Westland, A Villa Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westland, Michigan.
- Location
- 36137 West Warren, Westland, Michigan 48185
- CMS Provider Number
- 235332
- Inspections on file
- 35
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Westland, A Villa Center during CMS and state inspections, most recent first.
A resident with quadriplegia, depression, and schizoaffective disorder was sent to a hospital for psychiatric evaluation after exhibiting behavioral changes. Hospital records show the resident was cleared to return and repeatedly stated they only wanted to go back to their prior facility, but the DON informed the hospital that the physician wanted the resident transferred to a sister facility and that the home facility would not accept the resident back. The resident reported their belongings had already been moved to the sister facility, and hospital notes documented the resident’s refusal to go there. Facility progress notes did not document any agreement by the resident to transfer, any police arrests, or changes in leave-of-absence status, despite the facility’s policy requiring notice, preparation, and information about appeal rights for transfers and discharges.
The facility failed to implement and document adequate supervision interventions in the care plans of two cognitively intact residents after alleged incidents of inappropriate touching in exchange for candy. A complainant reported witnessing one resident’s hand up another resident’s dress and the other resident’s hand near his genitals. One resident denied any inappropriate contact, stating he only tried to stop the other from eating snacks, while the other resident, communicating via gestures due to a speech impairment, reported mutual groin touching on two occasions and expressed feeling unsafe. Despite these reports and the residents’ psychiatric and neurocognitive diagnoses, review of their care plans showed no added supervision measures, contrary to the facility’s own comprehensive care plan policy.
Two residents reported that shower beds and rooms were not clean, leading them to avoid showers and opt for bed baths. Observations confirmed unsanitary conditions, including standing brown water, residue, and debris on a shower bed. Staff interviews indicated that cleaning protocols were not consistently followed, despite the availability of cleaning supplies and established policies.
A resident dependent on staff for transfers, with a history of hemiplegia and bipolar disorder, reported that staff were rough during wheelchair transfers, causing arm pain. The resident expressed anxiety about reporting the incidents. Observation showed the resident held one hand tightly to their chest, but no visible skin impairments were present at the time. The facility did not thoroughly assess or determine the root cause of the reported skin impairment.
A resident with a history of bipolar disorder, self-harm, and repeated 911 calls did not receive appropriate medically related social services. Despite multiple incidents of agitation, self-injury, and frequent emergency calls, there was no documented follow-up or intervention from social services, and care plans were not updated to address escalating behaviors. Facility staff, including the DON and Social Services Director, were unaware of the resident's self-harming actions and did not assess or address the root causes of the behaviors.
A resident's controlled medication was misappropriated when an LPN falsified the shift inventory records, started a new inventory sheet with incorrect counts, and removed the previous inventory documentation. The discrepancy was not immediately detected during the shift change count, as the oncoming LPN did not verify the new inventory against the previous one, contrary to facility policy. The missing medication was only discovered when the oncoming nurse attempted to administer it later, and the resident did not report any issues with pain management.
The facility failed to ensure residents' rights to receive unopened and private mail, as reported by two residents during a group interview. Residents stated their mail was sometimes delivered opened, with one resident receiving an opened personal letter. The Activities Director confirmed that the business office opened mail if the facility's name was on it, contrary to the facility's policy that staff should not open mail without resident permission.
The facility failed to maintain a clean and homelike environment, with issues such as clogged toilets, dusty fans, and soiled floors. Additionally, two residents reported missing personal property, specifically socks, which were not adequately addressed. The facility's policies on cleanliness and personal belongings were not upheld.
The facility did not complete the required 12 hours of annual in-service education for five CNAs. Despite efforts by the DON to contact a third-party education company for records, the necessary documentation was not provided by the end of the survey. The facility's policy outlines essential training topics, but the deficiency indicates non-compliance with these guidelines.
The facility failed to maintain cleanliness in the exterior dumpster area, as observed during a survey with the Dietary Manager. Several bags of trash were found on the ground around the dumpsters, with loose trash items accumulating between and along the sides. The maintenance department is responsible for cleaning this area. The facility's policy requires dumpsters to be kept closed and free of surrounding litter, but this was not adhered to, potentially affecting all residents, staff, and visitors.
The facility failed to maintain proper infection control practices, including the storage of nebulizer masks for two residents and the cleaning of blood pressure cuffs. Nebulizer masks were left uncovered, and LPNs did not clean equipment between residents. The DON acknowledged these lapses, and the facility's infection control program was found lacking in documentation and staff education.
The facility failed to complete necessary PASARR Level II evaluations for four residents with mental illness or intellectual disabilities. One resident with PTSD and Bipolar Disorder, another with Schizoaffective Disorder, and two others with significant cognitive impairments did not have the required evaluations or exemption letters in their records, despite facility policy requiring such assessments.
The facility failed to serve food in a palatable manner and at the preferred temperature for several residents. A resident reported the food as horrible with no input on the menu, while another found the food always cold and preferences ignored. A lunch tray temperature test showed lukewarm food, and a pureed meal was left untouched due to poor taste. The dietary manager and administrator acknowledged the issues, despite the facility's policy requiring appetizing temperatures.
A resident with multiple health issues, including Schizophrenia and Morbid Obesity, did not have regular care conferences as scheduled, leading to unmet needs and concerns. The resident, who is cognitively intact and dependent on staff for mobility, expressed that their concerns were ignored. The facility's policy requires resident participation in care planning, which was not adhered to.
A resident with Down Syndrome and severely impaired cognition was observed in a hallway with their tube feeding equipment exposed, compromising their dignity and privacy. Despite the facility's policy on maintaining dignity, the resident's stomach and tubing were visible to passersby, which the DON acknowledged should not have occurred.
The facility failed to ensure a call light was within reach for a resident with Alzheimer's and muscle weakness, observed multiple times with the call light out of reach. Additionally, another resident, who is 6'5" and 450 pounds, was not provided with a properly fitting wheelchair, causing discomfort and mobility issues. Despite being measured for a better chair, no suitable wheelchair was provided, and the facility was reluctant to cover the cost, as noted by the local Ombudsman.
