West Woods Of Bridgman
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgman, Michigan.
- Location
- 9935 Red Arrow Hwy, Bridgman, Michigan 49106
- CMS Provider Number
- 235625
- Inspections on file
- 23
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 53 (1 serious)
Citation history
Health deficiencies cited at West Woods Of Bridgman during CMS and state inspections, most recent first.
A resident with dementia and psychiatric comorbidities developed fatigue, poor appetite, flank and abdominal pain, and was suspected by an NP to have a UTI, with hand‑written orders for CBC, CMP, and UA/C&S that were never entered into the EMR or completed. During a later night shift, the resident experienced an acute decline, becoming lethargic and then unresponsive, with fluctuating vitals, cold extremities, and poor SpO2 readings; CNAs alerted RNs, and an on‑call PA agreed the resident required hospital evaluation. While one RN, who was in orientation, focused on completing transfer paperwork and calling report to the ED, 911 was not promptly called, an abandoned 911 call from the facility was later reported as “no emergency,” and EMS ultimately arrived to find the resident unconscious without CPR in progress, leading to emergent transport and subsequent death the same day.
The facility failed to provide sufficient licensed nursing staff on a night shift when census and its own staffing matrix called for three nurses, leaving only two nurses on duty, one of whom was still in orientation. Staff interviews described frequent short staffing on nights, high-acuity back units where many residents required two staff for care, and CNAs caring for 15–16 residents with delayed call-light response. On the cited night, two residents required hospital transfer, and the orienting RN focused on completing transfer paperwork for a resident with hypotension, lethargy, cool skin, edema, and heel blisters while relying on another RN, who went to eat, for guidance on calling 911. Conflicting accounts from the two RNs and 911/EMS records showed that after an initial EMS call for another resident, an abandoned 911 call from the facility, and a return call in which staff reported no emergency, the local ED and ambulance service had to contact 911 to initiate EMS response for an unresponsive resident the facility said it could not get through to 911 about, resulting in a delayed emergent transfer for that resident, who later died in the hospital.
A newly hired RN, who had not completed orientation and had never transferred a resident to a hospital before, was responsible for two resident transfers during one shift, including a resident who became unresponsive and required emergent EMS transport. The RN reported she was still being trained on the hospital transfer process, including required paperwork and steps, and was left to continue paperwork while the assisting RN went to eat. 911 and EMS records showed an abandoned 911 call from the facility, a return call where staff reported no emergency, and subsequent involvement of the local ED and ambulance service before EMS was dispatched for a reported cardiac arrest. EMS found the resident unconscious, hypoxic, and minimally responsive, and hospital records documented severe clinical instability on arrival. The DON and NHA stated new nurses receive five days of training and an orientation checklist covering emergency procedures and rapid transport, but the DON acknowledged the checklist does not have to be completed before return, had not been turned in for this RN, and she did not know which training items were finished, demonstrating a failure to ensure and monitor effective training for new nursing staff.
A resident admitted with a C6 cervical fracture, syncope, and weakness had provider orders and discharge instructions to wear an Aspen collar at all times, with documentation confirming the fracture and collar use. However, the facility did not develop a care plan addressing the cervical fracture or Aspen collar, even though interdisciplinary notes described the resident as confused, repeatedly removing the collar despite education, and requiring two-person assistance for mobility and transfers. During interviews, the IPM/RN and DON acknowledged that a care plan for the fracture and collar should have been created by the assigned clinical care coordinator at admission but was not.
A resident with a history of bipolar disorder, dementia, and delusional disorder had an order for metoprolol succinate ER 25 mg daily with instructions to hold the dose and notify the provider if systolic BP was <110 or pulse <60. Review of MARs over several months showed that nursing staff repeatedly administered metoprolol on days when documented systolic BP readings were below 110, and there was no record of provider notification when BP readings were outside the ordered parameters. In interviews, an LPN confirmed that medications with parameters should be held when vital signs are outside those limits, the PA and NP stated the metoprolol should have been held under those conditions, and the DON acknowledged that giving the medication without contacting the provider when BP was outside parameters was a medication error.
The facility did not complete required annual performance evaluations for two CNAs, as identified through record review and staff interviews. One CNA hired more than a year earlier had no evaluation on file, and another CNA’s last documented evaluation was not updated on an annual basis. The NHA stated that the DON was responsible for conducting evaluations and HR for tracking due dates, but the DON reported she was unaware of this responsibility and had not completed any evaluations since assuming her role. Regional clinical leadership confirmed that evaluations were expected annually on each employee’s hire-date anniversary, yet no current evaluations for the two CNAs were available during the survey.
