The Orchards At Redford
Inspection history, citations, penalties and survey trends for this long-term care facility in Redford, Michigan.
- Location
- 25330 West Six Mile Road, Redford, Michigan 48240
- CMS Provider Number
- 235014
- Inspections on file
- 32
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at The Orchards At Redford during CMS and state inspections, most recent first.
Surveyors found that mechanical ventilation in a soiled utility room and in resident bathrooms on two halls was not functioning. A strong, pungent odor was present in the soiled utility room, and testing of the ceiling vents with tissue paper showed no suction. The maintenance supervisor confirmed the vents were non-functional and reported that a single unit controlled ventilation for the soiled utility room and both halls’ bathrooms, suggesting a possible belt issue. This failure had the potential to affect all residents on those halls.
A resident with COPD, OSA, and HTN, cognitively intact per BIMS, reported that their call light had not worked since returning from the hospital and that on multiple nights they were unable to summon staff for needed toileting assistance, resulting in incontinence episodes. Observation showed the call light button lying on the bed with the call system box detached from the wall, and no alternate means for the resident to contact staff. An LPN stated that call lights should alert staff pagers and display on an office screen, but when the LPN tested this resident’s call light, no pager alert or audible signal occurred, even though the room number appeared on the office monitor. The LPN confirmed the call light for this resident was not functioning and could not explain the cause.
Multiple dependent residents were not provided timely assistance with ADLs, positioning, and toileting, and did not have reliable access to a functional call system. One resident with severe contractures and multiple pressure-related wounds was left in the same twisted position for extended periods without appropriate offloading devices or a specialty mattress, and with the call light out of reach. Another resident with cognitive impairment and chronic conditions remained in bed in a poor position, unable to reach the call light or effectively use the bed controls. A resident with stroke and heart failure reported nonfunctioning call lights and was later observed slid down in a wheelchair and unable to reposition or lock brakes without help. Additional residents reported delays in being changed when wet, missed showers, and difficulty obtaining assistance after incontinence, while their call lights were placed across the room or did not reliably signal staff. Staff acknowledged that the call light system had not produced an audible alert for months, with calls only visible on a monitor inside the nurse’s office and no door lights or chimes, contrary to the facility’s own policy on answering call lights promptly.
Surveyors found that multiple residents had nonfunctional or inaccessible call lights, with devices placed out of reach, hidden under bedding, or looped over wall boxes across the room. Some residents reported that their call lights did not work and were given hotel-style desk bells that did not reliably ring or summon staff. Testing showed that call light activations appeared visually on the nurse office monitor but did not trigger any audible alarm or corridor door light, including one call that had been active for an extended period. An LPN stated the call lights had not been audible for months and that the system had not worked properly for more than six months, while the facility’s policy addressed answering call lights promptly but did not address maintaining call light functionality.
Surveyors found that the facility failed to implement and maintain effective fall-prevention interventions and environmental safety measures for two residents with significant cognitive and physical impairments. One resident, who was totally dependent for bed mobility and had severe contractures and pressure wounds, had an actual fall from bed but was repeatedly observed without the care-planned concave or specialty mattress, without supportive pillows, with an unsecured catheter leg anchor, and with an inaccessible call light on a unit where staff reported the call system had not worked properly for months. Another resident, identified in the care plan as at risk for falls due to weakness, poor safety awareness, and impulsivity, experienced multiple falls resulting in head injuries and later a hip fracture, yet no new or revised fall-prevention interventions were documented between the initial and subsequent falls, and staff described relying mainly on monitoring and keeping the resident in common areas despite ongoing impulsive behavior.
A resident with anxiety disorder and chronic kidney disease activated their call light, which remained unanswered for over an hour and a half. The call light system did not illuminate over the door and was only visible on a screen at the nurses' station, which staff reported as unreliable. Staff interviews confirmed reliance on this system, and resident council notes documented ongoing concerns about delayed call light responses.
