Villa At Borgess Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalamazoo, Michigan.
- Location
- 3057 Gull Road, Kalamazoo, Michigan 49048
- CMS Provider Number
- 235289
- Inspections on file
- 25
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Villa At Borgess Place during CMS and state inspections, most recent first.
A resident with multiple comorbidities and moderate cognitive impairment had an existing sacral pressure ulcer that rapidly progressed from stage 2 to a large unstageable ulcer with extensive slough and eschar, while a new facility-acquired unstageable dorsal sacral ulcer also developed and enlarged. Care plans noted potential and actual skin breakdown and referenced an alternating air mattress and repositioning, but corresponding physician orders for the pressure-reducing mattress were delayed, and no new interventions were added when the new wound developed. Documentation gaps included missing wound assessments, incomplete pressure injury evaluation forms, lack of timely treatment orders for the dorsal sacral wound, and absence of documented treatments on the TAR, even though the resident later presented with two unstageable sacral-area wounds and reported severe (9/10) pain.
A resident with severe cognitive impairment and multiple complex conditions, including chronic respiratory failure, COPD, vascular dementia, CHF, and lung cancer, required assistance with eating and was dependent for hygiene and other ADLs per the MDS. The resident’s family reported that the resident said he was not regularly receiving ADL care or meals. Review of the medical record showed multiple shifts with blank documentation for hygiene-related ADLs and missing entries for eating, with "NA" in place of required meal documentation on numerous evenings. The DON stated that CNAs are expected to complete and document ADLs each shift and to document eating after all meals, and confirmed that the blanks and "NA" entries did not demonstrate that ADL care or meals were provided.
A resident with multiple comorbidities and unstageable pressure injuries on the coccyx and sacral area underwent a dressing change during which staff did not fully adhere to infection control practices. While supplies were placed on a clean barrier and some hand hygiene and glove changes occurred, the wound nurse handled a phone to take wound photos, then proceeded with cleansing and dressing a second wound without clearly performing hand hygiene and glove changes between phone use and wound care, and placed the phone into a pocket without cleaning it. The DON later described an expectation for stepwise hand hygiene, glove changes, and phone disinfection for each wound, which was not followed during this observed procedure.
A resident with severe cognitive impairment, repeated falls, and therapy assessments showing impaired safety awareness and need for at least one-person assist for transfers and ambulation was identified as high risk for falls, but no fall-prevention care plan, transfer status, toileting program, or increased supervision interventions were implemented or communicated to CNAs via the Kardex. The resident, who did not use a call light and walked independently despite unsteadiness, was later found on the bathroom floor after an unwitnessed fall, with a head laceration and a blood trail from the bed to the bathroom, and was hospitalized with SAH and SDH. Staff and the DON confirmed that required fall-risk information and interventions were not entered into the care plan or Kardex until after the fall, despite a facility policy requiring identification of at-risk residents and implementation of individualized fall precautions and supervision.
A resident with hemiplegia and dependence for transfers was discharged home without effective discharge planning or documentation. The care plan called for coordinated discharge orders, home health and therapy referrals, and DME, but social services did not clearly assist with the insurance appeal process, did not document a comprehensive discharge plan, and did not arrange post‑discharge services. The family member reported receiving short‑notice of discharge, no caregiver education, no referrals for home health or outpatient therapy, and no help obtaining needed DME such as a wheelchair and hospital bed. Nursing staff were unaware of the exact timing of discharge and the ambulance left without the printed discharge paperwork. Therapy staff were not informed in time to complete a discharge assessment and stated the resident remained dependent with transfers and unsafe to stand. The discharge packet later found in a shred box was incomplete, lacking transportation details, instructions review, signatures, and key contact information, demonstrating that the resident was discharged without a safe, orderly, and well‑documented transition plan.
A facility failed to develop and implement a baseline care plan addressing fall risk for a newly admitted resident with sepsis, weakness, severe cognitive impairment (BIMS 4), insomnia, and a history of repeated falls. A fall assessment identified the resident as high risk, but no fall-prevention or transfer/ambulation assistance interventions were added to the care plan or Kardex within the first days after admission. The only early care plan focused on ADLs and feeding assistance, with no documentation of continence status or toileting program. Nursing and therapy staff later confirmed the resident required at least one-person assist for transfers and ambulation, but this was not documented until after an unwitnessed fall with major injury occurred. CNAs reported they were unaware the resident was a high fall risk, lacked clear guidance on assistance and toileting needs, and relied on an incomplete Kardex while the resident’s room door remained closed and checks were infrequent.
A resident with COPD and a recent history of influenza and persistent cough had PRN orders for Benzonatate (Tessalon) capsules and later Guaifenesin syrup, but the care plan did not reflect the respiratory diagnoses or ordered cough medications, and medication records showed multiple days when the ordered Tessalon was not administered despite availability. The resident reported repeatedly requesting Tessalon and being refused by an RN, who instead offered cough syrup and claimed there was no order, while other staff confirmed the resident’s frequent requests and upset over medication timing. Documentation showed the RN had administered Guaifenesin on several occasions but had not administered Tessalon, and a nurse manager acknowledged that the resident had a valid order for Tessalon and that it should have been given.
Two residents experienced a lack of dignity when one waited over an hour for call light assistance, resulting in incontinence and feelings of embarrassment, while another was observed moving through the facility with an uncovered Foley catheter urine bag, leading to emotional distress after being seen by an acquaintance. Staff interviews and documentation confirmed these lapses, and facility policy requiring privacy for catheter bags was not followed.
A resident admitted with a sacral fracture and an indwelling catheter did not have Enhanced Barrier Precautions (EBP) documented in the baseline care plan or Kardex within 48 hours of admission, despite facility policy and staff awareness that EBP was required. The omission was identified through observation, interviews, and record review, with EBP only added to the care plan five days after admission.
A resident with a history of hip fracture, malnutrition, and COPD did not receive physician-ordered laboratory tests to monitor anemia following surgery. Multiple orders for CBC, CMP, TSH, and FT4 were not completed as required, and staff interviews confirmed the labs were not drawn or documented. Nursing staff indicated that while labs were usually drawn weekly, it was their responsibility to complete them on other days if ordered, but this was not done.
A resident with a sacral fracture and an indwelling urinary catheter was admitted without corresponding physician orders for the catheter, and staff failed to provide timely catheter care, including emptying the urine bag. Interviews revealed that required admission order verification processes were not followed, and the facility's policy for catheter management was not implemented until several days after admission.
A resident with a PICC line for prolonged IV antibiotics did not have a documented physician order or monitoring instructions for the line. Staff were observed disconnecting IV tubing without proper documentation, and the resident reported needing a hospital visit to replace the IV. Facility staff demonstrated lack of knowledge regarding PICC line management, and required surveillance and documentation per facility policy were not followed.
A resident with a PICC line requiring enhanced barrier precautions did not receive care in accordance with facility policy, as an LPN was observed disconnecting IV tubing without wearing a gown. Both the care plan and facility policy required gown and glove use for such high-contact care, and staff interviews confirmed this expectation.
Two residents at risk for accidents were not adequately supervised, resulting in one resident eloping from the facility on multiple occasions despite being identified as a high elopement risk and having a wander alert device. Another resident, requiring supervision and a gait belt for ambulation, was repeatedly observed walking unassisted in hallways. Staff interviews revealed confusion about responsibilities for monitoring safety devices, inconsistent communication of care plan changes, and lack of proper documentation of incidents.
The facility failed to ensure complete and accurate documentation for several residents, including missing entries for medication and treatment administration, lack of incident and behavior reports after significant events such as elopement and inappropriate behaviors, and gaps in wound care documentation. Staff interviews confirmed that omissions in records were common and sometimes directed by management, leading to incomplete resident medical histories.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight by the facility.
The facility did not report two elopements and an abuse allegation to the State Agency within the required timeframe. In one case, a resident identified as an elopement risk was found outside the building without proper documentation or timely notification. In another case, a resident with dementia reported inappropriate touching by a visitor, but the incident was not reported to the State within the mandated two-hour window. Facility policy requires immediate reporting, which was not followed in these instances.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
Menus failed to consistently meet residents' nutritional needs, were not always prepared in advance or updated, and lacked regular review by a dietician, resulting in unmet dietary requirements.
Multiple residents reported receiving food items they were allergic to or disliked, and staff described frequent shortages of both main and alternate menu items, leading to unmet dietary needs and small portion sizes. Dietary staff were unable to consistently explain or implement portion control, and communication breakdowns between nursing and kitchen staff resulted in ongoing meal errors and resident dissatisfaction. Facility leadership was unaware of these widespread food service concerns.
Staff referred to residents requiring eating assistance as "feeders" in the presence of other residents and staff, including during care discussions and in the dining room. This language was used openly and could be overheard by the residents involved, some of whom had cognitive impairments and required assistance due to conditions like dysphagia or decreased strength. These actions did not align with the facility's policy on resident rights to dignity and respect.
