The Laurels Of Kent
Inspection history, citations, penalties and survey trends for this long-term care facility in Lowell, Michigan.
- Location
- 350 N Center St, Lowell, Michigan 49331
- CMS Provider Number
- 235253
- Inspections on file
- 31
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at The Laurels Of Kent during CMS and state inspections, most recent first.
A cognitively intact resident with chronic pain relied on a nightly oxycodone 10 mg dose for pain control. In January, the resident reported that staff ran out of her medication, had difficulty obtaining doses from the backup box, and that she did not receive her pain pill one night, resulting in pain rated 10/10 and poor sleep. Records showed the last tablet from her main supply was used, backup oxycodone was pulled on several but not all subsequent nights, and the MAR documented a held dose due to needing a new prescription. An LPN later stated she likely gave a late dose from backup but did not document it correctly, and the DON could not account for a dose documented as given on another night, concluding it appeared the resident did not receive that dose despite MAR documentation.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
The facility failed to monitor and prevent sexual abuse between residents with severe cognitive impairment and guardianship, resulting in multiple incidents of inappropriate sexual contact without proper consent. Staff observed or were informed of sexual interactions, such as fondling and oral sex, but did not consistently report these events or verify guardian consent for sexual activity, contrary to facility policy.
Staff failed to immediately report and investigate multiple incidents of sexual contact between cognitively impaired residents, despite facility policy requiring immediate reporting to the abuse coordinator. Several staff members observed or were informed of these incidents but did not notify the abuse coordinator, and no documentation or investigation was completed, even though the residents involved lacked capacity to consent and had guardianship in place.
Several residents with cognitive and mental health diagnoses engaged in romantic or sexual relationships without timely or adequate care plan updates specifying boundaries or interventions. Staff were often unaware of relationship boundaries due to incomplete or delayed care plans, and incidents of inappropriate sexual behavior were not promptly addressed in documentation, contrary to facility policy.
A resident who was dependent for care and at risk for pressure ulcers developed unstageable wounds on the sacrum and right ear after staff failed to consistently assess, report, and initiate timely treatment. Despite multiple staff observing wounds, there was a lack of communication and delayed provider involvement, resulting in the wounds worsening to infection, sepsis, and requiring hospitalization and surgical intervention.
A staff member failed to interact respectfully with a resident who has Down syndrome and dementia, telling her not to "sit and cry" and leaving without offering support or diversion, despite the resident's care plan calling for supportive interventions. The resident reported feeling negatively about the interaction, and the staff member admitted to using a harsh tone, which was confirmed as inappropriate by facility leadership.
A resident with severe dementia and other health issues was found to have a large bruise on her thigh, which was not reported or investigated by the facility. Despite a family member's concern and a previous fall, the facility did not report the injury to the State Agency or complete an incident report.
A facility failed to investigate a large bruise of unknown origin on a resident with severe dementia. The bruise was noticed by a family member, but the facility had no explanation and did not conduct an investigation. The resident had a fall five days prior, but no injuries were noted at that time, and a subsequent skin assessment showed no new issues. Despite policy requirements, no incident report or investigation was completed for the bruise.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in personal hygiene documentation and dental care follow-up. One resident's poor hygiene was not accurately recorded, and another resident's need for dental care was not documented or communicated, resulting in a lack of necessary follow-up.
The facility did not post complete nurse staffing information daily, affecting all 98 residents. Observations revealed missing total hours in the staffing report. The MRS responsible for posting was unaware of the requirement to include total hours, and the NHA was also unaware of this requirement.
The facility failed to provide adequate supervision and accurately implement the elopement policy for three residents, resulting in the potential for injury. A cognitively impaired resident was able to leave the facility unsupervised due to a receptionist's mistake. Inaccurate documentation and assessments for elopement risk were found for multiple residents, and the facility's policy on elopement was not followed.
