Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa At Borgess Place during CMS and state inspections, most recent first.
A resident with multiple comorbidities and moderate cognitive impairment had an existing sacral pressure ulcer that rapidly progressed from stage 2 to a large unstageable ulcer with extensive slough and eschar, while a new facility-acquired unstageable dorsal sacral ulcer also developed and enlarged. Care plans noted potential and actual skin breakdown and referenced an alternating air mattress and repositioning, but corresponding physician orders for the pressure-reducing mattress were delayed, and no new interventions were added when the new wound developed. Documentation gaps included missing wound assessments, incomplete pressure injury evaluation forms, lack of timely treatment orders for the dorsal sacral wound, and absence of documented treatments on the TAR, even though the resident later presented with two unstageable sacral-area wounds and reported severe (9/10) pain.
A resident with severe cognitive impairment and multiple complex conditions, including chronic respiratory failure, COPD, vascular dementia, CHF, and lung cancer, required assistance with eating and was dependent for hygiene and other ADLs per the MDS. The resident’s family reported that the resident said he was not regularly receiving ADL care or meals. Review of the medical record showed multiple shifts with blank documentation for hygiene-related ADLs and missing entries for eating, with "NA" in place of required meal documentation on numerous evenings. The DON stated that CNAs are expected to complete and document ADLs each shift and to document eating after all meals, and confirmed that the blanks and "NA" entries did not demonstrate that ADL care or meals were provided.
A resident with multiple comorbidities and unstageable pressure injuries on the coccyx and sacral area underwent a dressing change during which staff did not fully adhere to infection control practices. While supplies were placed on a clean barrier and some hand hygiene and glove changes occurred, the wound nurse handled a phone to take wound photos, then proceeded with cleansing and dressing a second wound without clearly performing hand hygiene and glove changes between phone use and wound care, and placed the phone into a pocket without cleaning it. The DON later described an expectation for stepwise hand hygiene, glove changes, and phone disinfection for each wound, which was not followed during this observed procedure.
A resident with severe cognitive impairment, repeated falls, and therapy assessments showing impaired safety awareness and need for at least one-person assist for transfers and ambulation was identified as high risk for falls, but no fall-prevention care plan, transfer status, toileting program, or increased supervision interventions were implemented or communicated to CNAs via the Kardex. The resident, who did not use a call light and walked independently despite unsteadiness, was later found on the bathroom floor after an unwitnessed fall, with a head laceration and a blood trail from the bed to the bathroom, and was hospitalized with SAH and SDH. Staff and the DON confirmed that required fall-risk information and interventions were not entered into the care plan or Kardex until after the fall, despite a facility policy requiring identification of at-risk residents and implementation of individualized fall precautions and supervision.
A resident with hemiplegia and dependence for transfers was discharged home without effective discharge planning or documentation. The care plan called for coordinated discharge orders, home health and therapy referrals, and DME, but social services did not clearly assist with the insurance appeal process, did not document a comprehensive discharge plan, and did not arrange post‑discharge services. The family member reported receiving short‑notice of discharge, no caregiver education, no referrals for home health or outpatient therapy, and no help obtaining needed DME such as a wheelchair and hospital bed. Nursing staff were unaware of the exact timing of discharge and the ambulance left without the printed discharge paperwork. Therapy staff were not informed in time to complete a discharge assessment and stated the resident remained dependent with transfers and unsafe to stand. The discharge packet later found in a shred box was incomplete, lacking transportation details, instructions review, signatures, and key contact information, demonstrating that the resident was discharged without a safe, orderly, and well‑documented transition plan.
A facility failed to develop and implement a baseline care plan addressing fall risk for a newly admitted resident with sepsis, weakness, severe cognitive impairment (BIMS 4), insomnia, and a history of repeated falls. A fall assessment identified the resident as high risk, but no fall-prevention or transfer/ambulation assistance interventions were added to the care plan or Kardex within the first days after admission. The only early care plan focused on ADLs and feeding assistance, with no documentation of continence status or toileting program. Nursing and therapy staff later confirmed the resident required at least one-person assist for transfers and ambulation, but this was not documented until after an unwitnessed fall with major injury occurred. CNAs reported they were unaware the resident was a high fall risk, lacked clear guidance on assistance and toileting needs, and relied on an incomplete Kardex while the resident’s room door remained closed and checks were infrequent.
A resident with COPD and a recent history of influenza and persistent cough had PRN orders for Benzonatate (Tessalon) capsules and later Guaifenesin syrup, but the care plan did not reflect the respiratory diagnoses or ordered cough medications, and medication records showed multiple days when the ordered Tessalon was not administered despite availability. The resident reported repeatedly requesting Tessalon and being refused by an RN, who instead offered cough syrup and claimed there was no order, while other staff confirmed the resident’s frequent requests and upset over medication timing. Documentation showed the RN had administered Guaifenesin on several occasions but had not administered Tessalon, and a nurse manager acknowledged that the resident had a valid order for Tessalon and that it should have been given.
Two residents experienced a lack of dignity when one waited over an hour for call light assistance, resulting in incontinence and feelings of embarrassment, while another was observed moving through the facility with an uncovered Foley catheter urine bag, leading to emotional distress after being seen by an acquaintance. Staff interviews and documentation confirmed these lapses, and facility policy requiring privacy for catheter bags was not followed.
A resident admitted with a sacral fracture and an indwelling catheter did not have Enhanced Barrier Precautions (EBP) documented in the baseline care plan or Kardex within 48 hours of admission, despite facility policy and staff awareness that EBP was required. The omission was identified through observation, interviews, and record review, with EBP only added to the care plan five days after admission.
A resident with a history of hip fracture, malnutrition, and COPD did not receive physician-ordered laboratory tests to monitor anemia following surgery. Multiple orders for CBC, CMP, TSH, and FT4 were not completed as required, and staff interviews confirmed the labs were not drawn or documented. Nursing staff indicated that while labs were usually drawn weekly, it was their responsibility to complete them on other days if ordered, but this was not done.
A resident with a sacral fracture and an indwelling urinary catheter was admitted without corresponding physician orders for the catheter, and staff failed to provide timely catheter care, including emptying the urine bag. Interviews revealed that required admission order verification processes were not followed, and the facility's policy for catheter management was not implemented until several days after admission.
A resident with a PICC line for prolonged IV antibiotics did not have a documented physician order or monitoring instructions for the line. Staff were observed disconnecting IV tubing without proper documentation, and the resident reported needing a hospital visit to replace the IV. Facility staff demonstrated lack of knowledge regarding PICC line management, and required surveillance and documentation per facility policy were not followed.
A resident with a PICC line requiring enhanced barrier precautions did not receive care in accordance with facility policy, as an LPN was observed disconnecting IV tubing without wearing a gown. Both the care plan and facility policy required gown and glove use for such high-contact care, and staff interviews confirmed this expectation.
Failure to develop a timely, person-centered pressure ulcer prevention care plan for a resident with CVA, left-sided hemiplegia, aphasia, and a PEG tube. The resident was dependent for mobility and had a Braden score indicating high risk, but the care plan lacked specific preventive interventions at admission. Staff and leadership interviews showed uncertainty about responsibility for wound care planning, and pressure-relief interventions were only added after wounds were identified on the coccyx and heel.
Failure to Prevent Pressure Ulcers: A resident with CVA, left-sided hemiplegia, PEG tube, and total dependence for care was assessed as high risk for skin breakdown, yet pressure injury prevention was not consistently documented or observed. Staff and family reported the resident needed frequent turning, heel offloading, and moisture control, but he was repeatedly found supine with heels on the mattress and poorly positioned in a wheelchair. The resident later developed a coccyx wound and a pressure-related heel wound, and the record showed gaps in documentation of repositioning and wound care completion.
Food storage, sanitation, and dishwashing practices were deficient. Ready-to-eat foods in coolers and a satellite kitchen were found without proper date marks or beyond allowed holding times, and some items were spoiled or slimy. Raw pork chops were stored above ready-to-eat hot dogs, shell eggs were stored above ready-to-eat sandwiches, and clean utensil bins, pans, the ice machine, microwaves, and dish areas had visible debris or moisture. The dish machine log showed final rinse temperatures below the required 180F.
Two residents at risk for accidents were not adequately supervised, resulting in one resident eloping from the facility on multiple occasions despite being identified as a high elopement risk and having a wander alert device. Another resident, requiring supervision and a gait belt for ambulation, was repeatedly observed walking unassisted in hallways. Staff interviews revealed confusion about responsibilities for monitoring safety devices, inconsistent communication of care plan changes, and lack of proper documentation of incidents.
The facility failed to ensure complete and accurate documentation for several residents, including missing entries for medication and treatment administration, lack of incident and behavior reports after significant events such as elopement and inappropriate behaviors, and gaps in wound care documentation. Staff interviews confirmed that omissions in records were common and sometimes directed by management, leading to incomplete resident medical histories.
Failure to preserve resident dignity during personal care: An unknown CNA used a personal cellphone on speakerphone outside an occupied room, and 8 of 8 residents in a confidential group meeting reported staff used personal cellphones, sometimes with earbuds, while providing care. Residents described being left naked on a shower chair during a phone call, overhearing staff argue on the phone while waiting in the bathroom, and feeling embarrassed and unimportant. The NHA confirmed staff were not expected to use personal cellphones during cares or in public areas, and the facility’s dignity policy required residents to be treated with dignity and respect at all times.
Failure to clearly explain binding arbitration agreements at admission. Residents with schizophrenia, sepsis, and post-stroke hemiplegia later said they did not understand the agreement, did not recall signing it, or signed while heavily medicated. The DOA described the agreement in very general terms, and multiple residents in a confidential meeting said they did not know what the agreement was or whether they had agreed to it.
Unsafe and Unsanitary Environment and Shared Equipment: A sit-to-stand lift outside multiple resident rooms was repeatedly observed with white powder, dirt, debris, crumbs, and dried liquid on the base, footrest, knee pad area, straps, and stem. Other areas were also disorganized or contaminated, including clean supplies on the floor in the CNA supply closet, oxygen tubing on the floor in the oxygen room, open linens exposed on a sink counter, and dried bowel movement on a shower chair wheel. Staff interviews and facility policy indicated shared equipment should be cleaned between resident uses.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight by the facility.