The facility did not ensure that a CNA completed the required 12 hours of annual in‑service training, including dementia care and abuse prevention. Record review showed that the CNA, hired several months earlier, had not attempted any of the electronically assigned in‑service modules. The NHA confirmed that in‑services were assigned at the beginning of the year and monthly, that CNAs were notified electronically of new trainings, and that the HR staff member responsible for tracking completion was not available during the survey. This failure created the potential for decreased resident safety due to lack of required CNA education.
Multiple residents with significant care needs experienced prolonged delays in call light response, resulting in unmet toileting and hygiene needs. Staff interviews confirmed that complaints about long wait times were common, and some staff admitted to turning off call lights before completing care, contrary to facility policy. These actions led to discomfort and distress for residents and concern from families.
A resident was readmitted after a hospital stay with orders for occupational and physical therapy evaluation and treatment, but the facility did not complete a therapy evaluation. Staff believed that if the resident returned at baseline, therapy was not needed, despite hospital documentation indicating ongoing therapy requirements.
The facility failed to develop person-centered care plans for two residents, leading to deficiencies in their care. One resident, who is bed-bound, was observed unkempt and unshaven, with staff unaware of his preference to be shaved by a family member. Another resident, diagnosed with PTSD, had a care plan lacking interventions for his condition, with staff unaware of his diagnosis and triggers. The facility's policy emphasizes person-centered care, but the care plans did not reflect this, resulting in inconsistent care.
A resident experienced a skin tear due to the facility's failure to update her transfer status from a one-person assist to a two-person assist after a hospital readmission. Despite therapy's recommendation for increased assistance, the care plan was not revised, leading to the incident during a transfer by a CNA who followed the outdated care plan.
A resident who was bed-bound and required total care was observed with long and soiled fingernails, despite being scheduled for showers twice a week where nail care was supposed to be provided. Staff interviews revealed that nail care was expected during showers, but the resident's nails remained unkempt. The DON confirmed the deficiency, acknowledging that the nails should have been trimmed.
The facility failed to use gait belts during transfers for two residents, leading to potential injury risks. One resident, with increased weakness, was transferred without a gait belt, resulting in a skin tear. Another resident, with impaired mobility, was frequently transferred without a gait belt, as observed by a family member. Staff interviews confirmed the expectation of gait belt use, but the facility lacked a specific policy, and gaps in staff training were identified.
A facility failed to identify and address PTSD triggers for a resident, who had a history of aggression and past trauma. Despite having a care plan for potential acute changes related to PTSD, no specific interventions were in place. The Social Services Director was initially unaware of the resident's PTSD diagnosis and related triggers, contributing to the deficiency in trauma-informed care.
The facility did not ensure the Medical Director attended QAPI meetings at least quarterly, as required. Sign-in sheets from January to April 2024 showed the Medical Director's absence, which was acknowledged by the NHA. The facility's policy mandates the Medical Director's attendance at these meetings.
The facility failed to ensure proper use of PPE for enhanced barrier precautions for two residents. One resident, with a stroke and diabetes, did not have PPE worn by CNAs during care despite signage. Another resident, with cerebral palsy and a gastrostomy tube, lacked signage indicating PPE requirements. Staff were either unaware or did not comply with PPE protocols.
A resident with atrial fibrillation and high blood pressure experienced an overdose of blood thinner medication due to incorrect transcription of warfarin orders at an LTC facility. Despite protocols for triple-checking medication orders, the facility failed to accurately transcribe and verify the complex dosing schedule, leading to a significant medication error. Interviews revealed a lack of effective communication and documentation among the healthcare team, contributing to the deficiency.
A resident with atrial fibrillation was overdosed on Warfarin due to incorrect transcription of hospital discharge orders, leading to a critically high INR. The facility failed to promptly address the error, resulting in delayed intervention and communication with the provider. This incident highlights lapses in medication management and monitoring processes.