The facility failed to provide a dignified dining experience for several residents, with some waiting to be served while others ate, and others not receiving necessary assistance or appropriate meal items. Observations included residents watching others eat without being served, a resident with a wet shirt and no clothing protector, and a CNA explaining delays within hearing range of residents. The facility's policy on dignity was not upheld in these instances.
The facility failed to provide two residents with alternate meal options and desserts during scheduled meals. One resident, a vegetarian, was served a meal without dessert, and another resident did not consume their meal due to dislike, with only a bacon sandwich offered as an alternative. The facility's menu guidelines were not followed, affecting the nutritional needs of all 78 residents.
The facility failed to provide post-dinner snacks to 18 residents in the [NAME] Houses. Observations and interviews revealed that the kitchen did not send snacks, and the [NAME] House Manager reported no contract existed for snack provision. Limited food items were found in the kitchen, and staff often used personal funds to buy snacks. The Certified Dietary Manager stated snacks were not her responsibility, indicating a lack of communication and responsibility.
The facility failed to ensure proper sanitization of dishware in the [NAME] House, as the dish machine lacked a connected sanitizer and staff used incorrect test strips. This deficiency had the potential to cause foodborne illness among residents.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple medical devices, as staff did not wear necessary protective equipment and there was no signage indicating EBP requirements. Additionally, a linen cart was improperly used to store personal items and had a stained, damaged cover, which was not addressed promptly despite being reported.
The facility failed to maintain a functioning resident call system for four residents, with issues such as tied or detached cords and dead batteries rendering the systems unusable. The Maintenance Director was unaware of these issues until shown, highlighting a lapse in communication and maintenance reporting.
A resident with an indwelling urinary catheter developed a UTI due to the facility's failure to provide appropriate catheter care, assessment, and monitoring. The resident's clinical record lacked orders or documentation for catheter care, despite the presence of dark, cloudy urine with sediment. The facility's policy required routine catheter care to prevent infections, but it did not include documentation of the care provided.
A resident experienced significant weight loss due to inadequate nutrition and monitoring at the facility. The resident, a vegetarian, was served meals lacking in protein and variety, and was not provided with dessert on one occasion. Despite recommendations for weekly weight monitoring, the facility failed to conduct regular weight checks and re-weights, violating their own policies. The dietary manager acknowledged the meals were not nutritious and that protein replacements should have been offered.
A resident with a history of acute respiratory failure and a feeding tube was observed receiving tube feeding at an incorrect rate. The pump was set to deliver 70 mL per hour, contrary to the physician's order of 75 mL per hour. The error was confirmed by the Certified Dietary Manager, highlighting a failure to adhere to the facility's enteral nutrition guidelines.
A facility failed to provide a legally authorized representative for an incapacitated resident with cerebral palsy and polyneuropathy, who was unable to make informed healthcare decisions. Despite being deemed incapacitated, the resident had no healthcare power of attorney or legal guardianship in place, and the Social Services department had not secured a legal representative. The resident's niece was making healthcare decisions without legal documentation, and the facility did not provide evidence of securing representation by the survey's end.
Failure to Maintain Functional Mechanical Ventilation in Soiled Utility Room and Resident Bathrooms
Penalty
Summary
The facility failed to maintain functional mechanical ventilation for the [NAME] and North halls and the [NAME] soiled utility room. During observation with Maintenance Supervisor I, the soiled utility room was noted to have a strong, pungent odor. The mechanical ventilation in this room was tested by placing a piece of toilet tissue against the ceiling vent grate, and no suction was present, as the tissue did not cling to the grate cover. Maintenance Supervisor I confirmed that the vent was not functional. Mechanical ventilation in the resident bathrooms on the [NAME] and North halls was checked in the same manner and was also found to be non-functional. Maintenance Supervisor I confirmed that the same unit controlled ventilation for the soiled utility room and the [NAME] and North Hall bathrooms and stated that there might be an issue with the belt. This failure to maintain the mechanical ventilation system had the potential to affect all residents on the [NAME] and North halls.