The facility did not report two elopements and an abuse allegation to the State Agency within the required timeframe. In one case, a resident identified as an elopement risk was found outside the building without proper documentation or timely notification. In another case, a resident with dementia reported inappropriate touching by a visitor, but the incident was not reported to the State within the mandated two-hour window. Facility policy requires immediate reporting, which was not followed in these instances.
Two residents had inaccurate or missing advance directive documentation. One resident’s chart and nurse station records did not contain signed DNR paperwork even though the facesheet and orders listed DNR, while another cognitively intact resident had a signed Michigan DNR form but the EMR banner still showed Full Code. Staff interviews confirmed the residents’ CPR wishes were not consistently or accurately documented in the medical record.
A resident with depression and anxiety had a PRN lorazepam order with an indefinite end date. Staff interviews showed differing understanding of PRN medication limits, and the DON stated PRN psychotropic medications should be ordered for only 14 days unless a provider rationale is documented; no rationale was provided by exit.
Failure to Provide Bedhold Notification: A resident with Alzheimer’s disease, delusions, and visual hallucinations was sent to a psych hospital for ongoing behaviors, but the facility could not show that a bedhold notice was provided to the resident or family. Staff and admin stated a bedhold should be given whenever a resident transfers to the hospital, yet no evidence of one was available.
Failure to develop and implement a baseline care plan for a resident with sexually inappropriate behaviors and sex offender registry history. The resident was cognitively intact, had prior documented sexual misconduct toward staff, and was later placed on 1:1 after being found in another resident’s room. Multiple staff members were unaware of the reason for the 1:1, and the chart contained no baseline care plan addressing the resident’s behaviors or registry status.
Delayed incontinence care occurred when a CNA mistakenly believed a resident with CVA-related ADL deficits was independent with personal care. The resident, who required staff assistance and peri care after each incontinent episode, was left in a heavily saturated brief for several hours overnight after a verbal handoff was misunderstood and the CNA confused the resident with another room’s resident. Later assessment found wet bedding and brief, with no peri-area redness noted.
A facility failed to follow a pharmacist’s medication review recommendation for one resident and failed to have monitoring orders or documentation for psychotropic side effects for two residents. One resident with schizophrenia, dementia, bipolar disorder, anxiety, and hypothyroidism remained on Synthroid 150 mcg after the pharmacist recommended a dose decrease, and another resident with depression received venlafaxine ER without a monitoring order. Staff interviews confirmed that monitoring orders for psychotropics were expected but were not present in the chart.
Medication storage practices were inconsistent when an RN placed a refused Norco tablet back into a locked narcotic box, an LPN stored a cup of pills in a cart drawer, and an RN later retrieved medication cups from a cart drawer to continue dispensing. Multiple med carts had visible spills or residue, one medication room refrigerator was left unlocked, and refrigerator temp logs had missing entries.
Failure to Follow EBP During Resident Care: Staff did not follow physician-ordered Enhanced Barrier Precautions for two residents. One resident with stroke-related left-sided weakness and a pressure wound received peri-care without a gown, and another resident with dementia, weakness, and repeated falls was assisted with toileting and transfers without a gown and gloves, despite room signage and orders indicating EBP.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
Menus failed to consistently meet residents' nutritional needs, were not always prepared in advance or updated, and lacked regular review by a dietician, resulting in unmet dietary requirements.
Multiple residents reported receiving food items they were allergic to or disliked, and staff described frequent shortages of both main and alternate menu items, leading to unmet dietary needs and small portion sizes. Dietary staff were unable to consistently explain or implement portion control, and communication breakdowns between nursing and kitchen staff resulted in ongoing meal errors and resident dissatisfaction. Facility leadership was unaware of these widespread food service concerns.
Staff referred to residents requiring eating assistance as "feeders" in the presence of other residents and staff, including during care discussions and in the dining room. This language was used openly and could be overheard by the residents involved, some of whom had cognitive impairments and required assistance due to conditions like dysphagia or decreased strength. These actions did not align with the facility's policy on resident rights to dignity and respect.
A resident who was cognitively intact and required assistance with toileting was left in a soiled brief for an extended period, despite care plan instructions for regular checks. Multiple staff observed and reported the neglect, but leadership did not promptly investigate or report the incident as required by facility policy.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
Two residents did not receive necessary ADL assistance, including feeding support for a resident with dysphagia and supervision needs, and timely toileting care for another resident who was left in a soiled brief for several hours. Staff interviews and observations confirmed lapses in following care plans and inconsistent staff awareness of required interventions.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with open wounds or indwelling devices. One resident with an open wound lacked EBP signage and an isolation cart, while another with a nephrostomy tube had no signage. A third resident's EBP setup had empty hand sanitizers. The facility's EBP policy was not followed, risking cross-contamination.
A resident with a nephrostomy tube and orders for Enhanced Barrier Precautions did not have the required signage posted on the door to alert staff or visitors, despite the presence of an isolation cart with PPE inside the room. This was confirmed during observation and review by the unit manager.
A resident requiring Enhanced Barrier Precautions due to an indwelling catheter and pressure wound was observed to have an isolation cart with PPE and signage, but both hand sanitizer dispensers at the cart were empty. An LPN confirmed the dispensers were empty and noted housekeeping was responsible for refilling them, resulting in a failure to provide required hand hygiene resources at the point of care.
A resident without a diabetes diagnosis was mistakenly given insulin by an LPN, leading to dizziness and malaise. The error occurred due to a failure to follow medication administration protocols, including verifying the right patient and medication. Despite the facility's systems to prevent such errors, the nurse did not correctly identify the resident, resulting in the administration of insulin intended for another resident.
A facility failed to follow medication labeling standards when an LPN administered Lantus insulin from a pen that lacked an open date and expiration date. The pen, used for a resident, had approximately 80-90 units left and was not labeled correctly, compromising medication integrity. The LPN, who had used the pen the previous day, acknowledged the oversight and subsequently labeled a new pen before administering the medication.
A resident without diabetes was mistakenly given insulin by an agency LPN who had not received orientation or training at the facility. The error occurred because the LPN, working her first shift, administered the medication in the resident's room, where his name was on the door. The facility did not provide agency staff with necessary training or support, leading to the medication error and the resident experiencing dizziness and malaise.
A resident with a sacral pressure ulcer was not consistently monitored or assessed for wound care, leading to potential slow healing and new pressure ulcers. Despite being at high risk for skin breakdown, the resident lacked a specific care plan for wound and incontinence management. Observations and interviews revealed the resident was often left in soiled briefs and not repositioned as required, contributing to the deterioration of her wound.
The facility failed to use gait belts during transfers for two residents, R100 and R102, despite their care plans and facility policy requiring it. R100, with Parkinson's disease, and R102, with muscle weakness and a history of falls, were transferred without gait belts by CNA E and LPN L. Staff interviews confirmed the necessity of gait belts for safe transfers, yet they were not used, posing a risk of falls or injuries.
The facility failed to ensure proper infection control practices for two residents under Enhanced Barrier Precautions due to pressure ulcers. Staff, including a CNA and an LPN, did not wear gowns during care, despite CDC signage indicating the need for such precautions. Interviews revealed a lack of training and education on infection control practices, contributing to the deficiency.
The facility failed to maintain professional standards for food safety, with observations of debris accumulation on kitchen equipment and expired sanitizer test strips. The walk-in cooler, utensil bins, meat slicer, can opener, and Traulson cooler and freezer were all found with various forms of debris. Additionally, the facility lacked unexpired test strips to ensure proper sanitizer concentration, posing a risk of foodborne illness.
The facility failed to notify the State LTC Ombudsman of transfers and discharges since November 2019. Interviews revealed that the required notices were not sent, with the last notice dated November 2019. The facility's policy mandates that the social worker or designee provide these notices, which was not followed.
A resident with hemiplegia and frequent incontinence experienced long call light wait times and delays in incontinence care, leading to discomfort and a lack of dignity. Despite being cognitively intact and dependent on staff for toileting, the resident reported that staff did not change him as needed, and a CNA confirmed frequent complaints about these delays.
Failure to Provide Adequate Pressure Ulcer Prevention and Treatment for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to promote healing of existing pressure ulcers and to prevent the development of new pressure ulcers for one resident. The resident was admitted with multiple medical conditions including circulatory system aftercare, muscle disorder, gait difficulty, abnormal posture, cognitive and communication deficits, dysphagia, atherosclerotic heart disease, hypertension, GERD, IBS, overactive bladder, constipation, PVD, pneumonia, urinary retention, osteoarthritis, mild cognitive impairment, hyperlipidemia, and osteoporosis. An MDS with an ARD of 03/26/2026 documented moderate cognitive impairment (BIMS 9/15) and one unstageable pressure ulcer on admission. On observation, the resident reported having a coccyx wound and another wound on the left buttock, describing severe pain rated 9/10, while lying on a bed with an air mattress pump that appeared operational. Record review showed that on 03/22/2026 the sacral wound was documented as a stage 2 pressure ulcer measuring 0.7 cm by 0.5 cm by 0.2 cm with 100% epithelial tissue. By 03/23/2026, the same area was documented as an unstageable pressure ulcer measuring 2.0 cm by 1.3 cm by 0.2 cm with 60% slough. By 03/30/2026, the unstageable sacral ulcer had enlarged to 6.8 cm by 5.0 cm by 0.2 cm (34.00 cm²) with 60% slough, and by 04/13/2026 it had further progressed to 8.5 cm by 8.5 cm by 0.10 cm (72.25 cm²), with no documented evaluation of intact skin or slough. A separate dorsal sacral wound, documented as facility-acquired, was first recorded on 04/07/2026 as an unstageable pressure ulcer measuring 2.8 cm by 2.2 cm by 0.10 cm with 90% non-granulation tissue and 10% slough, and by 04/13/2026 had increased to 4.2 cm by 2.7 cm by 0.10 cm (11.24 cm²). A wound PA note on 04/13/2026 described the dorsal sacral wound bed as having 100% slough with no eschar or epithelization. The facility’s care planning and orders did not reflect timely or adequate interventions for these wounds. A care plan problem for potential skin breakdown related to mobility deficits, initiated 03/20/2026, included use of an alternating air mattress and assistance with turning and repositioning, but the DON later confirmed that an order for the alternating pressure mattress was not written until 04/07/2026, despite it being listed on the care plan since 03/20/2026. A new care plan problem for actual skin breakdown related to the coccyx, initiated 04/20/2026, contained no interventions to treat or prevent further decline of the wound or prevent additional breakdown. Another problem statement for a pressure ulcer to the sacrum, initiated 04/07/2026, did not include new interventions after the development of the new wound. A Pressure Injury Unavoidable Evaluation dated 04/07/2026 listed risk factors such as immobility, chronic bowel incontinence, chronic heart disease, and weight loss/poor nutrition, but the weight loss section was not completed and the physician signature line was blank. Physician orders for coccyx wound care were present from 03/21/2026 through 04/15/2026, with changes in cleansing solutions and dressings, but no order was found for treatment of the lateral/dorsal sacral wound when it was identified on 04/06/2026. The DON was unable to provide documentation of interventions in place prior to the development of the dorsal sacral wound and could not provide an order for treatment of that wound at the time it developed. On review of the medical record on 04/21/2026, no active wound treatment orders were found for the resident’s wounds, and the April TAR did not show that any treatment had been completed for the dorsal sacral wound. During observed wound care on 04/21/2026, the dressing removed from the buttock was dated 04/20/2026 and covered both the coccyx and left dorsal sacral wounds; both wounds appeared unstageable with eschar present, and the wound nurse assessed approximately 65% eschar in the dorsal sacral wound and 85% eschar in the coccyx wound, with the coccyx wound measuring 10.0 cm by 9.0 cm by 1 cm. The resident continued to report severe pain associated with these wounds.