Failure to Act on Change in Condition and Delay in Activating 911 for Unresponsive Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to an acute change in condition for one resident, including failure to follow provider orders for diagnostic testing and failure to promptly activate 911 EMS when the resident became unresponsive and hypotensive. The resident was an elderly female with bipolar disorder, dementia, and delusional disorder who had been evaluated by a nurse practitioner two days prior for fatigue, poor appetite, right flank/low back pain, and lower abdominal tenderness. The NP suspected a UTI and hand‑wrote orders on a Doctor’s Orders sheet for CBC, CMP, and urinalysis with C&S if indicated. These orders were to be entered into the EMR by clinical care coordinators, but the Infection Prevention Manager later confirmed that no such orders were entered and no labs or UA were completed, and there were no results in the lab system. During the overnight shift, multiple CNAs reported that the resident was her usual self at the beginning of the shift but later became very lethargic, unable to keep her eyes open, and then completely unresponsive. CNAs stated they notified the nurse, and that two RNs (one being newly oriented) repeatedly assessed the resident, took vital signs several times, and made numerous phone calls. One CNA recalled that one RN wanted to send the resident to the hospital while the other RN was not convinced this was necessary. The orienting RN reported that both nurses assessed the resident and noted fluctuating vital signs, pain, lack of responsiveness except to painful stimuli (sternal rub), cold hands, and difficulty obtaining pulse oximetry readings. She contacted the on‑call PA, who agreed the resident required hospital evaluation, and she documented that the focus at that time was on facilitating transport and maintaining safety while awaiting transfer. The orienting RN described that she and the other RN were the only two nurses in the building that night and that she was being trained on the transfer process, including completing a transfer checklist and packet. She stated she had already transferred another resident earlier in the shift and had learned that 911 arrived quickly and would not wait for incomplete paperwork, so for this resident she took extra time to complete all transfer forms, call the family, and call report to the ED before calling 911. She reported asking the other RN whether they should call 911 and being told to finish the packet while the other RN went to eat. She then completed the electronic transfer form, including documenting last vital signs and that report was called to the ED, but she did not call 911 and believed the other RN would do so. EMS and 911 records show an abandoned 911 call from the facility, a return call in which staff stated there was no emergency, and subsequent calls from the local ED and ambulance service indicating the facility had called the ED with report on an unresponsive resident but had not sent the patient. EMS ultimately received a dispatch at approximately 5:37 a.m. for a 77‑year‑old female in cardiac arrest, arrived to find the resident unconscious but with spontaneous respirations and a pulse, and documented that no CPR or ventilations were in progress on arrival. The resident was transported emergently to the hospital, where she was found comatose, hypotensive, tachycardic, cool and cyanotic, and later died the same day. The PA who had been contacted by the facility stated that, based on the nurse’s documentation, the resident should have been sent to the hospital right after their call and that he would not have told staff to delay transfer. Additional interviews with leadership clarified that the DON expected nurses to assess residents with a change in condition, call the on‑call provider, complete transfer forms, and call 911 EMS for transport, with immediate transfer for an unresponsive resident. The DON acknowledged that night shift staffing could be as low as two nurses and that she believed there was little to do after evening med pass. The Infection Prevention Manager stated she did not receive any call from the facility during the overnight hours and arrived at work as EMS was taking the resident out on a stretcher. The Nursing Home Administrator reported there was no phone outage on the dates in question, although the facility’s voice‑over‑IP phone system could go down and be switched to another Wi‑Fi connection, and staff were expected to use personal cell phones if needed. 911 service records documented that when 911 returned the abandoned call from the facility, staff told them there was no emergency, and only after subsequent calls from the ED and ambulance service was EMS dispatched for the resident described as unresponsive and in cardiac arrest.
Removal Plan
- All licensed nurses were re-educated that 911 EMS must be called without delay for any resident exhibiting signs of an acute decline, including but not limited to unresponsiveness, hypotension, altered mental status, respiratory distress, or other emergent conditions.
- Staff were instructed that contacting the emergency department or hospital does not replace activation of 911 EMS.
- Emergency response protocol reeducation requiring immediate activation of 911 followed by notification of the supervisor or administrator on call.
- The monthly on call schedule was posted at the nurse's station.
- The Director of Nursing or designee are available 24 hours a day, 7 days a week to support clinical decision-making during all shifts.
- Re-education will be completed in person or by telephone prior to staff’s next scheduled shift being worked.
- No licensed staff will be allowed to start a shift or give care until education is completed.
- Medical director was notified.
- Facility health care providers will enter their own orders into the electronic medical record.
- A facility wide review of all current residents was initiated to identify those at risk for acute clinical decline.
- All residents exhibiting signs of deterioration were immediately assessed and transferred via EMS per the emergency response protocol.
- A licensed nurse will conduct a chart review of all current residents for change in condition and follow through with health care practitioner orders.
- All licensed nurses will receive education prior to their next worked shift, including those on leave of absence upon return.
- Agency licensed nurses will be educated and will complete a competency test prior to their shift worked.
- The facility change in condition policy was reviewed by the interdisciplinary team and updated to clearly require activation of 911.
- Emergency condition decision-support tools were implemented at the nurse's station.
- Leadership oversight was implemented to review all emergency transfers.