A facility failed to maintain accurate advance directive information for a resident with impaired cognition, resulting in a discrepancy between the resident's stated preferences and documented code status. The LPN struggled to locate the correct information, and the process for updating records was not effectively implemented.
The facility failed to report and investigate a verbal altercation between two residents, leading to a room change for one resident without proper documentation. The incident involved a resident with Schizoaffective disorder, who verbally abused and threatened their roommate. The Director of Nursing was aware of the incident, but no formal investigation was documented, and the Nursing Home Administrator was not informed, contrary to facility policy.
A facility failed to accurately complete a PASARR for a resident with Bipolar Disorder and Weakness. The resident's medical record showed intact cognition and required assistance with mobility, while being on multiple psychotropic medications. However, the PASARR screening incorrectly indicated no mental illness diagnosis or treatment, and no updated PASARR or Level II screening was found. The issue was attributed to a social worker's leave, resulting in incomplete tasks.
The facility failed to implement care plan interventions for two residents. One resident, with multiple diagnoses, was often left unsupervised without required floor mats, contrary to their care plan. Another resident with an ankle tether had no care plan for skin checks under the device, despite it impeding therapy. Staff acknowledged the lack of documentation and care planning.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident, with multiple diagnoses including dysphagia, was placed on an NPO order, but their care plan was not updated. Another resident with PTSD had a care plan lacking individualized interventions. The social worker acknowledged the need for revisions.
The facility failed to provide adequate ADL assistance for two residents. One resident was observed with poor hygiene and reported not receiving regular showers or grooming. Another resident, requiring 1:1 feeding assistance due to Dysphagia and Muscle Weakness, was left to eat independently without meal setup. The facility's policy on ADLs was not followed, as residents did not receive necessary services to maintain good nutrition and hygiene.
A resident with Critical Illness Myopathy and Muscle Weakness, requiring staff assistance and having intact cognition, was not scheduled for a timely follow-up ophthalmology appointment despite recommendations due to retinal bleeding. The resident was unaware of the appointment status, and the Unit Secretary cited difficulties due to the resident's hospital visits. The DON noted that implementing ancillary service recommendations is a process, and the facility did not provide a policy on ancillary services.
A resident known for throwing and breaking plates was provided with a breakfast tray containing glass plates and regular utensils, contrary to instructions for paper products only. An LPN confirmed the need for paper products for safety, and the Dietary Manager attributed the error to a new staff member. The facility's accident policy did not address this issue.
A facility failed to obtain physician orders for colostomy care for a resident, who reported their colostomy bag had not been changed in two months. The resident, admitted with multiple diagnoses and cognitively intact, had a medical record indicating an ostomy bag but lacked a physician's order for its care. The DON confirmed the necessity of such an order for proper nursing care.
The facility failed to ensure nurse staffing information was readily accessible, with incomplete postings observed on multiple occasions. The scheduler delayed completing the forms due to potential staffing changes, resulting in missing information for certain shifts. Additionally, the facility did not maintain access to 18 months of staff postings, as some records were shredded by a third party.
A facility failed to review, act upon, and document medication regimen irregularities for a resident with multiple diagnoses, including Heart Failure and Depression. Despite a pharmacist noting irregularities, the facility did not provide the necessary documentation or physician response. Additionally, the facility's policy lacked guidance on reviewing pharmacy reports.
A resident with multiple diagnoses, including Morbid Obesity and Schizophrenia, was observed with yellow and discolored teeth. Despite a recommendation for a dental clinic visit for x-rays, the resident was not seen by dentistry due to sleeping, and no follow-up appointment was scheduled. The facility's policy did not address ensuring timely follow-up on dental recommendations.
A resident's call light system was not functioning properly, as the light outside the room did not alert staff to the resident's need for assistance. The resident reported the issue had persisted for some time, and there were no work orders for repairs. The facility's policy mandates functional call lights and prompt reporting of defects, which was not followed.
A resident with contracted fingers was not provided with a hand splint as ordered by occupational therapy. The splint was found unused, and there was no physician's order or care plan documentation for it. The resident's cognition was not assessed, and the restorative aide was unaware of the splint. The facility's policy on integrating therapy recommendations into care plans was not followed.
A resident was found with unauthorized medications in their room, including Fluticasone nasal spray and other medications without proper orders for self-administration. The resident's cognitive status was not assessed, and the facility's policy requires an interdisciplinary team evaluation for self-administration. An LPN noted the resident's confusion and the DON confirmed the need for proper orders and assessments.
The facility failed to provide timely lab services for two residents, leading to delays in health assessments. One resident had an invalid dilantin level and no documentation of a required Phenytoin trough level, while another had missing lab results and out-of-range values. The facility's policies on timely lab services were not followed.
A resident with schizophrenia and PTSD physically assaulted another resident over a clothing dispute, resulting in hospitalization for the victim. The aggressor had a history of behavioral issues that were not addressed in their care plan, and the facility failed to document and intervene appropriately, leading to the altercation.
A resident with multiple medical conditions fell from a full body mechanical lift, marking the fourth such incident. The resident experienced severe pain and required hospital evaluation. The facility failed to document the incident properly, and unsafe transfer practices were not reported. Additionally, the resident's wheelchair was inadequately cushioned, and the armrest was loose, contributing to the risk of injury.
The facility failed to maintain a clean and homelike environment, with issues such as a wall patch with dust, urine odor in hallways, and mold in a toilet bowl. Observations included gnats around food, a stopped wall clock, and cigarette butts in the smoking area. These deficiencies were noted despite the facility's policy on identifying safety risks and environmental hazards.
A resident with intact cognition and a medical history of Major Depressive Disorder, Asthma, Respiratory Failure, and Muscle Weakness was found in a room with stained privacy curtains. The resident had previously reported the issue to housekeeping. The Housekeeping Supervisor confirmed monthly cleaning of curtains, and the Nursing Home Administrator acknowledged the expectation for a clean environment, as per the facility's Resident Rights policy.
The facility failed to update a PASARR screening for a resident diagnosed with Anxiety and Schizophrenia who remained in the facility for more than 30 days. The required updated screening was not conducted, and the responsible social worker was no longer with the company. The facility's policy on annual and significant change PASARR screenings was not followed.
