Medilodge At The Shore
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Haven, Michigan.
- Location
- 900 South Beacon Boulevard, Grand Haven, Michigan 49417
- CMS Provider Number
- 235356
- Inspections on file
- 27
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Medilodge At The Shore during CMS and state inspections, most recent first.
The facility did not follow its pressure injury prevention and wound management policies, resulting in missed skin assessments, delayed provider notifications, incomplete wound documentation, and failure to update care plans for residents with pressure injuries. Several residents did not receive wound treatments as ordered, and staff interviews revealed issues with communication, care plan adherence, and timely response to resident needs.
Two cognitively intact residents were involved in a physical altercation, with one resident observed by a CNA to be hitting the other. Although staff intervened and separated the residents, the incident was not reported to the state survey agency within the required timeframe, as the NHA was initially informed it was only a verbal argument. The delay in reporting and lack of clear documentation led to a deficiency for not timely reporting suspected abuse.
A resident with multiple complex diagnoses did not have her care plan updated to reflect new physician orders, changes in condition such as new onset seizures, or deterioration of a pressure injury. The care plan also failed to include specific dietary orders, individualized food preferences, and effective pain management interventions. Staff were observed using inappropriate feeding utensils and not consistently following the care plan, resulting in incomplete and inaccurate care.
Staff failed to follow Enhanced Barrier Precautions and infection control protocols during care for two residents with complex medical needs, including not wearing required PPE, improper glove use, inadequate hand hygiene, and mixing clean and soiled linens. Additionally, the facility did not properly track or document staff illnesses, omitting key information needed for infection surveillance.
The facility did not establish or follow required policies and procedures for administering flu and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
Three residents experienced medication administration errors, including controlled pain medications given at incorrect intervals without documented rationale and a cardiac medication administered without required pre-dose vital sign assessments. Facility records lacked appropriate documentation to justify these deviations from physician orders and facility policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with hemiplegia and cognitive impairment did not receive prescribed splint therapy for the left upper extremity as ordered, with multiple missed applications and lack of follow-up documentation or re-approach by licensed staff. The splint was found unused in the resident's drawer, and staff interviews confirmed the care plan was not consistently followed.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided according to regulatory standards.
A resident with severe cognitive impairment and multiple medical conditions did not receive a required face-to-face visit from a physician or non-physician practitioner within the mandated 60-day interval after the initial 90 days post-admission. Review of records and staff interviews confirmed a gap of over 90 days without a documented visit, despite the resident receiving care from an outside provider and experiencing a hospitalization during this period.
A pharmacist made a medication regimen review recommendation for a resident with severe cognitive impairment and multiple diagnoses, but the facility failed to document the recommendation or show that a physician reviewed or acted on it. Required documentation was missing from the EMR, and attempts to retrieve it from an outside provider were unsuccessful, resulting in noncompliance with facility policy.
Surveyors found that individual medication containers, such as a nasal spray and a diskus, were not labeled with resident names inside the medication cart, even though the outer boxes were labeled. Nursing staff confirmed that the usual practice is to label each container to prevent mix-ups, but this was not done in these cases.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with multiple complex medical conditions was started on a new Clonidine transdermal patch, but the facility failed to remove the old patch when applying a new one and did not initiate monitoring for side effects after starting the medication. The resident was later found unresponsive with two patches still in place and was sent to the ER, where staff confirmed the medication administration error.
Two residents receiving tube feeding did not have their feeding equipment properly labeled or maintained according to standards of practice. Feeding solution bottles lacked required information such as initiation date, time, and ordered rate, and syringes were not separated, rinsed, or dried between uses. The DON confirmed these lapses and noted the absence of a facility policy addressing these practices.
The facility failed to meet the needs of two residents by not ensuring timely response to call lights. A resident with Alzheimer's had her call light out of reach, while another with multiple sclerosis experienced delays in response, especially during the third shift. Staff interviews confirmed similar complaints from other residents.
The facility failed to provide quality care to two residents. A resident with a feeding tube had incorrect wound care orders followed, leading to pus and a foul smell at the site. Another resident with Alzheimer's had outdated nursing notes, and a low blood pressure reading was not promptly addressed. These deficiencies highlight lapses in following care orders and timely documentation.
