The Villa At Parkridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Ypsilanti, Michigan.
- Location
- 28 S Prospect Street, Ypsilanti, Michigan 48198
- CMS Provider Number
- 235503
- Inspections on file
- 35
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at The Villa At Parkridge during CMS and state inspections, most recent first.
Unresolved Resident Council Grievances About Call Light Response Times: Residents reported ongoing slow call light response times discussed at monthly council meetings for months without improvement. Residents described waits of more than an hour on night shift and said staff responded with comments about being busy or short staffed. Meeting minutes showed repeated complaints over multiple months, with the facility documenting only staff re-education. Residents also reported they did not know where to find or how to complete a grievance form or how the grievance process worked.
Failure to inform residents of the grievance process and ongoing call light delays. During a confidential Resident Council meeting, 8 residents reported repeated slow call light response times, including waits of more than 1 hour on the night shift, and said staff responses were dismissive and made them feel like a bother. The residents stated the issue had been discussed for months without improvement, and none of the 8 residents knew where to find a grievance form or how to complete the grievance process.
A facility failed to provide enough nursing staff to meet resident needs and ensure timely response to call lights. Residents reported waits of more than an hour, including one resident who said he had waited up to 3 hours, while observations showed two nurses sitting at the nurses' station as multiple call lights were active. A resident with paraplegia, neurogenic bowel, and sarcoidosis, another resident needing bathroom assistance, and a resident with a painful brief all reported unmet needs, and a CNA reported being assigned 17 residents with no break.
Failure to Maintain Resident Dignity and Privacy: A resident with paraplegia, neurogenic bowel, and intact cognition reported that staff were rude, did not explain care, and left him exposed during wound care and pericare, including not pulling the privacy curtain and exposing his genitals while his roommate was present. An LPN was also observed entering the room without properly knocking, and the DON stated staff are expected to knock, introduce themselves, wait for an answer, and pull privacy curtains during care.
A resident with stroke-related apraxia, dysarthria, and right-sided weakness was unable to use a standard push-button call light, which was observed clipped out of reach on his affected side. Staff were unsure how he communicated needs, a communication board was not in his room, and the DON stated a soft-touch or pancake call light would be more fitting. The resident was also observed thirsty, warm, unbathed, and in an unkempt condition.
Damaged Bathroom in Resident Room: A resident on reverse isolation was found in a room with a dark, visibly damaged bathroom, including a large hole at the wall-ceiling junction in the shower, exposed pipes, a covered tub reported as unusable, and visible debris and staining on the tub and mirror. The resident stated the condition had been present for an extended period, and maintenance staff acknowledged awareness of the repair issue after a prior pipe leak.
A resident with type 2 diabetes and a left calf wound did not receive ordered wound care even though the TAR showed it as completed by multiple LPNs. The resident reported the dressing had not been changed for several days, and surveyors observed the same dated dressing still in place. Staff interviews showed the LPNs could not confirm the care was done, and the DON stated the nurses did not follow the physician's orders.
Misappropriation of resident property: A resident with intact cognition and diagnoses including difficulty walking and partial intestinal obstruction reported that a CNA entered his room while he was asleep, removed his phone from its charger, and plugged in the CNA’s personal iPhone at his bedside. A UM stated staff should not charge personal cellphones in resident rooms using residents’ property.
Incomplete Care Planning and Failure to Implement Ordered Monitoring and Treatments: The facility did not document required monitoring for a resident on antidepressant therapy and with mood-related diagnoses, did not document mood observations in the EMR, and failed to provide or re-order ordered BIPAP support for another resident after hospital returns. A third resident with stroke-related impairments was observed unbathed, thirsty, unable to reach the call light, and needing assistance with drinking and hygiene, while the care plan did not reflect implemented monitoring or support.
Ineffective Communication and Inaccessible Call Light: A resident with post-stroke apraxia, dysarthria, and right-sided weakness was rarely or never understood, yet staff stated they had no effective way to communicate with him and often guessed his needs. He could answer yes/no questions by nodding, indicated he was thirsty and had not been bathed, and showed he could not use the push-button call light because of limited arm function. The communication board was not in the room, and the call light was observed out of reach or on his affected side.
Failure to provide ADL care including bathing and grooming: A resident with stroke-related apraxia, dysarthria, and right-sided weakness was observed unbathed, unkempt, with dry lips, overgrown toenails, and a call light out of reach. The resident indicated he had not been receiving showers and wanted a shower, shaving, and a haircut. Records showed he was dependent for bathing, showers were scheduled, but only bed baths were documented over the past 30 days with no refusals noted.
A resident with post-stroke apraxia, dysarthria, and right-sided weakness was dependent on staff for food and fluids, but was found thirsty with dry lips, limited bedside water, and no reliable way to summon help. Staff stated he could not use the call light, the communication board was not in his room, and the EMR showed no consistent fluid intake documentation or monitoring. The resident indicated he had not been receiving showers and could not give himself drinks of water.
Failure to Provide Ordered BiPAP Therapy: A resident with COPD, OSA, chronic respiratory failure, and recent hypercapnic respiratory failure returned from the hospital with discharge instructions to use BiPAP when sleeping and napping, but the facility did not re-order it and there was no evidence it was used for about two months. The resident reported staff had not assisted with the BiPAP and the machine was found in her closet; the ADON confirmed the order was not re-entered after the hospital return.
A resident with type 2 diabetes and intact cognition had ordered wound care for a left calf wound, but the dressing remained dated and unchanged while the TAR was signed off as completed by multiple LPNs. Interviews showed the nurses could not confirm the care was actually provided, the DON stated the orders were not followed, and prior discipline for falsified documentation was found in the staff files.
A resident with stroke-related apraxia, dysarthria, and right-sided weakness was found in a very warm room with dry lips, poor hygiene, an out-of-reach call light, and limited water access. Surveyors observed duct tape sealing the window shut so it could not be opened or cracked, and maintenance said it had been taped because it was drafty when temperatures were low; no related work order was found.
A resident experienced a fall resulting in a hip fracture that was not immediately assessed or reported to the physician or responsible party. An LPN and CNA assisted the resident back to bed without documenting the fall or conducting a full assessment, including range of motion or neuro checks. The incident was only discovered after the resident reported pain to therapy and the guardian was informed by the roommate, leading to delayed hospital transfer and diagnosis.
The facility did not adequately address repeated concerns from the Resident Council about food palatability, call light response times, and provision of evening snacks. Residents reported long waits for call light responses, particularly during afternoon and night shifts, and noted that staff sometimes consumed snacks meant for residents. Additionally, grievances and concerns raised by the Resident Council were not satisfactorily resolved.