A resident's PICC line dressing was not changed or dated as required. The resident reported that the dressing had not been changed since hospital discharge. The LPN planned to call for an order to remove the PICC line, and the DON confirmed that an order for regular dressing changes should have been entered per policy.
Failure to Allow Resident to Return After Hospitalization and Honor Discharge Preferences
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return to the facility following a hospitalization and to ensure the transfer/discharge met the resident’s needs and preferences. The resident had been admitted to the facility with diagnoses including quadriplegia, depression, and schizoaffective disorder, was cognitively intact, and required assistance with ADLs. After exhibiting behaviors described by the NHA and DON as manic and psychotic, including accusations against staff and residents and behavior they stated led to police involvement and a petition for psychiatric evaluation, the resident was sent to a local hospital. Hospital records show that psychiatric services evaluated and cleared the resident to return. However, the hospital social worker documented that the DON reported the resident’s physician wanted the resident transferred to a sister facility and that the home facility was not allowing the resident to return. The resident reported by phone that they had been cleared to return, wanted to go back to the facility they considered home for almost two years, and were informed instead that they would be transferred to another facility in a different city and that their belongings had already been moved there. Hospital documentation further showed that the resident refused transfer to the sister facility and stated they only wanted to return to the home facility, while the chart indicated the home facility would not accept them back. The NHA and DON stated that discussions about transferring the resident to the sister facility occurred among the hospital liaison, corporate staff, the physician, and the resident, and that the resident agreed to the transfer; however, the facility’s own progress notes did not contain documentation of the resident’s agreement to transfer, any arrests by local police, or any change in the resident’s ability to leave the building alone due to mental health. The facility’s transfer and discharge policy requires timely notice, adequate preparation, orientation, and information about appeal rights, but the record lacked evidence that these requirements were met in connection with this transfer/discharge decision.
Failure to Implement Supervision and Care Plan Interventions After Alleged Inappropriate Touching
Penalty
Summary
The deficiency involves the facility’s failure to implement supervision interventions and care plan revisions after an incident of alleged inappropriate touching between two cognitively intact residents. A complainant reported that an unknown male resident on Unit 3 gave a female resident a bag of candies in exchange for allowing him to touch her inappropriately, and that the complainant witnessed the male resident’s hand up the female resident’s dress while her hand was on the outside of his pants near his genitals. The facility’s investigation into the incident between the two identified residents was documented as inconclusive because one resident denied the touching occurred while the other resident reported that it did. Both residents’ medical records showed they were cognitively intact, had psychiatric or neurocognitive diagnoses including schizoaffective disorder, bipolar disorder, vascular dementia, anxiety, and depression, and required assistance with activities of daily living. During interviews, the male resident stated that the female resident came into his room and began touching his snacks, and he denied touching her body, explaining he only tried to stop her from eating because he knew she was not supposed to eat by mouth. The female resident, who communicated via nodding and hand gestures due to a speech impairment, indicated that she touched the male resident in his groin area and that he also touched her groin area in exchange for candy, and she indicated this occurred twice and that she did not feel safe because of him. The NHA and DON acknowledged the conflicting accounts and stated that staff were aware of the need to monitor both residents and that the residents were told to stay out of each other’s rooms; however, a review of both residents’ current care plans showed no interventions addressing increased supervision following the alleged incidents. This failure to incorporate supervision measures into the comprehensive, person-centered care plans occurred despite the facility’s own Care Plan Standard Guideline policy requiring services to meet residents’ medical, nursing, mental, and psychosocial needs identified in the assessment.
Failure to Maintain Clean and Sanitary Shower Beds
Penalty
Summary
The facility failed to maintain clean and sanitary shower beds, as evidenced by observations, interviews, and record review. Two residents reported that the shower beds and shower rooms were not clean, with one resident providing photographic evidence of the unsanitary conditions on multiple days. Both residents stated they had been opting for bed baths instead of showers due to the lack of cleanliness. During an observation, a shower bed was found with standing brown water in the crevices, white residue, and brown flakes on both the covering and the frame. Staff interviews revealed that CNAs are responsible for cleaning the shower beds after each use, and the Infection Control Preventionist confirmed that cleaning should occur between each patient use, with a deep clean performed during the night shift. Cleaning supplies, including scrub brushes and disinfectant, were reportedly available in every shower room. A review of the facility's policy indicated that equipment surfaces should be cleaned according to manufacturer instructions, but the observed and reported practices did not align with these requirements.
Failure to Assess and Determine Root Cause of Skin Impairment During Transfers
Penalty
Summary
The facility failed to thoroughly assess and determine the root cause of a skin impairment for a resident reviewed for skin management. During an unannounced onsite investigation, a resident with hemiplegia and bipolar disorder, who was dependent on staff for transfers, reported that staff were rough when transferring them to a wheelchair, causing pain to their arms. The resident expressed fear and anxiety about reporting these incidents, stating they did not want to get anyone in trouble. Observation revealed the resident held their left hand tightly against their chest, with uncertainty about their ability to straighten the arm, while the right arm was freely movable. At the time of observation, no visible bruising or skin impairments were noted on the arms. The clinical record review confirmed the resident's dependency on staff for transfers and intact cognition.
Failure to Provide Medically Related Social Services for Resident with Self-Harm and Behavioral Issues
Penalty
Summary
The facility failed to provide medically related social services to a resident with a history of self-harm, mood disorders, and repeated 911 calls. The resident, who had diagnoses including hemiplegia, hemiparesis, and bipolar disorder, expressed dissatisfaction with care, reported thoughts of suicide, and had multiple documented incidents of agitation, resisting care, and self-harming behaviors such as hitting themselves and banging their head against the wall. Despite these behaviors and repeated emergency calls, there was no evidence of follow-up or intervention from the social services department after an initial note in March, nor was there documentation of assessment or discussion regarding the root causes of the resident's actions. The resident's clinical record showed frequent calls to 911 for various complaints, resulting in multiple hospital transfers, but there was no documentation of any attempt by staff to determine the underlying reasons for these calls. Psychiatric evaluations were conducted, but they did not address the repeated emergency calls or incidents of self-harm. The care plan for the resident was not updated to reflect new or escalating behaviors, and no new interventions were implemented after the resident exhibited self-harming actions. Interviews with facility staff, including the Administrator, DON, and Social Services Director, revealed a lack of awareness and communication regarding the resident's suicidal ideation and self-harming behaviors. The Social Services Director was unaware of these incidents and had not provided follow-up or interventions. The Administrator acknowledged that there should have been documented follow-up and interventions after the resident's return from the hospital, but none were present in the record.