Failure to Maintain Functional Call Light System for Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a properly functioning call/communication system for a resident’s room and bathroom/bathing area. The resident reported that since returning from the hospital two weeks prior, their call button had not worked. They stated that on the past two nights they needed assistance to use the restroom, depended on staff for toileting, and when they pressed the call bell no one responded; by the time staff arrived, the resident had already had a bowel movement on themselves. During observation of the room, the call light button was found on the resident’s bed and the call light box was detached from the wall. The resident had no bell or any other means to communicate with staff when assistance was needed and reported feeling uneasy at times due to being unable to contact staff. Record review showed the resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, and Essential Hypertension, and had a BIMS score of 15, indicating no cognitive impairment. An LPN reported that the call lights were supposed to send alerts to staff pagers and display on a screen in the office. When asked to demonstrate the system in this resident’s room, the LPN pressed the call button and confirmed that no alert went to their pager; although the room number appeared on the office screen, there was no sound or pager alert to notify staff that assistance was needed. The LPN acknowledged that the call light was not working for this resident and was unsure why it was not functioning. The facility’s call light/response time policy was requested but was not provided prior to survey exit.
Failure to Provide Timely ADL Assistance and Maintain Functional Call Light Access
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), positioning, and access to call systems for multiple dependent residents. One resident with multiple sclerosis, lower leg contractures, malnutrition, and documented dependence on staff for all hygiene, toileting, dressing, bed mobility, and transfers was repeatedly observed lying in bed in the same position over extended periods on consecutive days. The resident’s legs were contracted with heels at the buttocks, knees pointed to one side, and the torso twisted, with visible gauze dressings on both feet and the right hip showing bloody drainage soaked through in several areas. No pillows or devices were in place to pad bony prominences or separate the legs and feet, and no specialty or low air loss mattress was in use despite care plan directions to reposition frequently and use a concave mattress. The call light was either under the covers or hanging over the headboard, out of the resident’s reach, while the responsible party reported multiple open pressure-related wounds on heels, sides of feet, hips, and buttocks. Another resident with Alzheimer’s disease, heart disease, chronic pain, and a care plan indicating dependence or supervision for ADLs and bed mobility was observed in bed with the head of the bed elevated but positioned so that their waist was beyond the bed’s break. The bed controller was hooked on the head of the bed and not readily usable, and the resident was unable to reach the call light placed at the shoulder or under the blankets. Over several observations in one day, the resident remained in bed with limited ability to adjust their own position and without clear access to the call system. A third resident with stroke, heart failure, dysphagia, and care plan needs for substantial assistance with bed mobility and dressing was observed pressing the call light multiple times without staff response during the interaction, reporting that the call lights were not working. Later, this resident was seen in a wheelchair in a hallway corner, slid down with buttocks at the edge of the chair and shoulders at the top of the low back, unable to lock both wheelchair brakes or reposition independently, and stating they needed help while nearby staff were occupied elsewhere. The same resident was later observed in bed with feet on the floor and the backs of the knees at the edge of the bed, still dependent on staff for ADLs. A resident with traumatic brain injury, epilepsy, anxiety, and a care plan indicating dependence on staff for most ADLs reported not being changed in a timely manner after waking early and requesting assistance, and also reported shoulder pain for which the facility did not consistently do anything. This resident’s call light cord was looped over the wall junction box, and a bell on the tray table did not ring reliably when tested, with no immediate staff response. Another resident with dementia and diabetes, dependent for toileting and needing substantial or partial assistance for other ADLs, was observed in bed without pants, with the call light looped over a wall box across the room from the bed and no secondary bell visible. The resident reported missed scheduled showers, difficulty getting staff to assist after incontinence episodes, and described being left in a wet brief that eventually soaked through to their pants before staff removed it. A urinal partially filled with urine was hanging inside a trash can, and the resident stated they did not always feel the need to void and had accidents. Across these residents, the call light system itself was found to be nonfunctional as an effective alert mechanism. Multiple residents reported or demonstrated that call lights did not work properly, and clocks in at least two rooms were not running. The LPN assigned to the unit stated that only one nurse was assigned to care for 17 to 24 patients and that the call light system had not worked properly for more than six months, with no audible tone and the monitor located inside the nurse’s office on top of a desk. During observation, activated call lights showed on the monitor, including one that had been on for 20 minutes, but there were no lights above the doors and no audible chime. The facility’s call light policy addressed prompt answering of call lights but did not address ensuring the functionality of the call light system. These conditions resulted in residents who were dependent on staff for ADLs, positioning, toileting, and safety being unable to reliably summon assistance or receive timely care.