A resident who was cognitively intact and required assistance with toileting was left in a soiled brief for an extended period, despite care plan instructions for regular checks. Multiple staff observed and reported the neglect, but leadership did not promptly investigate or report the incident as required by facility policy.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
Two residents did not receive necessary ADL assistance, including feeding support for a resident with dysphagia and supervision needs, and timely toileting care for another resident who was left in a soiled brief for several hours. Staff interviews and observations confirmed lapses in following care plans and inconsistent staff awareness of required interventions.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds or indwelling devices. One resident with an open wound lacked EBP signage and an isolation cart, while another with a nephrostomy tube had no signage. A third resident's EBP setup had empty hand sanitizers. The facility's EBP policy was not followed, risking cross-contamination.
A resident with a nephrostomy tube and orders for Enhanced Barrier Precautions did not have the required signage posted on the door to alert staff or visitors, despite the presence of an isolation cart with PPE inside the room. This was confirmed during observation and review by the unit manager.
A resident requiring Enhanced Barrier Precautions due to an indwelling catheter and pressure wound was observed to have an isolation cart with PPE and signage, but both hand sanitizer dispensers at the cart were empty. An LPN confirmed the dispensers were empty and noted housekeeping was responsible for refilling them, resulting in a failure to provide required hand hygiene resources at the point of care.
A resident without a diabetes diagnosis was mistakenly given insulin by an LPN, leading to dizziness and malaise. The error occurred due to a failure to follow medication administration protocols, including verifying the right patient and medication. Despite the facility's systems to prevent such errors, the nurse did not correctly identify the resident, resulting in the administration of insulin intended for another resident.
A facility failed to follow medication labeling standards when an LPN administered Lantus insulin from a pen that lacked an open date and expiration date. The pen, used for a resident, had approximately 80-90 units left and was not labeled correctly, compromising medication integrity. The LPN, who had used the pen the previous day, acknowledged the oversight and subsequently labeled a new pen before administering the medication.
A resident without diabetes was mistakenly given insulin by an agency LPN who had not received orientation or training at the facility. The error occurred because the LPN, working her first shift, administered the medication in the resident's room, where his name was on the door. The facility did not provide agency staff with necessary training or support, leading to the medication error and the resident experiencing dizziness and malaise.
A resident with a sacral pressure ulcer was not consistently monitored or assessed for wound care, leading to potential slow healing and new pressure ulcers. Despite being at high risk for skin breakdown, the resident lacked a specific care plan for wound and incontinence management. Observations and interviews revealed the resident was often left in soiled briefs and not repositioned as required, contributing to the deterioration of her wound.
The facility failed to use gait belts during transfers for two residents, R100 and R102, despite their care plans and facility policy requiring it. R100, with Parkinson's disease, and R102, with muscle weakness and a history of falls, were transferred without gait belts by CNA E and LPN L. Staff interviews confirmed the necessity of gait belts for safe transfers, yet they were not used, posing a risk of falls or injuries.
The facility failed to ensure proper infection control practices for two residents under Enhanced Barrier Precautions due to pressure ulcers. Staff, including a CNA and an LPN, did not wear gowns during care, despite CDC signage indicating the need for such precautions. Interviews revealed a lack of training and education on infection control practices, contributing to the deficiency.
The facility failed to maintain professional standards for food safety, with observations of debris accumulation on kitchen equipment and expired sanitizer test strips. The walk-in cooler, utensil bins, meat slicer, can opener, and Traulson cooler and freezer were all found with various forms of debris. Additionally, the facility lacked unexpired test strips to ensure proper sanitizer concentration, posing a risk of foodborne illness.
The facility failed to notify the State LTC Ombudsman of transfers and discharges since November 2019. Interviews revealed that the required notices were not sent, with the last notice dated November 2019. The facility's policy mandates that the social worker or designee provide these notices, which was not followed.
A resident with hemiplegia and frequent incontinence experienced long call light wait times and delays in incontinence care, leading to discomfort and a lack of dignity. Despite being cognitively intact and dependent on staff for toileting, the resident reported that staff did not change him as needed, and a CNA confirmed frequent complaints about these delays.
A resident with severe cognitive impairment and osteoarthritis was found without access to her call light, which was placed out of reach, contrary to her care plan and the facility's policy. This resulted in the resident's inability to call for staff assistance, as confirmed by both the resident and a chaplain. The facility's policy requires call lights to be within reach when residents are in bed or confined to a chair.
The facility failed to ensure a clean environment for two residents, resulting in soiled fans with dust buildup. One resident with respiratory issues had a dusty fan near her bed, and another resident with sleep apnea had a dusty fan blowing directly toward her. Housekeeping staff provided inconsistent information about cleaning procedures.
A resident with Parkinson's disease was repeatedly found wet and soiled, indicating potential neglect. The LPN-UM was informed of the situation but delayed reporting it to the NHA. The facility's abuse policy mandates timely reporting, which was not followed, risking continued neglect.
A resident with Parkinson's disease was found wet and soiled on multiple occasions, and the facility failed to report these allegations of neglect to the state agency in a timely manner. The LPN-UM and DON were aware of the situation, but the NHA did not report the allegations due to oversight, violating the facility's abuse policy.
The facility failed to implement care plan interventions for two residents, leading to potential unmet care needs. A resident with heart failure was observed eating without required assistance, despite a care plan and order for meal assistance. Another resident, severely cognitively impaired, was found without a necessary Roho cushion in his recliner, contrary to his care plan for pressure ulcer prevention. Staff interviews revealed a lack of awareness or understanding of these care plan requirements.
A facility failed to assess and treat a resident's skin condition, resulting in untreated open wounds and pain. The resident, with severe cognitive impairment and at risk for pressure ulcers, was observed with bleeding wounds on shins and arms, despite orders for regular skin checks and pain assessment. The lack of timely intervention and proper wound care led to ongoing discomfort and potential risk of infection.
A resident with pulmonary hypertension received incorrect oxygen flow rates and outdated tubing, contrary to physician orders. Facility staff confirmed the discrepancies, highlighting a failure to follow protocols for respiratory care.
A facility failed to document the indication for Zoloft use for a resident with anxiety, did not obtain consent or educate on risks/benefits, and lacked non-pharmacological interventions in the care plan. Staff interviews revealed confusion about the medication's purpose, and the facility could not provide necessary documentation, leading to potential unmet psychosocial needs and unnecessary medication use.
The facility failed to implement its policy on food storage for residents, leading to expired and improperly labeled food in a resident's personal refrigerator and a shared refrigerator. A resident, who was cognitively intact, reported a rotting smell from her fridge, which was found to be packed with undated or expired items. An LPN discarded several questionable items at the resident's request, but was unsure of the responsibility for checking and cleaning the food. The Unit Manager acknowledged the issue and planned to develop a new process.
A resident with severe cognitive impairment and a stage 3 pressure ulcer received inadequate infection control during a wound dressing change. An RN failed to perform proper hand hygiene and glove changes, handled soiled and clean items without changing gloves, and used gloves with artificial nails that broke through. These actions were against the facility's infection control protocols.
A resident with hypertensive heart disease and heart failure was not administered the pneumococcal vaccine despite being eligible and expressing a desire to receive it. The facility failed to assess and administer the vaccine, as confirmed by the Infection Preventionist, resulting in a deficiency in vaccination protocol.
The facility failed to offer COVID-19 vaccinations to three residents, increasing the risk of infection. A resident with heart disease was not vaccinated despite wanting the vaccine, while another with heart failure was not offered the vaccine in 2023. A third resident with respiratory failure, who declined the vaccine in 2022, was not re-offered it in 2023, and no updated consent form was completed. The facility could not provide documentation verifying vaccine offers.
