Wellbridge Of Clarkston
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarkston, Michigan.
- Location
- 5655 Clarkston Road, Clarkston, Michigan 48348
- CMS Provider Number
- 235726
- Inspections on file
- 26
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Wellbridge Of Clarkston during CMS and state inspections, most recent first.
A resident with recent hip surgery, rib and manubrial fractures, and multiple comorbidities, who required substantial assistance with bed mobility and was care planned for fall risk, fell from an elevated bed during incontinence/ADL care when a CNA rolled the resident away from herself and did not stop care or seek help despite the resident exhibiting unusual jerking movements. The resident was later found to have additional fractures and neurologic complaints, and hospital imaging confirmed new manubrial and rib fractures. The facility’s internal investigation concluded the resident rolled too far and slid off the bed, documented the fall as not preventable, and did not fully address the CNA’s description of the resident’s movements, the elevated bed, or the positioning technique used, and contained inconsistencies regarding staff presence, continence status, and environmental details, leading to a deficiency for failure to ensure safe care and adequate accident prevention.
Surveyors found one narcotic wall storage unit with both the outer and inner doors unsecured, with rubber bands around the inner lock and multiple resident controlled medications stored inside while no staff were present. When an RN arrived, they initially believed the unit was locked, then locked the outer door but were unable to lock the inner door, and the DON confirmed there was no working key for that inner lock. Leadership later acknowledged they were already aware that this specific controlled medication wall unit required lock repair, while other similar units had no reported issues, and could not explain why controlled medications had not been removed from the malfunctioning unit despite this knowledge.
Surveyors found that the facility did not maintain sanitary and safe conditions, including an expired ice machine filter and significant lint and chemical residue in the laundry area, with staff unable to explain or address these deficiencies at the time.
A resident with multiple comorbidities, including Alzheimer's, diabetes, and hypertension, who was on blood thinners and antihypertensive medication, experienced a fall with head injury. Facility staff failed to consistently monitor and document vital signs and neuro checks as required by physician orders and facility policy, and blood pressure readings were not regularly recorded prior to medication administration. Documentation of the incident and subsequent monitoring was incomplete and not properly entered into the EMR.
The facility did not assess, monitor, or document non-pressure skin wounds or growths for two residents, failing to follow professional standards and care plans as required.
A resident with fragile skin and multiple health conditions sustained a skin tear from a wheelchair with a missing armrest cap, exposing a sharp edge. Despite the injury being reported, staff did not thoroughly inspect the wheelchair or identify the hazard until prompted by a surveyor, and the resident continued to use the unsafe wheelchair for several days. The facility failed to conduct a timely and thorough investigation or update the care plan in response to the incident.
Two residents experienced deficiencies in skin and wound care, including lack of documentation and assessment of a cutaneous horn and failure to obtain physician orders or properly date dressings for a forearm wound. Facility policy did not address non-pressure skin conditions, contributing to incomplete care practices.
Surveyors found that the facility did not document the required monthly battery test for the generator, omitting either the specific gravity or cold crank amperage check needed to confirm battery operability. This deficiency was confirmed by the Maintenance Director and Administrator and could impact all occupants during a power outage or emergency.
Facility hallways were found to contain gown and isolation cabinets without wheels, preventing quick removal and potentially obstructing emergency egress. This was confirmed by the Maintenance Director and Administrator during surveyor observation, affecting a portion of the facility's occupants.
A portable fire extinguisher in the kitchen service hallway was found without the required monthly maintenance and inspection tag, indicating a failure to document compliance with NFPA 10 standards. This was confirmed by the Maintenance Director and Administrator during surveyor interviews.
Facility staff failed to maintain the required 36-inch clearance around breaker panels in the maintenance office, with combustibles found in front of the panels. This was confirmed by the Maintenance Director and Administrator during the survey.
Surveyors observed that the oxygen cylinder storage rack in the oxygen storage room on hallway #800 was not properly labeled to indicate whether cylinders were EMPTY or FULL, as required by NFPA 99. This deficiency was confirmed by facility leadership and could affect 16 out of 87 occupants in the event of a fire emergency.
A resident with multiple medical conditions sustained a second-degree burn to the left upper thigh after spilling hot coffee. Nursing staff failed to transcribe and implement the physician's order for wound care, did not document the treatment provided, and did not notify the DON or Administrator of the new injury, resulting in a failure to meet professional standards of nursing practice.
A resident with significant medical history experienced a fall resulting in a head injury and elevated blood pressure. The facility failed to notify the physician of the resident's change in condition, including increased bleeding and cognitive impairment. Nursing staff did not escalate the situation appropriately, and the resident's son had to request a hospital transfer. The facility lacked adequate weekend resources, contributing to the deficiency.
A resident with serious health conditions was admitted to the facility and noted to be on oxygen, but no initial physician order was documented. The facility's policy requires verification of a physician's order for oxygen administration, which was not followed. The resident's oxygen orders were not implemented until three days after admission, despite nursing notes indicating the resident was on oxygen. The DON acknowledged the concern but could not explain the delay.
A resident with severe cognitive impairment and high fall risk experienced two falls within nine days of admission to an LTC facility. Despite being aware of the risk, the facility failed to implement timely, resident-specific interventions, resulting in a hip fracture requiring surgery. Staff interviews revealed inconsistencies in fall prevention strategies, contributing to the deficiency.