Failure to Maintain Functional and Accessible Call Light System
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call lights were functional and accessible in multiple rooms and bathrooms, affecting at least six identified residents and additional rooms on the Transitional Care Unit. Surveyors observed several residents in bed over extended periods with call lights either out of reach, hidden under blankets, or looped over wall junction boxes across the room. One resident’s call light was repeatedly found under the covers or hanging over the headboard, while another resident reported their call light did not work and was instead provided a hotel-style desk bell that did not reliably ring or summon staff. Another resident’s call light was placed behind the head of the bed or at the shoulder where the resident could not reach it, and yet another resident pressed their call light multiple times without staff response. Additional residents had their call light cords looped over wall boxes far from the bed and were also given hotel-style bells, which did not consistently function when tested. Surveyors further noted that the central call monitoring station in the nurse office displayed activated room numbers but produced no audible chime, and corridor door lights did not illuminate when call lights were activated. During testing with the Maintenance Director, all tested call lights registered visually on the nurse office monitor but none triggered an audible sound, including one room that had been activated for 20 minutes. An LPN reported that the call lights had not been audible for months, that only one nurse was assigned to care for 17 to 24 patients on the unit, and that the call light system had not worked properly for more than six months. The facility’s written call light policy addressed prompt answering of call lights but did not address ensuring the functionality of the call light system itself. The administrator reported being unaware of the call light problem.
Failure to Implement and Maintain Effective Fall-Prevention Measures for Two High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain effective fall-prevention interventions and environmental safety measures for two residents with known fall risk and significant functional impairments. For one resident (R901), surveyors observed the individual lying in bed with severe muscle wasting, contracted lower extremities, and dependence on staff for all bed mobility and activities of daily living. The resident’s bed was positioned with one side against the wall, a floor mat on the opposite side, and a pillow placed under the bottom sheet on the right side that did not actually support the resident. The call light was found under the bedcovers on the wall side and later hanging over the headboard, not accessible to the resident. The urinary catheter leg anchor was not secured, and no low air loss or specialty mattress was in place despite a care plan intervention for a concave mattress with side bolsters that had been initiated and revised in January. The resident’s responsible party reported multiple pressure-related wounds and questioned how the resident, who had contracted legs and minimal ability to move, could have fallen from bed onto the floor. Record review for R901 showed an actual fall documented on 01/10/26, with a progress note stating the resident was found lying on the floor mat near the bedside during morning rounds. The care plan documented that the resident had an actual fall and included interventions such as frequent repositioning in bed and use of a concave mattress. The Minimum Data Set indicated impaired cognition and total dependence on staff for hygiene, toileting, dressing, rolling in bed, and transfers. Despite these documented needs and planned interventions, surveyors repeatedly observed the resident over two days without the ordered specialty or low air loss mattress, without pillows or bolsters supporting the torso, and with the call light not positioned within reach. Additionally, an LPN reported that the call light system on the resident’s unit had not worked properly for more than six months, with no audible tone heard upon activation. For the second resident (R903), the facility did not implement additional or modified fall-prevention interventions despite multiple falls and known cognitive and mobility issues. Progress notes documented that on 01/16/26 the resident was found sitting on the floor with knees bent, with a hematoma and laceration to the forehead and abrasions to the cheek. The resident was assisted back to a wheelchair and later sent to the ED for a CT scan at the granddaughter’s request. Staff interviews indicated that this resident was wheelchair-bound, unsteady, impulsive, often attempted to ambulate or transfer without assistance, and was non-compliant with directions. The DON and unit manager reported that the resident had severe cognitive deficits, wanted to be independent, was less directable, and had three falls in a short period, including one in the chapel and another in a common area, with staff suspecting a UTI during this time. R903’s care plan identified the resident as at risk for falls due to weakness, gait imbalance, poor safety awareness, impulsivity, and