Failure to Provide and Document ADL and Meal Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide and document ADL care, including hygiene and eating assistance, for a resident with extensive care needs. The resident was admitted with multiple serious diagnoses, including chronic respiratory failure, COPD, type 2 diabetes, staphylococcal arthritis in the left shoulder and right knee, metabolic encephalopathy, vascular dementia with agitation, PVD, CHF, lung cancer, and chronic kidney disease. An MDS assessment dated 01/14/2026 showed a BIMS score of 6, indicating severe cognitive impairment, and documented that the resident required partial/moderate assistance with eating and was dependent for oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, footwear, and all transfers. The resident’s family member later reported that the resident stated he was not receiving regular ADL assistance or meals. Record review showed multiple shifts where the plan of care documentation for ADL/GG hygiene (oral, toileting, personal) was blank, including on 01/11/2026 (6 a.m.–6 p.m.), 01/12/2026 (6 a.m.–6 p.m.), 01/15/2026 (both 6 a.m.–6 p.m. and 6 p.m.–6 a.m.), 01/16/2026 (6 a.m.–6 p.m.), 01/17/2026 (6 a.m.–6 p.m.), 01/24/2026 (6 a.m.–6 p.m.), and 01/31/2026 (6 p.m.–6 a.m.). Documentation for eating (ability and percentage eaten) was also blank for the 9 a.m. and 1 p.m. meals on multiple dates, and “NA” (nonapplicable) was entered for the 6 p.m. meal on numerous dates. The DON stated that CNAs work 12-hour shifts (6 a.m.–6 p.m. and 6 p.m.–6 a.m.), that ADL tasks including hygiene are expected to be completed and documented each shift, and that documentation for eating is expected after all meals. The DON confirmed the blanks and “NA” entries in the record and acknowledged that such documentation did not demonstrate that ADL services or meals were provided to the resident at those times.
Failure to Follow Infection Control Practices During Wound Dressing Changes
Penalty
Summary
The deficiency involves the facility’s failure to follow acceptable infection prevention and control procedures during clean dressing changes for one resident with pressure injuries. The resident had multiple medical conditions, including circulatory system surgical aftercare, muscle disorder, difficulty walking, cognitive and communication deficits, dysphagia, atherosclerotic heart disease, hypertension, GERD, IBS, overactive bladder, constipation, PVD, pneumonia, urinary retention, osteoarthritis, mild cognitive impairment, hyperlipidemia, and osteoporosis. An MDS assessment showed moderate cognitive impairment and one unstageable pressure ulcer on admission, and at the time of observation the resident reported a coccyx wound and another wound on the left buttock. During the observed dressing change, staff prepared supplies on a clean barrier, and the RN and CNA performed peri care and incontinence care, then removed soiled gloves and sanitized hands before exposing the wounds, which appeared as unstageable wounds with eschar on the coccyx and left sacral area. The wound nurse then performed wound care but did not consistently follow the infection control steps described by the DON as professional practice. After sanitizing hands and donning gown and gloves, the wound nurse took a picture of the left dorsal sacral wound, removed gloves, sanitized hands, and replaced gloves, then cleansed and dressed the wound. The wound nurse then picked up the phone to take a picture of the coccyx wound, removed gloves, and proceeded to cleanse the coccyx wound and apply the ordered dressing without mention of hand hygiene or new gloves between handling the phone and cleansing the second wound. The wound nurse then placed the phone used for wound pictures into a pocket without cleaning it before removing gloves and gown and sanitizing hands. The DON later described that expected practice for a clean dressing change included removing soiled gloves, sanitizing hands, and donning new gloves between each step for each wound, obtaining wound pictures and measurements with glove changes and hand hygiene, and sanitizing the phone before placing it on a barrier, indicating that the observed practice did not follow the facility’s stated infection control procedures.
Failure to Implement Fall-Prevention Interventions and Supervision for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions for increased supervision and assistance for a resident assessed as high risk for falls, resulting in an unwitnessed fall with head laceration and subsequent hospitalization for SAH and SDH. The resident was admitted with diagnoses including sepsis, weakness, cognitive deficit, insomnia, and a history of repeated falls. A BIMS score of 4 indicated severe cognitive impairment. A fall risk assessment completed shortly after admission identified the resident as high risk for falls with a score of 24, noting intermittent confusion, recent hospitalization, and wheelchair confinement with disorientation; however, the mobility status documented on the assessment was not an accurate reflection of the resident’s actual status. Despite the high fall risk assessment, there was no fall prevention care plan or care plan addressing the resident’s high risk for falls in place until after the resident experienced a fall and was discharged to the hospital. The ADL care plan initiated shortly after admission only addressed assistance with daily care needs related to general weakness and included an intervention for direct feeding assistance; other interventions, including those related to transfer assistance and fall risk, were not added until after the fall. The record did not document whether the resident was continent or incontinent or whether a toileting program was in place. Staff interviews confirmed that the baseline care plan developed within 24 hours of admission did not include high fall risk status, fall prevention interventions, or the level of assistance needed for transfers and ambulation, and that this information was not carried over to the CNA Kardex. On the morning of the incident, a CNA found the resident on the bathroom floor in a puddle of blood and emesis, with a blood trail from the bed to the bathroom and bleeding from the head. The fall was unwitnessed, and the resident was unable to describe what had happened or localize pain. Nursing staff observed a head laceration and arranged for transfer to the hospital, where records documented a right scalp laceration and diagnoses of SAH and SDH after being found down at the facility. Interviews with CNAs and therapy staff indicated that the resident was unsteady, did not use the call light, walked on her own, and required at least one-person assistance for safe transfers and ambulation, but the CNAs were not aware she was a major fall risk because there were no fall-risk indicators in the room and the Kardex lacked this information. The facility’s fall policy required that residents at risk for falls be identified and individualized fall precautions implemented, including appropriate supervision and management of incontinence/toileting, but these measures were not implemented for this high-risk resident prior to the fall. Additional information from interviews further supported that the resident’s high fall risk and need for assistance were known but not translated into care planning and supervision practices. The DON reported that nursing had assessed the resident as high risk for falls upon admission and therapy had determined she required at least one assist for transfers and ambulation, yet this was not documented in the care plan or Kardex until after the fall. The DON also stated that the care plan is supposed to carry over direct care needs to the Kardex, which CNAs rely on to determine resident needs, and acknowledged that the resident should have had frequent checks and should not have been ambulating alone. Family reported that the resident had multiple falls at home and did not understand she was unsafe to walk independently. Therapy evaluations documented impaired safety awareness, severely impaired decision-making, and the need for partial/moderate assistance with transfers and ambulation, reinforcing that the resident required supervision and assistance that were not implemented before the fall. The facility’s written fall policy, "Fall Evaluation Safety Guideline," required completion of a fall risk evaluation, implementation of resident-specific interventions when risk is identified, and initiation and revision of a fall care plan with appropriate interventions such as environmental evaluation, applied supervision, and management of incontinence/toileting. In this case, although the resident was evaluated and identified as high risk for falls, the required individualized fall precautions and care plan interventions were not put into place prior to the unwitnessed fall. This lack of timely care planning, communication of transfer and ambulation needs to direct care staff, and implementation of increased supervision and assistance for a known high-risk resident led to the deficiency cited under the requirement to ensure the environment is free from accident hazards and that adequate supervision is provided to prevent accidents.
