The Orchards At Armada
Inspection history, citations, penalties and survey trends for this long-term care facility in Armada, Michigan.
- Location
- 22600 Armada Ridge Road, Armada, Michigan 48005
- CMS Provider Number
- 235609
- Inspections on file
- 24
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at The Orchards At Armada during CMS and state inspections, most recent first.
A resident with a chronic right lower extremity ulcer experienced progressive wound deterioration after a wound vac was replaced with an Unna boot, with documentation of increasing pain, edema, warmth, erythema, foul-smelling drainage, necrosis, and new lesions. Although the primary MD adjusted antibiotics and ordered detailed wound care, and nursing and wound care staff noted worsening signs of infection, the facility did not document any contact with the outside wound care specialist directing the resident’s wound care. The Treatment Administration Record lacked documentation of wound treatments, and interviews confirmed that facility staff understood it was their responsibility to notify the consulting specialist but did not do so until the resident’s next follow-up visit, when the specialist sent the resident to the ER for a wound infection.
Surveyors observed that the required circuit breaker locking device was not installed in the circuit breaker panel for the fire alarm booster module in the Mechanical Room (Memory Care). This deficiency was confirmed by the Maintenance Director and could impact all residents in the facility.
Surveyors found that the required evacuation map was missing in the Maple Ridge corridor, which is necessary for identifying locations and evacuation routes. This deficiency was confirmed with the Maintenance Director and could impact 26 of 64 residents during an emergency evacuation.
A volunteer was observed standing while feeding a resident with dementia and dysphagia and intermittently assisting another resident, contrary to the care plan and facility policy requiring one-to-one, seated feeding assistance to maintain dignity.
A resident receiving daily IV antibiotics via a PICC line was found with a dressing that included gauze under a transparent covering, which had not been changed according to facility policy. During IV medication administration, a nurse was observed attempting to connect tubing containing multiple air bubbles, which was only corrected after noticing the issue. The DON confirmed that both the dressing change interval and air bubble management did not meet professional standards of practice.
Two residents experienced lapses in infection prevention and control when a nurse failed to use required PPE during PICC line care and a volunteer did not perform hand hygiene between assisting residents during meals, contrary to facility policy and established protocols.
The facility failed to ensure opened food items were properly dated and discarded when expired, and did not maintain the ice machine filter. Several undated and expired food items were found in the kitchen and resident refrigerator, and ants were observed in the activity cabinet.
A facility failed to revise the care plan for a resident with Dysphagia and Aphasia. The resident, with impaired cognition, was observed eating without required assistance and had fluids with a straw at bedside, contrary to the care plan. The Registered Dietitian confirmed a change in liquid intake, but the care plan was not updated.
The facility failed to provide necessary meal assistance and proper positioning for two residents, resulting in inadequate nutritional intake and care. One resident was left unattended with uneaten meals despite needing help, while another did not receive the required 1:1 feeding assistance as per their diet order.
The facility failed to apply heel protectors and lids to drinks per physician orders for a resident with muscle weakness, difficulty in walking, and impaired cognition. Despite staff education and physician orders, the resident was repeatedly observed without heel protectors and with drinks that did not have lids.
A resident with an indwelling urinary catheter was observed multiple times without a leg strap to secure the catheter, and the drainage tubing was often found looped and on the floor. Despite the facility's policy requiring securement and proper positioning, these guidelines were not followed, leading to deficiencies in care.
The facility failed to provide timely assistance to residents, with multiple instances of call lights being activated for extended periods without response. Residents reported frequent delays of over an hour for assistance, and staff interviews confirmed that the facility was often understaffed, particularly on weekends. Observations and schedule reviews corroborated these findings, highlighting significant delays in meeting residents' needs.
The facility failed to administer medications per manufacturer recommendations and physician orders, resulting in a 7.89% medication error rate. An LPN administered cholestyramine with other medications, did not administer Doptelet as prescribed, and substituted a Lidoderm patch with a menthol patch without a physician's order.