An unattended medication cart was found unlocked with resident information visible and contained loose unidentified pills and an unsecured metal box with controlled substances. An LPN acknowledged the oversight, and another LPN confirmed that medication carts and narcotic boxes should always be locked when unattended. The facility's policy requires all medications to be stored securely.
The facility failed to provide adequate supervision and timely root cause analysis for fall incidents involving three residents, leading to significant injuries. Despite having care plans identifying them as at risk for falls, interventions were not effectively implemented, and residents were often left unsupervised. This resulted in multiple falls, with one resident sustaining a wrist fracture and another requiring emergency treatment for a laceration.
The facility failed to properly assess and implement advanced directives for two residents. One resident, not her own responsible party, had an advanced directive signed by herself instead of her Durable Power of Attorney. Another resident, who was her own responsible party, had an advanced directive incorrectly signed by her husband.
A facility failed to complete timely PASARR Level I and II evaluations for a resident with multiple diagnoses, including dementia and schizophrenia. The social worker did not follow up with the OBRA Coordinator to ensure the Level II Evaluation was scheduled, assuming the coordinator would see the need in the system. The Director of Nursing acknowledged the delay and lack of a tracking system, noting the social worker's failure to act promptly.
A resident with multiple health issues, including dysphagia and cognitive deficits, was observed eating alone without staff assistance, contrary to his care plan requiring one-person assistance. Despite being on a puree diet and receiving speech therapy, the resident was left unattended during meals, highlighting a failure in following the prescribed care plan.
A resident with multiple health issues, including dysphagia, was not adequately assessed for hydration and food intake. The resident repeatedly requested cold water but was not provided with appropriate thickened liquids due to a shortage. Discrepancies in fluid intake documentation were noted, with staff recording incorrect amounts. Observations showed the resident consumed minimal food and fluids, and staff assistance was inconsistent.
A facility failed to follow up on dialysis concerns for a resident with end-stage renal disease. The resident experienced issues such as cramping and hypotension during dialysis, but the facility did not complete necessary documentation or address these concerns. Interviews revealed a lack of clarity on responsibility and policy regarding dialysis communication.
A facility failed to ensure a pharmacist reported drug regimen irregularities to a physician for a resident with multiple diagnoses, including chronic kidney disease and bipolar disease. Despite medication reviews noting irregularities, the reports were not documented in the resident's medical record, and the DON could not obtain the necessary documentation from the pharmacist, leading to a potential lack of physician awareness.
A resident with chronic respiratory issues received Oxycodone five hours earlier than prescribed, contrary to the physician's order for 12-hour intervals. The facility failed to document the medication error or notify the physician, and no monitoring occurred post-administration. The DON confirmed the deviation from the policy, which allows a one-hour window for scheduled medications.
The facility failed to maintain complete medical records for three residents, missing hospice visit notes and a medication irregularity report. The DON struggled to locate hospice notes for two residents, eventually obtaining them from the hospice company. For another resident, a medication irregularity report was not documented in the electronic health record, contrary to facility policy.
A resident with an IV line was not provided with proper Enhanced Barrier Precautions (EBP) as required. Two CNAs were observed providing care without gowns, despite instructions to wear them for high-contact activities. The Infection Control Preventionist confirmed the oversight and noted the absence of PPE supplies in the resident's room.
A facility failed to offer a pneumococcal vaccine to a resident with diabetes, heart failure, and COPD, as required by their policy. The resident, who was cognitively intact, had previously received a PCV23 vaccine but was not offered the PCV20 vaccine upon admission. The oversight was identified during an immunization audit by the Infection Control Preventionist.
A resident with a history of stroke was admitted with existing wounds, but the facility failed to assess, monitor, and document these wounds accurately. The facility did not notify the physician or DPOA of new and worsening pressure injuries, and treatments were not completed as ordered. The resident was later hospitalized with severe sepsis due to an infected ulcer, highlighting the facility's inadequate wound management and communication.
The facility failed to ensure routine monitoring of patient care equipment, potentially affecting the safety of all residents. The DON reported no log for monitoring equipment, and while mechanical lifts are checked by an external company, other equipment like wheelchairs and bed rails are not routinely monitored. An electronic communication program exists for repairs, but no formal preventative maintenance system is in place.
The facility failed to ensure proper hand hygiene during meal tray delivery and incontinence care, leading to potential cross-contamination. Staff were observed not washing hands before or after entering resident rooms, and a CNA did not change gloves or perform hand hygiene during incontinence care for a resident with colitis.