Failure to Conduct and Document Safe, Coordinated Discharge Planning to Home
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process to ensure a safe and orderly discharge for one cognitively intact resident who was dependent for transfers and required extensive assistance. The resident had diagnoses including aftercare following joint replacement, an artificial left knee joint, and hemiplegia/hemiparesis following a cerebral infarction affecting the left dominant side. His care plan identified him as a short‑term stay resident with good discharge potential and included interventions such as coordinating physician orders for discharge, arranging home health and equipment, evaluating discharge potential, and ensuring discharge to a safe environment with ongoing services. Despite these documented expectations, the facility did not carry out the planned interventions or document a comprehensive discharge needs assessment and plan in the medical record. On 2/20, the business office and MDS staff received notice that the resident’s last covered day would be 2/22, and the resident was served a Notice of Medicare Non‑Coverage, which he signed. The social services staff member, who was new and minimally trained, believed the resident’s signature only confirmed understanding of appeal rights and did not recall discussing specific discharge plans, in‑home services, or outpatient therapy with the resident or his family. The family member reported believing that signing the form constituted an appeal and attempted to contact the insurer, but later learned the appeal had not been properly initiated. The facility’s business office manager discussed private‑pay costs with the family member and stated that, because there was no appeal on record, the resident would have to discharge or pay cash. The family member reported that social services did not assist with understanding or initiating the appeal process, despite the facility policy stating that residents would not be discharged while an appeal was pending and that social services would assist with appeals. On the day of discharge, the family member was notified that the resident would be leaving within about an hour, expressed anxiety about the discharge, and reported not having transportation arranged. She requested to borrow a wheelchair and was denied any assistance from the facility. She then packed the resident’s belongings, called an ambulance, and left to prepare the home, arranging for neighbors to help when the resident arrived. Nursing staff reported that an LPN took over care shortly before the end of her shift, was told the resident was packed and ready to discharge, and did not have any discharge conversations with the resident or family; she later learned from a CNA that the resident had already left and documented that the ride did not receive the printed discharge paperwork. Therapy staff stated they were not informed in time to complete a discharge assessment or plan, and that the resident remained dependent with transfers and not safe to stand, with no discussions about the family’s ability to care for him at home. The discharge packet later found in a shred box contained incomplete documentation, including blank sections for method of transportation, discharge instructions review, staff and resident signatures, and contact information, and there were no progress notes documenting discharge discussions beyond a single note about the family’s anxiety. The family member reported receiving no caregiver education, no referrals for home health or outpatient therapy, and no assistance obtaining DME, and stated it took about a week after discharge to obtain a wheelchair and hospital bed while the resident remained in bed at home. The facility’s written policy required that staff work with the physician to obtain adequate documentation for discharge, provide preparation and orientation to the resident and family, assist with appeals, and document the resident’s health status, discharge needs, and discharge plan, including services to be provided after discharge. It also required that residents not be discharged while an appeal was pending and that appropriate education and instructions be provided for a safe care transition. In this case, the NP’s last visit note did not mention discharge, and the recapitulation of stay and discharge documents lacked key clinical and contact information, special instructions, and confirmation that instructions were reviewed with the resident or representative. Interviews with the DON and other staff confirmed that social services were responsible for the discharge process and documentation, yet the record contained almost no documentation of discharge planning, no evidence of coordination of home services or DME, and no evidence that the resident and family were adequately prepared or oriented for discharge. These actions and omissions resulted in the resident being discharged to the community without a confirmed capable caregiver in place and without necessary DME available at the time of discharge.
Failure to Develop Baseline Fall-Prevention Care Plan for High-Risk New Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan addressing a resident’s high risk for falls within the required timeframe after admission. The resident was admitted with diagnoses including sepsis, weakness, cognitive deficit, insomnia, and a history of repeated falls. A BIMS score of 4 indicated severe cognitive impairment. A fall assessment completed shortly after admission identified the resident as high risk for falls with a score of 24, noting intermittent confusion, recent hospitalization, and wheelchair confinement with disorientation, although the mobility status documentation was not accurate. Despite these findings, no baseline care plan interventions were created to address fall risk, fall prevention, or the level of assistance needed for transfers and ambulation within the first days after admission. The record showed that the only care plan initiated shortly after admission was an ADL care plan indicating the resident required assistance with daily care needs related to general weakness/debility and direct feeding assistance, with other ADL interventions not added until after the fall. There was no documentation in the care plan or record indicating whether the resident was continent or incontinent or whether a toileting program was in place. The fall prevention care plan and additional ADL interventions, including the resident’s transfer needs, were not developed until after the resident experienced a fall and was discharged to the hospital. The DON confirmed that the resident had been assessed as high risk for falls upon admission and that therapy had determined the resident required at least one-person assistance for transfers and ambulation, but this information was not entered into the care plan or Kardex until after the incident. Staff interviews further demonstrated that direct care staff did not have clear guidance on the resident’s fall risk status or required assistance level. The RN manager stated that a baseline care plan had been developed within 24 hours of admission but did not include high fall risk, fall prevention interventions, or transfer/ambulation assistance needs, and acknowledged the importance of having transfer needs on the baseline care plan so staff know how to care for the resident. One CNA reported that the resident was able to get out of bed and walk but was unsteady and that she did not consider the resident a major fall risk because there were no fall-related signs or equipment in the room and no indication for frequent checks. Another CNA reported not knowing the resident’s continence status, that the resident could not communicate toileting needs, that the door remained closed all night, and that the last check occurred several hours before the fall. The DON stated that the care plan information should carry over to the Kardex for CNA use and acknowledged that the resident’s fall care plan and transfer status were missing until after the fall, which occurred four days after admission.
Failure to Administer Ordered PRN Cough Medication per Physician Orders and Resident Requests
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received medications in accordance with professional standards and physician orders. The cognitively intact resident, admitted with chronic bronchitis/COPD and recovering from influenza, had physician orders for PRN Benzonatate (Tessalon) capsules for cough and later for PRN Guaifenesin syrup. The care plan did not document the resident’s chronic bronchitis, COPD, cough, or related physician-ordered medications. Medication administration records showed Benzonatate was ordered twice over specified time frames and was not administered on several days when it was available and ordered, including multiple missed days during the second order period. None of the administered Benzonatate doses were initialed by the RN later implicated in the complaint. During interviews, the resident reported repeatedly requesting Tessalon on multiple days and being told he could not have it, stating that an RN became defensive, refused to give the ordered Tessalon, and instead offered cough syrup. Another LPN confirmed the resident had a persistent cough, regularly requested Tessalon, and that the medication was stored in the cart and not unavailable. A CNA reported the resident frequently became upset about not receiving medications on time. The RN in question stated the resident frequently requested Tessalon but claimed there was no order for it, did not notify the physician, and did not recall administering cough syrup, despite records showing she had administered Guaifenesin on three occasions. The nurse manager confirmed there was an issue with this RN not honoring the resident’s request for cough medication, that the resident had a valid physician order for Tessalon, and that the medication was available and should have been administered. A provider visit note documented the resident’s multiple complaints about medications and timing following treatment with Tessalon and Tamiflu for influenza A and ongoing intermittent dry cough.
Failure to Maintain Resident Dignity Due to Delayed Call Light Response and Lack of Privacy for Catheter Bags
Penalty
Summary
The facility failed to maintain resident dignity for two cognitively intact female residents. One resident, who had a fractured hip, malnutrition, and COPD, experienced extended call light response times, with documented waits of up to 1 hour and 28 minutes. During these delays, the resident was unable to access timely assistance, resulting in an episode of incontinence. The resident expressed embarrassment, humiliation, and frustration, and apologized to staff for being a bother. Staff interviews and call light logs confirmed the prolonged response times, and the concern was also documented in a grievance form submitted by the resident's family. Another resident, admitted with a sacral fracture and requiring an indwelling Foley catheter, was observed without a privacy covering on her urine collection bag while moving through the facility. The resident reported feeling embarrassed and humiliated after encountering an acquaintance while her urine bag was visible. Observations confirmed the absence of a privacy bag, and staff interviews acknowledged that all urine collection bags should be covered to promote privacy. The facility's own policy required drainage collection devices to be covered to ensure dignity, but this was not followed in the resident's case.
Failure to Develop Timely Baseline Care Plan Including Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident who was admitted with a minimally displaced zone 1 sacral fracture and required an indwelling catheter. Upon review, there was no documentation of Enhanced Barrier Precautions (EBP) in the resident's care plan or Kardex, despite signage on the resident's door and staff awareness that EBP was required due to the indwelling catheter. Interviews with staff confirmed that EBP should have been included in the baseline care plan, but it was not documented until five days after admission. The resident was cognitively intact, as indicated by a perfect BIMS score, and was aware that staff sometimes wore gowns when providing care but did not know the reason. Facility policy requires the interdisciplinary team to collect and record data for the admission baseline care plan within 24 hours and to develop and implement the baseline care plan within 48 hours of admission. The lack of timely documentation and implementation of EBP in the baseline care plan resulted in the potential for unmet care needs for the resident.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure that professional standards of nursing practice were maintained by not following physician orders for laboratory diagnostic testing for one resident. The resident, a cognitively intact female admitted with a fractured left hip, malnutrition, and COPD, had multiple physician orders for laboratory tests including CBC, CMP, TSH, and FT4 to monitor a new condition of anemia following surgery. These orders were entered on several occasions by both a nurse practitioner and a medical doctor, specifying that the labs were to be completed on certain dates and results reported to the provider. Despite these orders, review of the Medication Administration Record (MAR) and electronic MAR showed no documentation that the required labs were completed as ordered. Interviews with nursing staff, including LPNs, an RN, the Nurse Manager, the DON, and the Regional Nurse Consultant, confirmed that the labs were not drawn on the specified dates and that no results could be located. Staff reported that while labs were typically drawn weekly by a lab nurse, it was the responsibility of facility nurses to draw labs on other days if ordered. The failure to complete the ordered laboratory testing resulted in the facility not meeting professional standards of quality for nursing services.
Failure to Ensure Proper Indwelling Catheter Management and Physician Orders
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter for one resident. Upon admission, the resident, who had a minimally displaced sacral fracture and was cognitively intact, was observed with a urinary catheter and collection bag. However, there were no physician orders in place for the indwelling catheter at the time of admission, and the care plan referenced catheter care without corresponding medical orders. The resident reported not knowing why she had a catheter and stated that her urine bag was not emptied for the first few days, suggesting a lack of awareness and attention from staff regarding her catheter care needs. Interviews with nursing staff and management revealed that the process for verifying and entering admission orders was not followed, resulting in the absence of required physician orders for the catheter. Staff members acknowledged that orders should have been in place and that nurse managers were responsible for verifying their accuracy. The facility's policy required evaluation and documentation of medical necessity for indwelling catheters upon admission, as well as corresponding physician orders, but these steps were not completed for this resident until several days after admission.
Failure to Ensure Proper PICC Line Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of a Peripherally Inserted Central Catheter (PICC) for a resident who required prolonged intravenous antibiotic therapy. Observation revealed that an LPN disconnected IV tubing from the resident's PICC line, but there was no documented physician order for the PICC line or for monitoring the site. The resident reported having to return to the hospital to have the IV line replaced and indicated that the dressing on the PICC line was last changed at the hospital several days prior. Review of the nursing admission record noted the presence of an IV but lacked specific details such as size, length, and arm circumference. Additionally, a transfer note documented redness and swelling around the PICC site, which prompted a hospital transfer. Interviews with facility staff revealed a lack of knowledge regarding the need for physician orders for PICC lines and the appropriate frequency for dressing changes. The Nurse Manager was unsure about the requirements for PICC line orders and dressing change intervals, while the Director of Nursing stated that orders should be in place for both the PICC line and its monitoring, and that dressings should be changed every 7 days. Facility policy required regular surveillance and documentation of the PICC site, including dressing changes every 5 to 7 days and monitoring for signs of infection, but these practices were not followed or documented for the resident.