The facility failed to accurately complete MDS assessments for several residents, leading to discrepancies in medical records. A resident did not receive a pneumococcal vaccination despite consent, and another had incorrect documentation regarding a Gradual Dose Reduction. Weight loss data was inaccurately recorded for a resident, and the use of bed bolsters as potential restraints was not properly assessed for two residents. The facility's staff provided conflicting information about restraint use, indicating a lack of proper assessment and documentation.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies in care. A resident with bullous pemphigoid had an unplugged pressure mattress, another on dialysis lacked proper monitoring and care plan updates, a resident with psychiatric conditions had missing behavioral interventions, and a resident with a history of falls had an inaccessible call light. These issues highlight a lack of proper care plan implementation and monitoring.
The facility failed to provide adequate staffing, resulting in delayed response times to call lights, particularly during afternoon and night shifts. Residents reported waiting 45 to 60 minutes for assistance, with some experiencing incontinence due to the delays. Staff were observed turning off call lights without providing care, and residents' concerns about staffing were not addressed.
The facility failed to provide palatable and safe food, affecting 125 residents. Several residents expressed dissatisfaction with the quality and temperature of the food, leading some to store personal food items unsafely. Food trays were transported in non-insulated carts, contributing to improper food temperatures. The facility's meal distribution policy did not ensure proper temperature maintenance, as evidenced by surveyor observations and resident complaints.
A resident reported missing clothing items that were not returned from the laundry, despite being labeled. The facility staff failed to follow the grievance process, as no grievance form was completed, and the Nursing Home Administrator confirmed no grievances were documented. The resident was cognitively intact and had diagnoses including adjustment disorder and Alzheimer's Disease.
The facility failed to assess bed bolsters as potential restraints for two residents, leading to a deficiency. One resident with schizoaffective disorder and dementia had bolsters that restricted their ability to get out of bed, and another resident with a history of falls had a positioning wedge and bolster that prevented them from getting out of bed. The medical records lacked restraint assessments, and staff confirmed the use of bolsters for fall prevention without proper evaluation.
A facility failed to timely complete a Significant Change MDS assessment for a resident with dementia who had recently ended hospice services. The assessment, required within 14 days of a significant change, was completed late, as confirmed by the MDS Coordinator.
The facility failed to provide necessary care and assistance with ADLs for two residents, resulting in unmet personal care preferences and lack of engagement in activities. One resident, with multiple medical conditions, was not assisted in participating in activities like bingo, while another resident, with severe cognitive impairment, did not receive showers as preferred due to a broken shower bench. The staff's inaction and lack of proper documentation contributed to the deficiency.
A resident in a long-term care facility, who was cognitively intact and dependent on all care, was not provided with meaningful and individualized activities, leading to potential feelings of depression and boredom. Despite expressing a desire to participate in activities like Bingo, the resident was not assisted in getting out of bed in time to attend. Staff interviews revealed a lack of coordination and communication, and records showed no documented participation in activities over the past 30 days.
The facility failed to manage the nutritional care and weight of two residents effectively. One resident, who was cognitively intact and had a gastrostomy, experienced significant weight gain without adjustments to their tube feeding regimen, despite their preference for weight loss. Another resident, with severe cognitive impairment, suffered significant weight loss, and the facility did not update their care plan with new interventions. The facility did not adequately address the nutritional needs and preferences of these residents.
A facility failed to ensure proper dialysis care for a resident with end-stage renal disease. The resident reported that their dialysis access site was not routinely monitored, and there was no active physician's order for their fluid restriction. The Kardex did not reflect the resident's dialysis status or care considerations. Interviews with staff revealed inconsistencies in understanding the resident's care needs, and the Director of Nursing acknowledged that necessary orders were not reimplemented after a hospital visit.
A resident with a cerebral infarction was not provided with necessary personal items and expressed dissatisfaction with having a legal guardian and being unable to leave the facility. Despite being cognitively intact, the resident's requests for basic supplies and communication with the guardian were not adequately addressed by social services or nursing staff. The resident's condition worsened to suicidal ideation, highlighting the facility's failure to provide timely and appropriate social services.
A resident did not receive their prescribed morning dose of Lithium Carbonate due to a medication administration error. An RN pre-filled a medication cup and stored it in the medication cart, but failed to include the Lithium capsule. The Director of Nursing confirmed that medications should be administered directly from the bubble pack at the time they are due.
A resident with celiac disease was not provided meals that adhered to her gluten-free diet, as the facility frequently substituted her meals with hot dogs and hamburgers. Despite having a diet order for a gluten-free diet with extra protein, the resident reported a lack of dietician visits and a downward trend in her weight. Staff interviews confirmed the resident's complaints, indicating a failure to meet her dietary needs.
A facility failed to ensure proper collaboration and communication with a hospice provider for a resident receiving hospice services. Despite a scheduled hospice visit calendar, documentation was lacking in both the Hospice Binder and the electronic medical record. Interviews revealed that hospice visit notes were expected to be available but were not, and a request for the hospice communication log was not fulfilled before the survey exit.
A resident with severely impaired cognitive skills did not receive a pneumococcal immunization despite consent from their DPOA. The ADON/IP confirmed the consent but was unsure why the immunization was not administered.
The facility failed to update care plans for two residents, one experiencing significant weight loss and another with unadjusted tube feeding despite oral intake. The care plans did not reflect current needs and preferences, leading to deficiencies in care.
A resident suffered second-degree burns after a CNA failed to check the temperature of reheated noodles, which were then spilled. The facility did not follow proper procedures for reheating food or providing immediate burn care. Staff were inadequately trained on these protocols, contributing to the incident.
A resident suffered burns from hot noodles due to inadequate temperature checks and delayed physician notification. The facility failed to provide immediate and appropriate burn treatment, and staff were not adequately trained in reheating food or responding to burn injuries.
A resident suffered second-degree burns after spilling hot noodles on himself due to inadequate food temperature checks and lack of immediate burn care. The facility failed to report the incident promptly and lacked proper training and policies for reheating food and treating burns, contributing to the resident's injuries.
A resident with multiple health issues and a BIMS score indicating cognitive intactness was not informed of the resolutions to grievances they submitted regarding facility concerns. Despite documentation of actions taken, the facility's computerized system did not track whether the resident was notified, and the Nursing Home Administrator could not confirm that the resident was informed or satisfied with the outcomes.