Failure to Provide Adequate Pressure Ulcer Prevention and Treatment for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to promote healing of existing pressure ulcers and to prevent the development of new pressure ulcers for one resident. The resident was admitted with multiple medical conditions including circulatory system aftercare, muscle disorder, gait difficulty, abnormal posture, cognitive and communication deficits, dysphagia, atherosclerotic heart disease, hypertension, GERD, IBS, overactive bladder, constipation, PVD, pneumonia, urinary retention, osteoarthritis, mild cognitive impairment, hyperlipidemia, and osteoporosis. An MDS with an ARD of 03/26/2026 documented moderate cognitive impairment (BIMS 9/15) and one unstageable pressure ulcer on admission. On observation, the resident reported having a coccyx wound and another wound on the left buttock, describing severe pain rated 9/10, while lying on a bed with an air mattress pump that appeared operational. Record review showed that on 03/22/2026 the sacral wound was documented as a stage 2 pressure ulcer measuring 0.7 cm by 0.5 cm by 0.2 cm with 100% epithelial tissue. By 03/23/2026, the same area was documented as an unstageable pressure ulcer measuring 2.0 cm by 1.3 cm by 0.2 cm with 60% slough. By 03/30/2026, the unstageable sacral ulcer had enlarged to 6.8 cm by 5.0 cm by 0.2 cm (34.00 cm²) with 60% slough, and by 04/13/2026 it had further progressed to 8.5 cm by 8.5 cm by 0.10 cm (72.25 cm²), with no documented evaluation of intact skin or slough. A separate dorsal sacral wound, documented as facility-acquired, was first recorded on 04/07/2026 as an unstageable pressure ulcer measuring 2.8 cm by 2.2 cm by 0.10 cm with 90% non-granulation tissue and 10% slough, and by 04/13/2026 had increased to 4.2 cm by 2.7 cm by 0.10 cm (11.24 cm²). A wound PA note on 04/13/2026 described the dorsal sacral wound bed as having 100% slough with no eschar or epithelization. The facility’s care planning and orders did not reflect timely or adequate interventions for these wounds. A care plan problem for potential skin breakdown related to mobility deficits, initiated 03/20/2026, included use of an alternating air mattress and assistance with turning and repositioning, but the DON later confirmed that an order for the alternating pressure mattress was not written until 04/07/2026, despite it being listed on the care plan since 03/20/2026. A new care plan problem for actual skin breakdown related to the coccyx, initiated 04/20/2026, contained no interventions to treat or prevent further decline of the wound or prevent additional breakdown. Another problem statement for a pressure ulcer to the sacrum, initiated 04/07/2026, did not include new interventions after the development of the new wound. A Pressure Injury Unavoidable Evaluation dated 04/07/2026 listed risk factors such as immobility, chronic bowel incontinence, chronic heart disease, and weight loss/poor nutrition, but the weight loss section was not completed and the physician signature line was blank. Physician orders for coccyx wound care were present from 03/21/2026 through 04/15/2026, with changes in cleansing solutions and dressings, but no order was found for treatment of the lateral/dorsal sacral wound when it was identified on 04/06/2026. The DON was unable to provide documentation of interventions in place prior to the development of the dorsal sacral wound and could not provide an order for treatment of that wound at the time it developed. On review of the medical record on 04/21/2026, no active wound treatment orders were found for the resident’s wounds, and the April TAR did not show that any treatment had been completed for the dorsal sacral wound. During observed wound care on 04/21/2026, the dressing removed from the buttock was dated 04/20/2026 and covered both the coccyx and left dorsal sacral wounds; both wounds appeared unstageable with eschar present, and the wound nurse assessed approximately 65% eschar in the dorsal sacral wound and 85% eschar in the coccyx wound, with the coccyx wound measuring 10.0 cm by 9.0 cm by 1 cm. The resident continued to report severe pain associated with these wounds.
Failure to Provide and Document ADL and Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide and document ADL care, including hygiene and eating assistance, for a resident with extensive care needs. The resident was admitted with multiple serious diagnoses, including chronic respiratory failure, COPD, type 2 diabetes, staphylococcal arthritis in the left shoulder and right knee, metabolic encephalopathy, vascular dementia with agitation, PVD, CHF, lung cancer, and chronic kidney disease. An MDS assessment dated 01/14/2026 showed a BIMS score of 6, indicating severe cognitive impairment, and documented that the resident required partial/moderate assistance with eating and was dependent for oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, footwear, and all transfers. The resident’s family member later reported that the resident stated he was not receiving regular ADL assistance or meals. Record review showed multiple shifts where the plan of care documentation for ADL/GG hygiene (oral, toileting, personal) was blank, including on 01/11/2026 (6 a.m.–6 p.m.), 01/12/2026 (6 a.m.–6 p.m.), 01/15/2026 (both 6 a.m.–6 p.m. and 6 p.m.–6 a.m.), 01/16/2026 (6 a.m.–6 p.m.), 01/17/2026 (6 a.m.–6 p.m.), 01/24/2026 (6 a.m.–6 p.m.), and 01/31/2026 (6 p.m.–6 a.m.). Documentation for eating (ability and percentage eaten) was also blank for the 9 a.m. and 1 p.m. meals on multiple dates, and “NA” (nonapplicable) was entered for the 6 p.m. meal on numerous dates. The DON stated that CNAs work 12-hour shifts (6 a.m.–6 p.m. and 6 p.m.–6 a.m.), that ADL tasks including hygiene are expected to be completed and documented each shift, and that documentation for eating is expected after all meals. The DON confirmed the blanks and “NA” entries in the record and acknowledged that such documentation did not demonstrate that ADL services or meals were provided to the resident at those times.
Failure to Follow Infection Control Practices During Wound Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to follow acceptable infection prevention and control procedures during clean dressing changes for one resident with pressure injuries. The resident had multiple medical conditions, including circulatory system surgical aftercare, muscle disorder, difficulty walking, cognitive and communication deficits, dysphagia, atherosclerotic heart disease, hypertension, GERD, IBS, overactive bladder, constipation, PVD, pneumonia, urinary retention, osteoarthritis, mild cognitive impairment, hyperlipidemia, and osteoporosis. An MDS assessment showed moderate cognitive impairment and one unstageable pressure ulcer on admission, and at the time of observation the resident reported a coccyx wound and another wound on the left buttock. During the observed dressing change, staff prepared supplies on a clean barrier, and the RN and CNA performed peri care and incontinence care, then removed soiled gloves and sanitized hands before exposing the wounds, which appeared as unstageable wounds with eschar on the coccyx and left sacral area. The wound nurse then performed wound care but did not consistently follow the infection control steps described by the DON as professional practice. After sanitizing hands and donning gown and gloves, the wound nurse took a picture of the left dorsal sacral wound, removed gloves, sanitized hands, and replaced gloves, then cleansed and dressed the wound. The wound nurse then picked up the phone to take a picture of the coccyx wound, removed gloves, and proceeded to cleanse the coccyx wound and apply the ordered dressing without mention of hand hygiene or new gloves between handling the phone and cleansing the second wound. The wound nurse then placed the phone used for wound pictures into a pocket without cleaning it before removing gloves and gown and sanitizing hands. The DON later described that expected practice for a clean dressing change included removing soiled gloves, sanitizing hands, and donning new gloves between each step for each wound, obtaining wound pictures and measurements with glove changes and hand hygiene, and sanitizing the phone before placing it on a barrier, indicating that the observed practice did not follow the facility’s stated infection control procedures.
Failure to Implement Fall-Prevention Interventions and Supervision for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions for increased supervision and assistance for a resident assessed as high risk for falls, resulting in an unwitnessed fall with head laceration and subsequent hospitalization for SAH and SDH. The resident was admitted with diagnoses including sepsis, weakness, cognitive deficit, insomnia, and a history of repeated falls. A BIMS score of 4 indicated severe cognitive impairment. A fall risk assessment completed shortly after admission identified the resident as high risk for falls with a score of 24, noting intermittent confusion, recent hospitalization, and wheelchair confinement with disorientation; however, the mobility status documented on the assessment was not an accurate reflection of the resident’s actual status. Despite the high fall risk assessment, there was no fall prevention care plan or care plan addressing the resident’s high risk for falls in place until after the resident experienced a fall and was discharged to the hospital. The ADL care plan initiated shortly after admission only addressed assistance with daily care needs related to general weakness and included an intervention for direct feeding assistance; other interventions, including those related to transfer assistance and fall risk, were not added until after the fall. The record did not document whether the resident was continent or incontinent or whether a toileting program was in place. Staff interviews confirmed that the baseline care plan developed within 24 hours of admission did not include high fall risk status, fall prevention interventions, or the level of assistance needed for transfers and ambulation, and that this information was not carried over to the CNA Kardex. On the morning of the incident, a CNA found the resident on the bathroom floor in a puddle of blood and emesis, with a blood trail from the bed to the bathroom and bleeding from the head. The fall was unwitnessed, and the resident was unable to describe what had happened or localize pain. Nursing staff observed a head laceration and arranged for transfer to the hospital, where records documented a right scalp laceration and diagnoses of SAH and SDH after being found down at the facility. Interviews with CNAs and therapy staff indicated that the resident was unsteady, did not use the call light, walked on her own, and required at least one-person assistance for safe transfers and ambulation, but the CNAs were not aware she was a major fall risk because there were no fall-risk indicators in the room and the Kardex lacked this information. The facility’s fall policy required that residents at risk for falls be identified and individualized fall precautions implemented, including appropriate supervision and management of incontinence/toileting, but these measures were not implemented for this high-risk resident prior to the fall. Additional information from interviews further supported that the resident’s high fall risk and need for assistance were known but not translated into care planning and supervision practices. The DON reported that nursing had assessed the resident as high risk for falls upon admission and therapy had determined she required at least one assist for transfers and ambulation, yet this was not documented in the care plan or Kardex until after the fall. The DON also stated that the care plan is supposed to carry over direct care needs to the Kardex, which CNAs rely on to determine resident needs, and acknowledged that the resident should have had frequent checks and should not have been ambulating alone. Family reported that the resident had multiple falls at home and did not understand she was unsafe to walk independently. Therapy evaluations documented impaired safety awareness, severely impaired decision-making, and the need for partial/moderate assistance with transfers and ambulation, reinforcing that the resident required supervision and assistance that were not implemented before the fall. The facility’s written fall policy, "Fall Evaluation Safety Guideline," required completion of a fall risk evaluation, implementation of resident-specific interventions when risk is identified, and initiation and revision of a fall care plan with appropriate interventions such as environmental evaluation, applied supervision, and management of incontinence/toileting. In this case, although the resident was evaluated and identified as high risk for falls, the required individualized fall precautions and care plan interventions were not put into place prior to the unwitnessed fall. This lack of timely care planning, communication of transfer and ambulation needs to direct care staff, and implementation of increased supervision and assistance for a known high-risk resident led to the deficiency cited under the requirement to ensure the environment is free from accident hazards and that adequate supervision is provided to prevent accidents.