transferring without assistance, with interventions such as ensuring wheelchair wheels were locked, appropriate footwear, a safe environment, bed brakes locked, call light in reach, Dycem to the wheelchair, supervision so whereabouts were known, and a floor mat when in bed. However, no new or revised fall-prevention interventions were documented between the initial fall and subsequent falls on or before 01/19/26. The activity aide who witnessed one fall in the chapel reported the resident suddenly slid out of a chair and did not recall seeing non-slip material in the wheelchair seat. Staff also reported that after the initial fall, the facility’s practice was to keep residents in-house unless they were on blood thinners or had a mental status change, and the unit manager confirmed that the resident was kept in common areas after one fall but continued to be impulsive and experienced another fall from the wheelchair later the same day. The facility’s own fall management guidelines stated that the interdisciplinary team would review and modify the plan of care to minimize repeat falls, but documentation showed no additional interventions were added for this resident prior to the later fall with a hip fracture identified at the hospital.
Failure to Timely Respond to Resident Call Light
Penalty
Summary
A deficiency was identified when a resident activated their call light at 12:11 PM, and it remained unanswered for over an hour and a half, with no staff responding until at least 1:43 PM. The resident reported that call lights are often not answered when activated, sometimes remaining on all night, and noted that the call light does not illuminate over the door but only appears on a screen at the desk, which was described as barely working. Observations confirmed that the call light was still activated at multiple intervals, and no staff entered the room to address the resident's needs during this period. Interviews with staff revealed reliance on a system at the nurses' station to monitor call lights, with staff indicating they check the system as long as it is functioning properly. The resident involved had diagnoses of General Anxiety Disorder and Chronic Kidney Disease and required assistance with bed mobility and transfers. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14/15. Review of resident council notes from the previous six months showed ongoing concerns about timely call light response, particularly during the midnight shift. Facility policy states that call lights should be answered promptly by available staff, but this expectation was not met in the observed incident.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, as observed during lunch meals on two separate occasions. On one occasion, three residents were seated together, but only two were served their meals promptly, leaving the third resident waiting and watching others eat. This resident was eventually served after the others had finished their meals. Additionally, another resident was observed with a wet shirt and no clothing protector, watching others eat without receiving assistance or a beverage until much later. When a beverage was finally provided, it included a straw, contrary to the resident's meal ticket instructions. Further observations revealed that two residents were left watching others eat without being served their meals, as they required assistance and had to wait for staff. A CNA explained this within hearing range of the residents, potentially causing embarrassment. The facility's policy on resident dignity and personal privacy emphasizes the importance of respecting and enhancing each resident's dignity and individuality, which was not upheld in these instances. The administrator acknowledged the issues and indicated a need for process refinement in the dining rooms.
Failure to Provide Alternate Meal Options and Desserts
Penalty
Summary
The facility failed to provide two residents, R44 and R69, with the option of an alternate entree, beverages, and preferred desserts during scheduled meals. On multiple occasions, R44 was observed without a meal or beverage while other residents were eating. When R44 was finally served a beverage, it contained a straw, contrary to their meal ticket instructions. Additionally, R44, a vegetarian, was served a meal that did not include the dessert on the menu, and the staff was unable to identify one of the pureed items served to them. On another occasion, R69 was observed not consuming their meal because they did not like the pot pie served. The only alternative offered was a bacon sandwich, which was the only available option in the greenhouse unit. R69 expressed a desire for dessert, which was not provided. The CNA reported that desserts were not supplied to the greenhouse residents, and there were no alternate menus or always available items for them. The facility's menu guidelines require that menus be planned in advance to meet residents' nutritional needs and include alternate meals and always available items. However, the facility did not adhere to these guidelines, as evidenced by the lack of alternate entrees and desserts for the residents. The deficiency in meal service has the potential to affect all 78 residents who rely on the kitchen for their meals.