Failure to Implement Pressure Ulcer Prevention and Treatment Protocols
Penalty
Summary
The facility failed to implement its policy for pressure injury and wound management and did not ensure that treatments were completed as ordered for multiple residents with skin integrity issues. One resident, a female with dementia, Alzheimer's disease, dysphagia, peripheral vascular disease, and urinary incontinence, was identified as high risk for pressure injuries but did not receive consistent skin assessments or timely notification to the provider or responsible party when a pressure injury developed. Documentation showed missed skin assessments, delayed notification of a new pressure injury, and incomplete wound assessments. The care plan for this resident did not include specific interventions such as a turning/repositioning schedule, and interventions were not updated in response to wound deterioration. Staff interviews revealed that the resident was often left wet and not repositioned as required, with communication gaps and staffing issues contributing to missed care. Other residents with wounds or pressure injuries also did not receive wound treatments as ordered, with documentation showing missed treatments on several occasions. Staff interviews indicated that some CNAs did not follow care plans, and there were reports of staff not assisting with care, leaving residents waiting for extended periods, and not responding promptly to call lights. Cognitively intact residents reported waiting so long for assistance that they became incontinent, and observed staff ignoring call lights or engaging in personal conversations instead of providing care. Review of facility policy and nursing standards highlighted the requirement for individualized care plans, timely provider notification of wound changes, and consistent implementation of interventions based on risk assessments. The facility did not consistently document or communicate interventions, modify care plans in response to wound deterioration, or ensure that all staff were aware of and followed the required interventions. These failures resulted in residents not receiving appropriate pressure ulcer care and prevention as required by facility policy and professional standards.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving two cognitively intact residents who were involved in a physical altercation. According to the records, one resident was observed by a Certified Nursing Assistant (CNA) to be hitting another resident in the upper chest and collarbone area while the other resident was lying in bed in a defensive posture. The CNA immediately intervened and separated the residents. Statements from multiple staff members, including the CNA and a Registered Nurse (RN), confirmed that the incident involved physical contact, with the CNA consistently stating she witnessed one resident hitting the other. Despite these observations, the Nursing Home Administrator (NHA) was initially informed that the incident was only a verbal argument. The NHA did not receive or document clear information about the physical nature of the altercation until after further investigation the following day. The facility's own policy requires that allegations of abuse be reported to the Administrator, state agency, and other required authorities immediately, but no later than two hours after the allegation is made. However, the incident was reported to the state survey agency approximately 17 hours after it occurred. The delay in reporting was compounded by inconsistent communication and documentation. The NHA did not document a follow-up conversation with the CNA, who maintained her original statement about witnessing physical abuse. Additionally, the NHA did not have the CNA revise her statement to reflect any uncertainty, as claimed during the investigation. The facility's failure to promptly and accurately report the abuse allegation as required by policy resulted in a deficiency.
Failure to Update and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed, revised, and implemented according to the resident's changing needs and physician orders. The resident, an elderly female with diagnoses including dementia, Alzheimer's disease, dysphagia, peripheral vascular disease, and urinary incontinence, had multiple care needs that were not accurately reflected or updated in her care plan. For example, her care plan did not address the need for a geri chair with direct supervision as ordered, nor did it reflect the restriction against using a broda chair. Additionally, the care plan failed to include the administration of pain medication one hour prior to wound dressing changes, despite a physician's order for this intervention. The resident experienced new onset seizures, but her care plan did not include this diagnosis or interventions for seizure precautions and injury prevention. There was also a lack of updated interventions following the deterioration of her unstageable pressure injury, such as specific positioning or offloading measures. The care plan did not reflect the need for frequent repositioning as documented in provider notes, nor did it address the significant weight loss the resident experienced over a three-month period. Dietary orders for pureed food and nectar thick liquids by teaspoon were not fully incorporated into the care plan, and the use of inappropriate feeding utensils, such as straws, was observed during meal assistance. Furthermore, the care plan lacked individualized details regarding the resident's food preferences, dislikes, and effective non-pharmacological pain interventions. Staff interviews and observations confirmed that the care plan was not consistently referenced or followed, leading to discrepancies between the resident's documented needs and the care provided. These omissions and failures to update the care plan resulted in incomplete and potentially inappropriate care measures for the resident.