Failure to Follow Enhanced Barrier Precautions During PICC Line Care
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during care activities requiring enhanced barrier precautions (EBP) for a resident with a PICC line. Observation revealed that signage outside the resident's room indicated EBP were in place, requiring staff to wear a gown and gloves during high-contact care. Despite this, an LPN was observed disconnecting IV tubing from the resident's PICC line without wearing a gown. The resident's care plan and physician orders both specified the need for EBP due to the presence of the PICC line. Interviews with the LPN, Nursing Home Administrator, and Director of Nursing confirmed that the expectation was for staff to wear appropriate PPE, including a gown, when providing care involving the PICC line. The facility's policy also required gown and glove use for high-contact activities such as central line care. The LPN acknowledged not wearing a gown during the procedure and recognized this was not in compliance with the established precautions.
Failure to Develop Timely Pressure Ulcer Prevention Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan for pressure ulcer prevention for a male resident with CVA, left-sided hemiplegia, aphasia, and a PEG tube. On admission, the resident was dependent for all mobility-related activities in Section GG of the MDS, and his Braden score on 7/26/25 was 12, indicating high risk for pressure injury. The nursing evaluation on 7/26/25 documented no skin impairments on admission, and the care plan included general statements about limited mobility and potential skin impairment, but it did not include specific preventative measures for pressure ulcer prevention despite the resident’s high-risk status. Family reported that the resident had been in the facility for almost 3 weeks and had developed multiple wounds that were not present when he was admitted. The record showed that interventions related to skin protection and pressure relief were not added until after the coccyx wound was identified on 8/5/25, and additional interventions were not added until 8/11/25 after the left heel wound was identified. The wound care nurse reported that she initiated interventions such as floating heels, turning every 2 to 3 hours, and weekly wound measurements only after the coccyx wound was noted. Interviews with nursing leadership showed uncertainty about who was responsible for wound-related care plans after the wound nurse position became vacant. A nurse manager observed creating a custom wound care plan and stated that floor nurses could create care plans but were still working on doing so. The DON stated the resident should have had pressure ulcer prevention interventions in place at admission because he was clearly at risk based on his Braden score, and she noted that if it was not documented, it was not done. The facility policy also stated that baseline care plan data should be collected within 24 hours and interventions should be individualized to the resident.
Failure to Prevent Pressure Ulcers
Penalty
Summary
Adequate pressure ulcer care was not provided for a male resident with a recent CVA, left-sided hemiplegia, aphasia, PEG tube, and dependence on staff for ADLs, transfers, and bed mobility. On admission, the resident was assessed as high risk for pressure injury with a Braden score of 12, but the record showed no unhealed pressure ulcers at that time. The care plan documented risks related to immobility and incontinence, yet the record review and observations showed that pressure injury prevention measures were not consistently in place or documented when the resident was first admitted. During observations, the resident was repeatedly found supine in bed with his heels resting directly on the mattress, including the left heel, which was wrapped with a dressing but still in direct contact with the mattress. He was also observed in a wheelchair with poor positioning, leaning to one side, with his left arm hanging down and his left foot resting in direct contact with the footrest. Staff and family reported that he required total assistance, needed turning and repositioning every 2 hours, and should have had heel protection and offloading measures in place. CNA staff stated there was no place to document repositioning, and the RN acknowledged there was no documentation by CNAs showing that repositioning had occurred. The resident developed a coccyx wound and a left heel wound after admission. Skin documentation showed the coccyx area was intact on admission, then later a small open area was found in the gluteal cleft, and the wound physician reportedly attributed the coccyx wound to moisture from incontinence. The left heel wound was later documented as pressure related and facility acquired. The TAR showed wound treatments and heel protector interventions with gaps in documentation of completion on multiple shifts, and the DON stated that if it was not documented, it was not done. The DON also stated the resident should have had pressure ulcer prevention interventions in place at admission because he was clearly at risk based on his Braden score.
Food Storage, Sanitation, and Dishwashing Deficiencies
Penalty
Summary
The facility failed to maintain food service safety practices in multiple areas of the kitchen and satellite serving areas. During observations, several ready-to-eat foods were found without proper date markings or with dates that exceeded the allowed holding period, including sliced ham, hot dogs, hardboiled eggs, lettuce, vanilla Med Pass 2.0, and cilantro. One open bag of cilantro had best-by dates of 7/20/2025 and portions that were brown and slimy to the touch. The walk-in cooler and other coolers also contained items such as raw pork chops stored above ready-to-eat hot dogs, shell eggs stored above ready-to-eat peanut butter and jelly sandwiches, and other refrigerated foods that were not properly separated. The kitchen also had multiple sanitation and storage concerns. Clean utensil bins contained scoops with dried food debris and crumb accumulation in the bottom of the bin. Clean pans were observed stacked with water droplets and moisture accumulation between them, and one pan had oatmeal stuck inside. The main ice machine had black accumulation on the inside plastic lip near the top hinge. Four bistro microwaves had heavy dried food debris on the inside surfaces, and the dish machine area had debris on top of the machine and a dark brown splatter on the wall between the dish machine and hand sink. The dish machine log showed a required final rinse temperature of 180F, but the recorded final rinse temperatures for dishes done during breakfast, lunch, and dinner were all below the required temperature for 30 entries from the 1st through the 10th of the month. The dry storage room also had a brown aqueous substance lining the back left floor juncture. These observations were cited against FDA Food Code requirements for date marking, disposition of ready-to-eat foods, cleanliness of food-contact surfaces and utensils, air-drying after sanitizing, mechanical warewashing temperatures, food separation during storage, and cleaning of physical facilities.
Failure to Prevent Elopement and Inadequate Supervision for Residents at Risk of Accidents
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents. One resident, with diagnoses including Parkinson’s disease, metabolic encephalopathy, and a history of hallucinations and wandering, was identified as an elopement risk. Despite being assessed as high risk for elopement and having interventions such as a wander alert device and room relocation, the resident was able to exit the building unsupervised on at least two occasions. Staff interviews revealed confusion about responsibilities for monitoring wander alert devices, inconsistent use and checking of the devices, and lack of proper documentation of elopement incidents in the resident’s medical record. The facility also lacked a systematic approach to ensure that all exit doors were properly alarmed and that alarms were audible to staff, with maintenance checks being inconsistently documented and no plan for checks during off-hours. Another resident, who was cognitively intact but had reduced mobility and required supervision and a gait belt when ambulating, was repeatedly observed walking unassisted in the hallway with a walker and without a gait belt. Staff were not consistently providing the required supervision, and there was a lack of direct observation during ambulation. Interviews with staff indicated a lack of awareness of the resident’s current care plan requirements, with some staff believing the resident was independent based on observation rather than documented care plans or therapy recommendations. The care plan and Kardex specified that the resident required stand-by assistance and a gait belt, but this was not consistently followed. Communication breakdowns between therapy, nursing, and direct care staff contributed to the deficiencies. Therapy staff reported challenges in ensuring that updated transfer and ambulation status information was communicated to nursing staff, and nursing staff reported that care plan changes were not always effectively communicated. Staff turnover and unclear assignment of responsibilities for safety device checks further contributed to the lack of consistent supervision and hazard mitigation for residents at risk of accidents or elopement.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as evidenced by missing documentation in medication and treatment administration records, as well as the absence of incident and behavior reports. For one resident with significant medical needs, including paralysis, stroke, and tube feeding, there were several instances where administration of medications, pain assessments, insulin, blood sugar checks, and wound care were not documented in the Treatment Administration Record (TAR). Interviews with nursing staff and management confirmed that if documentation was missing, it was assumed the care was not provided, and that such omissions could have significant consequences for the resident's health. In another case, a resident with a history of sexually inappropriate behavior and listed on the sex offender registry was placed on 1:1 observation after an incident involving another resident. However, there was no documentation in either resident's chart regarding the incident, nor were there any behavior notes or incident reports completed. Staff interviews revealed a lack of clarity about the incident and the required documentation, and social services staff were unaware of the event due to the absence of records. The facility administrator acknowledged the lack of documentation and incident reports for these events. Additionally, a resident identified as an elopement risk was observed by staff and family to have left the building on at least two occasions, but there was no documentation of these elopements in the resident's medical record or any incident reports. Staff interviews indicated that management instructed them not to document the incident in the electronic medical record. Another resident with complex wound care needs had multiple gaps in documentation for wound treatments, repositioning, and use of protective devices, as well as oral suctioning. Nursing management confirmed that all such care should be documented, and if it was not, it was considered not done.
Failure to Preserve Resident Dignity During Personal Care
Penalty
Summary
The facility failed to provide care and services that promoted dignity and respect for 8 of 8 residents who participated in a confidential group meeting. During an observation on 8/12/25 at 10:00am, an unknown CNA on the heirloom unit was sitting outside an occupied resident room and conducting a personal conversation on her cellphone using the speakerphone feature, and the conversation could be heard from inside the room. In the group meeting on 8/12/25 at 1:00pm, all 8 residents reported that staff members used personal cellphones, sometimes with earbuds, while providing care. Residents described specific incidents in which staff used cellphones during personal care. One resident said a staff member assisted him in the bathroom while talking to someone through earbuds, and he reported feeling unimportant and embarrassed. A female resident reported being left sitting naked on a shower chair while a CNA made a phone call on her cellphone outside the shower area. Another resident reported frustration after overhearing a staff member arguing with her children on the cellphone while she waited for him in the bathroom. The NHA confirmed on 8/13/25 at 12:43pm that staff were not expected to use personal cellphones during cares or in public areas while working. The facility's Dignity policy stated that residents shall be treated with dignity and respect at all times, privacy shall be promoted during personal care, and demeaning practices that compromise dignity are prohibited.