Unresolved Resident Council Grievances About Call Light Response Times
Penalty
Summary
The facility failed to address and resolve grievances raised in Resident Council meetings regarding slow call light response times and resident treatment during care requests. During a confidential Resident Council meeting, 8 of 8 participating residents reported an ongoing issue with call lights not being answered in a timely manner, with concerns discussed at every monthly meeting for months without improvement. Residents described call light response times of more than one hour on night shift and reported that when staff arrived, they were told staff were busy and short staffed, and one resident stated, "That is not our problem" when asking for help with basic care such as using the bathroom. Review of Resident Council meeting minutes from 9/23/25 through 3/8/26 showed resident complaints about long call light response times in 5 of 6 months. The facility responses documented in the minutes were that staff were re-educated on call light answering, but the same concerns continued to be raised. During the confidential meeting, 8 of 8 residents also reported they were not aware of where to locate or how to complete a grievance form or how the grievance process worked.
Failure to Inform Residents of Grievance Process and Ongoing Call Light Delays
Penalty
Summary
The facility failed to notify residents of where to find grievance forms and how to file a grievance, as discussed during a confidential Resident Council meeting with 12 residents present and 8 actively participating. During the meeting, all 8 participating residents reported ongoing slow response to call lights, stating the issue had been discussed at every Resident Council meeting for months without improvement. Residents described call light response times of more than one hour on the night shift and reported that when staff arrived, they were told, "I am busy, we are short staffed, what do you need," which made them feel like a bother to staff. Another resident reported being told the facility was short staffed after waiting for a call light to be answered, and stated, "That is not our problem when we have to ask for assistance with basic care like going to the bathroom." Eight of 8 confidential residents were not aware of where to locate or how to complete a grievance form or how the grievance process worked.
Delayed Response to Call Lights and Inadequate Nursing Coverage
Penalty
Summary
The facility failed to provide adequate nursing staff every day to meet resident needs and to ensure a licensed nurse was in charge on each shift. Review of observations, interviews, and records showed repeated delays in answering call lights and unmet resident care needs for residents including R7, R41, and R64, as well as eight residents identified in confidential group interviews. R7, who was admitted with paraplegia, neurogenic bowel, and sarcoidosis and had intact cognition on MDS assessment, reported waiting as long as 3 hours for his call light to be answered and said his roommate often had to go to the nurses' station because staff were sitting there talking and response times routinely exceeded an hour. During a confidential Resident Council Meeting, 8 of 8 participating residents reported ongoing slow response to call lights, with examples of waits greater than one hour on night shift and staff responding with comments about being short staffed. Residents also reported they were not aware of where to locate or how to complete a grievance form. On observation, multiple call lights were activated while two nurses remained seated at the nurses' station chatting. R41 was heard repeatedly calling for a nurse and later stated she had been waiting over an hour to use the bathroom, while a confidential CNA reported having 17 residents assigned and no break. R64 reported his call light had been on since after lunch because his brief was digging into his skin and causing pain. The DON stated that all staff are responsible for answering call lights and that ignoring them is not acceptable.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat a resident with dignity by not consistently providing privacy and courtesy during care. The resident was admitted with diagnoses including paraplegia, neurogenic bowel, and sarcoidosis, and had intact cognition with a BIMS score of 15/15. During an interview, the resident stated that staff were rude, did not explain what they were doing before providing care, and often left him exposed during wound care and pericare. He specifically reported that during recent wound care his privacy curtain was not pulled, he was not covered, he could see his roommate ambulating in the room, and his genitals were exposed. He also stated that staff routinely did not pull the privacy curtain while providing care and that he wanted basic common courtesy. During observation, an LPN entered the resident's room without knocking and only knocked after opening the door and seeing that an interview was in progress. The LPN stated she sort of knocked, had her phone in her hand, and was looking for the bladder scanner. The resident reported that staff rarely knock before entering his closed door. During an interview with the DON, it was stated that staff are expected to knock, introduce themselves, and wait for an answer before entering resident rooms, and that staff should always pull privacy curtains when performing resident care.
Call Light Not Adapted to Resident’s Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident with apraxia following cerebral infarction, dysarthria, and right-sided weakness/paralysis had a call system adapted to his physical limitations. The resident’s MDS reflected that he was rarely or never understood. During observation, he was seen lying in bed with his push-button call light clipped out of reach on his curtain or mattress on his affected right side. When asked to demonstrate use of the call light, he was unable to do so and indicated he could only raise and lower his left arm, with his fingers fixed in a fanned-out position. The resident also communicated that he could not use the push-button call light, and the DON stated that a soft touch or pancake call light would be more fitting for him. Interviews showed staff were unsure how the resident communicated his needs and one CNA stated she was not sure if he could use his call light, while another CNA stated he could not use it. The UM stated the resident communicated by nodding yes or no or using a communication board, but the communication board was not in his room. The resident was observed without the adapted communication support in place, and his call light remained positioned where he could not reach or use it. During the same observations, he was also noted to be very warm, thirsty, unbathed, and in an unkempt condition, with dry, chapped lips, overgrown toenails, and water left on the bedside table without a straw.
Damaged Bathroom in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for one resident who was on reverse isolation precautions. The resident was admitted with pancytopenia, immunodeficiency due to drugs, asthma, paraplegia, depression, and anxiety, and had a BIMS score of 15/15 indicating intact cognition. A sign was posted to see staff before entering the room, and the resident was confirmed to be in reverse isolation due to immunosuppressive long-term linezolid use. When the room was observed, the resident was lying in bed while the bathroom area was dark and visibly damaged. The bathroom door was open, and a large hole measuring about 6 inches by 6 inches was seen where the wall and ceiling met in the shower, with dark rust-colored debris and two exposed pipes. The ceiling had a replacement piece covering apparent damage, the tub was covered with a board and was reported as unusable, and there was a brown splatter-like substance on the tub exterior near the floor and a white streaking substance on the mirror. The resident stated the wall and shower area had been in that condition for an extended period and had been worse in the past. Maintenance staff acknowledged awareness of the bathroom repair issue and stated the original problem began with a pipe leak in mid-November 2025.
