committee will be educated on the importance of routinely educating and scheduling drills of the evacuation of residents from elevated levels to the ground. 3. To ensure compliance is maintained, the Administrator will complete audits monthly to ensure staff are educated on the evacuation of residents from elevated levels. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Conduct Fire Drills at Unexpected Times
Penalty
Summary
The facility failed to conduct fire drills as required by regulations 19.7.1.4 through 19.7.1.7. Specifically, record review showed that fire drills for both the 1st and 2nd shifts from the 2nd quarter of 2024 to the present were consistently held at similar, expected times, rather than at unexpected times under varying conditions as required. The times for the 1st shift drills were all around midday, and the 2nd shift drills were all in the mid-afternoon. This pattern was confirmed during an interview with the Maintenance Director at the time of record review. The deficiency could potentially affect all 175 residents in the facility in the event of a fire situation.
Plan Of Correction
K712- Fire Drills 1. The facility failed to conduct fire drills as required by 19.7.1.4 through 19.7.1.7. a. The facility conducted a fire drill at an unexpected time and under varying conditions from the previous month/quarter. 2. The Maintenance Director was educated on the importance of running fire drills at unexpected times and under varying conditions from previous drills. 3. To ensure substantial compliance, the Administrator will do an audit of fire drills monthly for the 6 months. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Deficient Emergency Generator Maintenance and Documentation
Penalty
Summary
The facility failed to maintain compliance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 requirements for emergency electrical systems. During observation, both of the facility's emergency backup power generators were found with unsecured access panels, lacking the required handle locks or other devices to prevent unauthorized access. This was confirmed by the Maintenance Director at the time of observation. Additionally, the facility was unable to provide documentation of the required annual servicing date and annual 90-minute load bank test for the emergency generator set, despite the generator's initial service date being recorded. Further record review revealed that the facility did not have evidence of the required monthly load tests for the generator set from February 2024 onward. The facility also failed to provide documentation of the annual fuel analysis for the stored diesel fuel used by the emergency backup power generators. No compliance documentation was presented to the surveyor by the time of exit, and these findings were confirmed with the Maintenance Director during the record review process.
Plan Of Correction
K918 – Electrical Systems- Essential 1. The facility failed to ensure generators or other alternative power sources are in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70. a. The installed emergency backup power generators were supplied with lock/denying devices. b. The new emergency back-up power generator has had its annual 90-minute load back test and inspection scheduled. c. The monthly load run test and inspection has been performed and documented on the new generator. d. The annual fuel analysis for the stored diesel fuel for the emergency back-up power generator has been completed. 2. The maintenance director and staff were educated on weekly, monthly, and annually required generator tests as well as proper documentation according to NFPA standards. 3. To maintain continued compliance, the Maintenance Director or designee will complete a random audit week for 4 weeks to ensure the NFPA standards are being met. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Inoperative Stairway Path Interrupter on 2nd Floor Egress
Penalty
Summary
During an observation on April 14, 2025, it was found that the electronic stairway path interrupter installed on the 2nd floor stairway path of egress by the elevators was inoperative. This device is intended to guide occupants to the proper egress level during emergencies. The inoperative condition could result in individuals evacuating to the lower level and missing the correct exit during a fire or emergency event with diminished visibility. The deficiency was confirmed at the time of observation with the facility Maintenance Director. A total of 58 out of 175 residents could be affected by this issue in the event of a fire situation, as noted in the findings.
Plan Of Correction
K225- Stairways and Smoke Proof Enclosures 1. The facility has failed to ensure stairways and smokeproof enclosures used as exits are in accordance with 7.2, as required by 19.2.2.3 and 19.2.2.4. 2. The electronic stairway path interrupter installed on the 2nd floor stairway path of egress by the elevators is operative. 3. The maintenance director and staff will be educated on the importance of egress doors/gates being continuously activated and working properly. 4. To ensure continued compliance is maintained with the stairway path interrupter, the Maintenance Director/Designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 5. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Obstructed Fire Extinguisher in Physical Therapy Charting Room
Penalty
Summary
A deficiency was identified when, during an observation in the Physical Therapy Charting Room, a fire extinguisher located by the counter was found to be obstructed by combustible stock items. This situation was observed on April 14, 2025, at 12:25 PM and was confirmed through an interview with the facility Maintenance Director at the time of the observation. The report notes that this failure to ensure the fire extinguisher was accessible and properly maintained was not in accordance with NFPA 10 standards for portable fire extinguishers. The deficiency had the potential to affect 28 of 175 residents in the event of a fire.
