The Laurels Of Coldwater
Inspection history, citations, penalties and survey trends for this long-term care facility in Coldwater, Michigan.
- Location
- 90 N Michigan Avenue, Coldwater, Michigan 49036
- CMS Provider Number
- 235302
- Inspections on file
- 30
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at The Laurels Of Coldwater during CMS and state inspections, most recent first.
A resident with chronic inflammatory demyelinating polyneuritis and bradycardia, who was bedbound but cognitively intact, discovered through her medical record that a restorative nursing program for ankle ROM and bed mobility had been ordered but was rarely provided. She filed a written grievance describing that the restorative therapy, important to her physical health, had not been started as ordered and identified multiple staff who were aware of the issue. The facility could not locate its copy of the grievance, did not have it in recent grievance files, and did not maintain a grievance log, despite a policy requiring timely investigation and tracking of concerns such as missing therapy services. Task logs confirmed that the ordered restorative interventions were documented only a few times over a month, with many entries marked "Not Applicable" or "Resident Refused," and the resident reported receiving the service only a handful of times, with no documented follow-up to her grievance.
Two residents who smoked did not have their smoking care managed according to comprehensive, individualized care plans and the facility’s smoking policy. One resident with severe cognitive impairment and multiple medical conditions was on the smoking list but had no smoking evaluation or smoking care plan, and reported keeping cigarettes and a lighter on her person rather than in staff-controlled storage or designated lockers. Another cognitively intact resident with paraplegia had a smoking evaluation and a care plan stating staff would maintain all smoking paraphernalia, and had signed a policy prohibiting cigarettes and lighters in rooms or on the person except at designated times, yet he reported and was observed keeping his cigarettes and lighter in a fanny pack in his room and on his lap, using them independently without returning them to staff. Staff interviews, including with an LPN and the DON, confirmed that residents generally did not use the lockboxes and instead kept smoking materials in their rooms, and that smoking assessments and care plans were inconsistently developed and not implemented as written.
Two residents did not receive restorative nursing services as ordered to maintain or improve ROM and functional abilities. One resident with chronic inflammatory demyelinating polyneuritis and bradycardia had active orders and an evaluation for passive bilateral ankle ROM and bed mobility to sitting at the edge of the bed, but task logs over a month showed the services were rarely provided, frequently marked as Not Applicable, and often recorded as refused despite the resident reporting only one refusal and stating staff said no one was available to run the program; the resident filed a grievance that the facility could not produce. Another resident with malignant neuroleptic syndrome and catatonic schizophrenia had an order for daily 15‑minute hand‑over‑hand grooming ADLs, yet documentation over a month showed multiple days with no entries, many days where the 15‑minute goal was not met, and numerous Not Applicable entries. The ADON, who oversaw the restorative program and assigned CNAs to complete and document it, confirmed that the documentation reflected that restorative nursing was not being provided as ordered and stated that refusals should be documented in progress notes and that Not Applicable was not an appropriate entry.
A resident with osteomyelitis and multiple stage 4 pressure ulcers of the sacrum, ischium, and hip, who was on hospice and had detailed wound care orders in place, did not have documented routine examinations of these wounds by a licensed medical provider. Wound assessments showed stalled and improving wounds with undermining and tunneling, and an LPN reported that hospice directed treatments focused on comfort and infection control. However, review of progress notes over many months, along with a physician note and a hospice NP face-to-face encounter, showed references to decubitus and non-healing stage 4 ulcers but no documentation that the pressure ulcers were actually examined by a provider, resulting in the cited deficiency.
The facility did not update or revise care plans for multiple residents after incidents of aggression, including altercations between roommates and physical aggression towards a spouse. Despite documented behavioral changes and staff awareness, care plans were not modified to address new risks or interventions, and staff could not provide reasons for these omissions.
A resident with PTSD, anxiety, and a history of physical abuse, who was cognitively intact, was subjected to verbal abuse by a CNA after overhearing staff discuss her care and being accused of faking incontinence. When the resident requested a grievance form and the CNA's name, the CNA refused and responded with profane language, causing emotional distress. The incident was corroborated by another resident and confirmed through staff interviews and facility records.
A resident with severe cognitive impairment and limited upper body control was physically restrained in a wheelchair using a sheet tied by staff, including a CNA and an LPN, to prevent falls. Staff interviews confirmed the restraint was applied for about 15 minutes, and the resident was unable to remove it independently.