The facility failed to ensure call lights were within reach and answered promptly, leading to a deficiency in accommodating residents' needs. Observations revealed call lights were not placed within reach and were not answered timely, with some residents waiting over an hour. Specific instances included a resident with an activated call light for over 40 minutes without response and another with their call light out of reach. Despite claims of average response times, documentation did not reflect this, and staff were observed not addressing call lights promptly.
The facility failed to provide adequate ADL care, including personal hygiene and bathing, for eight residents, leading to complaints of poor hygiene and frustration. Residents reported not receiving scheduled showers or baths, and documentation often did not reflect refusals of care. Staff interviews revealed a lack of oversight in ensuring residents' needs were met.
A facility failed to maintain a medication error rate below five percent, resulting in a 22.22% error rate. Errors included incorrect dosages and failure to administer medications as prescribed, such as administering Docusate Sodium 250 mg instead of 100 mg, and not priming a NovoLog FlexPen before insulin injection. The DON confirmed that insulin pens should be primed and medications should not be marked as given until administered.
A facility employed an unlicensed individual as an RN, who worked multiple shifts before the discrepancy was discovered. The individual, with a background in phlebotomy, used another person's RN license to gain employment. The issue was identified by the facility's President of Clinical Services during a routine license check, leading to an investigation that confirmed the falsification of credentials. The former HR Manager responsible for verifying credentials failed to detect the issue and has since resigned.
The facility failed to maintain resident dignity, as evidenced by staff being disrespectful, arguing, and being rude, making residents feel like they were in a facility rather than a home. Incidents included a resident being told to use an incontinence brief instead of being assisted to the restroom, and another resident being given instructions about bathroom use loudly enough to be overheard from the hallway. The DON acknowledged these actions were inappropriate.
A resident's preferences for morning showers and daytime catheter changes were not honored by the facility, despite being cognitively intact and requiring assistance with ADLs. The facility cited scheduling constraints as the reason for not accommodating the resident's requests, which contradicts the Resident Rights Handbook stating residents have the right to choose schedules consistent with their interests.
A resident with intact cognition and multiple diagnoses, including Parkinson's and anxiety disorder, did not receive showers for several days despite multiple complaints from the resident and family. The facility failed to document or resolve the grievance, as staff were unaware of the complaints, and the grievance process was not followed.
A resident admitted with a lung transplant and idiopathic pulmonary fibrosis did not receive most of their medications, including crucial anticoagulant and antirejection drugs, until two days after admission. The initial nurse failed to input medication orders, and a second nurse also missed transcribing an essential antirejection medication, leading to a delay in administration.
A resident with hemiplegia and hemiparesis was not provided with a prescribed resting hand splint due to an error in the physician's order entry, which lacked a schedule for application. The resident, with intact cognition, was observed without the splint on two occasions and indicated that staff did not offer to apply it. The DON confirmed the order was entered incorrectly, leading to the deficiency in care.
A facility failed to follow physician orders and accurately document catheter care for a resident. The resident's catheter was overdue for a change, but the MAR was marked as completed by an LPN who did not perform the task. The LPN cited the resident's preference for a day shift change as the reason, but failed to document the refusal. The DON was unaware of the issue due to the inaccurate documentation.
A resident who had undergone a lung transplant did not receive timely administration of critical medications, including anticoagulant and antirejection drugs, due to transcription errors by nursing staff. The resident's medication orders were not entered upon admission, leading to a delay in medication administration until two days later, with the antirejection medication tacrolimus not being transcribed at all.
A resident's room contained improperly stored medications, including those belonging to a family member. Despite facility policy requiring regular monitoring, the medications remained in the room over several days. The DON was aware but had not addressed the issue with the family member.
Failure to Safely Position Resident During ADL Care Resulting in Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a safe manner to prevent an accident during ADL care, resulting in a resident’s fall from bed and subsequent fractures. The resident was an older adult with recent and significant medical issues, including a displaced intertrochanteric fracture of the right femur requiring surgery, a fracture of the manubrium, multiple right rib fractures, trigeminal neuralgia, Meniere’s disease, and psychosis. A recent MDS showed the resident had intact cognition, used a walker and wheelchair, required substantial/maximal assistance for bed mobility, and was dependent for toileting hygiene. The care plan identified the resident as at risk for falls related to multiple conditions, including recent fractures, and included an intervention to encourage and assist the resident to be positioned in the middle of the bed prior to rolling, as well as a transfer status of one-person assist with a two-wheeled walker and non-ambulatory status. During the night, while a CNA was providing incontinence/ADL care, the resident rolled out of bed and onto the floor. The nurse’s progress note documented that the CNA reported the resident rolled out of bed in the middle of ADL care and was found on the floor on her left side, with a broken left pinky nail and later complaints of left shoulder pain. The CNA’s written witness statement and subsequent interview described that the bed was elevated to a working height, the resident was being turned for care, and the CNA rolled the resident away from herself. The CNA reported that the resident began exhibiting unusual jerking and jolting movements and then fell to the floor. The CNA acknowledged rolling the resident away from her during repositioning and stated she did not stop care to seek additional help when the resident’s movements became unusual, explaining that she believed others were busy and she informed the nurse afterward. The DON later stated that the expectation is to roll residents toward the caregiver or get help, and to stop care and notify the nurse when there is a sudden change in condition. Following the fall, the resident complained of pain in the shoulder, ribs, and hip, and later reported dizziness, new visual changes, and a different type of headache. An NP note documented right upper extremity weakness, edema, limited arm elevation, bruising to the right temple, and ongoing rib pain, with the resident reporting she had hit her head during the fall. The NP ordered transfer to the hospital for CT imaging due to head injury complaints. Hospital CT imaging identified a minimally displaced fracture of the right anterior superior manubrium and fractures of the right 1st and 2nd ribs, and the hospital H&P recorded that the resident stated she rolled out of bed as she was being turned by staff. The facility’s internal investigation concluded that the resident rolled too far and slid off the bed during repositioning, characterized the fall as not preventable, and documented that the bed height was appropriate, but did not address the CNA’s description of sudden jerking/jolting movements, the elevated bed during care, or the technique of rolling the resident away from the caregiver despite the resident’s recent hip fracture and need for substantial assistance with bed mobility. Discrepancies were noted between the investigation documents and the clinical record regarding staff presence, continence status at the time of the incident, and environmental details. The surveyor also identified that the facility did not have a specific written policy on positioning, with corporate clinical staff stating that positioning was considered a basic skill staff should know. The facility’s QA tool for the fall with fracture indicated the fall was deemed not preventable and referenced new interventions, but left sections for staff education and QA committee review incomplete. The investigation and documentation did not reconcile or fully incorporate the CNA’s account of the resident’s unusual movements during care, nor did it analyze whether the resident’s functional limitations and recent right hip fracture affected safe repositioning during ADL care. These actions and omissions, including the manner of positioning and rolling the resident away from the caregiver on an elevated bed, the failure to stop care and seek assistance when the resident’s condition changed, and the incomplete and inconsistent internal investigation, led to the cited deficiency for not ensuring care was provided in a safe manner to prevent accidents.