Failure to Prevent Misappropriation of Resident Medication Due to Inadequate Controlled Substance Inventory Procedures
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's medication when an LPN diverted controlled substances by falsifying the shift inventory records. The LPN initiated a new Controlled Substance Shift Inventory and recorded an incorrect number of medication blister packs, which allowed the medication to be removed without immediate detection during the shift change count with another LPN. The previous inventory sheet and pharmacy controlled substance records were missing at the time, and the discrepancy was only discovered when the oncoming nurse attempted to retrieve the medication for the resident a few hours later. The missing inventory sheet was later found in the shred box and revealed a discrepancy in the count compared to the new inventory. The DON confirmed that the oncoming nurse did not verify the new inventory against the previous one, as required by facility policy, and the oncoming LPN acknowledged not following the standard procedure for handling inventory sheets. The resident involved did not report any concerns about missing medication or pain management and was observed to be comfortable, with no overt signs of pain. Facility policies required a thorough reconciliation of controlled substances at shift change and defined misappropriation as the wrongful use of a resident's belongings or money without consent.
Failure to Ensure Privacy in Mail Delivery
Penalty
Summary
The facility failed to ensure residents' rights to receive unopened and private mail delivery, as evidenced by the experiences of two residents who attended a resident group interview. During the interview, residents reported that their mail was sometimes delivered opened. One resident specifically mentioned receiving a personal letter from their sister that was opened without their understanding of why this occurred. The group further explained that facility staff would open mail if they suspected it contained a check. The Activities Director (AD) confirmed that the mail is received from the business office and delivered to residents by the activities department. The AD stated that the activities department does not open residents' mail, but the business office has opened mail before handing it over for delivery. The AD expressed discomfort with delivering opened mail, citing legal concerns. The Business Office Manager admitted to opening residents' mail if the facility's name appeared alongside the resident's name. The facility's policy on Resident Rights, dated 1/28/2017, clearly states that facility staff should never open residents' mail unless permitted by the resident, highlighting a breach in policy compliance.
Deficiencies in Environmental Cleanliness and Personal Property Protection
Penalty
Summary
The facility failed to maintain a clean, homelike, and odorless environment for its 194 residents. Observations revealed a toilet near nurse station one was repeatedly clogged with toilet paper, feces, and urine, emitting a strong odor. Additionally, a fan in a resident's room was covered in dust, and multiple resident council meeting notes from December 2024 to February 2025 indicated concerns about rooms not being cleaned daily. Interviews with staff revealed that maintenance was responsible for unclogging toilets, but a broken toilet required new bolts for repair. The facility's policy emphasized providing a clean and homelike environment, which was not upheld. Further observations on March 18, 2025, showed that the flooring in a resident's room was soiled with stains, sticky, and dull, with a buildup of grime in the bathroom. The over-bed table had exposed particle board, making it difficult to clean. Another room had a black, gummy substance around floor tiles, and a resident complained of old urine stains and odors, which were not addressed. The facility's policy stated that residents should have a clean, sanitary, and orderly environment with pleasant scents, which was not maintained. The facility also failed to protect the personal property of two residents, R3 and R47. R3 reported missing socks despite marking them, and the facility did not provide a personal inventory sheet. R47 also reported missing socks, which were labeled, and informed staff about the issue. The Environmental Services Director stated that missing items are replaced if a receipt is provided, or they refer to the personal inventory sheet, which was not available. The facility's policy encouraged residents to use personal belongings, but this was not effectively supported.
Failure to Complete Annual In-Service Education for CNAs
Penalty
Summary
The facility failed to complete the required 12 hours of annual resident care in-service education performance reviews for five Certified Nurse Aides (CNAs), identified as Z, AA, BB, CC, and DD. On the specified date, a request was made for these performance reviews, but the Director of Nursing (DON) reported that they were in the process of contacting a third-party education company to obtain the necessary staff education records. Despite this effort, the DON was unable to provide an estimated time for when the education in-services would be available, and the request for the CNAs' education was not fulfilled by the end of the survey. The facility's policy, titled 'Training Requirements Guideline' dated May 29, 2020, outlines the purpose of informing and guiding center leadership about training requirements and their role in developing, implementing, and maintaining an effective training program for all staff. The policy specifies that training topics must include effective communication, resident rights, abuse prevention, conflict resolution, infection control, and other essential areas. The failure to provide the required in-service education indicates a deficiency in adhering to these training guidelines.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the exterior dumpster area in a clean manner, as observed during a survey. On March 8, 2025, at 9:30 AM, an inspection of the two exterior dumpsters was conducted with the Dietary Manager (DM) O. Several bags of trash were found on the ground in front of the dumpsters, on the side, and behind the dumpsters. Additionally, there was an accumulation of loose trash items between and along the sides of the dumpsters. DM O indicated that the maintenance department is responsible for cleaning the dumpster area. The facility's undated policy on Food-Related Garbage and Rubbish Disposal states that outside dumpsters provided by garbage pickup services should be kept closed and free of surrounding litter. This deficiency in maintaining cleanliness in the dumpster area had the potential to affect all residents, staff, and visitors.