The facility failed to provide a resident with food items in a puree consistency as prescribed. Observations revealed the resident was given scrambled eggs, oatmeal, hard pretzels, and a regular piece of frosted cake, none of which were consumed. The diet order specified a pureed texture and thin liquid consistency, which was not followed.
A facility failed to wear proper PPE for a resident under Enhanced Barrier Precautions (EBP). An RN was observed entering and exiting the resident's room without appropriate PPE, despite an EBP sign and cart being present. The resident had a history of chronic urinary tract infections and required assistance with bed mobility and transfers. The RN was unaware of the specific reason for the EBP, indicating a lapse in following infection control protocols.
Failure to Notify Consulting Wound Specialist of Worsening Wound Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify and consult the outside wound care clinic consulting specialist (WCCCS) regarding a resident’s deteriorating right lower extremity wound, despite clear signs of infection and decline. The resident was admitted with a chronic ulcer of the right ankle and varicose veins of the right lower extremity with ulcer, and initially had a wound vac in place per the WCCCS. After a follow-up visit, the wound vac was removed and an Unna boot was ordered. In the days that followed, clinical documentation showed increasing edema, redness, warmth, and an elevated white blood cell count, and the primary medical doctor (PMD) changed antibiotics and ordered specific wound care treatments while noting they had spoken with the WCCCS about the plan of care. However, there was no documentation that the facility actually consulted or updated the WCCCS about the wound’s deterioration during this period. Progress notes over the next several days documented the resident’s increasing pain, edema, warmth, drainage, erythema, foul-smelling yellowish drainage, saturated dressings, and surrounding redness and warmth suggestive of cellulitis and wound infection. A wound care nurse later documented increased ulceration, slough/necrosis, heavy serous and purulent drainage, bright yellow thick purulence expressed with light pressure, and a new purple fluid-filled lesion with peri-wound erythema and pain, with notification only to the wound care nurse practitioner. Interviews with the PMD and wound care nurse practitioner confirmed that they did not assume responsibility for contacting the outside consulting provider and that it was the facility’s responsibility to notify the WCCCS of wound deterioration. The clinical record lacked documentation of any wound treatments on the Treatment Administration Record for the month and contained no evidence that the WCCCS was consulted about the worsening wound until the resident’s subsequent follow-up visit, when the WCCCS sent the resident to the emergency room for a wound infection.
Missing Circuit Breaker Locking Device for Fire Alarm Booster Module
Penalty
Summary
The facility failed to ensure that the fire alarm system was tested and maintained in accordance with an approved program that complies with NFPA 70 and NFPA 72. During an observation in the Mechanical Room (Memory Care), it was found that the required circuit breaker locking device was not provided in the circuit breaker panel for the installed fire alarm booster module. This omission was confirmed through an interview with the facility Maintenance Director at the time of observation. The lack of the locking device could potentially allow for unauthorized tampering with the fire alarm system, and this deficiency could affect all 64 residents in the facility.
Plan Of Correction
ELEMENT 1 The circuit breaker locking device has been placed on in the circuit breaker panel in the Mechanical room on Orchard View. ELEMENT 2 The Maintenance Director and/or designee did an audit on all circuit breaker panels in the facility to ensure there is a locking device present. Any areas of noncompliance were addressed immediately. ELEMENT 3 The Maintenance Director has been reeducated to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 2 months to ensure that the required circuit breaker locking device in the circuit breaker panel mechanical room for our installed fire alarm booster module on Orchard View is present. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.
Missing Evacuation Map in Corridor
Penalty
Summary
The facility failed to provide the required evacuation map in the Maple Ridge corridor, as observed during a survey. The evacuation map is necessary to identify locations within the facility and to highlight designated evacuation routes to the exterior of the building. This deficiency was confirmed through observation and interview with the Maintenance Director. The lack of an evacuation map could affect 26 of 64 residents in the event of a fire or other emergency requiring area evacuation. Employees were not periodically instructed in their duties under the evacuation plan as required by regulatory standards, and the written plan for the protection and evacuation of all residents was not fully implemented in this area.