Multiple cognitively intact residents reported that meals were consistently unappetizing, cold, or otherwise unpalatable, with some stating they had to supplement with outside food. Surveyors confirmed through direct observation and temperature checks that food was often served outside safe and appetizing temperature ranges, and palatability tests found meals to be bland and unappealing. Facility policies for meal quality and temperature monitoring were not effectively followed, leading to widespread dissatisfaction among residents.
A resident with a signed DNR order was incorrectly listed as full code on the face sheet of the medical record. The discrepancy occurred after the resident returned from the hospital, and staff acknowledged the code status was not updated as required.
Two residents receiving antipsychotic medications were not appropriately monitored for orthostatic hypotension, despite physician orders requiring such monitoring. Review of medical records showed no documentation of orthostatic blood pressure readings for either resident, and the DON confirmed that this monitoring and documentation was expected.
A resident with multiple health conditions and at risk for pressure injuries had a physician's order for protective boots to be worn while in bed, but this intervention was not added to the care plan or the CNA Kardex during the care plan's revision. The DON confirmed the omission despite the existing order.
A resident with multiple chronic conditions did not have a pharmacy medication regimen review recommendation properly followed up. The pharmacy recommended discontinuing loratadine-D due to hypertension, but there was no documented physician response or required signatures, and the DON reported not receiving the recommendation in time to act.
A medication cart was left unattended and unlocked in a hallway with several residents present. An LPN had left the area to use the restroom and forgot to secure the cart, which contained drugs and biologicals. The cart remained unlocked until the LPN returned and was notified of the oversight. Facility policy requires medication carts to be locked when not in use, and the DON confirmed this was not standard practice.
A facility failed to immediately report abuse allegations involving a resident with severe cognitive impairment. An LPN shouted at the resident during an incident, which was witnessed by two CNAs. The incident was not reported to the NHA or State Agency in a timely manner, violating the facility's abuse prohibition policy. The delay in reporting was not addressed through re-education or disciplinary action for the CNAs involved.
The facility failed to maintain clean kitchen equipment, leading to potential foodborne illness risks for residents. Observations revealed fruit flies, sticky floors, soiled sinks, and improperly stored food trays. Dietary staff confirmed inadequate cleaning practices, and pest control services were called due to the infestation. The 2017 FDA Food Code requirements for cleanliness and pest control were not met.
The facility failed to maintain a clean and homelike environment, with several resident rooms and common areas found in unsanitary conditions. A resident's room had a strong odor, stained mattress, and flies, while other areas had peeling paint, loose handrails, and pest issues. Residents were observed in unclean conditions, with dirty wheelchairs and long, unkempt facial hair. Housekeeping staff acknowledged the issues, and the housekeeping manager admitted to not having a documented deep cleaning schedule.
A resident with severe cognitive impairment was found with a bruise of unknown origin near the left eye. The bruise was reported by the resident's family to the DON, but no incident report or investigation was conducted. The Nurse Manager did not complete an incident report, and the DON acknowledged the oversight. The NHA was unaware of the incident until later and confirmed it should have been reported as an allegation of abuse.
A resident with severe cognitive impairment was found with a bruise of unknown origin, which was not investigated or reported as an allegation of abuse by the LTC facility. The DON and Nurse Manager failed to complete an incident report or conduct a thorough investigation, and the Nursing Home Administrator was unaware of the incident until later informed.
A resident with hearing impairments experienced unmet needs due to the facility's failure to implement an effective care plan. Despite having hearing aids, the resident struggled to hear staff, and staff were unaware of the aids' existence. An audiology consult recommended ear drops and irrigation for impacted cerumen, but no physician orders were found, and no cerumen removal was documented.
The facility failed to update care plans for two residents, leading to deficiencies in care management. One resident's care plan did not reflect a dialysis graft in her left arm, causing confusion among staff about her dialysis access. Another resident's care plan was outdated, missing recent diagnoses of pneumonia and rib fractures. Interviews with staff revealed that care plans should have been updated to reflect these changes, but they were not.
Two residents in an LTC facility did not receive adequate hygiene and grooming care. One resident with hemiplegia and reduced mobility was found with unkempt facial hair and dirty fingernails, unsure of the last time he received care. Another resident with major depressive disorder and multiple sclerosis had long facial hair coated in food and a soiled shirt. Both residents' rooms were infested with flies and gnats. Facility records showed refusals of showers without proper documentation or follow-up, and standard grooming care was not consistently provided.