Failure to Prevent Significant Medication Error in Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to scheduled pain management. A cognitively intact resident with chronic pain, including right knee and back pain, had a long-standing order for oxycodone 10 mg at bedtime for chronic pain, with no PRN pain medications. The resident reported that her pain was very bad without the scheduled dose and that she relied on one pain pill at bedtime. In January, the resident stated that the facility did not have her pain medication in the building, the pharmacy would not send it, and staff were obtaining doses from a backup supply box. She reported that on one night she did not receive her pain medication at all, her pain escalated to 10/10, was unbearable, and she did not get much sleep. Record review showed the last tablet from the resident’s primary oxycodone supply was given on 1/6, and backup oxycodone 10 mg tablets were pulled on 1/7, twice on 1/9, and on 1/10 and 1/12, with no backup tablet pulled on 1/8 or 1/11. The January MAR documented the 10 mg oxycodone as held on 1/8 with a note that a new prescription was needed and that the physician was aware. The LPN who made this entry later stated she likely held the dose because it was not available, then gave it late from the backup supply but failed to document the late administration or correct the original “held” entry. The DON confirmed that the last regular tablet was given on 1/6, that backup doses were used on specific subsequent days, and that there was no clear source for the dose documented as given on 1/11, concluding it appeared the resident did not receive a dose that night despite documentation indicating otherwise. Pharmacy records showed a new supply of oxycodone was not delivered until later in the month, supporting that there was at least one missed scheduled dose of oxycodone associated with the resident’s reported severe pain and sleep difficulty.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements.
Failure to Prevent and Monitor Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to monitor and prevent resident-to-resident sexual abuse among several residents with severe cognitive impairments and guardianship status. Multiple incidents were documented where residents with limited or no capacity to consent were found engaging in sexual activities with other residents. In several cases, staff observed or were informed of inappropriate sexual contact, such as fondling or oral sex, but did not consistently report these incidents to the abuse coordinator or follow up to determine if proper consent had been obtained from guardians for such interactions. For example, one resident with a traumatic brain injury and severe cognitive impairment was found in another resident's room, partially undressed, with the other resident also partially undressed and fondling her. Staff had previously observed these two residents together and had redirected them, but did not seek or document guardian consent for their relationship until after the incident occurred. In another case, a resident was observed groping another resident's breasts in a public area, but the incident was not reported or documented as abuse, and there was no evidence that guardian consent for sexual activity had been obtained or clarified beyond holding hands. Additionally, there were incidents involving residents with full guardianship engaging in sexual acts, such as oral sex, where one guardian explicitly did not consent to sexual activity, only to limited physical affection like holding hands and kissing. Despite this, staff did not report the incident to the state agency, did not conduct an investigation, and did not follow up with the residents or their guardians. The facility's own abuse prohibition policy defines sexual abuse as non-consensual sexual contact of any type and requires monitoring and evaluation of residents' capacity to consent, but these procedures were not followed in the documented cases.
Plan Of Correction
F600 Free from Abuse and Neglect Resident #101 still resides in the facility. Resident does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #102 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #104 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #105 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be met with to discuss what level of relationship to have. If resident has a guardian or DOPA, they will be met with to discuss what level of relationship they permit for the residents to have. Any concerns identified will be addressed immediately. Staff have been re-educated on the Abuse Prohibition Policy. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Abuse Prohibition Policy was reviewed by the QA committee and deemed appropriate. Management team will complete quality rounds to evaluate for inappropriate sexual interactions weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further recommendations. Administrator is responsible for sustained compliance.
Failure to Immediately Report and Investigate Resident-to-Resident Sexual Abuse Allegations
Penalty
Summary
The facility failed to ensure that staff implemented the abuse policy by immediately reporting allegations of abuse to the abuse coordinator for four residents who were reviewed for abuse. Multiple staff members, including RNs, LPNs, and CNAs, observed or were made aware of incidents involving sexual contact or interactions between cognitively impaired residents, but did not report these incidents to the abuse coordinator as required by facility policy. In several cases, staff were unsure if the residents involved had the capacity to consent or if their guardians had provided consent for sexual relationships, yet no immediate reporting or investigation was initiated. Specifically, one RN observed a resident groping another resident's chest in a lounge area but did not document or report the incident, stating she was unaware of the need to report it to the abuse coordinator. Another LPN witnessed similar behavior and also failed to report, believing that documentation in nursing notes was sufficient. In another incident, a CNA found two residents engaged in a sexual act, reported it to the unit manager, and the DON was notified, but the abuse coordinator was not informed, and no follow-up investigation was conducted. The DON confirmed awareness of the incident but did not report it, rationalizing that the residents had a longstanding relationship. All residents involved were documented as severely or moderately cognitively impaired and had full guardianship in place, indicating a lack of capacity to independently consent to sexual activity. The facility's abuse prohibition policy clearly requires immediate reporting and investigation of all allegations of abuse, including resident-to-resident sexual contact, especially when capacity to consent is in question. Despite this, staff failed to follow policy, resulting in unreported incidents and a lack of appropriate investigation or intervention.