Failure to Secure Controlled Medications in Narcotic Wall Storage Unit
Penalty
Summary
The deficiency involves failure to ensure controlled medications were securely stored in a locked compartment as required by facility policy and professional standards. During observation of the 800 hall narcotic wall storage unit, surveyors found the outer door not properly secured and able to be opened completely, and the inner door, which also had a locking mechanism, was unlocked. The inner door’s lock had several rubber bands around the locking mechanism and one around the lock and top of the inner door, while multiple resident narcotic medications were stored inside with no staff present in the hallway. When the Administrator arrived and was informed of the unlocked controlled substance wall unit, they attempted to locate the nurse responsible for the medications. Shortly thereafter, a nurse approached the wall unit and stated they thought it was locked. The nurse attempted to engage the outer door lock, which was already in the locked position and therefore unable to close, then used a key to lock the outer door. When questioned about the inner door, the nurse attempted to use the same key but reported it did not work and believed the lock had recently been changed or fixed. The DON then attempted to secure the inner door with the same keys and confirmed there was no working key for that door. The nurse reported last accessing the narcotic wall unit at approximately 9:00 AM. Later, during the exit conference, the DON confirmed there were six controlled medication wall units in the facility and that no issues had been found with the others. A corporate nurse acknowledged prior awareness of the need for repair to that specific wall unit’s lock and that they had been working on having it fixed, and did not provide an explanation when asked why controlled medications had not been removed from that storage area despite knowing it was not locking properly. The facility’s policy states that only authorized licensed nursing and pharmacy personnel have access to controlled medications and that the medication nurse on duty maintains possession of the key to controlled medication storage areas.
Failure to Maintain Sanitary and Safe Environmental Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During an environmental tour of the kitchen, the ice machine was found to have an expired filter with a 'change by date' that had passed, and the Regional Kitchen Manager was unable to explain why it had not been changed. Additionally, a tour of the laundry room revealed that the area behind multiple dryers had a floor surface covered with dried liquid spillage from cleaning chemicals, and the tops of the dryers were covered with a thick layer of lint. The facility Administrator acknowledged the presence of these unsanitary conditions.
Plan Of Correction
1.) The laundry room, including all machines and the floor behind the machines, was cleaned and dusted, and the ice machine filter was changed. 2.) A one-time audit was completed to ensure that dusting was completed throughout the facility and all ice filters were clean and changed. The housekeeping and maintenance departments were re-educated. 3.) System Change: All water filters will be changed according to manufacturer guidelines. The administrator/designee will complete rounds weekly to ensure the facility, including appliances/machinery, is kept clean. 4.) The administrator/designee will complete weekly rounds for 12 weeks to ensure the facility, including appliances/machinery, is dust free and will also conduct routine rounds to ensure there are no expired water filters. Any non-adherence will result in 1:1 education. All audits will be taken to QA for review. 5.) The administrator is responsible for ongoing compliance.
Failure to Consistently Monitor and Document Vitals and Neuro Checks After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received complete and accurate vital sign monitoring and documentation per physician orders and professional standards of practice. The resident, who had Alzheimer's disease, diabetes, and hypertension, was on two blood thinners (Plavix and Eliquis) and a blood pressure medication (Metoprolol Tartrate). After experiencing a fall in the bathroom and hitting her head, the resident was found with a bump on her head and a skin tear on her right arm. The nurse initiated neuro checks and contacted the provider, but there was no detailed documentation of the head wound in the medical record, and the neuro check documentation was not initially found in the electronic medical record (EMR). Further review revealed that the resident's blood pressure readings were not consistently documented prior to the administration of Metoprolol, as required by physician orders. The Medication Administration Record (MAR) showed the medication was given twice daily, but blood pressure readings were only recorded five times over a two-week period, despite 29 opportunities. This lack of consistent monitoring made it impossible to determine if low blood pressure contributed to the resident's fall. Additionally, the neuro check documentation began 15 minutes after the fall, and vital signs at the time of the fall were not initially available in the EMR. A paper copy of the neuro check sheet with hand-written vitals was later produced, but it had not been previously scanned or included in the EMR. Interviews with nursing staff and the Director of Nursing (DON) confirmed that vital sign monitoring was not consistently performed or documented as required. The DON acknowledged the absence of a detailed skin assessment and the incorrect entry of older vital signs in the change of condition form. The facility's policies required vital sign monitoring prior to medication administration and neurological assessment after falls with suspected head trauma, but these standards were not met in this case.