Failure to Clearly Explain Binding Arbitration Agreements at Admission
Penalty
Summary
The facility failed to ensure its binding arbitration agreement was explained in a clear and concise manner to residents at admission, and residents reported confusion about whether they had agreed to it. Review of records and interviews showed that Resident #71, who had schizophrenia, signed an agreement to arbitrate health care negligence claims, but later told the surveyor she had no recollection of signing it, did not know what it was, and said she would never sign anything like that after it was explained to her. Resident #37, admitted with sepsis, signed declining agreement to arbitrate health care negligence claims, but stated he was "pretty drugged" when he arrived, signed whatever was put in front of him, had no idea what the agreement was, and had no recollection of it being explained to him. Resident #27, who had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, signed accepting agreement to arbitrate health care negligence claims, but later stated she had no idea what a binding arbitration agreement was and did not sign it, or if she did, she had no idea what she was signing at the time. The Director of Admissions stated she explained the agreement as asking whether the resident wanted a mediator if they sued the facility, and said some residents read it while others did not. During a confidential resident meeting, 8 residents stated none of them knew what a binding arbitration agreement was, how it worked, or whether they had agreed to it. The Nursing Home Administrator also stated the facility did not maintain a list of residents who signed the agreement and described the agreement in terms of whether the resident wanted a mediator or a lawyer.
Unsafe and Unsanitary Environment and Shared Equipment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment. During multiple observations, a sit-to-stand device outside room T64 was found with white powder and dust debris on the base and footrest, and dirt, debris, and white powder between the knee pad and metal frame. A similar sit-to-stand outside room T67 had a plastic bag with wipes in it, and dirt and debris on the foot base and the metal bar where the pad and straps meet. On later observations, the sit-to-stand outside room T71 was also found with dirt, debris, crumbs, and heavy white powder on the footrest, knee pad attachment area, stem, and wide gray base, and the device outside room T64 again had white powder, dirt, food crumbs, and what appeared to be brown/tan dried liquid on the stem and base areas. Additional observations showed other storage and environmental concerns. The CNA supply closet on the Heirloom Unit had clean and sanitary items on the floor, including mouth swabs, gloves, toothpaste, briefs, and gauze, and slings stored on the bottom rack were laying off the rack and onto the ground. The Oxygen room on the Flower Garden Unit had three packs of oxygen tubing on the ground. The Spa room on the Enchanted Unit had clean and sanitary linens stored open and exposed on the counter of the sink, and dried bowel movement was observed on the wheel of the shower chair. A CNA stated that shared equipment was required to be cleaned between each resident for infection control, and the NHA stated staff should ensure shared equipment was cleaned of dirt and debris after each use. The facility policy stated mechanical lifts should be free of debris and dirt and cleaned prior to storage and between resident use.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all forms of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's protective measures and oversight.
Failure to Timely Report Elopements and Abuse Allegation
Penalty
Summary
The facility failed to report two elopements and an allegation of abuse to the State Agency in a timely manner for two residents. One resident, who was cognitively intact but identified as an elopement risk with a history of wandering, exited the building on at least two occasions. On one occasion, the resident was found alone outside, approximately 100 feet from the emergency exit, without her walker. Staff who witnessed the incident reported being instructed by the Nursing Home Administrator and Director of Nursing not to document the event in the electronic medical record. The incident was not reported to the State Agency, and there was no documentation or signed staff interviews related to the event in the resident's medical records. Another resident, with diagnoses including Alzheimer's disease and psychotic disorder, reported to her nurse that she had been inappropriately touched by a visitor. The facility's incident report indicated that the allegation of abuse was discovered in the evening and not reported to the State Agency until the following morning, exceeding the required two-hour reporting window. The former Nursing Home Administrator could not recall the details of the reporting process but confirmed that such allegations should be reported within two hours. Facility policy requires immediate reporting of abuse, neglect, or mistreatment to the State Agency, but in these cases, the required notifications were not made within the mandated timeframe. The lack of timely reporting and documentation resulted in the potential for ongoing mistreatment and unreported incidents.
Inaccurate and Missing Advance Directive Documentation
Penalty
Summary
The facility failed to ensure proper documentation and accurate advance directive information was in place for 2 residents reviewed for advance directives. For one resident, the admission record, MDS, facesheet, and physician orders reflected DNR status, but the chart contained no documentation or signed paperwork showing the resident wanted to be DNR. The nurse manager checked the nurse’s station book and could not find the paperwork, while the social service aide stated the physician had signed the DNR paperwork later and that residents should remain full code until the DNR was verified and signed by a physician. The nursing home administrator acknowledged awareness of the code status on the facesheet and the missing documentation in the chart. For the second resident, the record showed a cognitively intact resident with a physician order listing Full Code, but the resident also had a signed Michigan DNR form completed by the resident, physician, and two witnesses. The social worker stated that a resident who completed a Michigan DNR form signed by the physician should be listed as DNR immediately in the medical record, and the nursing home administrator stated the resident’s CPR wishes should be clarified and documented at admission. Review of the EMR banner still showed Advanced Directives: Full Code, and the resident reported that staff did not always have information about her preferences, abilities, and needs.
PRN Psychotropic Medication Ordered Without Required 14-Day Limit
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days for one resident. Resident #12, a female admitted with diagnoses including depression and anxiety disorder, had a physician order for lorazepam 0.5 mg by mouth every 4 hours PRN with an indefinite end date. During interviews, an LPN stated PRN medications did not need a specific stop date unless the provider indicated one, while the NM/LPN and DON stated that PRN psychotropic medications should be ordered for only 14 days unless a rationale was provided by the provider. When the documented rationale was requested for the resident’s lorazepam order, none was provided by the time of exit.
Failure to Provide Bedhold Notification
Penalty
Summary
The facility failed to ensure that a proper bedhold notification was completed for Resident #66, a female resident with Alzheimer’s disease with late onset, psychotic disorder with delusions due to a known physiological condition, and visual hallucinations. Review of the resident’s census screen in the electronic medical record showed an effective date of 8/6/25 with STOP BILLING, indicating the resident had been sent out of the facility. Interview findings showed Resident #66 was sent to a psychiatric hospital because of ongoing physical behaviors and hallucinations. The Social Services Director, Nursing Home Administrator, Nurse Manager, and Registered Nurse each stated that a bedhold should be provided when a resident is transferred to the hospital, either with the resident or to the family. The Nursing Home Administrator also stated the facility did not have a bedhold for Resident #66’s hospitalization and could not provide evidence that one had been given, and reported that Resident #66 should have had a bedhold given to her.
Failure to Develop Baseline Care Plan for Resident with Sexual Behaviors
Penalty
Summary
The facility failed to develop and implement a baseline care plan related to sexual behaviors for Resident #99 within 48 hours of admission. Resident #99 was admitted with diagnoses including spinal fracture and alcohol abuse, had a BIMS score of 15 out of 15 indicating cognitive intactness, and had a prior admission at the facility. The chart also showed that he was on the Michigan Sex Offender Registry List during the prior admission and remained on the list at the time of this admission, but no baseline care plan addressed this information or his behaviors. During the admission, staff documented and observed sexually inappropriate behavior. A prior behavior note from the earlier admission described Resident #99 grabbing a nurse’s breast and groin and fondling himself. During the current stay, staff reported that he was on 1:1 observation after being found in another resident’s room. Multiple staff members stated they observed him touching his private area, appearing to masturbate, or brushing up against staff. One CNA and one LPN stated they did not know why he was on 1:1 observation, and the nurse manager stated he was placed on 1:1 after being found in another resident’s room. Social services documentation indicated a history of behaviors and mistreatment of others, including sexual behavior, but the social work staff stated they were not aware he was on the Michigan Sex Offender Registry List or of the incident involving the other resident. The nursing home administrator also stated she did not know he was on the registry until it was pointed out in the chart. The baseline care plan in the chart contained no information about his behaviors, the registry status, or the incident involving the other resident.
Delayed Incontinence Care Due to CNA Misidentification
Penalty
Summary
Timely ADL care was not provided for Resident #109, who had aphasia following a stroke, weakness, and hemiplegia. The resident’s MDS showed a BIMS score of 99 and indicated the resident needed partial staff assistance for personal care. The care plan identified an ADL self-care performance deficit related to CVA, with interventions including max physical assist for bed mobility and physical assistance for personal hygiene. The Kardex directed staff to provide peri care after each incontinent episode. During the overnight hours, the resident’s family member reported that the incontinence brief was not changed for several hours and that no staff came in for several hours. A CNA who had cared for the resident earlier in the evening reported giving a verbal handoff to another CNA and stating that the resident was incontinent and would need assistance of 2 staff for incontinence care. The second CNA later reported she thought the resident was independent with cares and had not checked on her, having mistaken the resident for the resident in the next room. When the resident was checked around 5:00 a.m., the brief and pad were heavily saturated with urine. Another CNA later provided incontinence care and found the brief wet, though the urine was contained and the peri-area was not reddened.
Pharmacy Review and Psychotropic Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review recommendations were followed for one resident and failed to ensure monitoring for side effects of psychotropic medications for two residents. The record showed that Resident #57 was admitted with schizophrenia, dementia, bipolar disorder, anxiety, and hypothyroidism, and had a BIMS score of 8 out of 15, indicating moderate cognitive impairment. The consultant pharmacist recommended decreasing Synthroid from 150 mcg to 137 mcg after a low TSH level was noted, with follow-up thyroid labs if the dose changed, but the order was not changed until later and the physician did not sign the recommendation until after the change had already been made. Resident #57 was also receiving haloperidol 5 mg three times daily for delirium/bipolar disorder, but there was no order in the chart for monitoring signs and symptoms of the medication. Resident #64, who was admitted with type 2 diabetes and depression and had a BIMS score of 15 out of 15, was receiving venlafaxine ER 150 mg daily for depression, and there was also no order for monitoring signs and symptoms of that medication. Review of both charts found no documentation of monitoring their psychotropic medications. During interviews, an LPN stated she could not find a charted question or order to document signs and symptoms for the psychotropic medications and would have to document elsewhere if symptoms were observed. An RN stated that any resident on a psychotropic should have an order to monitor signs and symptoms. The SWD, SSA, NM, and DON all confirmed that monitoring orders should have been present for the residents’ psychotropic medications, and the DON described the monthly pharmacy review process as involving emailed recommendations that were printed and given to the provider for agreement or disagreement.