Plan Of Correction
ELEMENT 1 On 6/27/25 an evacuation map was placed on Autum Ridge to identify the current location within the facility and highlight designated evacuation routes to the exterior of the facility. ELEMENT 2 Rounds were conducted by the Maintenance Director and/or designee on all fire corridors to ensure there are evacuation maps present. ELEMENT 3 The Maintenance Director has been reeducated on maintaining evacuation maps throughout the building in all fire corridors. ELEMENT 4 The Maintenance Director/designee will conduct weekly audits for 1 month to ensure all fire corridors have the required evacuation maps. ELEMENT 5 Date of compliance 06/27/2025. The Maintenance Director and/or designee will be responsible for sustained compliance.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
A deficiency was identified when a volunteer was observed providing feeding assistance to a resident with dementia and dysphagia in the memory care unit dining room. The volunteer stood while feeding the resident and intermittently attended to another resident, rather than providing dedicated one-to-one assistance. The resident's care plan and physician orders specified the need for one-to-one feeding assistance, aspiration precautions, and that the resident should remain upright in a chair during feeding. The Director of Nursing confirmed that the facility's expectation is for staff to sit with residents while providing one-to-one feeding assistance and to avoid assisting more than one resident at a time to maintain dignity. Facility policy also directs staff not to stand while feeding residents. The observed actions did not align with these expectations or the resident's care plan, resulting in a failure to provide feeding assistance in a dignified manner.
Plan Of Correction
ELEMENT 1 Resident R15 still resides in the facility and continues to be assisted with feeding by staff and/or volunteers that have been reeducated to stay seated while assisting to feed as well as only assisting one resident at a time. ELEMENT 2 Residents that reside in the facility have the potential to be affected. An audit was done on residents residing in the facility that require assistance with meals to ensure they are being assisted by a staff member and/or volunteer that remains seated and only assisting one resident at a time. Any areas of deficiency at the time of the audit will be corrected immediately. ELEMENT 3 The Resident Rights policy was reviewed by the DON and the Administrator and deemed appropriate. The staff and volunteers were reeducated on remaining seated while assisting residents with eating as well as assisting one resident at a time. ELEMENT 4 The DON and/or designee will conduct random audits 2 times a week for 2 months to ensure that staff and/or volunteers are staying seated while assisting residents with meals as well as only assisting one resident at a time. Any areas of deficiency at the time of the audits will be corrected immediately, and the results of these audits will be presented at the facility's QAPI for further recommendations and/or corrective actions. ELEMENT 5 Date of compliance 06/27/2025. The Administrator and/or designee will be responsible for sustained compliance.
Failure to Follow Professional Standards for PICC Line Care and IV Administration
Penalty
Summary
A deficiency was identified when a resident with a peripherally inserted central catheter (PICC) line for daily intravenous (IV) antibiotic administration was observed to have a dressing that included a folded white gauze under a transparent covering, dated several days prior. The resident confirmed that the dressing was being changed weekly, despite receiving daily IV antibiotics. Review of the Treatment Administration Record and Medication Administration Record indicated the last dressing change occurred several days before the observation. Facility policy required site care every 72 hours and as necessary, and the Director of Nursing confirmed that a gauze dressing should be changed within 48 hours. Additionally, the presence of gauze under the transparent dressing prevented direct assessment of the insertion site for signs of infection. During an observed IV medication administration, a registered nurse donned gloves, cleaned and flushed the PICC line, and began to connect the IV tubing. Multiple air bubbles were observed in the tubing, which the nurse noticed and then replaced the tubing before completing the administration. The Director of Nursing acknowledged that air bubbles should be drained prior to connecting IV tubing. These actions demonstrated a failure to follow professional standards of practice for PICC line care and IV medication administration, as required by facility policy and regulatory standards.