Wound care documented as completed but not performed
Penalty
Summary
The facility failed to protect one resident, R135, from neglect when ordered wound care for a left posterior calf wound was not completed as prescribed, even though the treatment administration record (TAR) showed it as completed. R135 was admitted with type 2 diabetes and was cognitively intact with a BIMS score of 15 out of 15. The physician ordered the wound to be cleansed with normal saline, treated with Medihoney, and covered with a foam dressing every other evening shift, but the resident reported that the dressing had not been changed since 3/2/26 or 3/3/26. When observed on 3/8/26 and again on 3/9/26, the same dressing dated 3/3/26 remained in place, and the resident stated the wound care still had not been done. The TAR reflected wound care as completed on 3/4/26, 3/6/26, and 3/8/26 by three different LPNs, but interviews showed the staff could not confirm the care was actually provided. One LPN stated she changed a dressing on another resident and did not perform wound care on the back of a calf, another said she was not sure whether she completed the treatment, and a third could not recall if she completed the wound care. The DON stated the nurses did not follow the physician's orders and that there was no reason for the wound care to be signed out as completed but not done. The resident's dressing was finally changed during the survey observation, and the removed dressing showed drainage and an open wound bed.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to prevent misappropriation of resident property for one resident. The resident was admitted with diagnoses including difficulty in walking and partial intestinal obstruction, and the MDS assessment showed intact cognition with a BIMS score of 15/15. During observation, the resident was sitting at the edge of the bed eating lunch and reported that a staff member entered his room while he was asleep, said she needed to use his phone charger, removed the resident's phone from the charger, and plugged in her own phone at his bedside. A pink iPhone was observed plugged in and charging at the resident's bedside. The resident described the staff member, and it was determined that the phone belonged to a CNA. A UM stated that staff should not have cellphones in resident rooms or charge personal cellphones in resident rooms using residents' personal property.
Incomplete Care Planning and Failure to Implement Ordered Monitoring and Treatments
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents. For one resident with diagnoses including bipolar disorder, depression, generalized anxiety disorder, post-traumatic disorder, vascular dementia with anxiety, and major depressive disorder, the care plan included interventions to monitor and document adverse reactions to antidepressant therapy and to monitor and record mood changes, depression, anxiety, sadness, and related symptoms. However, the medical record contained no documentation that these monitoring interventions were completed, and the DON confirmed that no such documentation could be found in the EMR. For another resident with apraxia following cerebral infarction, dysarthria, and right-sided weakness/paralysis after a stroke, the resident was observed in bed wearing only an adult brief, lying flat on his back with heels not elevated, in a very warm room, with an unpleasant body odor, unkempt appearance, dry and chapped lips, and overgrown toenails. A Styrofoam cup on the bedside table contained only a small amount of water. The resident was unable to verbally respond but could answer simple questions by nodding or shaking his head, indicated that he was thirsty, stated he had not been receiving showers, and said he needed assistance with eating and drinking. He also indicated that he did not have a communication board and could not hold a cup to drink independently. For a third resident with recent admissions related to acute on chronic respiratory failure with hypoxia and hypercapnia, CO2 narcosis, sleep apnea, morbid obesity, COPD, respiratory failure with hypoxia dependent on oxygen, anxiety, and depression, the resident reported that staff had not assisted with use of the ordered BIPAP machine since returning from the hospital. The machine was found in the closet. The care plan identified a potential for difficulty breathing related to CHF, COPD, chronic respiratory failure, and OSA and included BIPAP per MD order, but the ADON verified that after the hospital readmissions the BIPAP was not re-ordered even though the resident remained on the care plan and staff were expected to follow it.
Ineffective Communication and Inaccessible Call Light
Penalty
Summary
The facility failed to ensure an effective and consistent means of communication for a resident with apraxia, dysarthria, and right-sided weakness/paralysis following a stroke. The resident’s MDS reflected that he was rarely or never understood. During observation and interview, he was unable to verbally respond, but he could answer simple questions by nodding yes or no and appeared to understand conversation. He indicated that he was thirsty, had not been receiving showers, wanted a shower, wanted his face shaved and a haircut, and required assistance with eating and drinking. He also indicated that he could not hold a cup or give himself drinks of water and could not explain how he requested help from staff. A psychiatric note also reflected that he was able to shake his head to answer simple questions. Despite this, staff members stated they did not have a way to effectively communicate with the resident and that they did their best to guess his needs. The resident’s call light was observed clipped out of reach or positioned on his affected side, and he demonstrated that he could not use the push-button call light because of his limited left arm function. A unit manager stated the resident communicated by nodding yes or no or by using a communication board, but the board was not in the room. The resident was also observed lying in bed in an unkempt condition, with dry and chapped lips, overgrown toenails, body odor, and water left at the bedside that he indicated he had not drunk.
Failure to Provide ADL Care Including Bathing and Grooming
Penalty
Summary
The facility failed to ensure activities of daily living were completed for one resident who was unable to perform them independently. The resident had diagnoses including apraxia following cerebral infarction, dysarthria, and weakness/paralysis affecting the right dominant side following a stroke. The MDS reflected the resident was rarely or never understood and was dependent for bathing. On observation, the resident was found in his room wearing only an adult brief, lying flat on his back with heels not elevated, with an unpleasant body odor, very dry and chapped lips, overgrown toenails, and a call light clipped out of reach. The resident indicated he had not been receiving showers, wanted a shower, wanted his face shaved and a haircut, and was thirsty. Record review showed the care plan identified bathing as requiring physical assistance, and the task list scheduled showers for Wednesdays and Saturdays. However, the past 30 days reflected only bed baths and zero showers, with no refusals documented. The resident was able to answer simple questions by nodding or shaking his head, and a psychiatric note documented that he could shake his head to answer simple questions. The DON reviewed the documentation and was unable to find any refusals or any preference for bed baths versus showers in the care plan.
Failure to Maintain Hydration Monitoring and Bedside Fluids
Penalty
Summary
The facility failed to ensure consistent availability of water at the bedside, failed to ensure hydration was offered, and failed to document fluid intake for one resident who was dependent on staff for bringing food or liquid to his mouth. The resident had a history of apraxia following cerebral infarction, dysarthria, and right-sided weakness/paralysis after a stroke. The MDS reflected that he was rarely or never understood and that he was dependent on staff for bringing food or liquid to his mouth. During observation, the resident was found lying flat in bed in a very warm room, wearing only an adult brief, with an unkempt appearance, unpleasant body odor, dry and chapped lips, and overgrown toenails. A Styrofoam cup on the bedside table contained only about one-quarter of water and was dated several days earlier. The resident indicated that he was thirsty, that he could not hold a cup or give himself drinks of water, and that he required assistance with eating and drinking. He also indicated that he had not been receiving showers and wanted a shower, a shave, and a haircut. The resident’s call light was observed clipped out of reach or positioned on his chest, and staff stated that he could not use it. The unit manager stated that the resident communicated by nodding yes or no or by using a communication board, but the communication board was not in his room. The electronic medical record showed no consistent documentation or monitoring of fluid intake. The DON stated that staff should be offering fluids to dependent residents every two hours and documenting fluid intake in the medical record.