Plan Of Correction
F0607 Develop/Implement Abuse/Neglect Policies Resident #103 still resides in the facility. Resident does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #104 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #105 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Resident #106 does not express or exhibit any decline in physical, mental, and psychosocial well-being. Care plan reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be met with to discuss what level of relationship to have. If resident has a guardian or DOPA, they will be met with to discuss what level of relationship they permit for the residents to have. Any concerns identified will be addressed immediately. Staff have been re-educated on the Abuse Prohibition Policy. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Abuse Prohibition Policy was reviewed by the QA committee and deemed appropriate. Management team will complete quality rounds to evaluate for inappropriate sexual interactions weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further recommendations. Administrator is responsible for sustained compliance.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans for Resident Relationships
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents who were involved in romantic or sexual relationships with other residents. Several care plans were either not initiated in a timely manner or lacked specific interventions and boundaries regarding the relationships. For example, one resident with cognitive communication deficit and major depressive disorder was involved in an incident of inappropriate sexual behavior with another resident, but his care plan was not updated until a week after the incident and did not address boundaries for the relationship. Another resident with muscle weakness and adult failure to thrive had a care plan that did not address his relationship with a specific female resident, despite documented episodes of hypersexuality and staff observations of inappropriate physical contact. Similarly, a resident with cognitive communication deficit and depression had a care plan that was only recently initiated and did not specify boundaries for her relationship with a male resident, even after staff witnessed inappropriate touching in public areas. Staff interviews confirmed a lack of awareness regarding established boundaries for these relationships, and social services staff admitted to forgetting or missing updates to the care plans. Additionally, two residents with dementia, depression, and cognitive communication deficits were in a long-term relationship involving sexual interactions, but their care plans were not updated to reflect boundaries or interventions until much later. Staff, including CNAs and nurses, reported not knowing what boundaries were in place and relied on care plans for this information, which were not kept current. The facility's own care planning policy requires individualized, resident-centered plans that communicate needs to direct care staff, but this was not consistently followed, resulting in unmet care needs and the potential for negative outcomes.
Plan Of Correction
F656 Develop/Implement Comprehensive Care Plan Resident #102 still resides in the facility. Care plan was reviewed and updated as needed. Resident #103 still resides in the facility. Care plan was reviewed and updated as needed. Resident #104 still resides in the facility. Care plan was reviewed and updated as needed. Resident #105 still resides in the facility. Care plan was reviewed and updated as needed. Residents who appear to be in a relationship have the potential to be affected. Residents who appear to be gravitating towards a relationship will be meet with to discuss what level of relationship to have and have been care planned. If resident has a guardian or DOPA, the will be meet with to discuss what level of relationship they permission for the residents to have and have been care planned. Any concerns identified will be addressed immediately. IDT has been re-educated on the Care Plan Policy. Care Plan Policy was reviewed by the QA committee and deemed appropriate. IDT will meet weekly to review residents who appear to be in a relationship care plans for any changes needed weekly x 4, then monthly and findings will be reported to QA committee for further recommendations. Administrator is responsible for sustained compliance.