Insufficient Night-Shift Nursing Staff Led to Delayed EMS Transfer After Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient licensed nursing staff on the night shift to meet resident needs and maintain residents’ highest practicable well-being, which contributed to a delayed emergency transfer for a resident who experienced an acute change in condition and later died. The facility used a corporate staffing matrix based solely on census, without documented consideration of resident acuity, despite a facility assessment stating that staffing levels would be based on acuity and diagnoses. On the night in question, the census was 75, and the staffing matrix and facility assessment both indicated there should be three nurses on the night shift; however, only two nurses (one of whom was still in orientation) were on duty for the entire overnight shift after a scheduled nurse called in. The DON acknowledged that the facility often worked with only two nurses at night and believed three nurses were not needed after the evening medication pass, and the staffing manager confirmed that when there was a call-in, a day-shift nurse might stay over only long enough to complete the evening medication pass, leaving the night shift short. Resident #1 was a female resident with bipolar disorder, dementia, and delusional disorder. On the cited night, two residents, including Resident #1, required transfer to the hospital. CNA interviews described that staffing on nights was frequently short, with only two nurses and five CNAs at times, and that the south and east (back) units had higher-acuity residents, many of whom required two staff for care. CNAs reported that when CNAs working 8‑hour segments left mid‑shift, remaining CNAs were left with 15–16 residents each, and that residents sometimes waited 20 minutes or more for call lights to be answered, especially when showers were being completed. One CNA stated that once staff were in the back units, they did not go to other parts of the building due to the high acuity and needs of those residents. During the night in question, the two nurses on duty were RN V, who was still completing orientation, and RN P, who was assisting RN V with orientation tasks, including learning how to transfer a resident to the hospital. According to RN V, around 3:00 a.m. two residents, including Resident #1, needed to be transported to the hospital. RN V reported that she had earlier transferred another resident that night and had learned that EMS would not wait if paperwork was not ready, so she took extra time to complete all transfer paperwork correctly for Resident #1. She stated she asked RN P whether they should call 911, and RN P told her to finish the paperwork while RN P went to eat and would help afterward. RN V believed RN P called 911; however, she later stated she did not call 911 herself. RN P, in contrast, initially stated she did not call 911 and then expressed uncertainty about who had called. Documentation by RN V, entered later that morning, indicated that at 3:16 a.m. the PA was notified of Resident #1’s change in condition (hypotension, lethargy, cool skin, significant bilateral lower-extremity edema, and fluid-filled blisters on the heels), that the PA agreed the resident required hospital evaluation, and that the hospital was notified and preparations for transfer were initiated. EMS and 911 records showed that 911 received a call at 3:20 a.m. for another resident, with that call clearing at 5:01 a.m., and that an abandoned call from the facility occurred at 5:24 a.m., which was returned and staff reported no emergency. At 5:29–5:30 a.m., the local emergency department and the ambulance service contacted 911, reporting that the facility had called the hospital with report on a patient over an hour earlier but the patient had not arrived, and that the facility had reported difficulty reaching 911 due to phone issues. A subsequent call detail report documented that 911 initially closed the call after being told there was no emergency, then reactivated it when the ambulance service called back with information that a 77‑year‑old female at the facility was hypertensive, unresponsive, and in cardiac arrest, and that the facility said they could not get through to 911. EMS was dispatched around 5:37 a.m. and arrived to find the resident unconscious but breathing with a pulse, on oxygen via nasal cannula, with no CPR or ventilations in progress. EMS documented severe hypoxia requiring escalation of oxygen support and transported the resident to the emergency department. Hospital records indicated that upon arrival to the emergency department, the resident was comatose, hypotensive, tachycardic, cool, and cyanotic, and was intubated, with crushed pill remnants noted in the back of the throat and concern for polypharmacy versus aspiration of medication. The resident was found to have a UTI and developed complications including unstable SVT, cardiogenic shock on top of sepsis, and DIC, ultimately leading to death later that day. The facility’s own data for the date of the incident showed that, with a census of 75, 35 residents required two or more staff for care such as transfers. Multiple CNAs and nurses reported that night shifts were often short-staffed, that there were not enough nurses to cover nights, and that they frequently did not get lunch breaks. The combination of working with only two nurses instead of the three indicated by the facility’s matrix and assessment, the high acuity and dependency of many residents, and the orientation status of one of the two nurses on duty contributed to delays and confusion in arranging timely EMS transport for Resident #1 after an acute change in condition.