Plan Of Correction
K355 - Portable Fire Extinguishers 1. The facility failed to ensure portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10. a. Fire Extinguisher by the counter in the Physical Therapy Charting Room is clear of combustible stock items. 2. Maintenance Director and Staff will be educated on the importance of keeping fire extinguishers free from obstruction and clear of combustible stock items. 3. To ensure continued compliance, the Maintenance director/designee will complete random audits 5x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Smoke Barrier Doors Failed to Latch and Lacked Self-Closure Devices
Penalty
Summary
Surveyors observed that several smoke barrier doors within the facility did not meet Life Safety Code (LSC) requirements. Specifically, the fire-rated cross corridor door at the 2nd floor storage room with roof access, the fire-rated double door set to Physical Therapy, and the door to the 2nd floor sitting room all failed to positively latch when tested. Additionally, the doors to the Physical Therapy storage area lacked required self-closure devices. These deficiencies were confirmed during the survey through direct observation and interview with the facility Maintenance Director. A total of 58 out of 175 residents could be affected by these issues in the event of a fire, as the doors in question are intended to serve as smoke barriers but did not function as required at the time of inspection.
Plan Of Correction
K374 - Subdivision of Building Spaces - Smoke Barrier 1. The facility failed to ensure smoke barriers doors meet the requirements of the LSC. a. Self-closers have been added to the Physical Therapy Storage doors. b. The fire-rated cross corridor door at the 2nd floor storage room with roof access has been repaired. c. The 2nd Floor Sitting Room door latch has been repaired. d. The latch to Physical Therapy double doors has been repaired. 2. The maintenance director and staff will be educated on the importance of the LSC requirements of various doors in the facility latch properly. 3. To ensure compliance is maintained, the maintenance director/designees will complete random audits 3x a week for 4 weeks. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Improper Storage of Oxygen Cylinders Near Combustibles
Penalty
Summary
Oxygen cylinders were observed stored within five feet of combustible stock items in the second floor clean linen room. This storage arrangement does not comply with NFPA 99 requirements, which mandate that oxidizing gases such as oxygen must be separated from combustibles by at least 20 feet, or 5 feet if the area is sprinklered, or stored in a compliant cabinet. The cylinders were not properly segregated from combustible materials, as required by the standard. The deficiency was identified during an observation conducted on April 14, 2025, at 10:35 AM, and was confirmed by the facility Maintenance Director at the time of the survey. The report notes that this practice could affect 76 of 175 facility residents in the event of a fire emergency, but does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Plan Of Correction
K923 – Gas Equipment- Cylinder and Container Storage. 1. The facility failed to ensure storage of nonflammable gasses meet all requirements of NFPA 99. a. Oxygen cylinders within 5' was cleared of combustible stock items on the 2nd floor of new side clean linen room. 2. Maintenance Director and staff were educated on the proper Oxygen cylinder storage requirements. 3. To ensure continued compliance, Maintenance Director/designee will complete random audits 5x a week for 4 weeks to ensure oxygen rooms and linen closets have proper storage of oxygen cylinders. Findings will be reported to the QAPI committee. 4. The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 5/13/2025 and for sustained compliance thereafter.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to protect a resident during an abuse investigation, resulting in fear of retaliation and feeling scared. The incident involved a staff member, Staff A, who was alleged to have misappropriated funds from a resident's bank account. The resident, R901, had opened a bank account with Staff A as a secondary account holder. Over time, R901 noticed unauthorized withdrawals and gambling transactions linked to the account, leading to a total unauthorized withdrawal of $18,364.14. Despite the resident's attempts to address the issue, Staff A continued to have access to the account until it was closed. The situation escalated when the police were involved, and Staff A was instructed not to have contact with the resident. However, the following day, Staff A entered the resident's room, confronting them aggressively and causing the resident to feel threatened and scared. The resident was unable to call for help as their phone was out of reach. Staff A's actions included leaving multiple voicemails and text messages, further intimidating the resident. The facility's failure to protect the resident during the investigation is evident in the lack of immediate removal of Staff A from the premises and the inability to prevent further contact with the resident. The facility's policy on abuse prevention was not effectively implemented, as Staff A was able to confront the resident despite being suspended. This oversight led to the resident experiencing significant emotional distress and fear for their safety.