Plan Of Correction
1.) Resident #64 was assessed and no acute issues were noted. All residents have the potential to be affected. 2.) A one-time review of all guests on hypertensive medications from the last 30 days was completed to ensure hypertensive parameters are being followed. A one-time review of falls within the last 14 days was reviewed to ensure neuro checks were being completed as ordered. 3.) Licensed nurses were re-educated on following parameters on hypertensive medications and on completing neuro checks with unwitnessed falls. System change: The nurse managers will review all new hypertensive medications for parameters if needed and will review all falls to ensure neuro checks were completed for unwitnessed falls. 4.) DON/Designee will review 5 medical records weekly x 12 weeks to ensure that hypertensive medications with parameters are being followed. Any non-adherence will result in 1:1 education. All audits will be taken to the QA committee for review. DON/Designee will review 5 medical records weekly x 12 weeks to ensure that neuro checks were being completed for unwitnessed falls. Any non-adherence will result in 1:1 education. All audits will be taken to the QA committee for review. 5.) The Executive Director is responsible for maintaining compliance with the regulation.
Failure to Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to assess, monitor, and document skin wounds or growths for two residents who were reviewed for non-pressure skin conditions. This deficiency was identified through observation, interview, and record review. The facility did not ensure that care and treatment for these residents were provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as required by regulations. The lack of assessment, monitoring, and documentation specifically pertained to non-pressure skin conditions for the two residents involved.
Plan Of Correction
1.) Residents #66 & #57 were reassessed, and no acute changes were noted. All residents have the potential to be affected. 2.) A one-time skin sweep was completed to ensure that all impaired skin integrity had treatments or were identified in other parts of the medical record as needed. 3.) Licensed nursing staff were re-educated on skin assessment, documentation, and treatment orders with impaired skin integrity. System change: The nurse managers will review skin assessments and 24-hour summary on the next business day to ensure the MD/provider was notified of impaired skin integrity. 4.) DON/Designee will review 5 medical records weekly x 12 to ensure that residents with impaired skin integrity had documentation and an order for treatment. Any non-adherence will result in 1:1 education. All audits will be reviewed by the QA committee. 5.) DON is responsible for ongoing compliance.
Failure to Investigate and Address Accident Hazard After Resident Injury
Penalty
Summary
A deficiency occurred when a resident with fragile skin and multiple comorbidities, including lumbar vertebra compression, sick sinus syndrome, postural dizziness, cirrhosis, and kidney failure, sustained a skin tear on their right forearm after hitting it on the armrest of their wheelchair. The incident happened while the resident was in the bathroom, and the injury was attributed to a missing plastic cap on the right armrest, which exposed a sharp metal edge. The missing cap was not visible to the resident while seated but was observable to someone inspecting the wheelchair from the front. Despite the resident reporting the injury and the presence of a visible dressing, no one inspected the wheelchair for hazards following the incident. Multiple observations over several days revealed that the resident continued to use the same wheelchair with the exposed sharp edge, and staff, including the assigned LPN and therapy staff, did not identify or address the missing cap. The LPN, who was present at the time of the incident and on subsequent days, reported checking the wheelchair but did not notice the hazard until it was pointed out by the surveyor. The resident's care plan noted the risk of skin impairment and included general interventions, but there were no updates or specific interventions added after the incident. The facility did not initiate a thorough investigation or root cause analysis immediately following the event, and no incident or accident report was completed until the surveyor brought the issue to the attention of facility leadership. Interviews with staff, including the DON and therapy staff, confirmed that a comprehensive inspection of the wheelchair was not performed in relation to the resident's injury. The facility's policy required prompt investigation and documentation of accidents, including a detailed account of the circumstances and contributing factors, but this process was not followed. The deficiency was identified due to the lack of timely and thorough investigation, failure to identify and remove the accident hazard, and inadequate follow-up to prevent further harm.
Plan Of Correction
1.) Resident #61 is no longer in the facility. All residents have the potential to be affected. 2.) A one-time review of residents in-house was completed to ensure that a root cause analysis was completed for any accident/incident that resulted in an injury. A one-time audit of all wheelchairs was completed to ensure no safety issues were identified. If any were found, they were corrected by IDT. 3.) Licensed nursing staff were re-educated on assessing potential cause of injury due to an accident/incident. System change: Nurse Managers will complete documentation on root cause analysis resulting in injury from accident/incident. 4.) Don/Designee will review 5 E-interact change of condition assessments weekly x 12 weeks to ensure that all injuries from an accident/incident are reviewed for root cause analysis. Any non-adherence will result in 1:1 education. All audits will be taken to QA for review. 5.) The Executive Director is responsible for maintaining compliance with the regulation.