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by multiple observations of staff not adhering to Enhanced Barrier Precautions (EBP) and proper infection control practices. In one instance, two certified nurse aides provided a bed bath to a resident with a feeding tube and severe cognitive impairment without wearing the required gowns, despite clear signage indicating EBP was necessary. The aides also failed to change gloves between soiled and clean activities, left the room with soiled gloves without performing hand hygiene, and continued care after inadequate handwashing. Both aides acknowledged awareness of the EBP requirements but admitted to not following them during care. Another resident, who was cognitively intact but nonverbal and dependent on staff for care, was observed receiving morning care from a certified nursing assistant who did not use any PPE, despite signage indicating EBP was required. The assistant used the same gloves and washcloths for both clean and soiled areas, mixed clean and dirty linens, and failed to perform hand hygiene when leaving and re-entering the room. A registered nurse assisted in transferring the resident but did not ensure the assistant donned appropriate PPE, even though the nurse was aware of the requirements and the assistant's noncompliance. Additionally, the facility's infection surveillance system was found lacking in tracking and documenting staff illnesses. The call-in log for staff absences due to illness did not consistently record essential information such as the unit worked, specific symptoms, onset dates, or return-to-work dates. The infection control preventionist confirmed these gaps, and there was no documentation of follow-up or analysis to identify potential clusters or prevent the spread of infection, contrary to facility policy and procedures.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards for medication administration for three residents. For one resident, a controlled pain medication (Norco) was administered at intervals shorter than the physician-ordered four hours, with doses given three hours apart and no documentation providing a rationale for this deviation. Another resident received Percocet doses at intervals of 2 to 2.5 hours instead of the ordered four hours, with no documentation explaining the early administration. In both cases, the medication administration records and electronic medical records lacked required documentation to justify the timing discrepancies. A third resident, prescribed Metoprolol with specific parameters to hold the medication if blood pressure or heart rate were below set thresholds, did not have vital signs assessed prior to several evening doses. Instead, morning vital sign results were inappropriately documented as if they were taken before the evening doses. The facility's own medication administration policy requires obtaining and recording vital signs when applicable or as ordered by the physician, and to hold medication for vital signs outside prescribed parameters. The Nursing Home Administrator confirmed these errors and reported no additional documentation to refute the findings.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Follow Physician Orders and Care Plan for Splint Application
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders and the care plan for a resident with hemiplegia, hemiparesis, vascular dementia, and pseudobulbar affect, who required a splint for the left upper extremity. The physician's order specified that the splint should be applied upon rising, removed for lunch, reapplied after lunch, and removed at bedtime, as tolerated by the resident. Multiple observations revealed that the resident was not wearing the splint at the required times, and the resident reported that the splint was never applied and was unaware of its location. The splint was later found in the resident's drawer, and the resident allowed it to be applied without resistance. Documentation showed that there were 21 instances where the splint application did not occur, with no follow-up documentation by licensed staff to address refusals or investigate the root cause. The care plan indicated that if the resident refused, staff should encourage compliance and document refusals, but there was no evidence that this was consistently done. Interviews with staff confirmed that the care plan was not followed, and communication regarding refusals was lacking.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Ensure Timely Face-to-Face Physician Visits
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician or non-physician practitioner conducted a face-to-face visit with a resident at least once every 60 days after the initial 90 days post-admission, as required. The resident in question was admitted with multiple diagnoses, including dementia, diabetes, bipolar disorder, depression, and hepatic encephalopathy, and was assessed as being severely cognitively impaired. Review of the resident's electronic medical record showed no documentation of a physician or non-physician practitioner visit between late February and early June, a period of 93 days, which exceeded the required interval for such visits. The Director of Nursing confirmed that there was no evidence in the facility's records of a face-to-face visit during this time frame. Although the resident received physician services from an outside company and had been hospitalized for part of the period in question, there was still a significant gap where no documented visit occurred. The deficiency was identified through both record review and staff interview, with the DON agreeing that a visit should have taken place within the required timeframe.