The facility failed to follow physician orders and provide necessary interventions for three residents. A resident with constipation did not receive appropriate interventions despite having a bowel program in place. Another resident with hearing loss was not provided with functioning hearing aids, and no action was taken for impacted cerumen. A third resident did not receive prescribed testosterone injections, with no documentation or physician notification of missed doses.
Failure to Follow Up on Resident Grievance Regarding Restorative Therapy
Penalty
Summary
The deficiency involves the facility’s failure to follow up on and process a resident grievance regarding ordered restorative therapy services. An alert and oriented resident, with a Brief Interview for Mental Status (BIMS) score of 14/15, reported that a friend had reviewed her electronic medical record and identified an order for a restorative therapy program intended to start on January 1, 2026. The resident stated she had only received the restorative service a total of five times since that date and had been told by staff that there was no one available to run the program. In response, the resident completed a written grievance on 3/25/2026, specifying that restorative therapy ordered in late December 2025 had not been initiated as expected and explaining that this was important to her physical health. The resident’s grievance form, photographed and provided by the resident, documented her concern about not receiving restorative therapy, identified multiple staff and a PA who were aware of the issue, and suggested using CNAs to provide the therapy and then float to assist elsewhere. The facility was unable to locate or provide its own copy of this grievance prior to survey exit, and the grievance was not found among the paper copies of grievances for the prior three months. The Environmental Manager, who oversees grievances, confirmed that the resident’s grievance was not in the available grievance files and reported that she did not maintain a grievance log, though she believed the policy required resolution within 5–7 days. Record review showed the resident had diagnoses including chronic inflammatory demyelinating polyneuritis and bradycardia, and required substantial/maximal assistance for bed mobility and was dependent for lower body dressing. A restorative evaluation dated 12/24/2025 identified functional deficits in bilateral ankle ROM and repositioning from supine to sitting at the edge of the bed, and a physician order directed participation in a nursing restorative program with daily passive ROM of both ankles and/or positional changes from supine to sitting for 15 minutes per 24 hours, with documentation. Task logs for the 30‑day look‑back period showed the passive ROM program was documented only six times, with numerous entries marked “Not Applicable” and some “Resident Refused,” and the bed mobility program was documented only three times, also with many “Not Applicable” and “Resident Refused” entries. The facility’s compliance policy required concerns such as services not provided by a vendor (including therapy) to be reported to the Facility Compliance Officer and investigated within five working days, and for all concerns to be tracked in the electronic system and summarized monthly for QAPI, but the resident’s substantiated concern about not receiving restorative therapy was not followed up through this process.
Failure to Develop and Implement Comprehensive Smoking Care Plans and Controls for Smoking Paraphernalia
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, individualized care plans addressing residents’ smoking status and management of smoking paraphernalia, as required by regulation and by the facility’s own smoking policy. For one resident with severe cognitive impairment and multiple medical diagnoses, including COPD, heart failure, dementia, cellulitis, difficulty walking, and anxiety, the record showed she was on the facility’s smoking list but had no smoking evaluation completed on admission and no smoking problem or interventions on her care plan. During interview, this resident stated she kept her cigarettes and lighter with her, either in her purse or on her person, and that staff did not store these items in the medication cart, medication room, or smoking-area lockers. Staff interviews confirmed that the facility was not following its stated process for managing smoking materials. An LPN reported that residents were supposed to use lockers in the smoking area for their smoking devices but acknowledged that residents did not use them and that staff did not keep extra smoking devices in the medication room. The DON stated he did not know who developed smoking care plans, was unaware that residents had smoking devices on them, and acknowledged that the resident in question was on the smoking list. The DON further explained that smoking assessments were done variably, often only when residents changed their minds about smoking after admission, indicating an inconsistent approach to assessment and care planning for smokers. For another resident with paraplegia who was cognitively intact, the record contained a smoking evaluation indicating the resident was a safe smoker who could smoke independently and a care plan stating that staff would maintain all smoking paraphernalia for both safe and unsafe smokers. The facility’s written smoking policy, which this resident had signed, specified that residents were not permitted to have cigarettes or lighters in their rooms or on their person except at designated smoking times, and that all smoking paraphernalia would be turned in to staff when smoking was finished. However, this resident reported keeping cigarettes and a lighter in a fanny pack in his room and on his lap, did not lock up or return smoking materials to staff, and was observed self-propelling to the smoking area with his fanny pack and smoking outside. An LPN and the DON both acknowledged that, contrary to policy and care plan interventions, residents generally kept their smoking paraphernalia in their rooms and did not use the lockboxes, demonstrating a failure to implement the care-planned and policy-required controls over smoking materials.