Plan Of Correction
Element 1 R42 no longer resides at the facility. Element 2 The residents that reside in the facility have the potential to be affected. An audit was completed on the residents residing in the facility that have PICC lines to ensure when a gauze dressing is used it is to be changed to no longer than 48 hours; and when priming IV lines that contain excessive air bubbles must be consistent with professional standards of practice. Any areas of deficiency at the time of the audit will be corrected immediately. Element 3 The IV Therapy policy was reviewed by the DON and ADON/IC and updated to our pharmacy's "Catheter Insertion and Care" policy and deemed appropriate. The nurses were reeducated on the Pharmacy's policy to ensure when gauze dressings are used, they are to be changed no longer than 48 hours, and when priming IV lines that contain excessive air bubbles must be consistent with professional standards of practice, i.e., fluid must run through the line into a waste receptacle until air is gone or acquire new IV tubing. Element 4 The DON and/or designee will conduct random audits twice a week for 2 months, to ensure nurses are following the "Catheter Insertion and Care". Any areas of deficiency at the time of the audits will be corrected immediately, and the results of these audits will be presented at the facility's QAPI for further review and/or corrective action. Element 5 Date of compliance 06/27/25. The Administrator and/or designee will be responsible for sustained compliance.
Deficient Infection Control in Central Line Care and Meal Assistance
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during the care of two residents. In one instance, a registered nurse (RN) administered IV medication to a resident with a peripherally inserted central catheter (PICC) line without donning a gown, as required by enhanced barrier precautions. The RN was observed entering the resident's room, which had signage indicating the need for a gown and gloves, but only donned gloves that were taken from their pocket, a practice acknowledged by the RN as an old habit. The resident in question had been admitted with diagnoses including osteomyelitis, discitis, and hepatitis C, and was under enhanced barrier precautions due to the central line. The Director of Nursing (DON) and Infection Control Nurse confirmed that gloves should not be stored in staff pockets and that both gown and gloves are required for such care activities. In another instance, a volunteer providing one-to-one feeding assistance to a resident with dementia and dysphagia failed to perform hand hygiene between assisting the assigned resident and another resident during meal service. The volunteer was observed setting down the resident's utensil, assisting another resident, and then returning to the original resident without washing hands in between. The DON stated that the expectation is for staff providing one-to-one feeding assistance not to assist other residents, but if they do, hand hygiene must be performed between residents. Facility policy on hand hygiene specifically requires hand washing with soap and water before and after assisting a resident with meals. A review of facility policies revealed clear requirements for infection control, including the use of enhanced barrier precautions for central line care and strict hand hygiene protocols during resident meal assistance. Despite these policies and staff training, the observed actions did not align with the established standards, resulting in deficiencies in infection prevention and control practices for the residents involved.
Plan Of Correction
Element 1 R42 no longer resides at the facility, and R15 continues to be assisted by staff and/or volunteers who have been reeducated to perform hand hygiene before and after assisting a resident with meals. Element 2 Residents that reside in the facility have the potential to be affected. An audit was done on the residents with PICC lines to ensure the staff are adhering to Enhanced Barrier Precautions and donning and doffing the appropriate PPE prior to performing any procedures for the PICC line. An audit was done on the residents that require assistance with meals to ensure staff and volunteers only assist one resident at a time and perform hand hygiene before and after assisting any resident. Any areas of deficiencies at the time of the audits will be corrected immediately. Element 3 The Enhanced Barrier Precaution and Hand Hygiene policies were reviewed by the DON and ADON/IC and deemed appropriate. The nurses were re-educated on the Enhanced Barrier Precaution policy and procedures regarding appropriate PPE when taking care of a PICC line. Staff and volunteers were re-educated on the Hand Hygiene policy regarding assistance with meals. Element 4 The ADON/IC and/or designee will complete random audits twice a week for 2 months to ensure nurses are Donning and Doffing appropriate PPE per our policy and procedures while caring for a PICC line. The Administrator and/or designee will complete random audits twice a week for 2 months to ensure that staff and/or volunteers are only assisting one resident at a time and using proper hand hygiene before and after assisting residents with meals. Any areas of deficiencies at the time of the audits will be addressed immediately, and the results of these audits will be presented at the facility's QAPI for further recommendations and/or corrective action. Element 5 Date of compliance 06/27/25. The Administrator and/or designee will be responsible for sustained compliance.