Failure to Prevent and Treat Pressure Ulcers Resulting in Severe Wound Complications
Penalty
Summary
A deficiency occurred when the facility failed to implement and monitor interventions, treatments, and assessments necessary to prevent and manage pressure ulcers for a resident at risk. The resident, who had diagnoses including muscle weakness and diabetes mellitus, was dependent on staff for mobility and personal care and was identified as being at risk for pressure ulcers. Despite this, documentation shows that staff did not consistently assess, report, or initiate timely treatment for new wounds, specifically on the resident's sacrum and right ear. Initial signs of skin breakdown were documented, but no treatment orders were initiated for several days, and there was a lack of communication among staff and with the facility's provider and DON regarding the resident's condition. Multiple staff interviews revealed that several CNAs and nurses observed significant wounds on the resident's coccyx and right ear, but these findings were not promptly or adequately reported or addressed. Nursing documentation was inconsistent, with some assessments failing to note the presence of wounds, and some staff not following up on abnormal findings. The facility's care plan and skin management policy required regular assessments and prompt notification of new skin impairments, but these protocols were not followed. The resident's wounds worsened, and there was a delay in both provider assessment and the initiation of appropriate wound care treatments. As a result of these failures, the resident developed unstageable pressure ulcers on the sacrum and right ear, which progressed to infection, sepsis, and required hospitalization. The sacral wound ultimately led to osteomyelitis and gangrene, necessitating surgical intervention. Interviews with facility leadership confirmed a lack of awareness and oversight regarding the resident's wounds, and documentation review showed that required notifications and interventions were not completed in accordance with facility policy.
Plan Of Correction
F686 Treatment/Services to Prevent/Heal Pressure Ulcer Resident #3 readmitted to the facility on 4/17/25. Skin assessment completed: Stage 4 pressure to sacrum and healed pressure injury to right ear. Care plan updated and currently being followed by the wound certified NP. Residents who reside in the facility have the potential to be affected. Skin sweep completed. Any concerns were addressed immediately. Nursing staff re-educated on Skin Management program. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Skin Management policy was reviewed by QA committee and deemed to be appropriate. The DON and/or designee will review Clinical Alerts, PCC dashboard, physician orders, and complete skin assessments weekly x 4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further review and recommendations. Administrator is responsible for sustained compliance.
Failure to Ensure Dignified and Respectful Staff Interaction with Resident
Penalty
Summary
A deficiency was identified when a staff member failed to interact with a resident in a dignified and respectful manner. The resident, who has Down syndrome, unspecified dementia, and a history of severe cognitive impairment, was observed calling out, moaning, and crying in her room. During this time, a housekeeping staff member entered the room, asked what the resident needed, and, upon not receiving a clear response, told the resident, "We're not just gonna sit and cry," instructed her not to call out and to use her call light, and then left the room after one to two minutes. The staff member did not offer any diversionary activities or seek assistance from nursing staff, despite the resident's ongoing distress. The resident later expressed negative feelings about the interaction, indicating that the staff member had spoken to her in this manner before. The staff member admitted to making the statement and acknowledged that it sounded harsh, but justified it as preferable to yelling. The staff member also reported that other staff sometimes used a harsh tone with the resident when she called out frequently, although she could not provide specific details. The resident's care plan included interventions for behavioral issues such as yelling and crying, recommending diversional activities and supportive, nonpharmacologic interventions, none of which were implemented during the observed incident. Facility policy requires staff to interact with residents in a way that maintains and enhances their dignity and self-worth. The staff member's actions did not align with this policy or with the resident's care plan, as the interaction lacked supportive responses and failed to provide recommended diversional activities. The incident was confirmed by both the Director of Nursing and the Nursing Home Administrator as inappropriate and not in accordance with facility expectations for resident interactions.