Failure to Provide Ordered Restorative Nursing Services for ROM and Grooming
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services as ordered to maintain or improve range of motion (ROM) and mobility for two residents. For one resident with chronic inflammatory demyelinating polyneuritis and bradycardia, the clinical record showed an active physician order for a restorative program including passive ROM of both ankles and progression to positional changes from supine to sitting at the edge of the bed for 15 minutes per 24 hours, with daily documentation. A restorative initial evaluation identified functional deficits in independent bilateral ankle ROM and repositioning from supine to upright sitting, and stated that the restorative program would prevent decline or possibly improve the resident’s abilities. However, task logs over a 30‑day look‑back period showed that passive ROM was documented as provided only 6 times, with 49 entries marked Not Applicable and 8 as Resident Refused, and bed mobility was documented as provided only 3 times, with 53 Not Applicable entries and 9 Resident Refused. During observation and interview, this resident was found lying in bed and reported that a friend had reviewed her electronic medical record and identified a restorative therapy order intended to start on January 1. The resident stated she had only received the service about five times since that date and had been told by staff that there was no one available to run the program. She reported filing a grievance about not receiving restorative therapy as ordered and stated she had not received any follow‑up. She also reported only one refusal of restorative therapy, on a day when she had a urinary tract infection and felt too dizzy to safely sit at the edge of the bed, and she adamantly denied any other refusals. The resident provided a photo of the grievance form, which documented her concern that restorative therapy ordered to start on January 1 had still not occurred and identified that she had discussed the issue with nurses, CNAs, a PA, and physical therapy. The facility was unable to locate or provide a copy of this grievance prior to survey exit. For a second resident with malignant neuroleptic syndrome and catatonic schizophrenia, the MDS showed severely impaired cognition and dependence for personal hygiene. This resident had an active physician order to participate in a nursing restorative program for 15 minutes daily, seven days a week, to assist staff with performing hand‑over‑hand grooming ADLs such as hair brushing/combing, teeth brushing, and face washing. Review of the task log for a 30‑day look‑back period showed seven days with no documentation of the service being provided or refused, 19 days when the 15‑minute goal was not met, and 47 entries marked Not Applicable. In an interview, the ADON, who was overseeing the restorative program after the prior restorative nurse quit, confirmed that CNAs were responsible for completing and documenting restorative therapy each shift, acknowledged that the documentation showed the first resident was not regularly receiving restorative nursing as ordered, and stated that refusals should be reported to the nurse and documented in a progress note and that there was no circumstance where Not Applicable would be appropriate for restorative documentation. The facility’s restorative nursing policy required daily documentation of minutes and initials by nursing assistants on days the program is delivered.
Failure to Ensure Provider Examination of Stage 4 Pressure Ulcers for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed medical provider routinely examined a resident’s stage 4 pressure ulcers, despite the resident being under hospice care and having multiple complex wounds. The resident was admitted and later readmitted with osteomyelitis of the vertebra, sacral and sacrococcygeal regions, and stage 4 pressure ulcers of the sacral region, right buttock, and left buttock. The resident’s MDS showed moderate cognitive impairment and four stage 4 pressure ulcers, two of which were present on admission or reentry. Wound assessments dated 3/11/26 documented stage 4 pressure ulcers on the left and right ischium, sacrum, and left rear hip, with some wounds described as stalled and others improving, and with undermining and tunneling present. Physician orders were in place for specific wound care treatments, including cleansing, packing, and application of Dakins-moistened gauze and foam dressings. During the survey, the wound care LPN reported that the resident was receiving hospice services and that hospice directed the wound treatments, focusing on comfort and infection control rather than healing. However, review of the resident’s progress notes from 5/1/25 through 3/12/26 did not show documentation that a provider had examined the resident’s stage 4 pressure ulcers during that period. When the surveyor requested the most recent date a provider evaluated the wounds, the facility produced a physician progress note from 6/26/25 and a hospice NP face-to-face encounter note from 2/28/26. Both documents referenced the presence of decubitus ulcers and non-healing stage 4 pressure ulcers, but neither documented an actual examination of the pressure ulcers. This lack of documented provider examination of the resident’s stage 4 pressure ulcers led to the cited deficiency.