Failure to Ensure Effective Orientation and Emergency Transfer Training for Newly Hired RN
Penalty
Summary
The deficiency involves the facility’s failure to provide and monitor an effective training program for a newly hired RN, specifically related to emergency procedures and hospital transfers, which contributed to a delayed response to a resident’s acute change in condition and emergent transfer. The facility’s DON and NHA stated that new nurses receive five days of training and an orientation checklist that includes emergency procedures, hospitalization, transfer forms, and emergency access for rapid transport. However, the DON acknowledged that the checklist does not have to be completed before being returned and that the orientation checklist for the involved RN had not been turned in, leaving the DON unaware of which training items had been completed. The orientation checklist for this RN was not provided to surveyors by the time of exit. The newly hired RN reported that she started at the end of the prior month and had not completed all of her training, including training on transferring a resident to an acute care hospital. On the night in question, she had to transfer two residents to the hospital for changes in condition and stated she had never done this before. She reported that another RN was assisting her with the orientation training checklist and with completing the paperwork, steps, and packet required for a hospital transfer. The assisting RN confirmed that the new RN appeared overwhelmed and unfamiliar with the transfer process and that she tried to help with the required paperwork. The new RN stated that she asked whether they should just call 911 for the resident and was told by the assisting RN to finish the paperwork while the assisting RN went to eat and would help again afterward. During this same shift, EMS and 911 records show multiple calls associated with the facility and a delay in EMS activation for the resident who was ultimately found unresponsive. 911 records documented an abandoned call from the facility, a return call from 911 during which facility staff reported no emergency, and subsequent calls from the local emergency department and ambulance service indicating that the hospital had received report on a patient from the facility but had not yet received the patient. EMS documentation for the resident later transported described dispatch for a cardiac or respiratory arrest, arrival to find the resident unconscious, minimally responsive, hypoxic, and requiring escalating oxygen support and eventual transfer to the emergency department. Hospital records documented that the resident, an older adult with dementia with psychotic features, major depressive disorder, and atrial fibrillation on Eliquis, was brought in unresponsive, hypotensive, tachycardic, cool, and cyanotic, and was intubated for airway protection. The combination of incomplete orientation, lack of verified competency in emergency transfer procedures, and the facility’s failure to ensure the new RN was effectively trained and monitored in these processes led to a delay in treatment and emergent hospital transfer for this resident. The DON confirmed that she did not know which emergency procedure and transfer-related training items the new RN had completed because the orientation checklist had not been returned. The Licensed Nurse Orientation and Skill Check form included items such as emergency procedures, hospitalization, transfer form from the electronic record, and emergency access for rapid transport, but there was no evidence these competencies had been completed or validated for the new RN. The new RN’s own statements that she had never transferred a resident to the hospital before, had not yet completed all of her training, and did not complete the first transfer’s paperwork correctly further demonstrate that the facility did not maintain an effective training and monitoring process for new nurses in critical emergency and transfer procedures, contributing to the deficient practice identified by surveyors.
Failure to Care Plan for Cervical Fracture and Aspen Collar Use
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan addressing a resident’s C6 cervical fracture and ordered Aspen collar use. The resident, a male admitted with diagnoses including a displaced fracture of the sixth cervical vertebra, syncope, collapse, and weakness, had a history and physical dated 12/6/25 documenting a syncopal episode with a fall, head strike, neck pain, and a scalp laceration requiring sutures. MRI showed an anterior superior vertebral body fracture, and he was stabilized in an Aspen collar with a recommendation for continued collar use and follow-up imaging. An after-visit summary dated 12/12/25 directed that the Aspen collar be worn at all times, and a provider note dated 12/15/25 confirmed the C6 fracture and Aspen collar, noting the resident was seen heading to therapy in the collar. Despite these documented orders and clinical findings, review of the resident’s care plan revealed no care plan related to the cervical fracture or the use of the Aspen collar. Interdisciplinary documentation on 12/16/25 described the resident as alert and oriented with some confusion, continuously removing the Aspen collar despite education to keep it in place per provider orders, and being unsteady, requiring assistance of two for bed mobility, transfers, and ambulation. During interviews, the Infection Prevention Manager/RN and the DON both confirmed there was no care plan in place for the C6 fracture or Aspen collar and stated that a care plan should have been created at admission by the assigned clinical care coordinator/RN responsible for the resident’s unit.