Failure to Conduct and Document Safe, Coordinated Discharge Planning to Home
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process to ensure a safe and orderly discharge for one cognitively intact resident who was dependent for transfers and required extensive assistance. The resident had diagnoses including aftercare following joint replacement, an artificial left knee joint, and hemiplegia/hemiparesis following a cerebral infarction affecting the left dominant side. His care plan identified him as a short‑term stay resident with good discharge potential and included interventions such as coordinating physician orders for discharge, arranging home health and equipment, evaluating discharge potential, and ensuring discharge to a safe environment with ongoing services. Despite these documented expectations, the facility did not carry out the planned interventions or document a comprehensive discharge needs assessment and plan in the medical record. On 2/20, the business office and MDS staff received notice that the resident’s last covered day would be 2/22, and the resident was served a Notice of Medicare Non‑Coverage, which he signed. The social services staff member, who was new and minimally trained, believed the resident’s signature only confirmed understanding of appeal rights and did not recall discussing specific discharge plans, in‑home services, or outpatient therapy with the resident or his family. The family member reported believing that signing the form constituted an appeal and attempted to contact the insurer, but later learned the appeal had not been properly initiated. The facility’s business office manager discussed private‑pay costs with the family member and stated that, because there was no appeal on record, the resident would have to discharge or pay cash. The family member reported that social services did not assist with understanding or initiating the appeal process, despite the facility policy stating that residents would not be discharged while an appeal was pending and that social services would assist with appeals. On the day of discharge, the family member was notified that the resident would be leaving within about an hour, expressed anxiety about the discharge, and reported not having transportation arranged. She requested to borrow a wheelchair and was denied any assistance from the facility. She then packed the resident’s belongings, called an ambulance, and left to prepare the home, arranging for neighbors to help when the resident arrived. Nursing staff reported that an LPN took over care shortly before the end of her shift, was told the resident was packed and ready to discharge, and did not have any discharge conversations with the resident or family; she later learned from a CNA that the resident had already left and documented that the ride did not receive the printed discharge paperwork. Therapy staff stated they were not informed in time to complete a discharge assessment or plan, and that the resident remained dependent with transfers and not safe to stand, with no discussions about the family’s ability to care for him at home. The discharge packet later found in a shred box contained incomplete documentation, including blank sections for method of transportation, discharge instructions review, staff and resident signatures, and contact information, and there were no progress notes documenting discharge discussions beyond a single note about the family’s anxiety. The family member reported receiving no caregiver education, no referrals for home health or outpatient therapy, and no assistance obtaining DME, and stated it took about a week after discharge to obtain a wheelchair and hospital bed while the resident remained in bed at home. The facility’s written policy required that staff work with the physician to obtain adequate documentation for discharge, provide preparation and orientation to the resident and family, assist with appeals, and document the resident’s health status, discharge needs, and discharge plan, including services to be provided after discharge. It also required that residents not be discharged while an appeal was pending and that appropriate education and instructions be provided for a safe care transition. In this case, the NP’s last visit note did not mention discharge, and the recapitulation of stay and discharge documents lacked key clinical and contact information, special instructions, and confirmation that instructions were reviewed with the resident or representative. Interviews with the DON and other staff confirmed that social services were responsible for the discharge process and documentation, yet the record contained almost no documentation of discharge planning, no evidence of coordination of home services or DME, and no evidence that the resident and family were adequately prepared or oriented for discharge. These actions and omissions resulted in the resident being discharged to the community without a confirmed capable caregiver in place and without necessary DME available at the time of discharge.
Failure to Develop Baseline Fall-Prevention Care Plan for High-Risk New Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan addressing a resident’s high risk for falls within the required timeframe after admission. The resident was admitted with diagnoses including sepsis, weakness, cognitive deficit, insomnia, and a history of repeated falls. A BIMS score of 4 indicated severe cognitive impairment. A fall assessment completed shortly after admission identified the resident as high risk for falls with a score of 24, noting intermittent confusion, recent hospitalization, and wheelchair confinement with disorientation, although the mobility status documentation was not accurate. Despite these findings, no baseline care plan interventions were created to address fall risk, fall prevention, or the level of assistance needed for transfers and ambulation within the first days after admission. The record showed that the only care plan initiated shortly after admission was an ADL care plan indicating the resident required assistance with daily care needs related to general weakness/debility and direct feeding assistance, with other ADL interventions not added until after the fall. There was no documentation in the care plan or record indicating whether the resident was continent or incontinent or whether a toileting program was in place. The fall prevention care plan and additional ADL interventions, including the resident’s transfer needs, were not developed until after the resident experienced a fall and was discharged to the hospital. The DON confirmed that the resident had been assessed as high risk for falls upon admission and that therapy had determined the resident required at least one-person assistance for transfers and ambulation, but this information was not entered into the care plan or Kardex until after the incident. Staff interviews further demonstrated that direct care staff did not have clear guidance on the resident’s fall risk status or required assistance level. The RN manager stated that a baseline care plan had been developed within 24 hours of admission but did not include high fall risk, fall prevention interventions, or transfer/ambulation assistance needs, and acknowledged the importance of having transfer needs on the baseline care plan so staff know how to care for the resident. One CNA reported that the resident was able to get out of bed and walk but was unsteady and that she did not consider the resident a major fall risk because there were no fall-related signs or equipment in the room and no indication for frequent checks. Another CNA reported not knowing the resident’s continence status, that the resident could not communicate toileting needs, that the door remained closed all night, and that the last check occurred several hours before the fall. The DON stated that the care plan information should carry over to the Kardex for CNA use and acknowledged that the resident’s fall care plan and transfer status were missing until after the fall, which occurred four days after admission.
Failure to Administer Ordered PRN Cough Medication per Physician Orders and Resident Requests
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received medications in accordance with professional standards and physician orders. The cognitively intact resident, admitted with chronic bronchitis/COPD and recovering from influenza, had physician orders for PRN Benzonatate (Tessalon) capsules for cough and later for PRN Guaifenesin syrup. The care plan did not document the resident’s chronic bronchitis, COPD, cough, or related physician-ordered medications. Medication administration records showed Benzonatate was ordered twice over specified time frames and was not administered on several days when it was available and ordered, including multiple missed days during the second order period. None of the administered Benzonatate doses were initialed by the RN later implicated in the complaint. During interviews, the resident reported repeatedly requesting Tessalon on multiple days and being told he could not have it, stating that an RN became defensive, refused to give the ordered Tessalon, and instead offered cough syrup. Another LPN confirmed the resident had a persistent cough, regularly requested Tessalon, and that the medication was stored in the cart and not unavailable. A CNA reported the resident frequently became upset about not receiving medications on time. The RN in question stated the resident frequently requested Tessalon but claimed there was no order for it, did not notify the physician, and did not recall administering cough syrup, despite records showing she had administered Guaifenesin on three occasions. The nurse manager confirmed there was an issue with this RN not honoring the resident’s request for cough medication, that the resident had a valid physician order for Tessalon, and that the medication was available and should have been administered. A provider visit note documented the resident’s multiple complaints about medications and timing following treatment with Tessalon and Tamiflu for influenza A and ongoing intermittent dry cough.
Failure to Maintain Resident Dignity Due to Delayed Call Light Response and Lack of Privacy for Catheter Bags
Penalty
Summary
The facility failed to maintain resident dignity for two cognitively intact female residents. One resident, who had a fractured hip, malnutrition, and COPD, experienced extended call light response times, with documented waits of up to 1 hour and 28 minutes. During these delays, the resident was unable to access timely assistance, resulting in an episode of incontinence. The resident expressed embarrassment, humiliation, and frustration, and apologized to staff for being a bother. Staff interviews and call light logs confirmed the prolonged response times, and the concern was also documented in a grievance form submitted by the resident's family. Another resident, admitted with a sacral fracture and requiring an indwelling Foley catheter, was observed without a privacy covering on her urine collection bag while moving through the facility. The resident reported feeling embarrassed and humiliated after encountering an acquaintance while her urine bag was visible. Observations confirmed the absence of a privacy bag, and staff interviews acknowledged that all urine collection bags should be covered to promote privacy. The facility's own policy required drainage collection devices to be covered to ensure dignity, but this was not followed in the resident's case.