Failure to Document and Communicate Pharmacy Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacist's medication regimen review recommendation was properly documented and communicated for one resident. The resident in question was admitted with multiple diagnoses, including dementia, bipolar disorder, and depression, and was assessed as being severely cognitively impaired. On a specific date, the pharmacist indicated that a comment or recommendation had been made regarding the resident's medication regimen, as noted in the progress note. However, a review of the resident's electronic medical record did not reveal any documentation of what the pharmacist's recommendation or comment was, nor any evidence that the physician had reviewed or acted upon it. Interviews with the DON confirmed that the expected documentation, which should have been scanned into the resident's EMR, could not be located. Further attempts to obtain the report from an outside company providing physician services were unsuccessful, as they also did not have a copy of the relevant pharmacy report. The facility's policy requires that any irregularities identified by the pharmacist be reported to the attending physician, medical director, and DON, and that the physician document their review and any actions taken in the resident's medical record. In this case, there was no documentation to confirm that these steps were followed.
Failure to Properly Label Individual Medication Containers
Penalty
Summary
During an inspection of the Southwest Medication Cart, surveyors observed that medications were not appropriately labeled in accordance with professional standards. Specifically, a box of Desmopressin Nasal Spray and a box of fluticasone and salmeterol were found with the respective residents' names on the outer boxes, but the individual nasal spray container and diskus inside the boxes were not labeled with any identifying information. This created a situation where, if the medication containers became separated from their boxes, it would not be possible to identify which resident they belonged to. Interviews with nursing staff confirmed that the standard practice is to label individual medication containers with the resident's name, either using pharmacy-provided labels or by writing the name directly on the item. Staff members acknowledged the importance of this practice, especially when multiple residents are prescribed the same medication, to prevent mix-ups. However, in these instances, the labeling procedure was not followed, resulting in a failure to ensure that all drugs and biologicals were properly labeled as required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Remove Old Clonidine Patch and Monitor After New Medication Initiation
Penalty
Summary
The facility failed to follow professional standards for medication administration for one resident. A male resident with a history of recent brain bleed, left-sided weakness and paralysis, chronic kidney disease stage 4, morbid obesity, insulin-dependent diabetes mellitus, and a feeding tube was admitted and started on a new order for a Clonidine transdermal patch. The electronic medication administration record showed that the patch was to be applied weekly, but there was a delay in administration due to the patch not being available, resulting in it being placed two days late. Additionally, there was no new monitoring ordered to assess for side effects after starting this new medication. On a later date, the resident was found unresponsive with labored breathing and was sent to the emergency room. Upon arrival, two unidentified Clonidine patches were found on each of his upper arms, one from the initial application and one from the later application, indicating that the old patch had not been removed as required. Nursing home staff confirmed that the patches were old and should have been removed. The presence of multiple patches was noted as concerning by the ER staff, and the resident exhibited symptoms including extreme drowsiness, difficulty arousing, and periods of apnea.
Failure to Follow Standards of Practice for Tube Feeding
Penalty
Summary
The facility failed to follow standards of practice for tube feeding for two residents. For one male resident with paraplegia and protein-calorie malnutrition, observations revealed that the irrigation container and syringe used for tube feed flushes were left on the bedside table with the plunger inside the syringe, and the syringe was sitting in a graduated container containing clear liquid dated from the previous day. Additionally, the bottle of tube feed did not have the time it was initiated as required. The resident's electronic medication administration record indicated an order to change and label the feeding syringe and/or container every night shift, but this was not followed. For a female resident with spastic quadriplegic cerebral palsy who is dependent on tube feeding, the tube feed solution bottle did not have the ordered rate or the date the feed was initiated written on it. The syringe and plunger were not separated and were left together in a cylinder with clear liquid on the bedside table. During an interview, the DON confirmed that the tube feed bottles should be labeled with the date, time, and ordered rate, and that syringes and plungers should be separated, rinsed, and allowed to dry between uses. The DON also reported that the facility did not have a policy addressing these standards of practice.
Failure to Ensure Timely Response to Call Lights
Penalty
Summary
The facility failed to ensure that residents' needs were met in a timely manner and that call lights were within reach for two residents. Resident #6, a female with Alzheimer's and rheumatoid arthritis, was observed multiple times with her call light out of reach and covered by a hat, making it inaccessible. Despite being in bed and needing assistance, she was unable to notify staff due to the call light's placement. The facility's policy requires staff to ensure resident access to call lights, but this was not adhered to in the case of Resident #6. Resident #9, a male with multiple sclerosis and difficulty speaking, reported delays in staff responding to his call light, particularly during the third shift. His roommate corroborated these delays, noting that staff would sometimes dismiss the urgency of the call. Confidential staff interviews revealed similar complaints from other residents about the third shift staff being rough, rushed, and slow to respond to call lights. The facility's policy states that any staff member who sees or hears an activated call light is responsible for responding, yet this was not consistently practiced, leading to unmet needs for Resident #9.