Deficiencies in Skin Assessment, Documentation, and Wound Care
Penalty
Summary
A deficiency was identified regarding the lack of proper skin assessment and documentation for a resident with a significant skin abnormality. Upon observation, a resident was found to have a cutaneous horn on the scalp, as well as similar protrusions on the hand and forearm. Despite the presence of this lesion, there was no documentation of the skin protrusion in the resident's admission assessment, progress notes, or by any nursing or medical staff. Interviews with nursing staff and the DON revealed uncertainty about whether the lesion was present at admission, and the attending physician confirmed the presence of a cutaneous horn but stated it was not something he would typically document. Hospital discharge paperwork did note the lesion, but this information was not incorporated into the facility's clinical record or baseline assessment. Another deficiency was noted in the management of a wound for a different resident. The resident was observed with an adhesive foam bandage on the right forearm, which showed signs of drainage and was undated. Review of the clinical record indicated the wound resulted from a fall, but there was no physician order for the dressing or wound care. The dressing was changed by a unit manager, who admitted to not dating the initial dressing due to lack of a marker and was unable to confirm how old the previous dressing was. The DON acknowledged that wound treatments should have a physician order and that all dressings should be dated, but these practices were not followed. Additionally, the facility's policy provided for review addressed only pressure ulcers and did not include guidance for non-pressure skin conditions. This lack of comprehensive policy, combined with the absence of documentation, assessment, and physician orders for wound care, contributed to deficiencies in the facility's skin and wound management practices for both residents.
Failure to Document Required Generator Battery Test
Penalty
Summary
The facility failed to document a required battery test during the monthly inspection of the facility's generator. Specifically, the records did not include documentation of either the specific gravity of the battery fluids or the cold crank amperage for maintenance-free batteries, as required to ensure the operational condition of the generator's battery. This omission was identified during a record review conducted by surveyors. The deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of record review. The lack of proper documentation and testing could affect all 87 occupants in the event of a facility-wide power outage or fire emergency, as the generator's reliability could not be assured according to NFPA standards.
Plan Of Correction
The Maintenance Director has completed the required monthly battery test inspection of the facility's generator on June 2nd. The Maintenance Director/Designee has been educated to ensure that the monthly battery test inspection of the facility's generator is being conducted and recorded to ensure compliance with the regulation. The Maintenance Director/Designee will conduct a routine review of the life safety binder to ensure that monthly battery test inspections of the facility's generator are conducted and recorded. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Obstructed Hallway Egress Due to Non-Movable Equipment
Penalty
Summary
During an observation on May 13, 2025, at approximately 12:05 PM, it was found that the facility did not maintain residential hallways free of non-essential or easily movable equipment. Specifically, gown and isolation cabinets located in the #500 hallway were not equipped with wheels, which would allow for quick movement to clear the hallway in case of a fire emergency. This issue was confirmed by both the Facility Maintenance Director and the Administrator during interviews conducted at the time of observation. The deficiency was noted to potentially affect 20 out of 87 occupants in the event of a fire emergency, as the means of egress was not continuously maintained free of all obstructions as required.
Plan Of Correction
The facility's added wheels to the isolation bins, and the hallways are equipped with isolation bins with wheels to aid in the quick movement to clear a hallway during a fire emergency. The Maintenance Director/Designee has been educated to ensure that the hallways are equipped with isolation bins with wheels to aid in the quick movement to clear a hallway during a fire emergency. The Maintenance Director/Designee will conduct routine rounds to ensure that there are wheels on isolation bins to ensure compliance with the regulation. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Missing Fire Extinguisher Maintenance Documentation
Penalty
Summary
During an observation on May 13, 2025, at approximately 9:45 AM, it was found that the facility failed to document the required monthly maintenance for a portable fire extinguisher located in the kitchen service hallway. The inspection and maintenance tag, which is necessary to demonstrate compliance with NFPA 10 standards, was missing from the unit. This issue was confirmed by both the Facility Maintenance Director and the Administrator during interviews conducted at the time of observation. The deficiency could potentially affect 16 out of 87 occupants in the event of a fire emergency, as noted in the findings.
Plan Of Correction
The facility added the fire extinguisher inspection tag to document the required monthly maintenance on the portable fire extinguisher located in the kitchen service hallway. The Maintenance Director/Designee has been educated to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. The Maintenance Director/Designee will conduct routine rounds to ensure that fire extinguishers have the fire extinguisher inspection tag to document the required monthly maintenance. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Inadequate Clearance Around Breaker Panels
Penalty
Summary
During an observation conducted on May 13, 2025, at approximately 9:45 AM, it was found that the facility did not maintain the required minimum clearance of 36 inches around the breaker panels located in the maintenance office. Combustible materials were observed placed in front of these breaker panels. This situation was confirmed by both the Facility Maintenance Director and the Administrator during interviews at the time of observation. The deficiency pertains to the facility's failure to ensure that equipment using gas or gas-related piping complies with NFPA 54 and that electrical wiring and equipment comply with NFPA 70, as required by regulatory standards. The report notes that this practice could affect 16 out of 87 occupants in the event of a fire emergency.
Plan Of Correction
The facility removed the combustible and there is no longer obstructions at the front of the breaker panels. The Maintenance Director/Designee has been educated to ensure that the maintenance office will maintain a minimum of 36 inches of clearance around the breaker panel. The Maintenance Director/Designee will conduct routine rounds to ensure that the maintenance office is maintaining a minimum of 36 inches of clearance around the breaker panel and they are not obstructed. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Improper Labeling of Oxygen Cylinder Storage Racks
Penalty
Summary
The facility failed to ensure proper labeling of oxygen cylinder storage racks inside the oxygen storage room located on hallway #800. During an observation, it was found that the storage rack did not have the required warning sign indicating whether the oxygen cylinders were EMPTY or FULL. This labeling is necessary to comply with NFPA 99 standards for the storage of nonflammable gases. The deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of observation. The lack of proper labeling could affect 16 out of 87 occupants in the event of a fire emergency, as noted in the findings. No additional details about specific residents or their medical conditions were provided in the report.