Failure to Develop Timely Baseline Care Plan Including Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident who was admitted with a minimally displaced zone 1 sacral fracture and required an indwelling catheter. Upon review, there was no documentation of Enhanced Barrier Precautions (EBP) in the resident's care plan or Kardex, despite signage on the resident's door and staff awareness that EBP was required due to the indwelling catheter. Interviews with staff confirmed that EBP should have been included in the baseline care plan, but it was not documented until five days after admission. The resident was cognitively intact, as indicated by a perfect BIMS score, and was aware that staff sometimes wore gowns when providing care but did not know the reason. Facility policy requires the interdisciplinary team to collect and record data for the admission baseline care plan within 24 hours and to develop and implement the baseline care plan within 48 hours of admission. The lack of timely documentation and implementation of EBP in the baseline care plan resulted in the potential for unmet care needs for the resident.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure that professional standards of nursing practice were maintained by not following physician orders for laboratory diagnostic testing for one resident. The resident, a cognitively intact female admitted with a fractured left hip, malnutrition, and COPD, had multiple physician orders for laboratory tests including CBC, CMP, TSH, and FT4 to monitor a new condition of anemia following surgery. These orders were entered on several occasions by both a nurse practitioner and a medical doctor, specifying that the labs were to be completed on certain dates and results reported to the provider. Despite these orders, review of the Medication Administration Record (MAR) and electronic MAR showed no documentation that the required labs were completed as ordered. Interviews with nursing staff, including LPNs, an RN, the Nurse Manager, the DON, and the Regional Nurse Consultant, confirmed that the labs were not drawn on the specified dates and that no results could be located. Staff reported that while labs were typically drawn weekly by a lab nurse, it was the responsibility of facility nurses to draw labs on other days if ordered. The failure to complete the ordered laboratory testing resulted in the facility not meeting professional standards of quality for nursing services.
Failure to Ensure Proper Indwelling Catheter Management and Physician Orders
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter for one resident. Upon admission, the resident, who had a minimally displaced sacral fracture and was cognitively intact, was observed with a urinary catheter and collection bag. However, there were no physician orders in place for the indwelling catheter at the time of admission, and the care plan referenced catheter care without corresponding medical orders. The resident reported not knowing why she had a catheter and stated that her urine bag was not emptied for the first few days, suggesting a lack of awareness and attention from staff regarding her catheter care needs. Interviews with nursing staff and management revealed that the process for verifying and entering admission orders was not followed, resulting in the absence of required physician orders for the catheter. Staff members acknowledged that orders should have been in place and that nurse managers were responsible for verifying their accuracy. The facility's policy required evaluation and documentation of medical necessity for indwelling catheters upon admission, as well as corresponding physician orders, but these steps were not completed for this resident until several days after admission.
Failure to Ensure Proper PICC Line Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of a Peripherally Inserted Central Catheter (PICC) for a resident who required prolonged intravenous antibiotic therapy. Observation revealed that an LPN disconnected IV tubing from the resident's PICC line, but there was no documented physician order for the PICC line or for monitoring the site. The resident reported having to return to the hospital to have the IV line replaced and indicated that the dressing on the PICC line was last changed at the hospital several days prior. Review of the nursing admission record noted the presence of an IV but lacked specific details such as size, length, and arm circumference. Additionally, a transfer note documented redness and swelling around the PICC site, which prompted a hospital transfer. Interviews with facility staff revealed a lack of knowledge regarding the need for physician orders for PICC lines and the appropriate frequency for dressing changes. The Nurse Manager was unsure about the requirements for PICC line orders and dressing change intervals, while the Director of Nursing stated that orders should be in place for both the PICC line and its monitoring, and that dressings should be changed every 7 days. Facility policy required regular surveillance and documentation of the PICC site, including dressing changes every 5 to 7 days and monitoring for signs of infection, but these practices were not followed or documented for the resident.
Failure to Follow Enhanced Barrier Precautions During PICC Line Care
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during care activities requiring enhanced barrier precautions (EBP) for a resident with a PICC line. Observation revealed that signage outside the resident's room indicated EBP were in place, requiring staff to wear a gown and gloves during high-contact care. Despite this, an LPN was observed disconnecting IV tubing from the resident's PICC line without wearing a gown. The resident's care plan and physician orders both specified the need for EBP due to the presence of the PICC line. Interviews with the LPN, Nursing Home Administrator, and Director of Nursing confirmed that the expectation was for staff to wear appropriate PPE, including a gown, when providing care involving the PICC line. The facility's policy also required gown and glove use for high-contact activities such as central line care. The LPN acknowledged not wearing a gown during the procedure and recognized this was not in compliance with the established precautions.
Failure to Prevent Elopement and Inadequate Supervision for Residents at Risk of Accidents
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. One resident, with diagnoses including Parkinson’s disease, metabolic encephalopathy, and a history of hallucinations and wandering, was identified as an elopement risk. Despite being assessed as high risk for elopement and having interventions such as a wander alert device and room relocation, the resident was able to exit the building unsupervised on at least two occasions. Staff interviews revealed confusion about responsibilities for monitoring wander alert devices, inconsistent use and checking of the devices, and lack of proper documentation of elopement incidents in the resident’s medical record. The facility also lacked a systematic approach to ensure that all exit doors were properly alarmed and that alarms were audible to staff, with maintenance checks being inconsistently documented and no plan for checks during off-hours. Another resident, who was cognitively intact but had reduced mobility and required supervision and a gait belt when ambulating, was repeatedly observed walking unassisted in the hallway with a walker and without a gait belt. Staff were not consistently providing the required supervision, and there was a lack of direct observation during ambulation. Interviews with staff indicated a lack of awareness of the resident’s current care plan requirements, with some staff believing the resident was independent based on observation rather than documented care plans or therapy recommendations. The care plan and Kardex specified that the resident required stand-by assistance and a gait belt, but this was not consistently followed. Communication breakdowns between therapy, nursing, and direct care staff contributed to the deficiencies. Therapy staff reported challenges in ensuring that updated transfer and ambulation status information was communicated to nursing staff, and nursing staff reported that care plan changes were not always effectively communicated. Staff turnover and unclear assignment of responsibilities for safety device checks further contributed to the lack of consistent supervision and hazard mitigation for residents at risk of accidents or elopement.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as evidenced by missing documentation in medication and treatment administration records, as well as the absence of incident and behavior reports. For one resident with significant medical needs, including paralysis, stroke, and tube feeding, there were several instances where administration of medications, pain assessments, insulin, blood sugar checks, and wound care were not documented in the Treatment Administration Record (TAR). Interviews with nursing staff and management confirmed that if documentation was missing, it was assumed the care was not provided, and that such omissions could have significant consequences for the resident's health. In another case, a resident with a history of sexually inappropriate behavior and listed on the sex offender registry was placed on 1:1 observation after an incident involving another resident. However, there was no documentation in either resident's chart regarding the incident, nor were there any behavior notes or incident reports completed. Staff interviews revealed a lack of clarity about the incident and the required documentation, and social services staff were unaware of the event due to the absence of records. The facility administrator acknowledged the lack of documentation and incident reports for these events. Additionally, a resident identified as an elopement risk was observed by staff and family to have left the building on at least two occasions, but there was no documentation of these elopements in the resident's medical record or any incident reports. Staff interviews indicated that management instructed them not to document the incident in the electronic medical record. Another resident with complex wound care needs had multiple gaps in documentation for wound treatments, repositioning, and use of protective devices, as well as oral suctioning. Nursing management confirmed that all such care should be documented, and if it was not, it was considered not done.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all forms of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Timely Report Elopements and Abuse Allegation
Penalty
Summary
The facility failed to report two elopements and an allegation of abuse to the State Agency in a timely manner for two residents. One resident, who was cognitively intact but identified as an elopement risk with a history of wandering, exited the building on at least two occasions. On one occasion, the resident was found alone outside, approximately 100 feet from the emergency exit, without her walker. Staff who witnessed the incident reported being instructed by the Nursing Home Administrator and Director of Nursing not to document the event in the electronic medical record. The incident was not reported to the State Agency, and there was no documentation or signed staff interviews related to the event in the resident's medical records. Another resident, with diagnoses including Alzheimer's disease and psychotic disorder, reported to her nurse that she had been inappropriately touched by a visitor. The facility's incident report indicated that the allegation of abuse was discovered in the evening and not reported to the State Agency until the following morning, exceeding the required two-hour reporting window. The former Nursing Home Administrator could not recall the details of the reporting process but confirmed that such allegations should be reported within two hours. Facility policy requires immediate reporting of abuse, neglect, or mistreatment to the State Agency, but in these cases, the required notifications were not made within the mandated timeframe. The lack of timely reporting and documentation resulted in the potential for ongoing mistreatment and unreported incidents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met according to their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Failure to Honor Resident Food Preferences, Allergies, and Portion Sizes
Penalty
Summary
The facility failed to consistently honor resident food preferences, allergies, and portion size requirements, as evidenced by multiple resident and staff interviews, observations, and record reviews. Several residents reported receiving food items they were allergic to or disliked, such as one resident with a cinnamon allergy being served food containing cinnamon, and others receiving disliked items like chocolate or pears. Residents also reported that their specific dietary needs, such as requests for no sugar or large breakfast portions, were not met, and that meal tickets were not always accurately completed or followed by kitchen staff. Staff interviews revealed ongoing issues with the kitchen frequently running out of both main and alternate menu items, resulting in residents not receiving their preferred or required foods. Dietary staff admitted to not always having the necessary food items due to incomplete deliveries and restrictions on purchasing missing items locally. There was also a lack of clarity and consistency in portion control, with dietary aides unable to explain or demonstrate how portion sizes were determined, leading to residents receiving insufficient amounts of food. Nursing and dietary staff described communication breakdowns and difficulties in correcting meal errors, further contributing to resident dissatisfaction. Residents and their representatives consistently voiced concerns about small portion sizes, lack of alternate menu options, and being served foods they could not or did not want to eat. These issues were corroborated by staff observations and interviews, which highlighted that residents were often left without adequate or appropriate meal choices. Facility leadership, including the NHA and DON, were unaware of the extent of these food service concerns at the time of the survey.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Staff failed to ensure that three residents were cared for with dignity and respect during daily care and meal assistance. Specifically, staff members repeatedly referred to residents who required assistance with eating as "feeders" in the presence of other residents and staff. For example, a CNA and an RN discussed which residents were "feeders" within earshot of a resident, and an LPN referred to another resident as a "feeder" outside the resident's room, where the resident could potentially hear. Additionally, during a dining observation, a CNA training a new staff member identified a resident as a "feeder" in a loud voice in the dining room, in front of other residents and staff. The residents involved had varying degrees of cognitive impairment, with two being severely cognitively impaired and one cognitively intact. Their care plans indicated the need for assistance with eating due to conditions such as dysphagia and decreased strength. The facility's own policy emphasized the right of residents to be treated with respect and dignity at all times, but the observed staff actions did not align with this policy, resulting in a failure to honor residents' rights to a dignified existence and self-determination.