Infection Control Deficiencies in Nebulizer Mask Storage and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper infection control practices, particularly in the storage of nebulizer masks for two residents and the cleaning of blood pressure cuffs. Observations revealed that one resident's nebulizer mask was left uncovered on a cluttered nightstand and even on the floor, while another resident's nebulizer mask was similarly left uncovered on a nightstand without being stored in a bag or placed on a barrier. The Director of Nursing (DON), who also served as the interim Infection Preventionist, acknowledged that nebulizer masks should be stored in plastic bags after use, but this practice was not followed. Additionally, during a medication pass, an LPN was observed taking vital signs of three residents without cleaning the equipment before or after use. Another LPN also failed to clean a blood pressure cuff after use. The facility's policy requires that reusable medical equipment be cleaned with bleach wipes between residents, but this was not adhered to. The DON confirmed that the expectation is for cleaning to occur between each resident. The facility's infection control program was also found lacking, with missing documentation and insufficient staff education on infection control practices.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to complete the necessary Preadmission Screening and Resident Review (PASARR) Level II evaluations for four residents who were identified as needing further assessment due to mental illness or intellectual disabilities. Resident R44 was admitted with diagnoses of PTSD and Bipolar Disorder, and their PASARR screening indicated the presence of mental illness, yet no Level II evaluation was found in their medical record. Similarly, Resident R177, who had a PASARR with a 30-day exemption, did not have an updated PASARR on file. The facility's social worker acknowledged that some tasks were not completed timely due to a staff member's leave. Resident R4, with diagnoses including Schizoaffective Disorder and Major Depressive Disorder, had a severely impaired cognition score and was dependent on staff for all activities of daily living, yet lacked a Level II evaluation or a Dementia Exemption letter in their record. Resident R10, diagnosed with Bipolar Disorder and later Dementia, also had a severely impaired cognition score and required significant assistance, but their record did not contain a Level II evaluation or a Dementia Exemption letter. The facility's policy on PASARR guidelines emphasizes the need for annual evaluations and assessments upon significant changes, which were not adhered to in these cases.
Failure to Serve Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for several residents, as observed and reported by both residents and surveyors. Resident R69 expressed dissatisfaction with the food, stating it was horrible and that residents had no input on the menu. R154 reported that the food was always cold and that their preferences were not considered, as evidenced by receiving cold chicken noodle soup. R53 described the food as terrible, and a temperature test of a lunch tray revealed that the food was not served at appropriate temperatures, with items like pork cutlet and cheesy potatoes being lukewarm. R30, who was served a pureed meal, found the food unpalatable and left it untouched, stating it tasted unpleasant. The dietary manager and the administrator acknowledged the issues, with the dietary manager indicating that food temperature was based on resident preferences and the administrator stating that food should be palatable and served at the appropriate temperature according to the facility's policy. The facility's policy on food palatability and temperature guidelines was reviewed, noting that food should be served at appetizing temperatures and distributed quickly to residents. Despite these guidelines, the observations and resident interviews highlighted a failure to adhere to these standards, resulting in dissatisfaction with the food's palatability and temperature.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to conduct regular care conferences for a resident, identified as R133, who was admitted with multiple diagnoses including Morbid Obesity, stiffness in both hands, Muscle Weakness, Muscle Wasting and Atrophy, and Schizophrenia. Despite being cognitively intact and dependent on staff for bed mobility and transfers, R133 expressed difficulty in having their needs met, as their concerns were not being addressed. The medical record review indicated that care conferences were scheduled but not conducted on three specific dates. The facility's Social Worker acknowledged the oversight, and the facility's Resident Rights policy emphasizes the importance of residents participating in their person-centered care planning.
Failure to Maintain Resident Dignity During Tube Feeding
Penalty
Summary
The facility failed to maintain the dignity of a resident during tube feeding. On multiple occasions, the resident was observed sitting in a geri chair in the hallway with their tube feeding equipment exposed to passersby. The resident's shirt was lifted, exposing their stomach, tubing, and patch, which compromised their privacy and dignity. This was observed on two separate days, indicating a pattern of neglect in maintaining the resident's dignity during care. The resident involved had a diagnosis of Down Syndrome and was noted to have severely impaired cognition, requiring full assistance from staff for activities of daily living. Despite the facility's policy on maintaining dignity and privacy, the Director of Nursing acknowledged that the resident's stomach and tubing should not have been exposed in a public area. The facility's failure to adhere to its own policy on dignity and privacy resulted in the resident being treated without the respect and dignity they are entitled to.
Failure to Ensure Call Light Accessibility and Proper Wheelchair Fit
Penalty
Summary
The facility failed to ensure the call light was within reach for a resident, identified as R70, who was observed multiple times with the call light hanging out of reach above their bed. Despite being asked how they would use the call light, R70 indicated they did not know how to use it and mentioned they could holler loudly for assistance. The resident's medical record showed they were admitted with Alzheimer's Disease, Diabetes, and Muscle Weakness, requiring varying levels of assistance for activities of daily living. The facility's policy mandates that call lights be accessible to residents, but this was not adhered to, as evidenced by repeated observations of the call light being out of reach over several days. The Director of Nursing confirmed the expectation for call light accessibility, yet the issue persisted throughout the survey period. Additionally, the facility failed to provide a properly fitting wheelchair for another resident, R131, who was observed sitting in a wheelchair that was too low to the ground, causing discomfort and difficulty in mobility. R131, who is 6 foot 5 inches tall and weighs 450 pounds, expressed that the wheelchair was too small and low, making it hard to pedal and causing fatigue. Despite being measured for a better-fitting chair, no suitable wheelchair was provided. The Physical Therapy Manager expressed concerns about accommodating R131's size needs upon admission, and the resident had been using various inadequate seating devices, resulting in broken equipment. The Nursing Home Administrator was reluctant to provide a costly wheelchair, despite advocacy from the local Ombudsman, highlighting the facility's failure to accommodate the resident's needs adequately.
Failure to Update Resident's Advance Directive Information
Penalty
Summary
The facility failed to ensure that updated and accurate advance directive information was in place for a resident with moderate impaired cognition, who was admitted with diagnoses including Dementia, Muscle Weakness, and Schizophrenia. The resident's medical record indicated a Full Code status, yet a Do-Not Resuscitate (DNR) order was signed by the resident, a witness, and the resident's physician on different dates. Additionally, the resident expressed a preference not to receive life-sustaining treatment in the event of respiratory distress, which was not reflected in the medical record. The Licensed Practical Nurse (LPN) was unaware of the resident's current code status and had difficulty locating the binder containing this information, indicating a lack of proper communication and documentation. The Social Worker and Director of Nursing (DON) both indicated that nursing staff are responsible for updating the medical record when there is a change in code status. However, the process for ensuring these updates was not effectively implemented, as evidenced by the discrepancy between the resident's stated preferences and the documented code status.