Failure to Update Care Plans Following Resident Aggression
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four out of eleven residents following incidents of aggression or behavioral changes. For one resident with a history of psychosis, insomnia, and major depressive disorder, an altercation with a roommate involving threats and aggressive behavior was documented. Despite this incident, the resident's care plan was not updated to address the new aggression, and no new interventions were added. The last care plan revision occurred months prior to the incident, and no additional care plan addressing aggression towards other residents was found in the electronic medical record. Two other residents were involved in a physical altercation after a disagreement over a room light. Both residents engaged in shoving and striking each other, and one was subsequently moved to another room. However, neither resident's care plan was updated to reflect the aggressive behavior or to include interventions to prevent further incidents. The care plans for both residents had not been revised since before the incident, and no new interventions addressing aggression were documented. Another resident was observed pushing his wife, also a resident, in her wheelchair and using physical force while shouting at her. The incident included yelling, grabbing, and striking, resulting in the wife being moved to another room. Despite this, there was no care plan created or updated to address the resident's aggression or the change in living arrangements. Interviews with facility staff confirmed that care plans should have been updated following these incidents, but the updates were not completed, and staff could not explain why the care plans were missed.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. A resident with diagnoses including PTSD, anxiety, and a history of physical abuse, and who was cognitively intact, overheard two CNAs discussing her care, with one CNA alleging the resident was faking her incontinence. The resident requested a grievance form and asked one of the CNAs for her name, which the CNA refused to provide. The CNA then used profane and abusive language towards the resident, raising her voice and swearing at her. The incident caused the resident emotional distress, and another resident corroborated the account of verbal abuse. Multiple interviews confirmed that the CNA used inappropriate language and refused to provide her name when requested by the resident. The incident was witnessed by another resident and reported by staff, with documentation in the facility's incident and investigation report. The CNA involved had recently completed training on abuse prevention, but still engaged in verbally abusive behavior towards the resident, violating the resident's right to be free from abuse.
Use of Physical Restraint on Cognitively Impaired Resident
Penalty
Summary
Staff failed to ensure that a resident was free from the use of a physical restraint. The resident, who had severe cognitive impairment and multiple medical diagnoses including alcohol-induced persisting dementia, pathological fractures, and anxiety disorder, was observed to have limited upper body control and had experienced multiple falls. On the night in question, staff observed the resident slumped over in a wheelchair, unable to maintain an upright position. In response, a CNA suggested and, with the agreement of an LPN, wrapped a sheet around the resident and tied it to the wheelchair handles to prevent the resident from falling. Another CNA witnessed the resident being tied to the wheelchair and confirmed that the resident could not get out of the restraint, which was in place for approximately 15 minutes. Staff interviews revealed that the decision to use the sheet as a restraint was made out of concern for the resident's safety, despite awareness that such an action constituted the use of a physical restraint and was not in compliance with regulations. The LPN acknowledged that restraints were not permitted but allowed the use of the sheet to prevent a fall. The resident was later returned to bed and remained there until a subsequent fall was discovered. The incident was later confirmed by the facility's administrator during an investigation.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
Surveyors identified a deficiency in the facility's provision of palatable, attractive, and appropriately tempered food and drink to residents. Multiple residents, all cognitively intact per their BIMS scores, reported that meals were consistently unappetizing, cold, or otherwise unpalatable. Observations included residents eating cold cereal, reporting never having received a hot meal or cold milk, and describing the food as 'nasty,' 'horrible,' or 'terrible.' Several residents stated they had to supplement with food from outside the facility due to dissatisfaction with the meals provided. Residents also reported that complaints about food temperature and quality had been made to staff without resolution. Direct observations and palatability tests conducted by surveyors confirmed the residents' reports. Lunch trays sampled during the survey were found to be lukewarm, bland, and lacking in flavor. Specific items such as breaded chicken patties, mashed potatoes, and spinach were described as bland, flavorless, and unappetizing. Food product temperatures were measured and found to be outside the safe and appetizing range, with hot foods served below the required 135°F and cold foods above the required 41°F, as per the 2022 FDA Model Food Code. For example, chef salads and milk were served at temperatures above 41°F, and hot dogs were served below 135°F. Review of facility policies revealed that the facility had established procedures to ensure a pleasant dining experience and proper food temperatures, including periodic test trays and monitoring by nutrition professionals. However, the observations, interviews, and temperature records indicated that these policies were not being effectively implemented, resulting in widespread dissatisfaction and potential nutritional decline among residents who rely on facility-provided meals.