Failure to Provide Post-Dinner Snacks to Residents
Penalty
Summary
The facility failed to ensure that post-dinner snacks were available and offered to 18 residents residing in the [NAME] Houses, out of a total census of 78. During observations and interviews, it was revealed that the Certified Nursing Assistant (CNA) and the [NAME] House Manager (GHM) reported that the kitchen did not send snacks to the houses. The GHM indicated that the kitchen staff did not have a contract with the [NAME] Houses to provide snacks, and they could not recall the last time snacks were provided. The facility's document titled HS (evening) snacks outlined that snacks and beverages should be provided as identified in individual care plans, but this was not being followed. Further observations of the [NAME] House kitchen revealed an empty snack basket and limited food items in the refrigerator, which were reserved for medication pass. The GHM stated that the residents were hungry, and staff often used their own money to buy snacks. A text message from the GHM to the Certified Dietary Manager (CDM) asking about snack provision went unanswered. When queried, the CDM stated that snacks were not her responsibility and referred the surveyor to the main kitchen, indicating a lack of communication and responsibility for ensuring residents received necessary snacks.
Improper Sanitization in Dish Machine
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety, as observed during a survey. The deficiency was identified when the dish machine in the [NAME] House was found to be a low temperature, chemical sanitizing dish machine without a sanitizer attached. The [NAME] House Manager F was unable to explain how staff checked for sanitizer levels when no liquid sanitizer was connected to the dish machine. Additionally, the staff was using Smart Power test strips, which were not appropriate for the chemicals in use, indicating a lack of proper monitoring and understanding of the sanitization process. Further investigation revealed that the dish machine had only a bottle of liquid detergent and two bottles of liquid rinse aid connected, with no sanitizer present. When the [NAME] House Manager F attempted to rectify the situation by replacing the rinse aid with a bottle of liquid chlorine sanitizer, the chlorine test strip did not change color, indicating the absence of sanitizer. This failure to ensure proper sanitization of dishware had the potential to result in foodborne illness among all residents consuming food from the kitchen, as the facility did not adhere to the 2017 FDA Food Code requirements for chemical sanitization.
Failure to Implement EBP and Maintain Linen Sanitation
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with multiple medical devices, including a urinary catheter, feeding tube, and tracheostomy. Observations revealed that staff did not wear isolation gowns or gloves when entering the resident's room or providing care, such as incontinence care and nebulizer treatment. Additionally, there was no signage indicating the need for EBP on the resident's door, and the facility's Director of Nursing confirmed that the resident should have been identified as requiring EBP. The facility also failed to store linens in a sanitary manner, as observed with a linen cart on the [NAME] Unit. The cart had a foam cup and a personal water bottle stored among clean linens, and the cover was stained and had holes. Staff acknowledged the inappropriate storage of personal items on the cart, and the Director of Nursing noted that the cart cover should be inspected for replacement. Despite being informed of the issue, the cover remained uncleaned and unreplaced by the following day.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to maintain a functioning resident call system in the bathrooms and bathing areas for four residents, leading to a deficiency in ensuring a safe environment. Observations revealed that the call system cords in the bathrooms of these residents were either tied to non-functional pieces, detached, or missing entirely, rendering them unusable for calling assistance. Specifically, one resident's bathroom had a pull-cord tied to a non-functioning piece of plastic, while another resident's shower pull-cord was detached from the alert system. Additionally, a resident's call light system was tested and found to be non-responsive, with no indication on the door or system monitor. The Maintenance Director (MD) was unaware of the issues until they were shown the non-functional systems. Upon inspection, the MD identified that some cords were improperly installed, and others had dead batteries, which contributed to the malfunctioning alert systems. The MD acknowledged the need for new cords and battery replacements to restore functionality. However, there was no prior communication to the MD regarding the need for repairs, indicating a lapse in reporting and addressing maintenance issues within the facility.