Plan Of Correction
Element 1: Cited Residents R901 no longer resides in the facility. The facility failed to protect one resident during an abuse investigation resulting in fear of retaliation and feeling scared. Element 2: Like Residents Residents who reside in the facility have the potential to be impacted by the identified practice. The facility completed an initial baseline audit to ensure that residents feel protected in the facility. Element 3: Education Staff will be educated on the facility abuse policy and process to ensure that residents are protected and free from abuse. Element 4: Audits Administrator or designee will complete 10 random audits x4 weeks to ensure that residents feel safe in this facility has no fear of retaliation. Element 5: Compliance The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 3/21/2025 and for sustained compliance thereafter.
Staff Misappropriation of Resident Funds
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's funds by a staff member, resulting in unauthorized withdrawals totaling $18,368. The incident involved a resident who had opened a joint bank account with a staff member, Staff A, after expressing frustration with their family's delay in assisting them. The account was opened with the resident as the primary account holder and Staff A as the secondary. Over time, the resident noticed declined transactions despite having funds in the account, leading them to discover unauthorized withdrawals linked to a gambling app used by Staff A. The resident reported the issue to their family, who then accompanied them to the bank to close the account and file a police report. The police instructed the resident to call 911 if Staff A approached them. Despite being suspended, Staff A confronted the resident aggressively, causing the resident to fear for their safety. Staff A also made multiple phone calls to the resident, leaving messages that further intimidated the resident. The facility's investigation revealed that Staff A had used the resident's account for personal gambling activities and claimed to have reimbursed some of the funds. However, the total amount taken was significantly higher than what was returned. The facility's policy on abuse and misappropriation of resident property was not effectively implemented, as the incident was not detected or prevented in a timely manner, leading to significant financial and emotional distress for the resident.
Plan Of Correction
Element 1: Cited Residents Resident R901 no longer resides in the center. The facility failed to prevent staff misappropriation of resident funds. The facility initiated immediate suspension and investigation of employee. Element 2: Like Residents Residents residing in the facility have the potential to be impacted by the identified practice. The facility completed an initial baseline audit to ensure residents' funds are protected. Element 3: Education Staff will be educated on resident rights with a focus on misappropriation and the abuse policy. Element 4: Audits Administrator or designee will complete random audits on 10 residents a week for 4 weeks to ensure residents are free from misappropriation/exploitation. Administrator or designee will complete random audits on 5 employees a week for 3 weeks to ensure staff have knowledge and understanding of the abuse policy. Element 5: Compliance The facility Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 3/21/2025 and for sustained compliance thereafter.
Failure to Notify Residents of Room Changes
Penalty
Summary
The facility failed to provide proper notification of room changes for two residents, R906 and R908, as required by their policy. R906's responsible party was not informed of the room change until two days after it occurred, and there was no documentation in the electronic medical record indicating prior notification. R906, who has diagnoses including dementia and severely impaired cognition, was moved to a room with a resident who frequently yelled, causing disturbance. The responsible party had to inquire about the new room location upon visiting, highlighting a lack of communication from the facility. Similarly, R908 was informed of their room change just before it happened, without the opportunity to preview the new room, which was smaller. The move was necessitated by the need to accommodate a COVID patient, but there was no documentation of prior notification to R908 or their family. R908, who has intact cognition and diagnoses including dementia and pulmonary disease, expressed dissatisfaction with the new room. The facility's policy requires written notice and discussion of room changes with residents or their representatives, which was not adhered to in these cases.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to implement care planned interventions to prevent a fall for a resident with a history of falls and medical conditions including Spina Bifida with Hydrocephalus, Paraplegia, and Epilepsy. The resident's care plan included an intervention to place an anti-slip pad in the wheelchair seat to mitigate fall risk. However, during an incident, the resident was left unattended sitting on a mechanical lift sling in the wheelchair, which was not in accordance with the care plan or facility expectations. On the day of the incident, a CNA was preparing to transfer the resident from the wheelchair to the bed using a mechanical lift. The CNA placed a sling under the resident but realized it was the wrong size and left to retrieve the correct one. During this time, the resident slid forward out of the wheelchair and fell to the floor. The LPN assessed the resident for injuries and arranged for hospital transfer for further assessment. The facility's Director of Nursing acknowledged that the resident should not have been left unattended on the sling, and the facility lacked specific policy documentation addressing this issue.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to perform transfers according to the plan of care for a resident with severe cognitive impairment and a history of chronic shoulder dislocations. The resident was admitted with diagnoses including developmental disorder of scholastic skills and unspecified dislocation of the left shoulder joint. The care plan specified that the resident should be transferred using a mechanical lift with the assistance of two people. However, staff used a sit to stand lift instead, which was not in accordance with the care plan. An incident occurred when a CNA observed a lump on the resident's left shoulder, indicating a dislocation, which was confirmed by an x-ray. The Director of Nursing reported that staff had been using the incorrect lift method due to not reviewing the Kardex, which contained the correct transfer instructions. This improper transfer method was identified as the root cause of the shoulder dislocation during a meeting of the facility's Interdisciplinary Team.