Failure to Accurately Update Advance Directive Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive status was accurately reflected in all parts of the medical record. One resident, who was cognitively intact and had multiple diagnoses including respiratory failure, dementia, lung cancer, and COPD, had a Do Not Resuscitate (DNR) order signed and witnessed in the electronic medical record. However, the resident's face sheet, also known as the banner, incorrectly listed the resident as full code rather than DNR. This discrepancy was identified during a record review and interview, where a social service worker acknowledged that the code status had not been updated following the resident's recent return from the hospital.
Failure to Monitor Orthostatic Blood Pressure in Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate monitoring for two residents who were receiving psychotropic medications. For one resident with vascular dementia and hypotension due to drugs, there was an active physician order for Seroquel, an antipsychotic, with instructions to monitor for side effects including orthostatic hypotension. However, there was no physician order for orthostatic blood pressure readings, and a review of the electronic medical record showed that no orthostatic blood pressures had been documented. The Director of Nursing confirmed that the expectation was to monitor and document orthostatic blood pressures. Another resident with diagnoses including type 2 diabetes, malnutrition, schizoaffective disorder, major depressive disorder, and anxiety was receiving Abilify, an antipsychotic, with a physician order to monitor for side effects such as orthostatic hypotension. The resident was cognitively intact according to the most recent assessment. Despite the order, the medical record did not reflect evidence of routine orthostatic blood pressure monitoring, and the DON stated that such documentation would be found in the vital signs section or progress notes, but none was present.
Failure to Revise Care Plan to Include Physician-Ordered Skin Integrity Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to include the use of protective boots as ordered by a physician. The resident, who had multiple diagnoses including Alzheimer's dementia, anemia, diabetes, hypertension, bipolar disorder, impaired cognition, incontinence, psychotropic drug use, and protein calorie malnutrition, was identified as being at risk for impaired skin integrity and pressure injury. Although there was a physician's order for the resident to wear specialized boots to both feet while in bed to maintain skin integrity, this intervention was not added to the resident's care plan during its most recent revision. Additionally, the use of the boots was not documented on the Certified Nurse Aid (CNA) Kardex, which serves as the CNA's plan of care. The Director of Nursing confirmed that the boots were not listed on either the care plan or the CNA Kardex, despite the presence of a physician's order. The expectation, as stated by the DON, was that physician-ordered interventions should be reflected in both the care plan and the CNA Kardex.
Failure to Follow Up on Pharmacy Medication Regimen Review
Penalty
Summary
The facility failed to ensure proper follow-up on a monthly pharmacy medication regimen review for one resident. The resident, who had diagnoses including type 2 diabetes, unspecified protein-calorie malnutrition, schizoaffective disorder, major depressive disorder, and anxiety, was cognitively intact according to the most recent assessment. The pharmacy review for this resident dated 1/31/25 included a recommendation to consider discontinuing loratadine-D due to its potential to worsen hypertension, and to consider an alternative antihistamine if needed. However, the pharmacy consultation report did not have a documented response from the physician, nor did it include signatures from the physician or the Director of Nursing (DON). Further review revealed that the recommendation was not followed up on, as the DON reported only receiving the blank pharmacy recommendation after the fact. The lack of documented follow-up and absence of required signatures indicated that the facility did not ensure the pharmacy's recommendation was addressed in a timely manner, as required by policy and procedure.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart located in the 100 hall was observed to be left unattended and unlocked for approximately six minutes, during which time no nurse was present in the area and several residents were seen wandering nearby. The cart contained drugs and biologicals, and it was not secured until an LPN returned and was informed that the cart was unlocked. The LPN stated she had left to use the restroom and forgot to lock the cart. Review of the facility's policy indicated that medication carts are to remain locked except during medication or treatment administration. The Director of Nursing confirmed that leaving the cart unlocked was not consistent with facility policy and that staff are expected to lock the cart when it is unattended.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to immediately report allegations of abuse involving a resident with severe cognitive impairment. On the evening of November 26, 2024, an LPN attempted to assist a resident with a bloody nose in the memory care unit. During the interaction, the resident, who had dementia and scored 3/15 on a mental status exam, became agitated and verbally aggressive. The LPN responded by shouting at the resident, which was witnessed by two CNAs. The incident was not reported to the Nursing Home Administrator (NHA) or the State Agency in a timely manner, as required by the facility's abuse prohibition policy. The CNAs involved reported the incident to the most senior nurse on duty, but it was not escalated to the NHA until the following morning. The facility's policy mandates immediate reporting of abuse allegations to the administrator, but this protocol was not followed. The delay in reporting was not addressed through re-education or disciplinary action for the CNAs involved. The failure to report the incident promptly resulted in a deficiency, as it increased the potential for further unreported abuse allegations.