Failure to Follow Metoprolol Hold Parameters Resulting in Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of metoprolol succinate ER. The resident, a female with bipolar disorder, dementia, and delusional disorder, had a physician’s order for metoprolol succinate ER 25 mg by mouth once daily for hypertension, with instructions to hold the medication if the systolic blood pressure was less than 110 or the pulse was less than 60, and to notify the physician. Review of the Medication Administration Records (MARs) for October, November, and December 2025 showed multiple instances where the resident’s systolic blood pressure was documented below 110, yet the metoprolol was still administered on those dates. Specific blood pressure readings below the ordered parameter included systolic values of 107, 102, 106, 107, 94, and 107 in October; 103, 106, 100, 100, 108, 105, and 109 in November; and 103, 104, 104, 106, 109, and 104 in December, all with documentation that the medication was given. The resident’s medical record contained no documentation that any provider was notified when blood pressure readings were outside the ordered parameters. In interviews, an LPN stated that medications with hold parameters should not be given if vital signs are outside those parameters. The physician assistant and nurse practitioner both reported that, based on the written order, the metoprolol should have been held whenever the systolic blood pressure was below 110, and the nurse practitioner did not recall being notified of any holds. The DON stated her expectation that medications be given per physician orders and acknowledged that if the provider was not contacted and the medication was given when blood pressure was outside parameters, it constituted a medication error.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete required annual performance evaluations for two CNAs out of five reviewed, resulting in potential for unidentified CNA performance concerns, lack of training related to performance review outcomes, and potential unmet care needs. Documentation provided by the NHA showed that one CNA hired on 8/24/24 had no performance evaluation completed, and another CNA hired on 3/9/15 had their last documented performance evaluation on 3/19/24, with no current annual review. During interviews, the NHA acknowledged that these two CNAs did not have completed performance reviews and stated that the DON was responsible for completing evaluations while HR was responsible for tracking due dates. The DON reported she was unaware that she was responsible for CNA performance evaluations and had not completed any since starting in her role about five months earlier. The Regional Clinical Support confirmed that performance evaluations were expected annually on each employee’s hire-date anniversary, and no evaluations for the two CNAs were available by the end of the survey. A cited reference from a healthcare performance review resource noted that performance reviews lead to improved performance, greater productivity, and a better overall experience for patients. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the report focused solely on staff performance evaluation practices and related documentation and interviews.
Failure to Ensure Required CNA In‑Service Training Completion
Penalty
Summary
The facility failed to ensure a certified nurse assistant (CNA) completed the required 12 hours of in‑service training needed to ensure continued competency. Interview and record review showed that one CNA, identified as CNA F, was hired on 8/24/24 and, as of the time of survey, had completed 0 hours of in‑service training. A list of assigned in‑service trainings for this CNA documented that none of the assigned trainings had been attempted. The Nursing Home Administrator (NHA) reported that in‑services were assigned at the beginning of the year and monthly, and that CNAs were notified electronically when new training was assigned. The NHA confirmed that CNA F did not have 12 hours of completed in‑service trainings and stated that the Human Resources staff member responsible for maintaining the list of employees and training completions was unavailable during the survey. This deficiency resulted in the potential for a decrease in resident safety, as the facility did not ensure that this CNA had the required in‑service education, including dementia care and abuse prevention, as required for ongoing competency.
Failure to Ensure Timely Call Light Response and Dignified Care
Penalty
Summary
The facility failed to provide care and services that promote dignity and respect for multiple residents, as evidenced by prolonged call light response times and unmet personal care needs. Several residents, all with significant physical or cognitive impairments requiring assistance with personal care and toileting, reported waiting extended periods—ranging from 30 minutes to several hours—for staff to respond to their call lights. In some cases, residents remained in soiled briefs or with full urinals for hours, causing discomfort and distress. Family members also observed and reported these delays, noting that staff sometimes turned off call lights before completing the requested assistance and occasionally forgot to return to fulfill the resident's needs. Staff interviews corroborated the residents' and families' accounts, with multiple CNAs and an LPN acknowledging that residents frequently complained about long call light wait times. One CNA admitted to turning off call lights before completing the task, intending to return later, while the facility's orientation materials specifically instructed staff not to turn off call lights until the resident's need was met. Despite these guidelines, the practice of prematurely turning off call lights persisted, leading to further delays and unmet care needs. The affected residents had diagnoses such as major depressive disorder, paraplegia, muscle weakness, paralysis, and cognitive communication deficits, making timely assistance with toileting and hygiene essential. The failure to respond promptly to call lights and to provide necessary personal care services resulted in residents experiencing discomfort and a lack of dignity, as well as frustration and concern from both residents and their families.
Failure to Complete Therapy Evaluation After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a therapy evaluation was completed for a resident upon readmission following an inpatient hospital stay. The resident, who had diagnoses including muscle weakness and required assistance with personal care, was discharged from the facility, hospitalized, and then readmitted. Upon return, the resident reported feeling weaker and more easily fatigued than before her hospitalization. Despite hospital discharge documentation and orders explicitly stating the need for occupational and physical therapy evaluation and treatment at the receiving facility, no therapy evaluation was conducted after her readmission. Interviews with facility staff revealed that the therapy manager and clinical care coordinator did not consider hospitalization alone as a reason to screen for therapy services, and believed that if a resident returned at their baseline, no therapy referral was necessary. However, hospital records indicated the resident required further skilled occupational therapy, and discharge instructions included orders for therapy evaluation and treatment at the facility. The interim director of nursing confirmed that the resident was not evaluated by therapy upon readmission, contrary to expectations.