Plan Of Correction
The storage rack inside the oxygen storage room on hallway #800 has the proper warning sign indicating that the oxygen cylinders are full. The Maintenance Director/Designee has been educated to ensure that oxygen storage racks are labeled with the proper warning sign indicating if the oxygen cylinders are either empty or full. The Maintenance Director/Designee will conduct routine rounds to ensure that the oxygen storage racks are labeled with the proper warning sign indicating if the oxygen cylinders are either empty or full. Negative findings will be corrected and forwarded to the Executive Director, and trends will be forwarded to the QAPI Committee for additional review. The Executive Director is responsible for attaining and maintaining compliance with the regulation.
Failure to Transcribe Physician Orders and Notify Administration of New Skin Injury
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of practice in the care of a resident who sustained a thermal burn to the left upper thigh. The resident, who had diagnoses including urogenital implants and neuromuscular dysfunction of the bladder, required staff assistance with most activities of daily living and had intact cognition. The burn was identified as a second-degree, in-house acquired injury, and was first noted by the resident, who reported it to nursing staff after returning from an eye appointment where they had spilled hot coffee on themselves. Upon assessment, the wound was described and measured, and a treatment plan involving a wound cleanser and silver sulfadiazine was indicated. However, there was no evidence that a physician's order for the silver sulfadiazine was transcribed into the electronic medical record, nor was there documentation of the treatment being applied on the treatment administration record for the date the wound was identified. Additionally, the nurse who first identified the burn did not notify the Director of Nursing or the Administrator about the new injury, nor did they document the application of an abdominal pad or the completion of the identified treatment in the resident's record. The lack of timely transcription and implementation of physician orders, failure to document wound care, and failure to notify administration of a new skin injury resulted in the facility not meeting professional standards of quality for nursing services. These actions and omissions were confirmed through observation, record review, and interviews with facility staff.
Failure to Notify Physician of Change in Condition Post-Fall
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, R901, following a fall. R901, who had a history of significant cardiac disease, lung cancer, COPD, and diabetes, was found on the floor with a head injury and shoulder abrasion. Initial assessments by RN D and RN A revealed discrepancies in the severity of the injuries, with RN A noting a more severe gash on the forehead than initially reported. Despite concerns about the resident's condition, including elevated blood pressure and cognitive impairment, the on-call physician was not adequately informed of these changes. The nursing staff, including RN A, failed to use their judgment to escalate the situation appropriately. RN A, who was unfamiliar with R901, relied on vague reports and did not immediately send the resident to the hospital despite recognizing the severity of the injuries. The on-call provider, who was not familiar with the resident's medical history, was not informed of the resident's deteriorating condition, including increased bleeding and changes in mental status. The Director of Nursing and the Nursing Home Administrator acknowledged that the facility lacked a charge nurse or nurse manager as a resource on weekends, which may have contributed to the inadequate response. The resident's son, upon visiting, expressed concern about the lack of communication and the resident's condition, ultimately requesting the transfer to a hospital where the resident was admitted under trauma surgery service. The facility's failure to notify the physician and adequately assess and respond to the resident's condition led to a deficiency in care.
Failure to Implement Timely Oxygen Orders
Penalty
Summary
The facility failed to adhere to its policy on oxygen administration for a resident, identified as R404, who was admitted with multiple serious health conditions including acute on chronic systolic congestive heart failure, atrial fibrillation, chronic kidney disease, cardiac murmur, cardiac pacemaker, and dyspnea. Upon admission, the resident was noted to be on oxygen at a rate of 1 liter per minute, but there was no initial physician order documented for this oxygen administration. The facility's policy requires verification of a physician's order for oxygen administration, which was not followed in this case. The deficiency was further highlighted by the fact that the resident's oxygen orders were not implemented until three days after admission, despite nursing notes indicating the resident was on varying levels of oxygen during this period. The Director of Nursing, who was not employed at the time of the incident, acknowledged the concern but could not provide an explanation for the delay in implementing the orders. The lack of timely implementation of physician orders for oxygen administration represents a failure to provide safe and appropriate respiratory care for the resident.
Failure to Implement Fall Prevention Measures for High-Risk Resident
Penalty
Summary
The facility failed to implement timely resident-specific interventions and provide adequate supervision to prevent falls for a resident identified as R702. R702, who had severe cognitive impairment and was at high risk for falls, experienced two falls within nine days of admission to the facility. The first fall resulted in a transfer to the emergency room, and the second fall led to a right hip fracture requiring surgery. Despite being aware of R702's high fall risk, the facility did not have appropriate interventions in place prior to the falls. R702 was admitted to the facility for a short-term stay following hospitalization for a left hip fracture. The resident's medical history included dementia, osteoarthritis, and osteoporosis. Upon admission, a fall risk assessment indicated a high risk for falls, yet the initial care plan lacked specific fall prevention measures. It was only after the first fall that interventions such as a toileting schedule and settling the resident in bed after dinner were initiated. However, these measures were insufficient, as evidenced by the second fall. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed inconsistencies in the implementation of fall prevention strategies. Staff members mentioned various potential interventions, such as frequent rounding, low beds, and floor mats, but these were not consistently applied to R702's care. The facility's failure to provide adequate supervision and timely, resident-specific interventions contributed to the resident's falls and subsequent injury.