Failure to Provide Ordered BiPAP Therapy
Penalty
Summary
The facility failed to ensure a resident received ordered respiratory care when BiPAP use was not provided after the resident returned from the hospital. The resident was a cognitively intact female with diagnoses including acute on chronic respiratory failure with hypoxia and hypercapnia, CO2 narcosis, sleep apnea, morbid obesity, COPD, respiratory failure with hypoxia dependent on oxygen, anxiety, and depression. Her history and physical reflected recent hospital transfer for pneumonia and obesity hypoventilation syndrome, and the hospital discharge summary stated that BiPAP was needed when sleeping and napping because the altered mental status was related to hypercapnia that resolved with BiPAP. The record showed physician orders for BiPAP at bedtime before the hospital transfer, but after the resident returned to the facility there was no evidence of a BiPAP order from the return through the survey date. The MAR and TAR also showed no evidence that BiPAP was used for about two months. During interview, the resident stated staff had not assisted her with the BiPAP since January and that the machine was in her closet. The ADON confirmed the resident had a history of COPD and BiPAP use, acknowledged the BiPAP order was not re-entered after the hospital return, and verified the equipment was located in the closet and was being set up at the time of interview.
Falsified Wound Care Documentation
Penalty
Summary
The facility failed to ensure medical records were accurate and not falsified for one resident with type 2 diabetes and a cognitively intact BIMS score of 15 out of 15. The resident had a physician’s order for wound care to the left posterior leg every other day on the evening shift, but on observation the dressing on the left calf was still dated 3/3/26 on 3/8/26 and again on 3/9/26, and the resident reported the dressing had not been changed since 3/2/26 or 3/3/26. The resident also reported the facility had removed his own wound care supplies from his room when he was admitted. The TAR showed the wound care was checked off and signed as completed on 3/4/26 by one LPN, on 3/6/26 by another LPN, and on 3/8/26 by a third LPN, but interviews showed the nurses could not confirm the care was actually done and one LPN stated she had changed a dressing on another resident’s heel, not this resident’s calf. The DON stated the nurses did not follow the physician’s orders and there was no reason for the wound care to be signed out as completed when it was not done. The resident’s progress notes contained no explanation for why the wound care was not completed on those dates, and the personnel files showed prior discipline for falsified or inaccurate documentation by the same nurses.
Window Sealed Shut in Resident Room
Penalty
Summary
The facility failed to provide a functional window for one resident with significant communication and mobility impairments. The resident was admitted and readmitted with diagnoses including apraxia following cerebral infarction, dysarthria, and weakness/paralysis affecting the right dominant side following a stroke. The MDS dated 1/16/26 reflected that the resident was rarely or never understood. During observation on 03/08/2026, the resident was found lying flat in his room wearing only an adult brief, with his heels not elevated, his room very warm, a Styrofoam cup of water on the bedside table, dry and chapped lips, an unkempt appearance, unpleasant body odor, and overgrown toenails. His call light was clipped to the curtain on his right side and out of reach. The resident communicated by nodding yes or no and indicated that he was warm, thirsty, had not been receiving showers, and wanted a shower, shave, haircut, and assistance with drinking water. On 03/10/2026, the resident was again observed lying flat with his heels not floated, and an LPN stated the room was hot. A full room-temperature cup of water was on the bedside table with no straw. On 03/08/2026, duct tape was observed around the perimeter of the window, preventing it from being opened or cracked and effectively sealing it shut. The room continued to feel very warm. Review of eight months of work order requests for the resident's room showed no work order related to the window. Maintenance stated the duct tape had been applied because the window was drafty when temperatures were low and said the facility intended to get window repair personnel out to repair the windows.
Failure to Notify Physician and Responsible Party After Resident Fall With Major Injury
Penalty
Summary
The facility failed to immediately assess and notify the physician and responsible party following a fall with major injury for one resident. The resident was found sitting next to his bed and was unable to articulate what happened. The LPN and CNA assisted the resident back to bed, and the LPN documented that there were no injuries or pain and that a body assessment was conducted. However, there was no documentation of a fall on the date of the incident, and no evidence that the physician or responsible party was notified at that time. Additionally, there was no documentation of range of motion assessment or neuro checks following the incident. The resident later complained of right hip pain to occupational therapy, who then notified nursing. The resident's guardian learned of the fall from the resident's roommate and requested immediate hospital transfer, where a right hip fracture requiring surgical repair was discovered. Interviews with staff revealed that the LPN who found the resident did not notify the physician or responsible party and did not perform a range of motion assessment. The DON confirmed that the facility's expectation was for the physician and responsible party to be notified after any incident once the resident was assessed and safe.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and respond to repeated concerns raised by the Resident Council regarding food palatability, call light response times, provision of evening snacks, and satisfactory resolutions to grievances. Review of the Resident Council Minutes from February to December 2024 indicated ongoing issues with the taste of food and delayed call light responses, particularly during the afternoon and night shifts. During a confidential resident group meeting, the majority of residents reported that their concerns about food taste and staffing had been discussed without any corrective actions being taken. Residents experienced long waits for call light responses, ranging from 45 to 60 minutes, and one resident noted that staff were often heard chatting at the nurse's station while call lights were on. Additionally, some residents reported that snacks were not offered, and staff would sometimes consume the snacks meant for residents. Several residents also expressed dissatisfaction with the resolution of grievances and concerns raised by the Resident Council.
Inaccurate MDS Assessments and Restraint Mismanagement
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their medical records. For Resident #48, the MDS indicated that the pneumococcal vaccination was offered and declined, despite the Durable Power of Attorney for Healthcare having consented to the vaccination. The resident did not receive the vaccination, and the MDS Coordinator admitted to not reviewing consents when completing assessments. Resident #103's MDS assessments were inaccurately coded regarding a Gradual Dose Reduction (GDR) for medications. The MDS indicated that a GDR was attempted and documented as clinically contraindicated, which was incorrect as no GDR was attempted. The MDS Coordinator acknowledged the coding errors in the assessments. For Resident #374, the MDS inaccurately reflected weight loss data, failing to indicate a significant weight loss that occurred. The Registered Dietician and MDS Nurse both confirmed the inaccuracy. Additionally, Residents #63 and #25 had issues with the use of bed bolsters, which were not properly assessed as potential restraints. The facility's Director of Nursing and MDS Coordinator provided conflicting information about the use of bolsters, indicating a lack of proper assessment and documentation regarding restraint use.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in care. Resident #48, who was admitted with bullous pemphigoid and had severely impaired cognitive skills, was observed multiple times with an alternating pressure mattress that was not functioning. Despite a physician's order to monitor the mattress, it was found unplugged, and staff had to troubleshoot the issue. This indicates a lack of proper monitoring and implementation of the care plan for skin integrity. Resident #75, who was cognitively intact and dependent on renal dialysis, reported that their dialysis access site was not routinely monitored by nursing staff. The resident's care plan and Kardex did not reflect their dialysis status or the location of the access site, which is crucial for their care. Additionally, the Nutrition Care Plan was not initiated until six months after admission, showing a significant delay in addressing the resident's nutritional needs. Resident #109, with a history of psychiatric conditions, had a care plan that did not include behavioral interventions known to be effective, such as changing conversation topics to reduce agitation. This omission was acknowledged by the Director of Nursing. Similarly, Resident #25, who had a history of falls and anoxic brain damage, was observed with a call light out of reach, contrary to the care plan intervention to ensure it was accessible. This oversight could prevent the resident from communicating needs effectively, highlighting a failure to implement the care plan for fall prevention.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing levels to meet the needs of residents, particularly during the afternoon and night shifts. This deficiency was highlighted by ongoing concerns documented in the Resident Council Minutes, which reported long call light response times ranging from 45 to 60 minutes. During a confidential resident group meeting, the majority of residents expressed that their concerns about staffing had not been addressed, with reports of staff being inattentive and spending extended periods at the nurse's station without responding to call lights. Specific incidents involved three residents who experienced significant delays in receiving care. One resident reported that staff would turn off the call light without providing the requested service, leading to prolonged waits for assistance. Another resident, who required two-person assistance, reported that it took hours for staff to respond to their call light at night. A third resident experienced delays of 30 to 45 minutes, particularly around meal times and shift changes, resulting in instances of incontinence due to the wait for assistance.