Plan Of Correction
F550 Resident Rights/Exercise of Rights Resident #9 still resides within the facility. Social Services followed up with resident and has had no emotional or mental effects from the interaction. Housekeeping staff F received 1:1 education. Residents who reside within the facility have the potential to be affected. Inter-viewable residents were queried regarding Resident Rights. Any concerns were addressed immediately. Staff were re-educated on Resident Rights policy. Those currently on leave of absence or PRN will be re-educated on their next scheduled workday. Resident Rights policy was reviewed by QA committee and deemed to be appropriate. Management team will complete quality rounds to evaluate for inappropriate interaction by staff members weekly x4, then monthly x 3. Concerns will be addressed immediately and findings will be reported to the QA committee for further review and recommendations. Administrator is responsible for sustained compliance.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the State Agency for a resident with severe dementia, depression, anxiety, high blood pressure, heart disease, and muscle weakness. The resident, who had a moderate cognitive impairment, was found to have a large bruise on her right inner thigh, which was first noticed by a family member. The family member reported the bruise to the facility staff, but the facility did not have an explanation for the injury. Despite the family member's concern, the bruise was not reported or investigated by the facility. The facility's records revealed that the resident had a fall five days prior to the bruise being identified, but no injuries were noted at that time. The Director of Nursing and the Administrator acknowledged that the bruise was not reported to the State Survey Agency. Additionally, a Registered Nurse indicated that an incident report should have been completed for any new injury or bruise of unknown origin, but no such report or investigation was conducted for the bruise on the resident's thigh.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe dementia and other health conditions, resulting in an incomplete investigation. A family member noticed a large bruise on the resident's right inner thigh during a visit and reported it to the facility. The facility had no explanation for the bruise, and the family member expressed concern that it was neither reported nor investigated. The resident had a history of agitation and self-transferring, which the Director of Nursing believed could have caused the bruise. However, there was no incident report or investigation conducted regarding the bruise. The resident's medical records indicated a fall five days prior to the bruise being identified, but no injuries were noted at that time. A total body skin assessment conducted two days after the fall did not reveal any new skin issues. Despite the facility's policy requiring an incident report for new injuries of unknown origin, no such report was completed for the bruise. Interviews with staff confirmed that management was responsible for investigating such incidents, yet no investigation was documented for the bruise on the resident's thigh.
Inaccurate Medical Records and Lack of Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in discrepancies in personal hygiene documentation and dental care follow-up. For one resident, observations revealed poor personal hygiene, including long and dirty nails, overgrown facial hair, and greasy hair. Despite these observations, the resident's personal hygiene task record indicated no refusals of care, and daily tasks were marked as completed, which was inconsistent with a CNA's report that the resident refused grooming. The social worker was unaware of any refusals, as they were not documented in the medical record dashboard. For another resident, a family member reported a broken tooth that required dental attention. Although the Director of Nursing (DON) was informed and assessed the resident, finding no issues with pain or eating, the resident was not referred to a dentist, and the assessment was not documented. Consequently, the resident was not on the list for the upcoming dental visit, and the Nursing Home Administrator was not informed of the need for dental care.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis for all 98 residents, resulting in a lack of available staffing information for residents and visitors. During observations and reviews of the Report of Nursing Staff Directly Responsible for Patient Care document in the main entryway on two consecutive days, it was found that the total hours columns were not filled in. In an interview, the Medical Records/Scheduler (MRS) responsible for posting the daily staffing report admitted to only recording the number of staff and was unaware that the total hours worked needed to be included. Additionally, the Nursing Home Administrator (NHA) also reported being unaware that nursing hours needed to be reflected on the posting.
Failure to Implement Elopement Policy and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and accurately implement the elopement policy for three residents, resulting in the potential for injury. Resident #203, who was cognitively impaired and had a history of stroke and seizure disorder, was able to leave the facility unsupervised. The receptionist, who was newly hired and had only received one day of orientation, mistakenly allowed the resident to exit the building, believing he was permitted to do so. The resident was later found walking on the sidewalk by a staff member driving to work, who then alerted another staff member to retrieve the resident and bring him back to the facility. The facility's documentation and assessments for Resident #203 were inconsistent and inaccurately documented. Despite having a wanderguard bracelet and being identified as at risk for elopement, the resident's elopement risk assessments were not accurately completed. The resident's care plan for elopement was only initiated after the incident occurred. Additionally, the facility's review revealed that several other residents had been inaccurately assessed for elopement risk, leading to inappropriate use of wanderguard bracelets. Residents #208 and #209 also had inconsistencies in their elopement risk assessments. Both residents had orders for wanderguard bracelets despite their assessments indicating no risk for elopement. The facility's policy on elopement required accurate documentation and regular reassessment of residents' elopement risk, which was not followed in these cases. The failure to accurately assess and document elopement risk, along with inadequate staff training and supervision, contributed to the deficiencies identified in the report.
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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