Failure to Timely Identify and Report Resident Neglect
Penalty
Summary
Staff failed to fully implement the facility's abuse and neglect policy by not promptly identifying and reporting an allegation of neglect involving a resident who was cognitively intact and required assistance with activities of daily living, specifically toileting. The resident was found in a soiled brief with bowel movement that had not been changed since early morning, despite the care plan indicating that checks and changes should occur every two hours. Multiple staff members, including CNAs and LPNs, observed and reported the resident's condition, noting that the brief was marked with a time indicating it had not been changed for several hours and that the resident had not received assistance throughout the day. Interviews revealed that concerns about the responsible CNA's failure to provide timely care were communicated among staff, with reports made to the nurse manager and the DON. The DON was informed of the situation but did not conduct a thorough investigation or speak directly with the resident or all involved staff. The administrator was notified later and was under the impression that the issue had been addressed, without recognizing the need for further investigation or reporting. The facility's abuse policy requires immediate reporting of suspected abuse or neglect to the administrator, with subsequent investigation and reporting to state agencies as mandated. In this case, the policy was not followed, as the allegation of neglect was not promptly reported or investigated, and key details about the resident's condition were not communicated to leadership. This resulted in a failure to ensure timely identification and reporting of neglect, as required by facility policy and regulatory standards.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Provide Required Assistance with Eating and Toileting
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for two residents, specifically in the areas of eating and toileting. One resident with severe cognitive impairment and a history of dysphagia was observed attempting to eat and drink independently without staff supervision or assistance, despite care plan and therapy notes indicating the need for feeding assistance and aspiration precautions. On multiple occasions, the resident was left alone in the dining area, struggled to eat, and experienced frequent coughing episodes. Interviews with staff confirmed inconsistent understanding and implementation of the required level of supervision and assistance for this resident during meals. Another resident, who was cognitively intact but had muscle weakness and depression, was found lying in bed with a soiled brief containing bowel movement that had not been changed for an extended period. The brief was marked with a time indicating it had not been changed for several hours, and the resident confirmed that no staff had assisted her throughout the day. Multiple staff interviews corroborated that the resident had not received timely toileting care as outlined in her care plan, which required regular checks and changes every two hours. The facility's failure to provide timely and appropriate assistance with eating and toileting for these residents was confirmed through observations, interviews, and record reviews. The lack of adherence to care plans and staff uncertainty regarding required interventions contributed to the deficiencies identified during the survey.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection control program, specifically in the application of Enhanced Barrier Precautions (EBP) for residents with open wounds or indwelling medical devices. For one resident with an open wound following surgical amputation, there was no indication of EBP being ordered or monitored, and no signage or isolation cart was present in the resident's room. The Unit Manager and Director of Nursing confirmed that EBP should have been implemented upon the resident's return from the hospital. Another resident with a nephrostomy tube also lacked proper EBP signage, although an isolation cart was present inside the room. Additionally, a third resident with an indwelling catheter and pressure wound had EBP signage and an isolation cart, but the hand sanitizers located above the cart were empty, as observed by an LPN. The facility's policy on EBPs, which includes the use of gowns and gloves for high-contact activities and the posting of signage to indicate precautions, was not adequately followed, leading to potential cross-contamination and increased infection risk.
Plan Of Correction
Element 1: Resident 101 remains at this facility. Enhanced Barrier Precautions (EBP) were implemented 2/25/25 with PPE cart and signage outside her room; care plan and orders updated for EBP 2/25/25. Resident 103 discharged to her home on 3/7/25 after completing her rehab stay at this facility. EBP signage was placed outside her door on 2/25/25 above the PPE cart and remained in place until she discharged. Resident 102 remains at this facility. Hand sanitizers outside his room at the PPE cart were refilled on 2/25/25. Element 2: All residents currently in-house are at risk of requiring EBP that have not been implemented. An audit of all in-house resident orders will be completed to ensure EBP is properly in place. All residents currently on EBP are at risk of signage not being outside their door or hand sanitizer not being available. Rooms of all residents currently on EBP will be audited to ensure proper PPE cart, signage and hand sanitizer is available. Element 3: Infection Prevention Coordinator received Infection Prevention and Control Consultation education from the State Licensing Consultative Section (SLCS) on 2/27/25. All Licensed Nurses will receive education regarding Enhanced Barrier Precautions (EBP). Element 4: DON/Designee will audit 10 isolation carts per week for 4 weeks to check for hand sanitizer availability and proper isolation signage. DON/Designee will audit all new admission resident charts and 5 long term care resident charts per week for 4 weeks to check for EBP requirements in place. The DON is responsible for sustained compliance. Under the supervision of the QAPI committee, audits will be presented to the QAPI committee monthly and will continue until QAPI has determined sustained compliance has been achieved.
Failure to Post Enhanced Barrier Precautions Signage for Resident with Nephrostomy Tube
Penalty
Summary
A cognitively intact resident with a history of kidney calculus and pyonephrosis had a nephrostomy tube placed and was under orders for Enhanced Barrier Precautions. On review of the resident's order summary and during an observation, it was found that there was no Enhanced Barrier Precautions signage on the resident's door. Although an isolation cart with PPE was present inside the room, there was no signage to alert staff or visitors to the required precautions. This lack of signage was confirmed by the unit manager during the observation and review.
Hand Sanitizer Unavailable at EBP Isolation Cart
Penalty
Summary
A cognitively intact resident with diagnoses including a pressure wound, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy was observed to require Enhanced Barrier Precautions (EBP) due to the presence of an indwelling catheter and a pressure wound. Facility policy mandates the use of EBP, including the availability of personal protective equipment (PPE) and hand sanitizer outside the resident's room, to reduce the transmission of multi-drug-resistant organisms (MDROs) during high-contact care activities. During an observation, signage for EBP and an isolation cart with PPE were present outside the resident's room, but both hand sanitizer dispensers located above the cart were empty. An LPN attempted to use the dispensers and confirmed they were empty, stating that housekeeping was responsible for refilling them. The lack of available hand sanitizer at the point of care represented a failure to fully implement the facility's EBP policy as required for infection prevention and control.
Resident Receives Unordered Insulin Due to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident, R101, who was administered insulin despite not having a diagnosis of diabetes mellitus. On the date of the incident, R101 reported feeling dizzy and unwell after receiving an insulin injection that was not ordered for him. The resident's medical records confirmed that there was no insulin prescribed, and his diagnoses did not include diabetes. Interviews with the resident and his family revealed that R101 was aware of the error and expressed concern about receiving insulin, which he knew was not meant for him. The error occurred when a nurse, identified as LPN I, administered insulin to R101, mistaking him for another resident who required the medication. The nurse reportedly did not adhere to the facility's medication administration protocols, which include verifying the right patient, medication, dosage, and time. Despite the presence of resident pictures on the electronic medical record system and names on room doors, the nurse failed to correctly identify R101 and administered insulin intended for another resident, R102, who had not yet received his medication that morning. Interviews with facility staff, including the Director of Nursing and other nurses, highlighted the expectations for medication administration checks, which were not followed in this instance. The facility's electronic medical record system, which includes resident pictures to assist in identification, was not utilized effectively by the nurse involved. The incident was further complicated by the nurse's insistence that no error had been made, despite evidence to the contrary, including R101's report of the incident and the absence of insulin administration records for R102 at the time of the error.