Failure to Properly Date and Discard Food Items and Maintain Ice Machine Filter
Penalty
Summary
The facility failed to ensure that opened food items were properly dated and discarded when expired, and did not maintain the filter for the ice machine. During a tour of the kitchen, several opened food items were found without proper dating, including deli turkey, salami, Caesar dressing, and enchilada sauce. Additionally, an unlabeled bin of white powder, identified as thickener, was found in the dry storage room. The ice machine filter was also found to be outdated. In the resident refrigerator, a container of cut pineapple with an expired use-by date and an undated container of chicken soup were observed. Ants were found crawling on the activity cabinet next to the resident refrigerator. The Dietary Manager confirmed that the undated and expired food items should be discarded and that the thickener should be labeled. The facility's policy on the safe storage and handling of outside food was reviewed, noting that any food not consumed immediately must be covered and labeled with the resident's name and date. The presence of ants in the activity cabinet was acknowledged by the activity staff, who stated they would inform Maintenance. These deficiencies were identified based on observations, interviews, and record reviews conducted by the surveyors.
Failure to Revise Care Plan for Resident with Dysphagia and Aphasia
Penalty
Summary
The facility failed to revise the care plan for a resident diagnosed with Dysphagia following Cerebral Infarction and Aphasia. The resident, who had an impaired cognition score of 2/15, was observed attempting to eat pureed food without the required 1:1 assistance. Additionally, the resident was repeatedly observed with fluids and a straw at their bedside, contrary to the care plan's intervention of no straws and no fluids at bedside. The Registered Dietitian confirmed that the resident's liquid intake had been changed to thin liquids, but the care plan was not updated to reflect this change, violating the facility's policy on re-evaluating and modifying care plans as necessary to reflect changes in care, service, and treatment.
Failure to Provide Meal Assistance and Proper Positioning
Penalty
Summary
The facility failed to ensure meal assistance and proper positioning for two residents, leading to deficiencies in their care. Resident R53 was repeatedly observed in a supine position, leaning to one side, with uneaten meal trays left untouched. Despite being frail, underweight, and requiring assistance with eating, staff did not provide the necessary help or encouragement. The resident's care plan lacked specific instructions for meal assistance, and staff failed to monitor and assist the resident adequately, resulting in poor nutritional intake over several days. Resident R56, diagnosed with dysphagia and aphasia, was observed attempting to eat without the required 1:1 feeding assistance. Despite a diet order specifying the need for slow feeding with small bites, no staff were present to assist during multiple observations. Interviews with staff revealed inconsistencies in understanding and implementing the resident's dietary needs, with some staff stating the resident could self-feed with cues, while others noted the resident's refusal to be fed. The facility's policies on resident assistance during meals and comprehensive care planning were not followed, leading to inadequate care for both residents. The lack of proper assistance and monitoring during meals, as well as the failure to update and implement care plans, contributed to the observed deficiencies in the residents' care.
Failure to Follow Physician Orders for Heel Protectors and Drink Lids
Penalty
Summary
The facility failed to apply heel protectors and lids to drinks per physician orders for one resident. On multiple occasions, the resident was observed in bed without heel protectors and with drinks that did not have lids, despite physician orders requiring these measures. The resident, who has muscle weakness, difficulty in walking, and impaired cognition, was noted to have their heels resting on the mattress without protection and was provided beverages without lids or handles. These observations were made over several days, indicating a consistent failure to follow physician orders. Interviews with staff revealed that the resident often refuses to wear heel protectors, but this refusal was not documented as required. The Director of Nursing confirmed that staff had been educated on the importance of ensuring drinks have lids and that heel protectors are used, but these measures were not consistently implemented. The facility did not provide a specific policy related to following physician orders, stating it was standard practice.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter. The resident was observed multiple times without a leg strap to secure the catheter, and the drainage tubing was often found looped and on the floor. This improper positioning and lack of securement were noted over several days, despite the resident's dependency on staff for personal hygiene and toileting. The resident reported needing to urinate and have a bowel movement, and the incontinence brief appeared tight and stretched, further complicating the situation. The Licensed Practical Nurse confirmed the absence of a securement device and improper positioning of the catheter tubing. The facility's policy on indwelling catheter care emphasizes the importance of inspecting the catheter and tubing to prevent obstructions and ensuring the drainage tube and collection bag are lower than the bladder at all times. The policy also requires the use of a leg band to secure the catheter and prevent tension on the tubing. Despite these guidelines, the facility did not adhere to its own policy, leading to the observed deficiencies. The Director of Nursing acknowledged the issues and indicated that corrective actions would have been taken, but these were not implemented at the time of the observations.