Deficiency in Call Light Response and Accessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach and answered promptly for several residents, leading to a deficiency in accommodating the needs and preferences of residents. Observations and interviews revealed that call lights were not placed within reach and were not answered in a timely manner, with some residents waiting over an hour for assistance. This issue was highlighted in multiple complaints reported to the State Agency and was also a concern raised during a resident council meeting. Specific instances included a resident whose call light was activated for over 40 minutes without response, and another resident who was observed with their call light out of reach on multiple occasions. Despite the facility's claim of average response times between 10-12 minutes, the documentation provided did not reflect this, and there was a lack of proper documentation for call light activations. Additionally, staff were observed not addressing activated call lights promptly, further contributing to the deficiency. The facility's procedures for responding to call lights were not effectively implemented, as evidenced by the repeated observations of call lights being out of reach and not being answered promptly. The Director of Nursing acknowledged the issue and noted that staff should ensure call lights are within residents' reach, but this was not consistently practiced. The deficiency was further compounded by the facility's inability to provide accurate call light reports, indicating a lack of proper monitoring and response to residents' needs.
Deficiency in ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) care, including personal hygiene, bathing, facial hair care, and dressing, for eight residents. This deficiency was identified through observations, interviews, and record reviews. Several residents, including those with intact cognition and those with cognitive impairments, reported not receiving showers or baths for extended periods, despite being scheduled for such care. For instance, one resident did not receive any showers or baths for 16 days, and another resident reported only receiving assistance from an occupational therapist for their first shower during their stay. Residents expressed frustration and embarrassment due to poor personal hygiene, with some residents having unshaven facial hair for several days and others wearing the same clothing repeatedly. Interviews with residents and their families revealed complaints about the lack of assistance with changing clothes and grooming. The facility's documentation often did not reflect refusals of care, and there were discrepancies between reported care and documented care in the electronic medical records. Staff interviews indicated that CNAs documented ADL care using electronic medical records, but there was a lack of oversight and monitoring to ensure that residents' needs were met. The Director of Nursing acknowledged the concerns and mentioned that residents were typically scheduled for two showers per week, with additional showers as needed. However, the documentation and resident reports indicated that this schedule was not consistently followed, leading to the identified deficiencies in care.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 22.22% error rate during a medication administration observation. This was observed when six medication errors occurred out of 27 opportunities for error involving three residents. The errors included incorrect dosages and failure to administer medications as prescribed. For instance, a Licensed Practical Nurse (LPN) administered Docusate Sodium 250 mg instead of the prescribed 100 mg to one resident. Another LPN failed to administer the correct dosage of Omega-3 and Vitamin B Complex to a second resident and marked Magnesium as given on the Medication Administration Record (MAR) despite not administering it. Additionally, a third resident received a Multivitamin without minerals, contrary to the physician's order for Multivitamins with minerals. The report also highlighted procedural errors during medication administration. An LPN was observed not priming a NovoLog FlexPen before injecting insulin, contrary to the manufacturer's instructions, which require an airshot to ensure proper dosing. The Director of Nursing (DON) confirmed that insulin pens should be primed before each use and acknowledged that medications should not be marked as given until they are administered. These observations indicate a lack of adherence to medication administration protocols, contributing to the high error rate.
Unlicensed Staff Employed as RN
Penalty
Summary
The facility failed to verify the credentials of an employee, identified as Staff 'M', who was employed as a Registered Nurse (RN) without having the required education, experience, and valid nursing license. This oversight was discovered after a complaint was filed with the State Agency, alleging that the facility allowed Staff 'M' to work 12 shifts before it was found they did not possess a valid RN license. The investigation revealed that Staff 'M' had used the identity of another individual, RN 'O', to obtain employment and had never been a nurse, although they had experience in phlebotomy. The facility's President of Clinical Services, Staff 'L', identified discrepancies in Staff 'M's license and registry information during a routine check. An interview with Staff 'M' confirmed that they had falsified their credentials and had never been a nurse. Staff 'M' admitted to using the knowledge gained from their phlebotomy experience to impersonate a nurse. The facility's investigation included a review of Staff 'M's time-punch reports, which showed they worked multiple shifts as an RN, including three days of orientation. The former HR Manager, Staff 'K', who was responsible for verifying employee credentials, failed to identify the discrepancies in Staff 'M's documentation and has since resigned. The facility conducted a thorough review of all employee files to ensure the accuracy of their credentials and found no further concerns. The investigation concluded that Staff 'M' had used RN 'O's license and was never a registered nurse, although no negative outcomes were reported for patients under their care during the time they worked at the facility.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure treatment in a dignified manner for three residents, resulting in potential feelings of embarrassment. A complaint was received by the State Agency alleging that residents were not being treated with dignity. The facility's policy on Quality of Life-Accommodation of Needs emphasizes maintaining residents' dignity and well-being. However, observations and interviews revealed that some staff were not respectful, argued, and were rude to one another, making residents feel like they were in a facility rather than a home. Specific incidents included a resident expressing dissatisfaction with staff behavior, another resident being told to use an incontinence brief instead of being assisted to the restroom, and a third resident being given instructions about bathroom use loudly enough to be overheard from the hallway. The Director of Nursing acknowledged that it was inappropriate for staff to be overheard giving such instructions and that residents should not be told to use their incontinence briefs. These actions and inactions by the staff led to the deficiency in maintaining resident dignity.