Failure to Provide Quality Care for Residents
Penalty
Summary
The facility failed to provide quality care to two residents, leading to deficiencies in their treatment. Resident #1, a female with a history of cerebral aneurysm, stroke, and other medical conditions, was admitted with a feeding tube. The hospital discharge orders specified that the tube feed site should be cleaned with a dermal wound cleanser. However, the facility's electronic medication administration record indicated that normal saline was used instead. This discrepancy in care led to the resident's daughter observing pus and a foul smell from the tube site, which was confirmed by an observation showing pus-like drainage and a saturated drain sponge. Resident #6, a female with Alzheimer's and rheumatoid arthritis, exhibited severely impaired cognition. The facility's nursing progress notes for this resident were outdated, with the last entries made over a month apart. A low blood pressure reading was recorded on 11/17/24, but there was no documentation of physician notification or a timely re-check of the blood pressure until four days later. This lack of timely documentation and follow-up on the resident's condition indicates a failure to provide appropriate care according to the resident's needs.
Unsecured Medication Cart with Controlled Substances
Penalty
Summary
The facility failed to secure an unattended medication cart, which was observed on 01/08/25 at 7:20 AM. The cart, designated for rooms 1-15, was found with resident information displayed on the computer screen and was unlocked. Inside the cart, 14 different loose unidentified pills were found in the second drawer on the left side, and an unsecured metal box containing controlled substances was found in the second drawer on the right side. During an interview shortly after the observation, an LPN acknowledged the oversight, expressing regret. Another LPN confirmed that medication carts and narcotic boxes are required to be locked at all times when not attended by a nurse. The facility's policy on medication storage, last reviewed on 01/30/24, mandates that all medications be stored in locked compartments, with controlled substances requiring double lock and key.
Inadequate Supervision and Fall Risk Management
Penalty
Summary
The facility failed to provide adequate supervision and timely root cause analysis for fall incidents involving three residents, leading to significant injuries. Resident R48, a female with a history of bipolar disorder, epilepsy, and muscle weakness, experienced multiple falls resulting in a wrist fracture. Despite having a care plan that identified her as at risk for falls, interventions such as bed height adjustments and non-skid footwear were not effectively implemented. Observations revealed that R48's bed was often at an unsafe height, and she was left unsupervised, contributing to her falls. Resident R102, diagnosed with congestive heart failure, Alzheimer's disease, and muscle weakness, also suffered from multiple falls, one of which resulted in a laceration requiring emergency treatment. Her care plan included interventions like wheelchair anti-rollback and non-skid footwear, but these did not address her cognitive deficits or history of unsafe transfers. The facility failed to conduct thorough investigations or root cause analyses for her falls, and there was no evidence of increased supervision despite her known safety issues. Resident R465, a male with dementia and visual problems, was found sitting on the floor after an unwitnessed fall. His care plan included interventions for fall risk, but there were no specific measures for supervision. Observations showed that R465 was often left alone and did not know how to use his call light, indicating a lack of adequate supervision. The facility did not conduct a root cause analysis or implement new interventions following his fall.
Failure to Implement Advanced Directives
Penalty
Summary
The facility failed to accurately assess and implement advanced directives for two residents upon admission. Resident R102, a female with multiple diagnoses including congestive heart failure and Alzheimer's disease, was not her own responsible party. The facility did not have a signed advanced directive from R102's son, who was her Durable Power of Attorney. Instead, an advanced directive form was signed by R102 herself, despite her not being her own responsible party. The Director of Nursing confirmed the absence of contact with R102's son regarding the advanced directive. Resident R110, who was her own responsible party, also had issues with her advanced directive. Although R110 was listed as her own clinical responsible party, the facility had an advanced directive signed by her husband. The Director of Nursing acknowledged that R110 should have signed her own advanced directive. The advanced directive on record incorrectly had the husband's signature, indicating a failure in the process of obtaining and verifying the correct responsible party's signature.