Failure to Provide Scheduled Grooming and Showering
Penalty
Summary
The facility failed to provide grooming and showers according to schedule and preference for two residents, leading to a deficiency in the care provided for Activities of Daily Living (ADLs). Resident R701, who was admitted with diagnoses of Generalized Anxiety Disorder and Depression, had an intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15. Despite being dependent on staff for bed mobility and transfers, R701 only received bed baths during their stay, with no showers documented. The Director of Nursing (DON) acknowledged that if bed baths were R701's preference, it should have been documented in the care plan and progress notes, which was not the case. Resident R714, who was admitted after hospitalization for Epididymitis, had a fluctuating BIMS score indicating severely to moderately impaired cognition. R714 was observed with long facial hair and expressed difficulty in shaving, stating that facility staff did not have time to assist. The facility records indicated a care plan for ADL self-care deficit, requiring assistance with personal hygiene, including shaving. However, the resident's request for help was not adequately addressed, leading to the deficiency in providing necessary grooming assistance.
Failure to Schedule Follow-Up Appointment for Resident with Catheter
Penalty
Summary
The facility failed to arrange a follow-up appointment for a resident who required a urology consultation after being discharged from the hospital with an indwelling catheter. The resident, who had an intact cognition and required assistance with mobility and transfers, was observed with a catheter drainage bag attached to their wheelchair. The resident reported that the catheter was initially removed but had to be reinserted due to a high bladder scan result. The hospital discharge paperwork indicated a need for a neurology follow-up within 5-7 days, which was not scheduled by the facility. The Director of Nursing and the Unit Clerk both acknowledged attempts to schedule the appointment, but they were unsuccessful in receiving a callback from the urology office. The Unit Clerk mentioned informing the floor nurses about the situation, but there was no documentation in the progress notes regarding the appointment or notification to the physician. The facility's policy on consultations requires scheduling appointments for external consultations, which was not adhered to in this case.
Failure to Serve Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to provide palatable and appropriately heated meals to residents, as evidenced by observations and interviews with four residents. Residents reported receiving cold or barely warm food, with one resident specifically mentioning cold eggs and another describing the food as awful and never hot. During an observation of the food service, meals were noted to be left uncovered on a steam table for several minutes before being served, which could contribute to the food cooling down. Additionally, a test tray revealed that while the coffee was very hot, the food was only very warm and not hot, with the pork medallion dish being extremely salty and the vegetables tasteless and inedible. The facility's Tray Delivery Schedule indicated that lunch trays were to be delivered between 11:00 AM and 12:30 PM, with the last unit receiving trays by 12:30 PM. However, the test tray for the last unit was received at 1:40 PM, indicating a delay in the delivery schedule. The Dietary Manager confirmed that food temperatures were checked before plating and were within limits, but could not explain why trays were delayed on the day of the survey. This discrepancy between the scheduled and actual delivery times, along with the residents' complaints and the test tray findings, highlight the facility's failure to ensure meals were served at a safe and appetizing temperature.
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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