Deficiencies in Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in their care. Resident #8, who is bed-bound and requires assistance with personal care, was observed unkempt and unshaven on multiple occasions. Despite being scheduled for showers twice a week, during which shaving was expected to occur, Resident #8 remained unshaven. Interviews with staff revealed that Resident #8 preferred to be shaved by a family member, a preference that was not documented in his care plan. The care plan lacked interventions related to his preferences or refusals for care, and staff were unaware of these preferences, leading to inconsistent care. Resident #32, diagnosed with major depressive disorder, PTSD, and generalized anxiety disorder, had a care plan that did not address his PTSD diagnosis. The care plan focused on the potential for acute condition changes but lacked specific interventions related to PTSD. Interviews with staff indicated a lack of awareness of Resident #32's PTSD diagnosis and the absence of documented triggers or interventions to manage his condition. This oversight resulted in staff being unprepared to address his needs, potentially leading to angry outbursts and stress. The facility's policy on care planning emphasizes the importance of person-centered care, including understanding resident preferences and documenting refusals of care. However, the care plans for both residents did not reflect these principles, resulting in deficiencies in meeting their individual needs. The lack of documentation and communication among staff contributed to the failure to provide appropriate and consistent care for these residents.
Failure to Update Transfer Status Results in Resident Injury
Penalty
Summary
The facility failed to update the transfer status of a resident, resulting in a skin tear. The resident, who was cognitively intact, was initially admitted with diagnoses including unsteadiness on feet and difficulty walking. After a hospital stay, the resident was readmitted to the facility, and therapy assessed that her transfer status required a change from a one-person assist to a two-person assist due to increased weakness. However, this change was not updated in her care plan, leading to a skin tear during a transfer when a CNA followed the outdated care plan. Interviews revealed that the therapy director communicated the need for a change in transfer status to nursing staff, but the care plan was not updated accordingly. The CNA involved in the transfer was unaware of the change and relied on the care plan, which still indicated a one-person assist. The incident highlighted a breakdown in communication between therapy and nursing staff, as well as a failure to update the care plan to reflect the resident's current needs.
Failure to Provide Adequate Nail Care to a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was dependent on staff for activities of daily living. The resident, who was bed-bound and required total care, was observed on multiple occasions with long and soiled fingernails. Despite being scheduled for showers twice a week, during which nail care was supposed to be provided, the resident's nails remained unkempt. Observations on different days confirmed the resident's unshaven and unkempt appearance, indicating a lack of personal care. Interviews with staff, including CNAs and the Director of Nursing, revealed that nail care was expected to be performed during the resident's scheduled showers. However, despite documentation indicating that a shower was completed, the resident's nails were still long and dirty. The Director of Nursing acknowledged the deficiency upon observation, confirming that the resident's nails should have been trimmed during the shower. This indicates a failure in the facility's process to ensure the resident's personal care needs were met as per their care plan.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to implement the use of gait belts during transfers for two residents, leading to potential injury risks. Resident #268 was admitted with diagnoses including unsteadiness on feet and required assistance with personal care. After a hospital readmission, her care plan indicated a one-person assist for transfers. However, a therapy screen revealed increased weakness, necessitating a two-person assist, which was not updated in her care plan. On a specific date, during a transfer without a gait belt, Resident #268 sustained a skin tear, highlighting the failure to adjust her care plan and use appropriate transfer aids. Resident #61, diagnosed with a neurocognitive disorder and a history of falls, required maximal assistance for transfers. Observations revealed that staff frequently transferred Resident #61 without using a gait belt, despite his impaired mobility. During one instance, a CNA assisted him to the toilet by placing her arms around his torso without a gait belt, as reported by a family member who regularly observed such practices. Interviews with staff, including the Therapy Director and Clinical Care Coordinator, confirmed that gait belts should be used for all transfers unless a mechanical lift is employed. The facility lacked a specific gait belt policy, relying on it as a standard of care. Additionally, a review of staff training revealed gaps in gait belt education, with some staff not receiving current training, contributing to the deficiency in safe transfer practices.
Failure to Address PTSD Triggers in Resident Care
Penalty
Summary
The facility failed to identify and implement interventions for PTSD triggers for a resident, leading to the potential for retraumatization and mental distress. The resident, who was admitted with diagnoses including major depressive disorder, PTSD, and generalized anxiety disorder, was cognitively intact as per a recent assessment. Despite having a care plan that mentioned the potential for acute condition changes related to PTSD, there were no specific interventions addressing the PTSD diagnosis. Additionally, a trauma-informed care life event screening identified past traumatic events, but no further trauma assessments were conducted by the facility staff. The Social Services Director (SSD) was initially unaware of the resident's PTSD diagnosis and any related triggers, despite the resident's history of physical aggression and past traumatic experiences, including abuse and significant personal losses. The resident had displayed aggressive behavior at the facility, such as breaking a window and threatening staff. The SSD later confirmed the PTSD diagnosis and the resident's history of violence but still lacked knowledge of specific PTSD triggers. This lack of awareness and intervention contributed to the deficiency in providing trauma-informed care.