Failure to Label Insulin Pen Correctly
Penalty
Summary
The facility failed to adhere to standards of practice for medication labeling, specifically concerning the labeling of insulin pens. During an observation, a Licensed Practical Nurse (LPN) was found administering Lantus insulin to a resident from a pen that was not labeled with the date it was opened or the expiration date once opened. The pen, which originally held 100 units, had approximately 80-90 units remaining. The LPN acknowledged that the insulin should have been labeled with an open date to ensure the medication's integrity and admitted to using the same pen the previous day without noticing the missing labels. Upon realizing the oversight, the LPN retrieved a new insulin pen, labeled it correctly, and administered the medication to the resident. The LPN stated that once opened, the insulin is good for 28 days.
Failure to Train Agency Staff Leads to Medication Error
Penalty
Summary
The facility failed to maintain an effective training program for agency staff, resulting in a medication error involving a resident, R101. R101, who does not have diabetes mellitus, was incorrectly administered insulin by an agency nurse, LPN I, who was working her first shift at the facility without receiving any orientation or training. This error led to R101 experiencing dizziness and malaise. The incident was reported on 10/5/2024, and it was discovered that the insulin was likely intended for another resident, R102. The nurse administered the insulin in R101's room, where his name was on the door, despite R101's protests that he does not receive insulin. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing/Staff Development, revealed that agency nurses typically do not receive orientation or training from the facility before starting work. The agency staffing company also did not provide training specific to medication administration. The facility relied on the agency to ensure the nurses met the necessary requirements and competencies. Additionally, there was a lack of clear communication and support for agency staff, as they were not provided with essential contact information or guidance on facility procedures, particularly during weekends when management presence was limited.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to consistently monitor and assess a resident, R100, for pressure ulcer care, leading to potential slow healing wounds and the development of new pressure ulcers. R100, who was cognitively intact and dependent on staff for all care, had a sacral pressure ulcer and was at high risk for skin breakdown as indicated by a Braden Scale score of 12. Despite the family's request for R100 to be checked and changed every two hours, observations and interviews revealed that R100 was often left sitting in soiled briefs for extended periods, which could have contributed to the deterioration of her wound. The facility's policy on skin protection was not adequately followed, as R100 did not have a resident-specific care plan for wound care or incontinence management. The care plan and Kardex lacked guidance for incontinence or wound care, and there was missing documentation for R100's wound care from April to June 2024. Observations showed R100 sitting in a recliner without proper offloading, and interviews with family members and staff indicated that R100 was not repositioned or changed as frequently as required. Interviews with the wound care nurse practitioner and facility staff highlighted inconsistencies in wound documentation and care. The wound nurse's notes differed from the facility's records, and there was a lack of consistent charting on R100's wound. The facility's failure to maintain R100's wound bed and ensure regular offloading and repositioning contributed to the worsening of her pressure ulcer, which progressed from a stage II to a Kennedy ulcer with necrotic tissue and tunneling.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to ensure the use of a gait belt during transfers for two residents, R100 and R102, which could potentially lead to falls or injuries. R100, who is cognitively intact but dependent on staff for all care due to Parkinson's disease, was observed being transferred multiple times without a gait belt by CNA E and LPN L. Despite the resident's care plan indicating the need for two-person assistance and the use of a gait belt, staff did not adhere to these guidelines. Interviews with staff, including CNA E and Unit Managers, confirmed the resident's decline in mobility and the necessity of a gait belt for safe transfers, yet it was not utilized. Similarly, R102, who requires maximal assistance due to muscle weakness and a history of falls, was also transferred without a gait belt by CNA E. The facility's policy on gait belt use clearly states its importance for residents at risk of falls and those needing assistance during transfers. However, CNA E admitted to not using the gait belt unless transferring the resident over a distance, contrary to the facility's policy and the Director of Nursing's statement that a gait belt should be used for all non-independent transfers.
Inadequate Infection Control Practices for Residents Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement adequate infection control practices, specifically regarding the use of Personal Protective Equipment (PPE) for residents R100 and R102, who were under Enhanced Barrier Precautions (EBP) due to their medical conditions. R100, who was cognitively intact and dependent on staff for care, had a sacral pressure ulcer and required EBP as per her care plan. However, during observations, it was noted that staff, including a CNA and an LPN, did not wear gowns while providing incontinence and wound care, despite CDC signage indicating the need for such precautions. Similarly, R102, who had a stage 2 sacral pressure ulcer, was also under EBP. Observations revealed that the same CNA did not wear a gown while providing incontinence care to R102. The CNA admitted to not wearing a gown during care, indicating a lack of adherence to the required infection control measures. Interviews with staff, including the Director of Nursing and a Unit Manager, revealed a lack of training and education on wound dressings and infection control practices. The Director of Nursing acknowledged that staff had not received education on wound dressings since June 2024, and the Infection Control Preventionist had not conducted any training. This lack of training and understanding of EBP signage contributed to the failure in implementing proper infection control measures, increasing the risk of cross-contamination in the facility.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations during an initial tour of the kitchen. The walk-in cooler had storage racks with a heavy accumulation of debris, which was acknowledged by the Director of Dining Services (DDS) as needing cleaning. Clean utensils were stored in bins next to a hand sink, and these bins contained crumb debris, contrary to the DDS's statement that they should be cleaned weekly. The meat slicer, although not frequently used, was found with dried meat debris, and the can opener had debris on its blade and a sticky substance on its handle and rail. Additionally, the Traulson cooler and freezer had black debris on door gaskets and crumb debris on the floor of the freezer. The facility also lacked proper testing devices for sanitizing solutions, as the kitchen did not have any unexpired test strips to ensure the correct concentration of the quaternary ammonium sanitizer. This was confirmed by the DDS, who stated that they would need to acquire new test strips. An observation of the Heirloom Bistro revealed that the available test strips were expired. These deficiencies in food storage, preparation, and sanitation practices have the potential to result in foodborne illness among residents, as they do not comply with the 2017 FDA Food Code requirements for cleanliness and sanitizing solutions.
Failure to Notify Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to provide written notification to the State Long-Term Care Ombudsman regarding facility-initiated transfers and discharges since November 2019. This deficiency was identified through interviews and record reviews. An email from the State LTC Ombudsman indicated that the required notices for transfers and discharges were not being sent. During interviews, the Director of Social Work and a Social Worker admitted that they had not been sending these notices to the Ombudsman, with the last known notice being sent in November 2019. The facility's policy, revised in November 2022, requires the social worker or designee to provide a copy of the notice to the Ombudsman, which was not adhered to, leading to the deficiency.
Failure to Ensure Timely Incontinence Care and Dignity
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity for a resident, resulting in long call light wait times and delays in incontinence care. The resident, who was cognitively intact with a BIMS score of 13, had a history of hemiplegia following a cerebral infarction, pain in both shoulders, and was frequently incontinent of bowel and bladder. The resident was dependent on staff for toilet transfers and required extensive assistance from two staff members for toileting. Despite these needs, the resident reported that staff did not change him as often as necessary and that he experienced long waits for his call light to be answered, leading to discomfort and a lack of dignity. Interviews with staff confirmed the resident's complaints, with a CNA acknowledging that it was common for residents to wait for their call lights to be answered. The CNA also confirmed that the resident frequently complained about the delays in having his brief changed. The care plan for the resident included interventions for toileting and incontinence care, but these were not consistently followed, resulting in the resident having to sit in his waste for extended periods, which was distressing for him.
Failure to Ensure Call Light Accessibility for a Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, leading to the inability to call for staff assistance and the potential for unmet care needs. Resident #10, who was admitted with a diagnosis of osteoarthritis and had a severely impaired cognitive status as indicated by a BIMS score of 6/15, was observed without access to her call light. The resident's care plan specifically included an intervention to keep the call light within reach, initiated on 11/30/23, to accommodate her communication needs. On 8/27/24, during an observation and interview, Resident #10 was found lying in bed without her call light, which was placed on a recliner out of her reach. The resident confirmed that she used her call light to request assistance but did not have it at that time. This observation was corroborated by Chaplain QQ, who confirmed the call light was out of reach. Additionally, CNA KK acknowledged that the resident used her call light to call for assistance. The facility's call light policy, last reviewed in January 2024, mandates that call lights should be within reach when residents are in bed or confined to a chair, which was not adhered to in this instance.
Failure to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for two residents, resulting in soiled fans and the potential for respiratory complications. Resident #53, a female with multiple health issues including respiratory failure and obstructive lung disease, was observed multiple times with a black pedestal fan near her bed that had visible dust buildup on the grates. Despite the presence of a housekeeper cleaning the floors, the fan remained uncleaned over several days. Interviews with housekeeping staff revealed inconsistencies in the cleaning process, with one housekeeper stating that cleaning fans was not part of the daily routine, while another indicated that it should be. Resident #54, a female with obstructive sleep apnea and other health conditions, was also affected by the facility's failure to clean her portable fan. The fan, positioned to blow directly toward her, had a significant amount of dust on the grates and blades. Despite being queried about the cleaning frequency, Resident #54 reported that the fan was not cleaned by the facility. Observations over several days confirmed that the fan remained uncleaned, posing a potential risk to her respiratory health.