Facility Fails to Provide Palatable and Safe Food
Penalty
Summary
The facility failed to provide palatable and safe food products, affecting 125 residents, which increased the likelihood of decreased resident food acceptance and nutritional decline. Multiple residents expressed dissatisfaction with the quality and temperature of the food. Resident #94 mentioned that the food could be better and expressed a preference for more than just hamburgers and hot dogs. Resident #105 reported a desire for specific nutritious vegetables and noted that the facility's green beans were often inedible, the rice was tough, and the beans were sour. Resident #103 complained about the poor taste and temperature of the food, particularly breakfast items, and resorted to storing personal food items in their room due to dissatisfaction with the facility's offerings. The surveyor observed that Resident #103 stored personal food items on a windowsill, using the open window for limited refrigeration, which is not a safe practice. The facility's policy on safe storage and handling of outside food was not adhered to, as the resident's food was not properly labeled or stored in a designated refrigerator. Additionally, Resident #65 criticized the facility's grilled cheese sandwiches and reported that the food was often cold and of poor quality, describing the meat as rubbery. During the survey, food trays were observed being transported in non-insulated carts, which likely contributed to the improper food temperatures recorded. The pork loin and green beans served to Resident #65 were below the required temperature, while the pineapple tidbits, lemonade, and yogurt were above the safe temperature for cold foods. The facility's meal distribution policy was not effectively ensuring proper temperature maintenance, as evidenced by the surveyor's palatability tests, which found some food items to be bland, cold, or of poor quality.
Failure to Resolve Resident Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to promptly resolve grievances for a resident, identified as R88, who was admitted with diagnoses including adjustment disorder with depressed mood and Alzheimer's Disease. R88, who was cognitively intact as per the Brief Interview for Mental Status, reported missing several clothing items, including sweatshirts, pants, t-shirts, and a green plaid jacket. Despite the items being labeled with R88's name, they were not returned from the laundry. R88 expressed uncertainty about whether a grievance form was filled out on their behalf. Interviews with facility staff revealed that the grievance process was not properly followed. Certified Nursing Assistant X acknowledged being informed by R88 about the missing items and verbally communicated this to the laundry staff but did not complete a grievance form. The Environmental Services Director indicated that all missing clothing items should be processed through the grievance system but was unsure if a follow-up was conducted with R88. The Nursing Home Administrator confirmed that no grievances related to the missing items were documented for R88, highlighting a failure in the facility's grievance handling process.
Failure to Assess Bed Bolsters as Potential Restraints
Penalty
Summary
The facility failed to assess the use of bed bolsters as potential restraints for two residents, leading to a deficiency in ensuring residents are free from physical restraints unless needed for medical treatment. Resident #63, who has schizoaffective disorder and unspecified dementia, was observed with bed bolsters that restricted their ability to get out of bed independently. The medical record did not reflect an assessment of the bolsters as restraints, and staff interviews indicated that the bolsters were used to prevent the resident from rolling out of bed, despite the resident's cognitive deficits preventing consistent removal of the bolsters. Similarly, Resident #25, with a history of falling, anoxic brain damage, and dementia, was observed with a positioning wedge and bolster that prevented them from getting out of bed. The resident's call light was out of reach, and the medical record lacked documentation of a restraint assessment. Staff confirmed that the bolsters and wedge were used to prevent falls, but the facility did not evaluate these as potential restraints. Interviews with the Director of Nursing and other staff revealed a lack of restraint assessments in the medical records for both residents. The facility's failure to assess the use of bed bolsters as potential restraints resulted in a deficiency, as the bolsters restricted the residents' freedom of movement without proper evaluation or documentation.
Delayed Completion of Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment in a timely manner for one resident out of 25 reviewed. The resident, who was admitted with a diagnosis of dementia, began hospice services on November 1, 2024, and ended these services on January 21, 2025. A Significant Change MDS assessment was initiated with an Assessment Reference Date of January 27, 2025, but was still in progress as of February 10, 2025, and was not completed until February 11, 2025. During an interview, the MDS Coordinator confirmed that the assessment was completed late, acknowledging that such assessments must be completed within 14 days of determining a significant change in the resident's condition, as per the Resident Assessment Instrument (RAI) Manual.
Deficiency in Providing Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for two residents, resulting in a deficiency. Resident #29, who has multiple medical conditions including acute and chronic respiratory failure, type 2 diabetes, and chronic obstructive pulmonary disease, was not assisted in participating in activities such as bingo, which she expressed a desire to attend. Despite being cognitively intact and dependent on all care, the staff did not facilitate her participation in activities, leaving her in bed during scheduled events. The care plan indicated that she should be reminded and assisted to attend activities, but there was no documentation of her participation in any activities over the last 30 days. Resident #49, who has severe cognitive impairment and multiple health issues such as cerebral infarction and end-stage renal disease, did not receive showers as preferred, instead receiving bed baths without hair washing. The resident expressed a desire for showers, but due to a broken shower bench, she was not provided with this option. The facility's records showed that she had not received a shower in the last 30 days, and oral care was documented at inappropriate times, such as during the middle of the night while she was sleeping. Additionally, there were discrepancies in the documentation of her ability to wheel herself in a manual wheelchair, which contradicted her assessed dependency on all care. The facility's failure to provide adequate care and assistance with ADLs for these residents resulted in a lack of engagement in activities and unmet personal care preferences. The staff's inaction and lack of proper documentation contributed to the residents not receiving the care needed to maintain their highest practicable well-being, leading to potential embarrassment and humiliation.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide meaningful and individualized activities for a resident, resulting in the potential for depression, boredom, and feelings of lack of self-worth. The resident, who was cognitively intact and dependent on all care, expressed a desire to participate in activities such as Bingo but was not assisted in getting out of bed in time to attend. Despite having a care plan that included reminders and assistance to attend activities, the resident was observed still in bed during a scheduled Bingo activity, and no staff member was seen assisting her to participate. Interviews with staff revealed a lack of communication and coordination in ensuring the resident's participation in activities. A CNA, unfamiliar with the resident's preferences, did not assist her in getting up for activities. The Activity Director acknowledged the resident's interest in participating but cited logistical challenges in getting her ready due to her need for a two-person mechanical lift. A review of the resident's records showed no documented participation in activities over the past 30 days, with staff only noting that the resident watched TV daily.