Failure to Honor Resident's Care Preferences
Penalty
Summary
The facility failed to honor a resident's personal preferences for care, specifically regarding shower and catheter change schedules. The resident, who is cognitively intact and requires assistance with activities of daily living, expressed a preference for morning showers instead of the scheduled Tuesday and Friday afternoons. However, the facility did not accommodate this request, citing that the day shift nurse aides were too busy. Additionally, the resident preferred their indwelling urinary catheter to be changed during the day rather than at night, but this preference was also not honored. The Director of Nursing confirmed that the resident's request for morning showers could not be accommodated due to the full schedule of the day shift CNAs. The facility's Resident Rights Handbook states that residents have the right to choose schedules consistent with their interests, which was not upheld in this case.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly follow up and resolve a grievance for a resident, resulting in feelings of frustration. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status score of 15/15, was admitted with diagnoses including Parkinson's, neuropathy, depressive disorder, anxiety disorder, and muscle weakness. The resident and their family reported grievances about not receiving showers or baths for several days, despite multiple complaints to facility leadership. However, the facility did not have any documentation of these grievances. Interviews with facility staff, including the Director of Care Transitions, Director of Nursing (DON), and the Administrator, revealed that the facility had a grievance process in place, which involved documenting grievances and following up within 24 hours. However, the DON and Administrator were not aware of any grievances related to the resident, and the Assistant Director of Nursing, who was reportedly handling grievances, did not document or follow up on the complaints. The facility's Resident Concerns Policy outlined a procedure for addressing grievances, but it appears this process was not followed in this case.
Failure to Transcribe Admission Medications Timely
Penalty
Summary
The facility failed to timely and accurately transcribe physician orders for admission medications for a resident who was admitted with diagnoses including lung transplant status and idiopathic pulmonary fibrosis. Upon admission, the resident's discharge summary from the hospital included a list of medications, such as anticoagulant and antirejection medications, which were crucial for their condition. However, the resident did not receive the majority of their medications until two days after admission, with only a few medications administered on the first day. The Director of Nursing (DON) acknowledged that the nurse responsible for admitting the resident did not input any medication orders, leading to a delay in transcription. Although a second nurse attempted to rectify the issue, they also failed to transcribe the resident's tacrolimus, an essential antirejection medication. This oversight resulted in the resident not receiving their necessary medications in a timely manner, as confirmed by a review of the medication administration record and the medication order summary.
Failure to Apply Prescribed Splint for Resident
Penalty
Summary
The facility failed to ensure that a splint was applied per the physician's order for a resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident, who had intact cognition with a BIMS score of 13, was observed on two separate occasions without the prescribed resting hand splint on their right arm. The splint was noted to be on the dresser, and the resident indicated that staff did not offer to apply it. The physician's order, dated December 22, 2023, required the splint to be donned during nighttime hours for contracture prevention, but there was no schedule or frequency attached to the order. A review of the resident's comprehensive care plan and treatment/medication administration records for May and June 2024 showed no documentation that the splint had been applied as ordered. The Director of Nursing confirmed that the order was entered incorrectly into the record, lacking a schedule, which resulted in the nursing staff not being prompted to apply the splint. This oversight led to the failure in providing the necessary care to maintain or improve the resident's range of motion as per the physician's directive.
Failure to Follow Physician Orders and Document Catheter Care
Penalty
Summary
The facility failed to follow physician orders and ensure accurate documentation for a resident with an indwelling urinary catheter. The resident, who was cognitively intact and required assistance with activities of daily living, reported that their catheter was supposed to be changed monthly. However, it had been a month and four days since the last change. The Medication Administration Record (MAR) indicated that the catheter change was marked as completed by an LPN, despite the procedure not being performed. The LPN admitted to not changing the catheter as the resident preferred the procedure to be done during the day shift rather than the midnight shift. Despite this, the MAR was inaccurately marked as completed. The Director of Nursing confirmed that documentation should only occur after a task is completed and that any resident refusal should be recorded. The oversight in documentation led to the Director of Nursing being unaware that the catheter change had not been performed.
Failure to Administer Critical Medications Timely
Penalty
Summary
The facility failed to timely and accurately transcribe and administer physician-ordered medications, including anticoagulant (warfarin) and antirejection medicine (tacrolimus), for a resident who had undergone a lung transplant. The resident was admitted to the facility with a discharge medication list from the hospital, which included critical medications such as tacrolimus and warfarin. However, upon review of the resident's medication administration record, it was found that the resident did not receive any medication on a specific date except for calcium carbonate, metformin, and acetaminophen. Notably, there was no documentation of the administration of the antirejection medication, tacrolimus, during the resident's stay. The deficiency occurred because the nurse responsible for admitting the resident failed to input any medication orders, leading to a delay in the administration of most medications until two days after admission. A second nurse attempted to rectify the situation by entering the medication orders, but still failed to include the tacrolimus. This oversight was identified during a conversation with the Director of Nursing, who confirmed the transcription errors and the subsequent delay in medication administration.
Improper Medication Storage in Resident's Room
Penalty
Summary
The facility failed to ensure proper storage and inventory of medications in a resident's room, leading to a deficiency. During an observation, several medications were found in clear storage cubes on the over-bed tray table of a resident, identified as R53. These included a bottle of Rolaids, eye drops, two inhalers, and two bottles of medications with unreadable labels. The resident explained that while the inhalers were theirs, the other medications belonged to a family member who would collect them after work. This situation persisted over multiple days, as the same medications were observed in the same location on subsequent visits. The facility's Director of Nursing (DON) was interviewed and acknowledged that the resident refused to allow the removal of the medications from their room. The DON admitted to not having discussed the issue with the resident's family member and was unaware of the specific medications being stored. The facility's policy on medication storage, which includes regular monitoring and quality assurance checks, was not effectively implemented in this case, as evidenced by the continued presence of the medications in the resident's room.
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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