Failure to Report and Investigate Verbal Altercation
Penalty
Summary
The facility failed to report and investigate a verbal altercation between two residents, R199 and R197. On March 17, 2025, R197 reported that R199 had verbally abused and threatened them and another roommate. Despite this incident, there was no documentation in R199's electronic medical record regarding the room change or the verbal altercation. The Social Worker confirmed that R199 was moved due to the altercation but acknowledged that no formal investigation was documented. The Director of Nursing (DON) was aware of the incident but admitted that the required note detailing the incident was not entered into the medical record. R199 was admitted to the facility with a diagnosis of Schizoaffective disorder, Bipolar Type, and had an intact cognition according to their Minimum Data Set (MDS) assessment. The care plan for R199 included monitoring for cognitive decline and administering psychotropic medications. The Nursing Home Administrator (NHA) was unaware of the room change and the incident, which was contrary to the facility's policy that mandates reporting such incidents to the administrator. The facility's policy on abuse requires immediate reporting and investigation of any suspected abuse, including verbal abuse, but this procedure was not followed in this case.
Failure to Accurately Complete PASARR for Resident
Penalty
Summary
The facility failed to accurately complete a Preadmission Screening and Resident Review (PASARR) for a resident, identified as R3, who was admitted with diagnoses of Bipolar Disorder and Weakness. The medical record review revealed that R3 had a Brief Interview for Mental Status score indicating intact cognition and required staff assistance with bed mobility and transfer. Despite being on medications such as Seroquel, Ativan, Zoloft, and Buspirone, the PASARR screening on file incorrectly indicated 'No' for questions regarding current diagnosis of mental illness, treatment for mental illness, and routine use of antipsychotic or antidepressant medications. The deficiency was further highlighted by the absence of an updated PASARR or Level II screening in R3's medical record. During an interview, Social Work T acknowledged that the previous social worker's leave resulted in incomplete tasks, including the timely update of R3's PASARR. The facility's policy on PASARR guidelines emphasizes the importance of ensuring individuals with mental illness and intellectual disabilities receive appropriate care and services, which was not adhered to in this case.
Failure to Implement Care Plan Interventions for Residents
Penalty
Summary
The facility failed to develop and implement appropriate care plan interventions for two residents, leading to deficiencies in their care. For one resident, who was admitted with diagnoses including Metabolic Encephalopathy, Muscle Weakness, End Stage Renal Disease, and Aphasia, the care plan required 1:1 supervision and the use of floor mats to prevent falls. However, observations revealed that the resident was often left unsupervised, without the required floor mats in place, and with soiled items left on the floor, indicating a lack of adherence to the care plan. Additionally, the resident was observed in situations that could lead to falls, such as being unsupervised in the bathroom, which was contrary to the care plan's interventions. Another resident, who was admitted with diagnoses including Pleural Effusion, Sepsis, and Weakness, was observed with an ankle tether monitoring device. The care plan did not include any interventions related to the monitoring or care of the skin under the ankle tether, despite the resident's report that the tether impeded their therapy and that no skin checks had been conducted. The facility's staff, including the Unit Manager and Director of Nursing, acknowledged the lack of documentation and care planning related to the ankle tether, which should have been addressed to prevent potential skin integrity issues.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure timely revisions of care plans for two residents, R4 and R44, leading to deficiencies in their care. R4, who was admitted with diagnoses including Cerebral Infarction, Schizoaffective Disorder, Depression, seizures, and Oral Phase Dysphagia, was observed in a wheelchair without a lunch tray. It was revealed that R4 was placed on a Nothing by Mouth (NPO) order due to increased difficulty with their pureed diet. However, the care plan was not updated to reflect this change in dietary status, despite the physician's order being placed the previous day. For R44, who was admitted with Post-Traumatic Stress Disorder (PTSD) and Bipolar Disorder, the care plan lacked individualized interventions related to PTSD. R44 expressed having past trauma from personal family affairs and loss, yet the care plan only included a general focus on potential ineffective coping without specific strategies. The social worker acknowledged the need to revise and individualize R44's care plan, indicating it was incomplete and inappropriate.
Failure to Provide Adequate ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, R32 and R177. R32 was observed multiple times over several days with unkempt greasy hair, long nails with an unknown brown substance underneath, and facial hair, indicating a lack of regular bathing and grooming. Despite being cognitively intact, R32 reported not receiving regular showers or grooming, and the Unit Manager and Director of Nursing (DON) were made aware of the resident's appearance but did not ensure appropriate hygiene care was provided. R177, who was diagnosed with Dysphagia and Muscle Weakness, was observed eating independently despite having a diet order requiring 1:1 feeding assistance. On one occasion, R177 was found with a breakfast tray that had not been set up, and the resident reported not receiving help with eating. The LPN confirmed that R177 required assistance with eating, and the DON indicated that R177 was on a red napkin program, which required staff to set up meals for the resident. The facility's policy on ADLs stated that residents unable to carry out ADLs independently should receive necessary services to maintain good nutrition and hygiene, which was not adhered to in these cases.
Failure to Schedule Timely Ophthalmology Appointment
Penalty
Summary
The facility failed to schedule a follow-up ophthalmology appointment in a timely manner for a resident who required specialized eye care. The resident, who was admitted with diagnoses of Critical Illness Myopathy and Muscle Weakness, had intact cognition and required staff assistance with bed mobility and transfers. An in-house vision group recommended that the resident see an ophthalmologist due to retinal bleeding in both eyes. However, the resident reported not being informed about the appointment status or any delays. The Unit Secretary acknowledged the difficulty in keeping up with the appointment due to the resident's hospital visits. The Director of Nursing mentioned that implementing recommendations from ancillary services is a process. The facility did not provide a policy on ancillary services by the end of the survey.
Failure to Provide Accident-Free Environment for Resident
Penalty
Summary
The facility failed to maintain an accident-free environment for a resident identified as R177. During an observation, R177 was found in their room with a breakfast tray that included glass plates, regular cups, and silverware, despite a clear instruction on the tray ticket indicating that R177 should only have paper products. This instruction was highlighted in capital letters due to R177's known behavior of throwing and breaking plates, which poses a safety risk. Licensed Practical Nurse (LPN) W confirmed that R177 should have paper products for safety reasons but was unsure how the regular plates ended up on the tray. Dietary Manager (DM) O also confirmed that R177 was not supposed to have regular plates and attributed the error to a new person on the tray line. The facility's policy on accidents did not address the use of paper products for residents with such behaviors.