Failure in Nutritional Care and Weight Management
Penalty
Summary
The facility failed to honor dietary preferences and manage weight effectively for two residents, leading to deficiencies in nutritional care. Resident #79, who was cognitively intact and had a gastrostomy for nutritional support, experienced significant weight gain over several months. Despite the resident's preference for weight loss and maintenance, the facility did not adjust the tube feeding regimen or consult the physician about the weight gain. The Registered Dietitian noted the resident's overweight status and the presence of a stage four pressure ulcer, but the medical record lacked documentation of discussions with the resident or their responsible party about the risks and benefits of the current diet orders. Resident #374, who had severe cognitive impairment and was at risk for malnutrition, experienced a significant weight loss of 11.7% over one month. The resident's care plan was not updated with new interventions after this weight loss, and the facility failed to implement the recommendations from the nutritional progress notes. The resident's weight continued to decline, and the medical record did not reflect any new or additional preventive measures to address the ongoing weight loss. The Registered Dietitian at the time of the survey was unfamiliar with the resident's case and could not explain why the previous dietitian's recommendations were not fully implemented. The deficiencies highlight the facility's failure to provide adequate nutritional care and weight management for the residents, as evidenced by the lack of appropriate adjustments to dietary plans and insufficient communication with residents and their responsible parties. The facility did not take necessary actions to prevent weight gain in one resident and weight loss in another, resulting in unmet nutritional needs and preferences.
Failure to Monitor Dialysis Access Site and Update Care Plans
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for Resident #75, who required such services due to end-stage renal disease and dependence on renal dialysis. The resident reported that the nursing staff were not routinely monitoring their dialysis access site, which was located in their left arm. The resident also mentioned that they were on a fluid restriction, but there was no active physician's order for this in their medical record. The Kardex, which guides Certified Nurse Aides (CNAs) in providing care, did not reflect the resident's dialysis status, the location of their access site, or any related care considerations. Additionally, the resident's Medication Administration Record (MAR) for February 2025 did not include orders for monitoring or assessing the dialysis access site. Interviews with facility staff revealed inconsistencies and a lack of clarity regarding the resident's care needs. A CNA, who did not frequently work on the resident's floor, was unsure about the location of the dialysis access site and relied on the Care Plan and Kardex for guidance. The Registered Dietitian reported that the resident was not on a fluid restriction, contradicting the information provided by the Registered Nurse (RN) and the Director of Nursing (DON). The RN was unable to locate orders for monitoring the dialysis access site, and the DON acknowledged that the orders were discontinued after the resident's hospital visit and not reimplemented upon their return. The DON also stated that the expectation was for daily monitoring of the dialysis access site, which was not being documented as required.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R375, who was admitted with a diagnosis of cerebral infarction. Despite being cognitively intact and able to communicate his needs and frustrations, R375 was not provided with necessary personal items such as clothing, shoes, and cigarettes, which were left at a previous facility. R375 expressed extreme dissatisfaction with his current situation, including having a legal guardian he did not want and being unable to leave the facility. The resident's requests for basic supplies and communication with his guardian were not adequately addressed by the facility's social services or nursing staff. R375's medical record indicated that he refused meals, showers, therapy, and medications, expressing a desire to be discharged from the facility. The social services notes revealed that the resident's guardian was aware of his behaviors and was in the process of finding another placement for him. However, the facility did not take steps to reassess the need for guardianship, despite R375's mental capacity to make his own decisions. The social workers were aware of the resident's dissatisfaction but did not take effective action to resolve his concerns or advocate for his needs. Interviews with social workers indicated a lack of initiative in addressing R375's situation, as they relied on the guardian to provide the requested items and did not pursue a competency evaluation to reassess the guardianship. The resident's condition worsened to the point of expressing suicidal ideation, yet the facility's response remained inadequate. The guardian eventually agreed to bring the resident's items and meet him at the hospital, but the facility's failure to provide timely and appropriate social services contributed to the resident's distress and unmet needs.
Medication Administration Error Due to Improper Storage
Penalty
Summary
The facility failed to ensure the safe storage and administration of medications for one resident, resulting in a medication error. During a medication administration observation, a Registered Nurse (RN) was seen removing a pre-filled medication cup from the top drawer of her medication cart, which she had filled earlier with the resident's 8:00 AM medications. The RN did not include the resident's prescribed Lithium Carbonate Oral Capsule 150mg in the medication cup, leading to the resident missing their morning dose. This incident was confirmed during an interview with the Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNA), where the DON stated that the expectation is for medications to be pulled from the bubble pack and administered directly at the time they are due.
Failure to Honor Gluten-Free Diet for Resident
Penalty
Summary
The facility failed to honor the food preferences and dietary needs of a resident diagnosed with celiac disease, which requires a gluten-free diet. The resident, who was cognitively intact, expressed frustration with the meals provided, stating that the kitchen frequently substituted her meals with hot dogs and hamburgers, sometimes including a bun, which is not gluten-free. Despite having a diet order for a gluten-free diet with extra protein due to pressure ulcers, the resident reported that the dietician had not visited her since her admission, and her weight was trending down. Interviews with facility staff confirmed the resident's complaints. A Certified Nursing Assistant (CNA) acknowledged that the resident was often sent hot dogs or hamburgers and was growing tired of them. The Registered Dietician (RD) stated that meat should not be substituted for residents with a gluten-free diet, indicating a failure to adhere to the dietary requirements. The deficiency was identified through observation, interviews, and record reviews, highlighting the facility's failure to provide meals that accommodate the resident's dietary needs and preferences.