Medication Storage, Cart Cleanliness, and Refrigerator Monitoring Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently stored in accordance with accepted professional principles. On 8/12/2025, an RN was observed placing a medication cup containing one white pill into the locked narcotic box on the medication cart for the flower unit after the resident refused the pills; the RN taped over the cup, wrote the resident’s name on it, and locked it back up. The RN later stated the pill was hydrocodone (Norco) and said it would need to be wasted with another nurse, but also reported she had not wasted the medication and had administered it later to the resident it was intended for. At another time, an LPN was observed placing a medication cup with two pills into the top drawer of the enchanted medication cart, locking the cart, and then returning to retrieve the cup and continue dispensing medications. An RN was also observed retrieving medication cups from the top drawer of the flower unit cart, including cups with loose pills and liquid, and then dispensing a narcotic from the lock box into one of the cups before administering the medications to a resident. The interior of multiple medication carts was observed to be unclean, with a white saltlike substance in the tea unit cart drawer, liquid medication spillage in the flower unit cart drawer, and liquid spillage in the heirloom unit cart drawer. A blue bottle in the flower unit cart had dried white crusted liquid on its side and was discarded by the RN, who stated the resident was no longer there. In the medication rooms, the refrigerator on the heirloom unit was observed unlocked, and refrigerator temperature logs on the tea unit and heirloom unit had missing entries. Staff interviews reflected inconsistent understanding of medication storage practices, including statements that dispensed medications should not be stored in cart drawers, that refrigerators should be locked when not in use, and that temperatures should be checked and recorded once per shift.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow physician-ordered Enhanced Barrier Precautions for 2 residents. One resident was an older female admitted with a stroke causing left-sided weakness and paralysis and a pressure wound on her coccyx; her BIMS score was 15 out of 15, indicating intact cognition. A sign on her room door indicated she required Enhanced Barrier Precautions, and the physician order summary showed an order for EBP with a start date of 02-25-25. During observation, a CNA provided peri-care without wearing a gown, and the resident stated that staff did not usually wear gowns when coming into her room for care. The second resident was an older female with dementia, weakness, and repeated falls. Her room door also had a sign indicating Enhanced Barrier Precautions, and the physician order summary reflected an EBP order with a start date of 02-17-25. During observation, a CNA assisted her off the toilet and into her wheelchair without a gown, then transferred her from the wheelchair to her bed without a gown and gloves. The facility policy on Personal Protective Equipment stated that Enhanced Barrier Precautions require the use of a gown and gloves during high-contact resident care activities.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Deficiency in Menu Planning and Nutritional Oversight
Penalty
Summary
Menus did not consistently meet the nutritional needs of residents as required. The menus were not always prepared in advance, were not consistently followed, and were not regularly updated to reflect residents' current needs. Additionally, menus were not always reviewed by a dietician, and there were instances where the dietary needs of residents were not met according to their care plans. These deficiencies were identified through review of facility records and observations, which showed lapses in menu planning, preparation, and oversight by qualified dietary staff.
Failure to Honor Resident Food Preferences, Allergies, and Portion Sizes
Penalty
Summary
The facility failed to consistently honor resident food preferences, allergies, and portion size requirements, as evidenced by multiple resident and staff interviews, observations, and record reviews. Several residents reported receiving food items they were allergic to or disliked, such as one resident with a cinnamon allergy being served food containing cinnamon, and others receiving disliked items like chocolate or pears. Residents also reported that their specific dietary needs, such as requests for no sugar or large breakfast portions, were not met, and that meal tickets were not always accurately completed or followed by kitchen staff. Staff interviews revealed ongoing issues with the kitchen frequently running out of both main and alternate menu items, resulting in residents not receiving their preferred or required foods. Dietary staff admitted to not always having the necessary food items due to incomplete deliveries and restrictions on purchasing missing items locally. There was also a lack of clarity and consistency in portion control, with dietary aides unable to explain or demonstrate how portion sizes were determined, leading to residents receiving insufficient amounts of food. Nursing and dietary staff described communication breakdowns and difficulties in correcting meal errors, further contributing to resident dissatisfaction. Residents and their representatives consistently voiced concerns about small portion sizes, lack of alternate menu options, and being served foods they could not or did not want to eat. These issues were corroborated by staff observations and interviews, which highlighted that residents were often left without adequate or appropriate meal choices. Facility leadership, including the NHA and DON, were unaware of the extent of these food service concerns at the time of the survey.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Staff failed to ensure that three residents were cared for with dignity and respect during daily care and meal assistance. Specifically, staff members repeatedly referred to residents who required assistance with eating as "feeders" in the presence of other residents and staff. For example, a CNA and an RN discussed which residents were "feeders" within earshot of a resident, and an LPN referred to another resident as a "feeder" outside the resident's room, where the resident could potentially hear. Additionally, during a dining observation, a CNA training a new staff member identified a resident as a "feeder" in a loud voice in the dining room, in front of other residents and staff. The residents involved had varying degrees of cognitive impairment, with two being severely cognitively impaired and one cognitively intact. Their care plans indicated the need for assistance with eating due to conditions such as dysphagia and decreased strength. The facility's own policy emphasized the right of residents to be treated with respect and dignity at all times, but the observed staff actions did not align with this policy, resulting in a failure to honor residents' rights to a dignified existence and self-determination.
Failure to Timely Identify and Report Resident Neglect
Penalty
Summary
Staff failed to fully implement the facility's abuse and neglect policy by not promptly identifying and reporting an allegation of neglect involving a resident who was cognitively intact and required assistance with activities of daily living, specifically toileting. The resident was found in a soiled brief with bowel movement that had not been changed since early morning, despite the care plan indicating that checks and changes should occur every two hours. Multiple staff members, including CNAs and LPNs, observed and reported the resident's condition, noting that the brief was marked with a time indicating it had not been changed for several hours and that the resident had not received assistance throughout the day. Interviews revealed that concerns about the responsible CNA's failure to provide timely care were communicated among staff, with reports made to the nurse manager and the DON. The DON was informed of the situation but did not conduct a thorough investigation or speak directly with the resident or all involved staff. The administrator was notified later and was under the impression that the issue had been addressed, without recognizing the need for further investigation or reporting. The facility's abuse policy requires immediate reporting of suspected abuse or neglect to the administrator, with subsequent investigation and reporting to state agencies as mandated. In this case, the policy was not followed, as the allegation of neglect was not promptly reported or investigated, and key details about the resident's condition were not communicated to leadership. This resulted in a failure to ensure timely identification and reporting of neglect, as required by facility policy and regulatory standards.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report.
Failure to Provide Required Assistance with Eating and Toileting
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for two residents, specifically in the areas of eating and toileting. One resident with severe cognitive impairment and a history of dysphagia was observed attempting to eat and drink independently without staff supervision or assistance, despite care plan and therapy notes indicating the need for feeding assistance and aspiration precautions. On multiple occasions, the resident was left alone in the dining area, struggled to eat, and experienced frequent coughing episodes. Interviews with staff confirmed inconsistent understanding and implementation of the required level of supervision and assistance for this resident during meals. Another resident, who was cognitively intact but had muscle weakness and depression, was found lying in bed with a soiled brief containing bowel movement that had not been changed for an extended period. The brief was marked with a time indicating it had not been changed for several hours, and the resident confirmed that no staff had assisted her throughout the day. Multiple staff interviews corroborated that the resident had not received timely toileting care as outlined in her care plan, which required regular checks and changes every two hours. The facility's failure to provide timely and appropriate assistance with eating and toileting for these residents was confirmed through observations, interviews, and record reviews. The lack of adherence to care plans and staff uncertainty regarding required interventions contributed to the deficiencies identified during the survey.
Inadequate Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement an effective infection control program, specifically in the application of Enhanced Barrier Precautions (EBP) for residents with open wounds or indwelling medical devices. For one resident with an open wound following surgical amputation, there was no indication of EBP being ordered or monitored, and no signage or isolation cart was present in the resident's room. The Unit Manager and Director of Nursing confirmed that EBP should have been implemented upon the resident's return from the hospital. Another resident with a nephrostomy tube also lacked proper EBP signage, although an isolation cart was present inside the room. Additionally, a third resident with an indwelling catheter and pressure wound had EBP signage and an isolation cart, but the hand sanitizers located above the cart were empty, as observed by an LPN. The facility's policy on EBPs, which includes the use of gowns and gloves for high-contact activities and the posting of signage to indicate precautions, was not adequately followed, leading to potential cross-contamination and increased infection risk.
Plan Of Correction
Element 1: Resident 101 remains at this facility. Enhanced Barrier Precautions (EBP) were implemented 2/25/25 with PPE cart and signage outside her room; care plan and orders updated for EBP 2/25/25. Resident 103 discharged to her home on 3/7/25 after completing her rehab stay at this facility. EBP signage was placed outside her door on 2/25/25 above the PPE cart and remained in place until she discharged. Resident 102 remains at this facility. Hand sanitizers outside his room at the PPE cart were refilled on 2/25/25. Element 2: All residents currently in-house are at risk of requiring EBP that have not been implemented. An audit of all in-house resident orders will be completed to ensure EBP is properly in place. All residents currently on EBP are at risk of signage not being outside their door or hand sanitizer not being available. Rooms of all residents currently on EBP will be audited to ensure proper PPE cart, signage and hand sanitizer is available. Element 3: Infection Prevention Coordinator received Infection Prevention and Control Consultation education from the State Licensing Consultative Section (SLCS) on 2/27/25. All Licensed Nurses will receive education regarding Enhanced Barrier Precautions (EBP). Element 4: DON/Designee will audit 10 isolation carts per week for 4 weeks to check for hand sanitizer availability and proper isolation signage. DON/Designee will audit all new admission resident charts and 5 long term care resident charts per week for 4 weeks to check for EBP requirements in place. The DON is responsible for sustained compliance. Under the supervision of the QAPI committee, audits will be presented to the QAPI committee monthly and will continue until QAPI has determined sustained compliance has been achieved.
Failure to Post Enhanced Barrier Precautions Signage for Resident with Nephrostomy Tube
Penalty
Summary
A cognitively intact resident with a history of kidney calculus and pyonephrosis had a nephrostomy tube placed and was under orders for Enhanced Barrier Precautions. On review of the resident's order summary and during an observation, it was found that there was no Enhanced Barrier Precautions signage on the resident's door. Although an isolation cart with PPE was present inside the room, there was no signage to alert staff or visitors to the required precautions. This lack of signage was confirmed by the unit manager during the observation and review.