Failure to Obtain Physician Orders for Colostomy Care
Penalty
Summary
The facility failed to obtain physician orders for colostomy care for a resident who required such services. The resident, who was cognitively intact, reported that their colostomy bag had not been changed in two months. The resident was admitted with diagnoses including Muscle Weakness, Heart Failure, Depression, and Paroxysmal Atrial Fibrillation. A review of the resident's medical record showed a Quarterly Minimum Data Set assessment indicating the presence of an ostomy bag, but no physician's order for its care was found. The Director of Nursing acknowledged that there should have been an order to guide the nursing staff in providing the necessary care.
Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was readily accessible for all residents, families, and visitors. On multiple occasions, the staff postings were observed to be incomplete, lacking information for the midnight shift on one day and for both the afternoon and midnight shifts on another day. The scheduler explained that she completes the form once she knows the staff for the shift, indicating a delay in posting due to potential changes in staffing. This practice resulted in incomplete postings that were not available at the start of each shift as required. Additionally, a review of the facility's staff postings over the past 18 months revealed that the facility did not maintain access to these records, as some months were sent to be shredded by a third party. The scheduler mentioned that when she was not at work, the charge nurse was responsible for completing the forms, which may have contributed to the inconsistency in maintaining complete records. The facility's policy requires that staffing information be posted daily and updated as changes occur, but this was not consistently followed, leading to the deficiency.
Failure to Document and Act on Medication Irregularities
Penalty
Summary
The facility failed to ensure that medication regimen irregularities were reviewed, acted upon, and documented for a resident identified as R32. The resident was admitted with diagnoses including Muscle Weakness, Heart Failure, Depression, and Paroxysmal Atrial Fibrillation, and was noted to be cognitively intact. During a review of R32's monthly medication regimen, irregularities were identified by the pharmacist on 11/24/24. However, when a request was made on 3/20/25 for the irregularities report and the physician's response, the facility did not provide the requested documentation by the end of the survey. Additionally, a review of the facility's Physician Services policy revealed that it did not outline the process for reviewing pharmacy reports following medication regimen reviews. This lack of documentation and policy guidance contributed to the deficiency in managing medication regimen irregularities for the resident.
Failure to Schedule Recommended Dental Services for a Resident
Penalty
Summary
The facility failed to schedule recommended dental services for a resident, identified as R133, who was observed with yellow and discolored teeth. R133, who was admitted with diagnoses including Morbid Obesity, Stiffness of both hands, Muscle Weakness, Muscle Wasting and Atrophy, and Schizophrenia, was cognitively intact and dependent on staff for bed mobility and transfers. The resident had a dental exam on 5/29/24, during which it was recommended that they be brought to the dental clinic for x-rays at their next visit. However, on 7/2/24, the resident was not seen by dentistry because they were sleeping, and no further appointment was scheduled. The Social Worker indicated that the medical records scheduler is responsible for making outside appointments, and an appointment should have been scheduled. The Director of Nursing acknowledged that dental recommendations are expected to be followed. The facility's Routine and Emergency Dental Services policy did not address the process for ensuring dental recommendations are followed in a timely manner.
Deficiency in Call Light Functionality
Penalty
Summary
The facility failed to ensure a functional call light system for a resident, identified as R61, which was observed during a survey. On multiple occasions, the call light inside R61's room was lit, indicating a request for assistance, but the corresponding light outside the room, which alerts staff, was not operational. R61 reported that the call light had been malfunctioning for some time and expressed concerns about the timeliness of staff responses to call lights. Upon review, there were no work orders for repairs in R61's room, indicating a lack of action to address the issue. The Director of Nursing and Environmental Services Assistant later confirmed the call light had been repaired, but the date of repair was not recalled. The facility's policy requires that call lights be functional at all times and that defective call lights be reported promptly, which was not adhered to in this case.
Failure to Implement Hand Splint for Resident
Penalty
Summary
The facility failed to implement a hand splint for a resident, identified as R500, who was observed with contracted fingers on their right hand. The hand splint, intended to provide proper alignment and prevent contractures, was found lying unused on the floor. R500 indicated that they were supposed to wear the splint but had never been shown how to apply it. A review of R500's records showed no physician's order or care plan documentation for the hand splint, despite occupational therapy having ordered it. The resident's cognition was not assessed, as indicated by the Minimum Data Set. The Physical Therapy director confirmed that occupational therapy had treated R500 and ordered a wrist hand finger orthosis, but no order was placed in the electronic medical record (EMR). The Director of Nursing, acting as the restorative nurse, stated that the restorative aide was unaware of the splint. The facility's policy on restorative nursing services emphasizes individualized care plans and integrating therapy recommendations, which was not followed in this case. The lack of documentation and communication led to the failure to provide the necessary care for R500's condition.