Failure in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to ensure proper collaboration and communication with the hospice provider for a resident receiving hospice services. The resident, who had been diagnosed with neuromyelitis optica and cerebral infarction, was admitted and readmitted to the facility and was receiving hospice care. Despite having a hospice visit calendar that scheduled 14 visits from hospice staff, the Hospice Staff Collaboration Log only noted four visits, and there were no progress notes pertaining to hospice visits in the Hospice Binder. Additionally, the resident's electronic medical record lacked documentation of hospice service visits, and their care plan did not reflect the hospice disciplines involved in their care. Interviews with facility staff revealed that hospice visit notes should have been available in the Hospice Binder and scanned into the electronic medical record, but this was not done. The Social Services Director reported coordinating hospice services, and the Director of Nursing confirmed that hospice visit notes were expected to be accessible to staff. An email request for the hospice visit calendar and communication log was made to the Nursing Home Administrator, but the hospice communication log was not provided before the survey exit.
Failure to Administer Pneumococcal Immunization
Penalty
Summary
The facility failed to administer a pneumococcal immunization to a resident, identified as R48, despite having received consent from the resident's Durable Power of Attorney (DPOA) for Healthcare. R48 was admitted to the facility with severely impaired cognitive skills for daily decision-making, as noted in the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/25. The medical record indicated that the pneumococcal immunization was not up to date, and although it was offered, it was initially declined. However, the Vaccine Consent and Administration Form showed that the DPOA consented to the immunization on 4/17/24. Despite this consent, the immunization was not administered. During an interview, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) acknowledged the consent but was unsure why the immunization had not been given.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, leading to deficiencies in their care. Resident #374 experienced a significant weight loss of 11.7% in one month, which was not reflected in their care plan. Despite being at risk for malnutrition due to their medical condition, no updates or additional interventions were made to the care plan after the weight loss and hospitalization. The Registered Dietician, who was new to the facility, was unable to provide an explanation for the lack of updates to the care plan. Resident #79's care plan did not reflect their preference to consume breakfast by mouth, despite receiving the majority of their nutrition through tube feeding. The resident reported gaining 20 pounds and consuming meals by mouth, but their tube feeding regimen had not been adjusted accordingly. The Director of Nursing acknowledged that the resident's meals should have been care planned, indicating a failure to update the care plan to reflect the resident's current nutritional preferences and needs.
Resident Burned Due to Unsafe Food Temperature
Penalty
Summary
The facility failed to ensure that hot food was served at a safe temperature, resulting in a resident suffering second-degree burns. The resident, a cognitively intact male with multiple health conditions including diabetes and chronic kidney disease, requested a CNA to heat a cup of noodles. The CNA heated the noodles in the microwave for 3-4 minutes and returned them to the resident without checking the temperature. The resident accidentally spilled the hot noodles on himself, causing burns to his abdomen, groin, and right thigh. The incident was not immediately reported to the necessary parties, including the physician, DON, and NHA. The initial response to the burn was inadequate, as the RN who assessed the resident did not apply appropriate first aid measures such as cooling the burn with water. Instead, petroleum jelly was applied, which is not recommended for acute burns. The incident was not documented in a timely manner, and the facility's policy on reheating food was not followed. Interviews with staff revealed a lack of training and awareness regarding the facility's policies on reheating food and immediate burn treatment. Several staff members, including CNAs and LPNs, were unaware of the correct procedures for checking food temperatures and providing first aid for burns. The facility's microwaves were not equipped with thermometers, and staff were not trained to use them prior to the incident. This lack of training and policy enforcement contributed to the resident's injury and the facility's failure to prevent the accident.
Delayed Physician Notification and Inadequate Burn Treatment
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, resulting in a delay in treatment of a burn and increased risk for pain and infection. The resident, a cognitively intact male with multiple medical conditions including diabetes and heart failure, accidentally spilled hot noodles on himself while eating in bed. The incident occurred when a CNA heated the noodles in a microwave for 3-4 minutes and returned them to the resident without checking the temperature. The resident suffered burns to his abdomen, groin, and right thigh. The incident was not reported to the physician, Director of Nursing, Nursing Home Administrator, or family member until over 15 hours later. Initial first aid was inadequate, as the RN who assessed the resident did not apply cool compresses or notify the physician immediately. The resident reported significant pain at the time of the incident, but this was not documented or addressed promptly. The facility lacked a clear policy for immediate burn treatment, and staff were not adequately trained in reheating food or responding to burn injuries. Interviews with staff revealed a lack of awareness and training regarding the facility's reheating policy and immediate response to burns. The microwaves were removed from resident floors after the incident, and staff were instructed to use a microwave in the staff breakroom. However, there was confusion about the appropriate temperature for serving food and the facility's policy on reheating. The facility's failure to provide timely and appropriate care for the resident's burns highlights deficiencies in staff training and communication protocols.
Failure to Provide Adequate Burn Care and Food Safety
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practical physical well-being of a resident, resulting in second-degree burns. The resident, a cognitively intact male with multiple health conditions including diabetes and hemiplegia, requested a CNA to heat a cup of noodles. The CNA heated the noodles in the microwave for 3-4 minutes and returned them to the resident, who was in bed. The resident accidentally spilled the hot noodles on himself, causing burns to his abdomen, groin, and right thigh. The incident was not immediately reported to the necessary parties, including the physician, Director of Nursing, and Nursing Home Administrator, until over 15 hours later. Initial first aid provided by the RN was inadequate, as it did not include cooling the burn areas with normal saline or cool cloths. The facility lacked a clear policy or training for immediate burn treatment, and staff were not educated on the proper procedures for heating and reheating food prior to the incident. Interviews with staff revealed a lack of awareness and training regarding the facility's reheating policy and immediate burn care. The CNA involved did not check the food temperature before serving it to the resident, and there was no thermometer available for staff use at the time. The facility's failure to follow its reheating policy and provide immediate and appropriate burn care contributed to the severity of the resident's injuries.
Failure to Notify Resident of Grievance Resolutions
Penalty
Summary
The facility failed to notify a resident of the investigation and resolution of grievances they had submitted. The resident, who was admitted with multiple diagnoses including cirrhosis of the liver, anxiety, and depression, was cognitively intact as indicated by a BIMS score of 15 out of 15. The resident expressed frustration during an interview, stating that they had submitted two concern forms regarding issues such as bathroom cleanliness, dietary requests, and roommate disturbances, but had not been informed of any resolutions. The grievance forms, dated in early July, documented that various managers had been notified and discussions had taken place to address the concerns. However, the forms did not indicate that the resident had been informed of these resolutions. The Nursing Home Administrator acknowledged that the computerized grievance system did not track whether residents were notified of the outcomes, and could not provide evidence that the resident had been informed or satisfied with the resolutions. The facility's grievance policy required a response to the resident, which was not demonstrated in this case.
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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