Failure to Complete Timely PASARR Evaluations
Penalty
Summary
The facility failed to ensure timely completion of the Pre-Admission Screening and Resident Review (PASARR) Level I and Level II evaluations for a resident. The resident, who was admitted with multiple diagnoses including dementia, depression, anxiety, and schizophrenia, was identified as needing a PASARR Level II Evaluation by a specific date. However, the PASARR Level I Screening was completed late, and the Level II Evaluation was not completed at all. The social worker responsible for coordinating these evaluations did not follow up with the OBRA Coordinator to ensure the Level II Evaluation was scheduled, assuming instead that the coordinator would automatically see the need for it in the system. Interviews revealed that the social worker did not have a system in place for tracking and following up on PASARR evaluations, relying instead on the OBRA Coordinator to notify her of necessary actions. The Director of Nursing acknowledged the delay and the lack of a tracking system, noting that the social worker had not heard from the OBRA Coordinator for over 30 days after the Level I Screening was completed. Despite receiving an email from the OBRA Coordinator about the need for the Level I Screening, the social worker delayed its completion by 35 days, contributing to the overall deficiency in the resident's care assessment process.
Failure to Assist Resident with Eating as per Care Plan
Penalty
Summary
The facility failed to follow the care plan for a resident, identified as R465, who required assistance with eating. R465, a male resident with diagnoses including kidney failure, dementia, macular degeneration, dysphagia, and cognitive communication deficit, was observed eating independently on multiple occasions without staff assistance, despite his care plan indicating he needed one-person assistance for eating. On one occasion, R465 was observed eating lunch alone and requesting cold water, but he was unable to use the call light to request help. A CNA briefly entered the room to get thickened cold water but left R465 alone with his meal tray. Further observations revealed R465 eating breakfast alone in his room on two separate occasions. During an interview, the Registered Dietitian confirmed that R465 was on a puree diet with thickened fluids and was receiving speech therapy for swallowing problems. The Speech Therapy Progress note indicated that R465 had impaired cognitive-communication and swallowing functioning, which affected his ability to safely complete activities of daily living and meet his nutrition and hydration needs independently.
Failure to Provide Adequate Hydration and Nutrition Assessment
Penalty
Summary
The facility failed to adequately assess and provide for the hydration and food intake needs of a resident, identified as R465, who was reviewed for nutrition. R465, a male resident with kidney failure, dementia, macular degeneration, dysphagia, and cognitive communication deficit, required assistance with eating. On multiple occasions, R465 was observed requesting cold water but was unable to use the call light to alert staff. The Certified Nurse Aide (CNA) L was unable to provide cold thickened water due to a shortage in the kitchen and instead offered thickened milk, which R465 refused. The Registered Dietitian (RD) K later provided thickened Pepsi, which R465 accepted in small sips, but he continued to request thin liquids, which were not provided due to his swallowing problems. There were discrepancies in the documentation of R465's fluid intake. CNA L and CNA J provided conflicting accounts of the amount of fluid R465 consumed, with CNA J initially recording an incorrect amount due to a misunderstanding of the cup size. The Director of Nursing (DON) confirmed the error in the recorded fluid intake. Additionally, observations showed that R465 consumed minimal food and fluids during meals, and staff were not consistently present to assist or accurately document his intake. These issues highlight a failure in the facility's processes to ensure accurate assessment and documentation of R465's nutritional and hydration needs.
Failure to Follow Up on Dialysis Concerns
Penalty
Summary
The facility failed to provide appropriate follow-up care for a resident requiring dialysis services. The resident, who had multiple diagnoses including end-stage renal disease and diabetes, experienced issues during dialysis sessions, such as intradialytic cramping and symptomatic hypotension. Despite these concerns being documented by the dialysis center, the facility did not complete the necessary sections of the hemodialysis communication records upon the resident's return. This included missing vital signs, site observations, and documentation of the resident's response to pain. Interviews with the Unit Manager and the Director of Nursing revealed a lack of clarity regarding who was responsible for addressing the dialysis communication and what the facility's policy was. The Director of Nursing confirmed the absence of documentation addressing the resident's concerns and acknowledged that education for staff on completing dialysis forms had just begun. Additionally, there was no evidence that the facility was applying lidocaine cream as directed by the dialysis center.