Improper Medication Storage for a Resident
Penalty
Summary
The facility failed to properly store medications for a resident, identified as R500, who was observed with two bottles of Fluticasone nasal spray on their nightstand and a clear plastic bag containing six medication bottles in their room. The medications included Colace, Certizine, and Meloxicam, with three bottles having illegible labels. R500's medical record did not contain orders for self-administration or to leave medications at the bedside, nor were there orders for Colace, Certizine, or Meloxicam. R500 was admitted with a diagnosis of polyarthritis, and their cognitive status was not assessed as indicated by the Minimum Data Set. LPN A acknowledged that R500 sometimes becomes confused and should not have medications in their room, but they were left there to avoid confrontation. The Director of Nursing confirmed that medications should not be in a resident's room without a physician's order and an assessment confirming the resident's ability to self-administer. The facility's policy requires an interdisciplinary team to assess a resident's cognitive and physical abilities before allowing self-administration of medications, and any unauthorized medications found at the bedside should be removed by the nurse in charge.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure timely completion of laboratory tests for two residents, resulting in a delay in health assessments. Resident R901, who was admitted with diagnoses of Diabetes and High Blood Pressure, had a physician order for Phenytoin trough levels every three months. However, the lab results showed an invalid dilantin level, and the last documented lab was a CBC in July 2024. Despite daily administration of Phenytoin, there was no documentation of a dilantin level in the hospital records from October 2024, and the facility could not provide this documentation during the survey. Resident R902, admitted with a history of Stroke and Diabetes, had a lab order for a CBC and CMP in May 2024, but the results were not documented in the electronic medical record. A subsequent lab in December 2024 showed twenty lab values out of range. The Director of Nursing confirmed that the labs ordered in May were not completed, and the facility was not notified of the missed labs. The facility's policies emphasize the importance of timely and accurate lab services, but these were not adhered to, leading to the deficiencies noted.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in a serious altercation between two residents. Resident R904, who had intact cognition and was diagnosed with end-stage renal disease, was involved in a physical altercation with Resident R903, who also had intact cognition and was diagnosed with schizophrenia and PTSD. The altercation began over a dispute about clothing, leading to R904 being hospitalized with a right eye fracture and other injuries after being punched and kicked by R903. Prior to the incident, R903 exhibited several behavioral issues, including cursing, expressing anger, and threatening others, which were documented but not adequately addressed in their care plan. Despite a history of hallucinations, delusions, and anger triggers, R903's care plan lacked mention of their psychiatric diagnosis or behaviors. The facility's failure to document and address these behaviors contributed to the escalation of the situation, as protective interventions were not implemented. Interviews with staff and residents revealed that the altercation was witnessed by others, and the facility's response was delayed. The Director of Nursing confirmed that there were no progress notes or incident reports for R903's behaviors on the days leading up to the incident, indicating a lack of proper documentation and intervention. The facility's policy on abuse prevention was not effectively implemented, as the needs and vulnerabilities of the residents were not adequately assessed or addressed to prevent the altercation.
Failure to Prevent Resident Fall from Mechanical Lift
Penalty
Summary
The facility failed to prevent an accident involving a resident, identified as R905, who experienced a fall from a full body mechanical lift. The incident was reported by a triage nurse at the hospital, where R905 presented with acute pain after falling onto their back and legs. This was reportedly the fourth occurrence of such an incident with the mechanical lift at the facility. Despite the resident's complaints of severe pain and the need for emergency medical attention, there was no documentation of the incident in the facility's records, other than a progress note by LPN F. The resident, R905, has a medical history that includes peripheral vascular disease, kidney failure, diabetes, stroke, paraplegia, anxiety, depression, and asthma. They are dependent on staff for bed mobility, transfers, and toileting. During the incident, R905 reported being lifted out of their wheelchair by CNA E using the mechanical lift when they suddenly fell back into the wheelchair, causing severe pain. The resident's wheelchair was observed to have a gap between the cushion and the seat, which may have contributed to the severity of the impact. CNA E admitted to not reporting the unsafe transfer practices to the nursing staff or therapy services, and the facility's mechanical lifts were noted to be short on batteries. Additionally, the right armrest of R905's wheelchair was found to be loose, which was not reported to maintenance. The facility's policy on safety and supervision was not followed, as there was no incident report or therapy referral made for R905 following the incident. The Nursing Home Administrator and Director of Nursing acknowledged the lack of appropriate documentation and intervention following the incident.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean and homelike environment, affecting multiple rooms and common areas. Observations included a wall patch with white dust and a hole in one room, a pungent urine odor in the hallway near several rooms, and closet cabinet drawers hanging down in another room. Additionally, a resident reported concerns about a water dispenser with a black substance and hard water stains, as well as numerous cigarette butts in the smoking area. The smoking area was observed to have over fifty cigarette butts on the ground. Further observations revealed gnats around an over bed table with food items in one room, a stopped wall clock, and flies and gnats around food in another room. The cove base outside a bathroom door was peeled away, revealing a hole in the wall with sheetrock debris on the floor. A black substance resembling mold was found in the toilet bowl of another room. These deficiencies were noted despite the facility's policy on identifying safety risks and environmental hazards through employee training, monitoring, and reporting processes.
Failure to Maintain Clean Environment for Resident
Penalty
Summary
The facility failed to maintain a clean, homelike environment for a resident, identified as R701, who was observed in their room with privacy cubicle curtains that had several round brown stains. The resident, who has a medical history of Major Depressive Disorder, Asthma, Respiratory Failure, and Muscle Weakness, expressed dissatisfaction with the cleanliness of the curtains, stating that they had informed the housekeeping staff about the issue. The resident's cognitive status was assessed as intact, with a BIMS score of 15. During an interview, the Housekeeping Supervisor confirmed that the curtains are cleaned once a month and acknowledged the expectation for them to be clean. The Nursing Home Administrator also affirmed the residents' right to a clean, homelike environment, as outlined in the facility's Resident Rights policy implemented in 2017.
Failure to Update PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to update a Preadmission Screening and Resident Review (PASARR) for a resident diagnosed with Anxiety and Schizophrenia. The initial PASARR Level I screening indicated the need for a comprehensive Level II OBRA evaluation, but the resident was admitted under a hospital exempted discharge, which allowed for a temporary exemption from the Level II evaluation. However, the resident remained in the facility for more than 30 days, necessitating an updated PASARR screening, which was not completed in a timely manner. On April 3, 2024, it was discovered that the required updated PASARR screening had not been conducted. The social worker responsible for the resident was no longer with the company, and the new social worker indicated they would redo the PASARR themselves. The facility's policy mandates that PASARR Level I screenings be completed annually and with any significant change of status, and that any changes identified via the screen be reported to the state mental health or intellectual disability authority promptly. This policy was not followed in the case of this resident.
Failure to Change and Date PICC Line Dressing
Penalty
Summary
The facility failed to change and date a peripherally inserted central catheter (PICC) line dressing for a resident. The resident was observed with a lifting and undated PICC line dressing, and stated that it had not been changed since being placed in the hospital. The Licensed Practical Nurse (LPN) acknowledged the presence of the PICC line and intended to call the nurse practitioner for an order to remove it. The Director of Nursing (DON) confirmed that the resident returned from the hospital with the PICC line and antibiotics, and an order should have been entered to change the dressing every seven days per policy. The facility's policy mandates regular dressing changes to prevent catheter-related infections.
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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