Failure to Report Allegations of Neglect in a Timely Manner
Penalty
Summary
The facility failed to ensure that staff fully implemented the abuse policy and reported allegations of neglect in a timely manner for a resident diagnosed with Parkinson's disease. The resident was admitted to the facility and was found to be wet and soiled on multiple occasions, as reported by the resident's daughter. On one occasion, the night aide discovered the resident soaked and soiled, indicating that the resident may not have been changed throughout the day. This incident was not isolated, as the resident's laundry was consistently soaked in urine, and a previous complaint had been filed regarding a similar incident earlier in the month. The Licensed Practical Nurse Unit Manager (LPN-UM) was informed of the situation by both a CNA and the resident's daughter, but did not report the allegations to the Nursing Home Administrator (NHA) until the following day. The Director of Nursing (DON) was not made aware of the earlier incident, and the NHA only learned of the allegations during a morning meeting. The facility's abuse policy requires that such allegations be reported within specific time frames, but this was not adhered to, resulting in a potential for continued neglect to go unreported.
Failure to Timely Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect to the State Agency in a timely manner for a resident who was reviewed for abuse and neglect. The resident, who was admitted with a diagnosis of Parkinson's disease, was found wet and soiled on multiple occasions. On one occasion, the resident's daughter reported the condition to the Licensed Practical Nurse Unit Manager (LPN-UM), who noted that the resident's pants, cushion, and brief were wet, indicating that rounds may not have been done in a timely fashion. The LPN-UM and the Director of Nursing (DON) were aware of the situation, but the allegations were not reported to the state agency as required. The Nursing Home Administrator (NHA) learned about the allegations during a morning meeting and confirmed that the facility had concerns for neglect based on the family's reports. Despite these concerns, the NHA did not report the allegations to the state agency, citing oversight as the reason. The facility's abuse policy requires that allegations of neglect be reported to the state agency within specific time frames, but this protocol was not followed, resulting in a deficiency in the facility's handling of the situation.
Failure to Implement Care Plan Interventions for Residents
Penalty
Summary
The facility failed to implement care plan interventions and orders for two residents, resulting in potential unmet care needs. Resident #50, who was admitted with a diagnosis of heart failure, had a care plan indicating the need for meal assistance. However, observations on two separate occasions revealed that Resident #50 was left unsupervised while eating, struggling to use utensils and spilling food onto her clothing. Interviews with staff, including an LPN and the LPN Unit Manager, indicated a lack of awareness or understanding of the necessity for meal assistance, despite an order from the speech pathologist who had observed Resident #50's difficulties and potential safety risks during meals. Resident #43, who was severely cognitively impaired with diagnoses including Alzheimer's disease and repeated falls, had a care plan for pressure ulcer prevention that required a Roho cushion in his recliner. Observations on multiple occasions showed that Resident #43 was sitting in his recliner without the required Roho cushion, only with Dycem pads. An interview with the Unit Manager confirmed the purpose of the Roho cushion was to relieve pressure, yet it was not in place as per the care plan. This oversight in implementing the care plan interventions for Resident #43 could potentially lead to increased risk of pressure ulcers.
Failure to Assess and Treat Resident's Skin Condition
Penalty
Summary
The facility failed to assess and address a change in skin condition for a resident, resulting in a delay in treatment and potential worsening of the condition. The resident, who was severely cognitively impaired and at risk for pressure ulcers, was observed with multiple open wounds on both shins and arms, with blood seeping through geri-sleeves. Despite orders to assess pain and check skin conditions every shift, the resident's wounds were not properly dressed, and there was a lack of timely intervention to address the bleeding and open sores. Observations revealed that the resident experienced pain when the geri-sleeves were removed, indicating a lack of appropriate wound care. The Unit Manager acknowledged that the resident's skin was paper-thin and required protective measures, but the necessary care was not consistently provided. The failure to follow physician orders and care plans for skin assessment and pain management contributed to the deficiency, as the resident's condition was not adequately monitored or treated, leading to ongoing discomfort and risk of infection.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to adhere to physician orders for the administration of oxygen to a resident, leading to a deficiency in respiratory care. Resident #10, who was admitted with pulmonary hypertension, was observed on multiple occasions with her oxygen set at 3.5 liters per minute, contrary to the physician's order of 2 liters per minute. Additionally, the oxygen tubing, which was supposed to be changed weekly and labeled with the date, was found to be outdated, with the last change recorded on 8/19/24, despite the facility's policy requiring a change on 8/24/24. Interviews with facility staff, including the Infection Preventionist and the Registered Nurse Unit Manager, confirmed the discrepancies in oxygen administration and tubing maintenance. The Infection Preventionist acknowledged that the tubing should have been changed on 8/24/24, and the Registered Nurse Unit Manager verified the incorrect oxygen flow rate and outdated tubing during a room visit with the surveyor. These observations and staff confirmations highlight the facility's failure to follow established protocols for respiratory care, potentially increasing the risk of respiratory infection for the resident.
Inadequate Documentation and Care Planning for Psychotropic Medication
Penalty
Summary
The facility failed to provide adequate documentation and care planning for a resident prescribed Zoloft for anxiety. The resident, a female with an unspecified anxiety disorder, was given a physician's order for Zoloft without proper documentation of the indication for its use. The care plan for the resident included administering the medication and monitoring for side effects but did not list any non-pharmacological interventions to manage the resident's anxiety. Additionally, there was no evidence of consent obtained from the resident or her responsible party, nor was there documentation of education on the risks and benefits of the medication. Interviews with facility staff revealed discrepancies in the understanding of the medication's purpose, with one social worker indicating that the resident's son believed the medication was for pain related to wounds. Despite requests for documentation, the facility was unable to provide evidence of non-pharmacological interventions or consent for the medication's use. This lack of documentation and care planning resulted in the potential for unmet psychosocial needs and the administration of unnecessary medication to the resident.
Deficient Food Storage Practices in Resident Refrigerators
Penalty
Summary
The facility failed to fully implement its policy regarding the use and storage of foods brought in by family and visitors for residents. This deficiency was observed in one resident's personal refrigerator and one of the shared resident refrigerators. The policy required that perishable foods be clearly marked with the resident's name and date, and used within three days. However, during a tour of the Heirloom Garden Bistro, several food items were found in the resident refrigeration unit without proper labeling or with expired dates, including mac and cheese, a fruit drink, milk, a chef salad, and another container of mac and cheese. Resident #53, who was cognitively intact, had a small dorm-style refrigerator in her room that was packed with personal food items. The resident reported that staff occasionally checked the food for expiration, but acknowledged that the fridge needed cleaning due to a rotting smell. Upon inspection, the refrigerator was found to have a noxious smell, spilled food debris, and several undated or expired food items. The resident expressed uncertainty about the dates and expiration of the food items. An Agency LPN was observed cleaning out Resident #53's refrigerator at the resident's request. The LPN discarded several items, including sugar snap peas, a sausage with visible mold, an unidentified item in a glove, and a questionable bag of pepperoni. The LPN was unsure who was responsible for checking and cleaning the food in personal refrigerators. The Unit Manager acknowledged the issue with food storage in personal refrigerators and indicated that the facility intended to develop a new process to address it.
Inadequate Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a wound dressing change and brief change for a resident identified as R43. The resident, who was severely cognitively impaired and had a stage 3 pressure ulcer, required assistance with daily activities and had specific physician orders for wound care. During an observation, a registered nurse (RN) was seen performing a wound dressing change without following proper hand hygiene protocols. The RN donned and doffed gloves multiple times without performing hand hygiene in between, used gloves with artificial nails that broke through, and applied wound care products directly with gloved fingers that had been used for other tasks. Additionally, the RN failed to use a barrier between the resident and the bedding during the procedure, and handled soiled and clean items without changing gloves or performing hand hygiene. The RN also dressed the resident in clean clothing and shoes while wearing the same gloves used during the wound care procedure. These actions were contrary to the facility's infection control practices, which require hand hygiene and glove changes before and after handling soiled items and when transitioning from soiled to clean tasks.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that residents were properly screened for eligibility and administered pneumococcal vaccinations, as evidenced by the case of one resident. This resident, who was admitted with a diagnosis of hypertensive heart disease with heart failure, had not received the pneumococcal vaccine despite expressing a desire to receive it, as documented in their Vaccine History and Consent form. An interview with the Infection Preventionist revealed that the resident was due and eligible for the vaccine, but the facility had missed assessing and administering it, leading to a deficiency in vaccination protocol.
Failure to Offer COVID-19 Vaccinations to Residents
Penalty
Summary
The facility failed to ensure COVID-19 immunizations were offered to three residents, resulting in an increased risk for infection and potential spread of COVID-19. Resident #2, who was admitted with hypertensive heart disease and heart failure, had not received a COVID-19 vaccine despite expressing a desire to be vaccinated. The Infection Preventionist (IP) acknowledged that the facility missed assessing and administering the vaccine to this resident. Resident #50, admitted with heart failure, did not receive a COVID-19 vaccine in 2023, and the IP could not provide evidence that the vaccine was offered. Resident #53, with acute and chronic respiratory failure, had declined the vaccine in 2022 but was not offered it again in 2023, and no updated consent form was completed. The facility was unable to provide documentation verifying that these residents were offered the vaccine in 2023.
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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