Facility Fails to Maintain Clean Kitchen Equipment, Increasing Foodborne Illness Risk
Penalty
Summary
The facility failed to maintain clean equipment in the kitchen and dining areas, leading to potential foodborne illness risks for all residents consuming food from the kitchen. Observations revealed numerous fruit flies near the handwashing sink and dishwasher, sticky floors, brown liquid stains on countertops, and soiled sinks with hard water buildup. The cupboards were sticky and warped from water damage, and portable steam table pans contained water and food debris. Food trays were improperly stored on a folding chair, and fruit flies were noted near the sink. In the B dining room kitchenette, similar issues were observed, including soiled countertops, food debris on the plate warmer, and soiled utensils stored in cupboards. The cupboards under the sink were warped and soiled with spider webs and particles. Interviews with dietary staff and management revealed that the steam tables were not cleaned after each use, contrary to the facility's procedures. Pest control services were called due to the fruit fly infestation, and recommendations were made to clean and sanitize the sink and drains, clean the grease trap, and address caulking needs. The Registered Dietician was not involved in assessing the kitchen's condition. The 2017 FDA Food Code was referenced, highlighting the requirement for equipment and surfaces to be clean and free of food residue, and for premises to be maintained free of pests.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in several resident rooms and common areas, as observed during a survey. In one instance, a resident's room was found with multiple cleanliness issues, including a strong foul odor, stained mattress, and floors, as well as the presence of flies and cobwebs. The resident reported frequent urinary incontinence, and despite housekeeping efforts, the room remained unclean over several days. Housekeeping staff acknowledged the persistent odor and stains, and the housekeeping manager admitted to not having a documented deep cleaning schedule. Other rooms and common areas also exhibited significant cleanliness and maintenance issues. Observations included smeared substances resembling blood on walls, peeling paint, loose toilet handrails, sticky debris on floors, and gaps around air conditioners allowing insect entry. Residents reported discomfort and dissatisfaction with the cleanliness and maintenance of their living spaces, including issues with ants and other pests. Additionally, several residents were observed in unclean conditions, with dirty wheelchairs, long and unkempt facial hair, and fingernails caked with debris. Some residents were unsure of when they last received grooming or nail care, and their personal spaces were cluttered and grimy. The presence of houseflies and gnats was noted in multiple rooms, further contributing to the unsanitary conditions.
Failure to Report and Investigate Bruise of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse involving a bruise of unknown origin for a resident with severe cognitive impairment. The resident, who had multiple diagnoses including a stroke, atrial fibrillation, and cognitive communication deficit, was observed with a bruise near the left eye. The resident's family member noticed the bruise and reported it to the Director of Nursing, but did not receive any information about the cause or corrective actions taken. A progress note indicated the bruise was possibly caused by a medical device during care, but no incident report was completed. Interviews with facility staff revealed that the Nurse Manager who documented the bruise did not complete an incident report, believing it was unnecessary. The Director of Nursing acknowledged that an incident report should have been completed and an investigation conducted, but neither occurred. The Nursing Home Administrator was unaware of the bruise until informed by the Director of Nursing, and confirmed that the bruise should have been reported as an allegation of abuse to the appropriate agency.
Failure to Investigate and Report Bruise of Unknown Origin
Penalty
Summary
The facility failed to investigate, implement preventive measures, and take corrective action for an allegation of abuse concerning a resident who was admitted with multiple diagnoses, including severe cognitive impairment. The resident was observed with a bruise of unknown origin on the outer corner of the left eye, which was noted in a progress note. The resident's family member reported the bruise to the Director of Nursing (DON), but no definitive cause or corrective action was communicated to the family. The progress note suggested a possible cause related to repositioning, but no incident report was completed, and the bruise was not investigated further. Interviews with facility staff revealed that the Nurse Manager did not complete an incident report, believing it was unnecessary, and did not conduct a thorough investigation by speaking with other staff members. The DON acknowledged that an incident report should have been completed and an investigation conducted, but neither occurred. The Nursing Home Administrator was unaware of the bruise until informed by the DON and confirmed that the incident was not reported as an allegation of abuse to the appropriate agency.