Failure to Provide Timely Assistance and Adequate Staffing
Penalty
Summary
The facility failed to provide timely assistance to meet the needs of residents, as evidenced by multiple instances of delayed response to call lights and insufficient staffing levels. On several occasions, residents reported waiting for an hour or more for assistance after activating their call lights. For example, one resident reported frequent delays of over an hour for assistance, and another resident's call light was observed to be on for nearly 30 minutes before receiving help. These delays were corroborated by observations and interviews with staff and visitors, who noted that staffing levels were often insufficient, particularly on weekends, leading to extended wait times for residents needing assistance. During the survey, multiple call lights were observed to be activated for extended periods without timely response from staff. One resident was found to be visibly diaphoretic and uncomfortable after waiting for nearly 30 minutes for assistance with toileting. Another resident, who required a mechanical lift and two-person assistance to transfer into their wheelchair, reported waiting for over an hour to be helped out of bed. The facility's call station monitor confirmed these extended wait times, with several call lights remaining activated for over 20 minutes. Interviews with staff revealed that the facility was frequently understaffed, with CNAs responsible for managing up to 23 residents each. Staff reported that having three CNAs on duty made the workload more manageable, but this was not consistently the case. A review of the facility's schedule and time punch data confirmed that staffing levels were often inadequate, particularly on weekends, leading to delays in meeting residents' needs. Despite the facility's policy that resident needs should be met within 20 minutes, this standard was not consistently upheld, resulting in significant delays in care.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were administered per manufacturer recommendations and physician orders for one resident, resulting in a medication error rate of 7.89 percent. During a medication pass observation, an LPN administered cholestyramine along with other medications to a resident, contrary to guidelines that recommend avoiding concurrent administration with other oral medications. Additionally, the resident was prescribed Doptelet, which had not been administered since the beginning of the month, and a Lidoderm patch, which was substituted with a menthol patch without a physician's order at the time of administration. The LPN confirmed the lack of Lidoderm patches in supply and reported the substitution practice to the DON, who later obtained an order to change the prescription to the menthol patch. The DON also addressed the administration schedule for Doptelet, which was to be provided by the resident's family. The facility did not provide a policy or protocol for cholestyramine administration when requested by the surveyors.
Failure to Provide Pureed Diet as Prescribed
Penalty
Summary
The facility failed to ensure that food items were provided in a puree consistency per the diet order for a resident. On multiple occasions, the resident was observed with food items that did not match the prescribed pureed diet, including scrambled eggs, oatmeal, a regular-sized bag of hard pretzels, and a regular cubed piece of frosted cake. These observations were made over two days, and it was noted that the resident had not consumed any of the provided food or liquids. The resident's medical record indicated a diet order for a regular diet with pureed texture and thin liquid consistency, dated earlier in the month. The Director of Nursing and the Registered Dietitian confirmed that the items observed were not part of a pureed diet. The facility's policy on assisting residents with eating emphasized the importance of verifying that the diet served is correct, which was not adhered to in this case.
Failure to Wear Proper PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to wear proper personal protective equipment (PPE) for a resident under Enhanced Barrier Precautions (EBP). On 5/21/2024, a Registered Nurse (RN) was observed entering and exiting the resident's room without wearing the appropriate PPE, despite an EBP sign and cart being present. The resident had a history of chronic urinary tract infections and required assistance with bed mobility and transfers. The RN was unaware of the specific reason for the EBP, indicating a lack of proper adherence to infection control protocols. The Infection Control Preventionist confirmed that all staff had been educated on EBP requirements, yet the deficiency occurred, highlighting a lapse in following the facility's policy on Enhanced Barrier Precautions.
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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