Failure in Catheter Care Leads to UTI
Penalty
Summary
The facility failed to provide appropriate urinary catheter care, assessment, and monitoring for a resident, resulting in the development of a urinary tract infection (UTI). The resident, who was observed with an indwelling urinary catheter, had dark, cloudy urine with sediment in the tubing. A review of the resident's clinical record showed no orders or documentation for catheter care, assessment, and monitoring, despite the resident's diagnoses, which included neuromuscular dysfunction of the bladder and a UTI. The resident's physician's orders included an antibiotic treatment for a UTI, but there was no documentation of routine catheter care as per the facility's policy. The Director of Nursing confirmed that an order should be written and documented by the assigned nurse. The facility's policy on indwelling catheter care emphasized the importance of routine care to prevent infections, but it did not include documentation of the care provided.
Inadequate Nutrition and Monitoring Leads to Resident Weight Loss
Penalty
Summary
The facility failed to provide adequate nutrition and monitoring for a resident, identified as R44, who experienced significant weight loss. Observations revealed that R44, who is a vegetarian, was served meals lacking in protein and variety, such as pureed sweet potato and cabbage, and tomato soup with lima beans. Additionally, R44 was not provided with dessert on one occasion. Interviews with staff indicated a lack of knowledge about the nutritional content of the meals and the facility's policy on replacing protein for vegetarian residents. The facility's dietary manager acknowledged that the meals provided were not nutritious and that protein replacements should have been offered. R44's clinical records showed a history of weight loss, with weights dropping from 118.8 lbs in October 2024 to 93 lbs in March 2025. Despite recommendations for weekly weight monitoring, only two weights were recorded in a four-week period, and no re-weights were conducted when deviations occurred. The facility's policies on weight management and unintended weight change were not followed, as evidenced by the lack of regular weight monitoring and re-weights. The dietary manager was unable to explain the failure to adhere to these policies, highlighting a deficiency in the facility's nutritional care and monitoring processes.
Incorrect Tube Feeding Rate for Resident
Penalty
Summary
The facility failed to ensure that a resident's tube feeding formula was delivered at the physician-ordered rate. Observations on multiple occasions revealed that the pump was set to deliver the formula at 70 mL per hour, while the physician's order specified a rate of 75 mL per hour. This discrepancy was noted during observations on 3/31/25 and 4/1/25, where the pump's programmed rate did not match the rate indicated on the formula bottle and the physician's order. The resident involved had a medical history that included acute respiratory failure, stroke, aspiration pneumonia, and the presence of a tracheostomy and feeding tube. The Certified Dietary Manager confirmed the error upon reviewing the orders and acknowledged that the pump was incorrectly programmed. The facility's policy on enteral nutrition guidelines requires that the nurse administers the feeding regimen according to the physician's order, which was not adhered to in this case.
Failure to Provide Legal Representative for Incapacitated Resident
Penalty
Summary
The facility failed to ensure that an incapacitated resident, identified as R17, was provided with a legally authorized representative to make informed healthcare decisions. R17, who has diagnoses including Cerebral Palsy and Polyneuropathy, was observed to have difficulty communicating and was unable to answer questions. The resident's medical record indicated a BIMS score of 10, suggesting moderately impaired cognition, and a comprehensive care plan noted the need for assistance with all decision-making. Despite being deemed incapacitated by a physician and psychologist in July 2024, R17 did not have any healthcare power of attorney or legal guardianship documentation in place. The facility's Social Services department was responsible for obtaining a legal representative for decision-making but had not secured one for R17. The resident's niece was making healthcare decisions without any legal documentation, and the Social Worker acknowledged that the process to secure guardianship had only just begun. A review of facility documents and relevant legal provisions revealed no documentation authorizing a legal representative for R17, and the facility did not provide any evidence of having secured such representation by the end of the survey.
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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