Hand Sanitizer Unavailable at EBP Isolation Cart
Penalty
Summary
A cognitively intact resident with diagnoses including a pressure wound, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy was observed to require Enhanced Barrier Precautions (EBP) due to the presence of an indwelling catheter and a pressure wound. Facility policy mandates the use of EBP, including the availability of personal protective equipment (PPE) and hand sanitizer outside the resident's room, to reduce the transmission of multi-drug-resistant organisms (MDROs) during high-contact care activities. During an observation, signage for EBP and an isolation cart with PPE were present outside the resident's room, but both hand sanitizer dispensers located above the cart were empty. An LPN attempted to use the dispensers and confirmed they were empty, stating that housekeeping was responsible for refilling them. The lack of available hand sanitizer at the point of care represented a failure to fully implement the facility's EBP policy as required for infection prevention and control.
Resident Receives Unordered Insulin Due to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident, R101, who was administered insulin despite not having a diagnosis of diabetes mellitus. On the date of the incident, R101 reported feeling dizzy and unwell after receiving an insulin injection that was not ordered for him. The resident's medical records confirmed that there was no insulin prescribed, and his diagnoses did not include diabetes. Interviews with the resident and his family revealed that R101 was aware of the error and expressed concern about receiving insulin, which he knew was not meant for him. The error occurred when a nurse, identified as LPN I, administered insulin to R101, mistaking him for another resident who required the medication. The nurse reportedly did not adhere to the facility's medication administration protocols, which include verifying the right patient, medication, dosage, and time. Despite the presence of resident pictures on the electronic medical record system and names on room doors, the nurse failed to correctly identify R101 and administered insulin intended for another resident, R102, who had not yet received his medication that morning. Interviews with facility staff, including the Director of Nursing and other nurses, highlighted the expectations for medication administration checks, which were not followed in this instance. The facility's electronic medical record system, which includes resident pictures to assist in identification, was not utilized effectively by the nurse involved. The incident was further complicated by the nurse's insistence that no error had been made, despite evidence to the contrary, including R101's report of the incident and the absence of insulin administration records for R102 at the time of the error.
Failure to Label Insulin Pen Correctly
Penalty
Summary
The facility failed to adhere to standards of practice for medication labeling, specifically concerning the labeling of insulin pens. During an observation, a Licensed Practical Nurse (LPN) was found administering Lantus insulin to a resident from a pen that was not labeled with the date it was opened or the expiration date once opened. The pen, which originally held 100 units, had approximately 80-90 units remaining. The LPN acknowledged that the insulin should have been labeled with an open date to ensure the medication's integrity and admitted to using the same pen the previous day without noticing the missing labels. Upon realizing the oversight, the LPN retrieved a new insulin pen, labeled it correctly, and administered the medication to the resident. The LPN stated that once opened, the insulin is good for 28 days.
Failure to Train Agency Staff Leads to Medication Error
Penalty
Summary
The facility failed to maintain an effective training program for agency staff, resulting in a medication error involving a resident, R101. R101, who does not have diabetes mellitus, was incorrectly administered insulin by an agency nurse, LPN I, who was working her first shift at the facility without receiving any orientation or training. This error led to R101 experiencing dizziness and malaise. The incident was reported on 10/5/2024, and it was discovered that the insulin was likely intended for another resident, R102. The nurse administered the insulin in R101's room, where his name was on the door, despite R101's protests that he does not receive insulin. Interviews with facility staff, including the Director of Nursing and the Assistant Director of Nursing/Staff Development, revealed that agency nurses typically do not receive orientation or training from the facility before starting work. The agency staffing company also did not provide training specific to medication administration. The facility relied on the agency to ensure the nurses met the necessary requirements and competencies. Additionally, there was a lack of clear communication and support for agency staff, as they were not provided with essential contact information or guidance on facility procedures, particularly during weekends when management presence was limited.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to consistently monitor and assess a resident, R100, for pressure ulcer care, leading to potential slow healing wounds and the development of new pressure ulcers. R100, who was cognitively intact and dependent on staff for all care, had a sacral pressure ulcer and was at high risk for skin breakdown as indicated by a Braden Scale score of 12. Despite the family's request for R100 to be checked and changed every two hours, observations and interviews revealed that R100 was often left sitting in soiled briefs for extended periods, which could have contributed to the deterioration of her wound. The facility's policy on skin protection was not adequately followed, as R100 did not have a resident-specific care plan for wound care or incontinence management. The care plan and Kardex lacked guidance for incontinence or wound care, and there was missing documentation for R100's wound care from April to June 2024. Observations showed R100 sitting in a recliner without proper offloading, and interviews with family members and staff indicated that R100 was not repositioned or changed as frequently as required. Interviews with the wound care nurse practitioner and facility staff highlighted inconsistencies in wound documentation and care. The wound nurse's notes differed from the facility's records, and there was a lack of consistent charting on R100's wound. The facility's failure to maintain R100's wound bed and ensure regular offloading and repositioning contributed to the worsening of her pressure ulcer, which progressed from a stage II to a Kennedy ulcer with necrotic tissue and tunneling.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to ensure the use of a gait belt during transfers for two residents, R100 and R102, which could potentially lead to falls or injuries. R100, who is cognitively intact but dependent on staff for all care due to Parkinson's disease, was observed being transferred multiple times without a gait belt by CNA E and LPN L. Despite the resident's care plan indicating the need for two-person assistance and the use of a gait belt, staff did not adhere to these guidelines. Interviews with staff, including CNA E and Unit Managers, confirmed the resident's decline in mobility and the necessity of a gait belt for safe transfers, yet it was not utilized. Similarly, R102, who requires maximal assistance due to muscle weakness and a history of falls, was also transferred without a gait belt by CNA E. The facility's policy on gait belt use clearly states its importance for residents at risk of falls and those needing assistance during transfers. However, CNA E admitted to not using the gait belt unless transferring the resident over a distance, contrary to the facility's policy and the Director of Nursing's statement that a gait belt should be used for all non-independent transfers.
Inadequate Infection Control Practices for Residents Under Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement adequate infection control practices, specifically regarding the use of Personal Protective Equipment (PPE) for residents R100 and R102, who were under Enhanced Barrier Precautions (EBP) due to their medical conditions. R100, who was cognitively intact and dependent on staff for care, had a sacral pressure ulcer and required EBP as per her care plan. However, during observations, it was noted that staff, including a CNA and an LPN, did not wear gowns while providing incontinence and wound care, despite CDC signage indicating the need for such precautions. Similarly, R102, who had a stage 2 sacral pressure ulcer, was also under EBP. Observations revealed that the same CNA did not wear a gown while providing incontinence care to R102. The CNA admitted to not wearing a gown during care, indicating a lack of adherence to the required infection control measures. Interviews with staff, including the Director of Nursing and a Unit Manager, revealed a lack of training and education on wound dressings and infection control practices. The Director of Nursing acknowledged that staff had not received education on wound dressings since June 2024, and the Infection Control Preventionist had not conducted any training. This lack of training and understanding of EBP signage contributed to the failure in implementing proper infection control measures, increasing the risk of cross-contamination in the facility.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations during an initial tour of the kitchen. The walk-in cooler had storage racks with a heavy accumulation of debris, which was acknowledged by the Director of Dining Services (DDS) as needing cleaning. Clean utensils were stored in bins next to a hand sink, and these bins contained crumb debris, contrary to the DDS's statement that they should be cleaned weekly. The meat slicer, although not frequently used, was found with dried meat debris, and the can opener had debris on its blade and a sticky substance on its handle and rail. Additionally, the Traulson cooler and freezer had black debris on door gaskets and crumb debris on the floor of the freezer. The facility also lacked proper testing devices for sanitizing solutions, as the kitchen did not have any unexpired test strips to ensure the correct concentration of the quaternary ammonium sanitizer. This was confirmed by the DDS, who stated that they would need to acquire new test strips. An observation of the Heirloom Bistro revealed that the available test strips were expired. These deficiencies in food storage, preparation, and sanitation practices have the potential to result in foodborne illness among residents, as they do not comply with the 2017 FDA Food Code requirements for cleanliness and sanitizing solutions.
Failure to Notify Ombudsman of Transfers/Discharges
Penalty
Summary
The facility failed to provide written notification to the State Long-Term Care Ombudsman regarding facility-initiated transfers and discharges since November 2019. This deficiency was identified through interviews and record reviews. An email from the State LTC Ombudsman indicated that the required notices for transfers and discharges were not being sent. During interviews, the Director of Social Work and a Social Worker admitted that they had not been sending these notices to the Ombudsman, with the last known notice being sent in November 2019. The facility's policy, revised in November 2022, requires the social worker or designee to provide a copy of the notice to the Ombudsman, which was not adhered to, leading to the deficiency.
Failure to Ensure Timely Incontinence Care and Dignity
Penalty
Summary
The facility failed to ensure timely care and services to promote dignity for a resident, resulting in long call light wait times and delays in incontinence care. The resident, who was cognitively intact with a BIMS score of 13, had a history of hemiplegia following a cerebral infarction, pain in both shoulders, and was frequently incontinent of bowel and bladder. The resident was dependent on staff for toilet transfers and required extensive assistance from two staff members for toileting. Despite these needs, the resident reported that staff did not change him as often as necessary and that he experienced long waits for his call light to be answered, leading to discomfort and a lack of dignity. Interviews with staff confirmed the resident's complaints, with a CNA acknowledging that it was common for residents to wait for their call lights to be answered. The CNA also confirmed that the resident frequently complained about the delays in having his brief changed. The care plan for the resident included interventions for toileting and incontinence care, but these were not consistently followed, resulting in the resident having to sit in his waste for extended periods, which was distressing for him.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kalamazoo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harold And Grace Upjohn Community Care Center | 3.6 mi | ★★★★★ | 7 | 0 |
| Medilodge Of Westwood | 5.5 mi | ★★★★★ | 2 | 0 |
| Friendship Village | 5.5 mi | ★★★★★ | 15 | 0 |
| The Laurels Of Galesburg | 5.8 mi | ★★★★★ | 34 | 0 |
| Plainwell Pines Nursing And Rehabilitation Communi | 6.3 mi | ★★★★★ | 12 | 1 |
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