Failure to Implement Effective Hearing Care Plan
Penalty
Summary
The facility failed to develop and implement an effective care plan for a resident with hearing impairments, resulting in unmet needs. The resident, who was cognitively intact, had a history of hearing loss and was observed struggling to hear staff despite having hearing aids. The care plan included interventions to encourage the use of hearing aids and ensure their functionality, but staff were unaware of the resident's hearing aids and could not locate them. The resident's hearing aids were eventually found, but the resident reported they were ineffective. Further review revealed that the resident had moderate to severe hearing loss and impacted cerumen, which was noted in an audiology consult and an ear care visit. The consult recommended ear drops and ear irrigation for cerumen removal, but there were no physician orders for these treatments, and no documentation indicated that the primary care physician was notified or that any cerumen removal procedure was performed. This lack of action contributed to the resident's continued hearing difficulties.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care management. Resident #68, who was admitted with a diagnosis of dependence on renal dialysis, had a care plan that did not reflect the presence of a dialysis graft in her left arm. Despite having a clear dressing on her right chest, staff were confused about the location of her dialysis access, as evidenced by conflicting reports from a CNA and an LPN. The care plan did not include specific instructions regarding the dialysis graft, such as avoiding blood pressure measurements on the arm with the graft, which was crucial for her care. Resident #88, who was readmitted to the facility with multiple diagnoses including pneumonia and rib fractures, had a care plan that was outdated and did not reflect his current medical conditions. The plan of care had not been updated to include his recent fall, which resulted in rib fractures, or his pneumonia diagnosis. Interviews with the Nurse Manager, MDS nurse, and DON revealed that the care plan should have been updated to include these significant changes in his health status, but it was not. The failure to update the care plans for both residents indicates a lapse in the facility's process for ensuring that care plans accurately reflect residents' current medical needs. This deficiency was identified through observations, interviews, and record reviews, highlighting the need for timely and accurate updates to care plans to ensure appropriate care and interventions for residents.
Failure to Provide Adequate Hygiene and Grooming Care
Penalty
Summary
The facility failed to meet the hygiene, grooming, and activities of daily living (ADL) needs for two residents, resulting in unmet care needs. Resident #38, who has hemiplegia, hemiparesis, aphasia, and reduced mobility, was observed with unkempt facial hair, long fingernails, and brown debris under his nails. He was unsure of the last time he received a shower or nail care and did not refuse grooming or nail care. His room was infested with houseflies and gnats, and his wheelchair was dirty. The facility's records showed that Resident #38 had refused all showers for the past thirty days, but there was no documentation explaining the refusals or if alternative care was provided. Resident #86, diagnosed with major depressive disorder, muscle weakness, and multiple sclerosis, was observed with long facial hair coated in food, a soiled shirt, and long fingernails with debris. His room was also infested with houseflies and gnats. He reported that showers were seldom offered, and he had not received assistance with facial hair or nail care. The facility's records indicated that Resident #86 was marked as refusing all offered showers for the past thirty days, with only one progress note documenting a refusal. Interviews with staff revealed that the expectation was to offer showers or bed baths three times, and if refused, nursing staff should be informed, and a note should be entered into the electronic medical record. However, there was a lack of consistent documentation and follow-up on refusals, and standard grooming care was not consistently provided. This resulted in the residents not receiving ADL care according to their individual preferences, with the potential for feelings of shame or embarrassment.
Failure to Follow Physician Orders and Provide Necessary Interventions
Penalty
Summary
The facility failed to follow physician orders and provide necessary interventions for three residents, leading to deficiencies in their care. Resident #27 was readmitted to the facility with multiple diagnoses, including bipolar disorder and type 2 diabetes. Despite having an order for Polyethylene Glycol 3350 for constipation, the resident had not had a bowel movement since readmission, and no interventions were taken. The facility's bowel program, which should have alerted staff after three days without a bowel movement, was not followed, and no bowel protocol was in place. Resident #24, who has a history of hearing loss and uses hearing aids, was observed unable to hear staff despite having a hearing aid in place. The resident's care plan included ensuring the availability and functioning of hearing aids, but staff were unaware of the resident's need for them. An audiology consult had recommended ear drops for impacted cerumen, but no physician order for these drops was found, and the primary care physician was not notified of the issue. Resident #102, diagnosed with paraplegia and major depressive disorder, reported not receiving his prescribed testosterone injections. The medication administration record showed missed doses, with no documentation or notification to the physician about the missed injections. The resident often left the facility, but the medication should have been administered upon return. The facility failed to provide accurate documentation and follow-up on the missed medication, leading to a deficiency in care.
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A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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