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Process Improvement (QAPI) meetings included the Medical Director as a mandatory attendee at least quarterly. This deficiency was identified through a review of the QAPI meeting sign-in sheets for January and February 2024, which revealed the absence of the Medical Director. Additionally, the Infection Control Meeting sign-in sheets, used for QAPI meetings in March and April 2024, also showed the Medical Director's absence. During an interview, the Nursing Home Administrator acknowledged that the Medical Director did not attend the meetings for four consecutive months, failing to meet the requirement of attending at least one meeting per quarter. The facility's Quality Assurance Performance Improvement Plan Policy, reviewed in May 2024, lists the Medical Director as a required attendee for these meetings.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure the proper use of personal protective equipment (PPE) for enhanced barrier precautions, which was observed in two residents. Resident #1, who had diagnoses including cerebral infarction and type 2 diabetes, was cognitively intact and required enhanced barrier precautions during high-contact care activities. Despite signage indicating the need for PPE, Certified Nurse Assistants (CNAs) L and S did not wear gowns or gloves while providing care to Resident #1. CNA S was unaware of the meaning of the signage, while CNA L acknowledged the requirement but did not comply. Resident #18, diagnosed with cerebral palsy and aphasia, required enhanced barrier precautions due to a gastrostomy tube. However, there was no signage on the door to indicate the need for PPE. Licensed Practical Nurse (LPN) BB confirmed the necessity of PPE when handling the tube. The Clinical Care Coordinator/Registered Nurse (CCC/RN) and the Director of Nursing (DON) both stated that enhanced barrier precautions were expected for residents meeting the criteria, yet these precautions were not properly implemented for Residents #1 and #18.
Medication Transcription Error Leads to Overdose
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of nursing practice, leading to an overdose of blood thinner medication. The resident, who had a history of atrial fibrillation and high blood pressure, was admitted with specific medication orders for warfarin. However, the facility transcribed the orders incorrectly, leading to the administration of an incorrect dosage. The hospital discharge summary specified a complex dosing schedule for warfarin, which was not accurately transcribed by the facility. Interviews with facility staff revealed a breakdown in the medication verification process. The nurse practitioner assumed that the pharmacy had correctly dosed the warfarin and did not verify the orders herself. The admission process involved multiple checks by different nurses, but these checks were not documented or retained, leading to a lack of accountability. The Clinical Care Coordinator noted that the order for pharmacy dosing of warfarin was not entered until days after the resident's admission, indicating a delay in the medication review process. Family members expressed concerns about the resident's medication regimen shortly after admission, highlighting the oversight in medication administration. Despite the facility's protocol for triple-checking medication orders, the failure to accurately transcribe and verify the warfarin dosage resulted in a significant medication error. The lack of effective communication and documentation among the healthcare team contributed to this deficiency, as noted in the review of nursing fundamentals.
Significant Medication Error Due to Incorrect Warfarin Dosing
Penalty
Summary
The facility failed to administer medications at the correct dose as per the physician's order for a resident, leading to a significant medication error involving an overdose of Warfarin, an anticoagulant. The resident, who had a history of atrial fibrillation and hypertension, was discharged from a local hospital with specific instructions for Warfarin dosing. However, the facility transcribed the orders incorrectly, resulting in the resident receiving 4.5 mg of Warfarin daily instead of the prescribed 2 mg or 2.5 mg. This error was not identified or corrected promptly, leading to a critically high INR level of 8.19, which was reported to the facility. Despite the critical lab results indicating a dangerously high INR, the facility did not take immediate action to address the overdose. The results were faxed to the pharmacy, but there was no documented follow-up with the provider regarding the critical lab results or the pharmacy's recommendation to administer Vitamin K. The resident's INR remained critically high, and there was a delay in obtaining a stat lab draw to reassess the INR levels. The lack of timely intervention and communication with the provider contributed to the resident's prolonged exposure to the risk of bleeding due to the Warfarin overdose. Interviews with facility staff revealed a breakdown in the medication administration and monitoring process. The nurse practitioner did not review the Warfarin orders closely, and the admission process failed to ensure accurate transcription and verification of medication orders. The facility's procedures for handling critical lab results and coordinating with the pharmacy and provider were inadequate, leading to a failure to address the resident's critical condition promptly. This deficiency highlights significant lapses in medication management and communication within the facility.
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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