Failure to Report Drug Regimen Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist reported identified drug regimen irregularities to the physician for a resident reviewed for monthly pharmacist Medication Regimen Reviews. The resident, who was admitted to the facility with multiple diagnoses including chronic kidney disease, diabetes, visual hallucinations, and bipolar disease, had medication reviews conducted by the pharmacist on two occasions. However, the reports and recommendations from these reviews were not documented in the resident's electronic medical record, as required by the facility's policy. During the survey, the Director of Nursing (DON) was unable to locate the pharmacist's reports or notes detailing the irregularities found on the specified dates. Despite attempts to contact the pharmacist for copies of the recommendations, the facility did not provide any documentation related to the pharmacist's findings by the completion of the survey. This lack of documentation and communication resulted in the potential for the physician to be unaware of drug irregularities, which is a violation of the facility's policy on addressing medication regimen review irregularities.
Early Administration of Oxycodone
Penalty
Summary
The facility failed to adhere to the physician's ordered time frame for administering a controlled substance, Oxycodone, to a resident. The resident, who was admitted with chronic respiratory failure with hypoxia, asthma, and dementia, had a physician's order for Oxycontin to be administered every 12 hours. However, the medication was administered five hours early, at 7:00 AM, instead of the scheduled time. This deviation from the prescribed schedule was not documented as a medication error, and there was no evidence that the physician was contacted or that any incident or monitoring occurred following the early administration. The Director of Nursing (DON) acknowledged that medications with a scheduled time frame should be administered within one hour before or after the scheduled time unless otherwise ordered by a physician. Despite this policy, the facility's documentation did not reflect any identification or explanation of the medication error. The facility's policy on medication administration, which emphasizes adherence to professional standards and verification of medication details, was not followed in this instance. As of the survey exit, no additional information or explanation was provided regarding the incident.
Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete medical records for three residents, which could potentially hinder providers from having an accurate and complete picture of the residents' stay. For one resident, the electronic medical record lacked hospice aide visit notes from a specified period. Despite the Director of Nursing's (DON) efforts to locate these notes, they were initially unavailable in the facility's system and had to be obtained from the hospice company. Another resident's electronic medical record also lacked hospice visit notes, including those from hospice aides and nurses, for a specific timeframe. The DON acknowledged the absence of these notes and indicated that the facility's medical records person was unable to locate them. Eventually, the hospice visit notes were retrieved from the hospice company and added to the resident's electronic medical record. For a third resident, the facility failed to document a medication irregularity report in the electronic health record. The surveyor could not find evidence of the irregularity report or the physician's response to it. The DON provided a document with recommendations but admitted that the final report, which should include the physician's signature, was not available. The facility's policy requires the attending physician to document any irregularities and actions taken, but this was not done in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident, identified as R5, who was under infection control practices due to an IV line. R5 was admitted with diagnoses including sepsis, diabetes, and a right femur fracture, and was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance with activities of daily living. During an observation, it was noted that a stop sign on R5's door instructed staff to wear gloves and gowns for high-contact care activities. However, two Certified Nurse Assistants (CNAs) were observed providing personal care to R5 while wearing gloves but not gowns, contrary to the posted instructions. When questioned, one of the CNAs stated that they believed gowns were not necessary for R5, as the precaution was only for her IV. Additionally, there was no personal protective equipment (PPE) stand or supplies found in R5's room. The Infection Control Preventionist (ICP) confirmed that the CNAs should have been wearing gowns and acknowledged the absence of PPE supplies in the room. The ICP indicated that re-education of the CNAs and placement of a PPE stand in R5's room would be necessary.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that immunizations were offered and provided to a resident, identified as R29, who was reviewed for immunizations. R29 was admitted to the facility with diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, and was cognitively intact with a BIMS score of 15 out of 15. According to the facility's Pneumococcal Vaccine policy, adults aged 19-64 with such diagnoses should be offered the pneumococcal vaccine upon admission. However, a review of R29's immunization record revealed that although R29 had received a PCV23 vaccine in 2011, they were not offered the PCV20 vaccine upon admission in 2023, as required by the policy. The Infection Control Preventionist acknowledged the oversight during an interview and record review, noting that an immunization audit had revealed several residents, including R29, were missed for the PCV20 vaccine offer.
Failure to Assess and Treat Pressure Injuries
Penalty
Summary
The facility failed to adequately assess, monitor, and document pressure injuries and wounds for a resident, leading to incomplete and inaccurate wound assessments and a delay in treatment. The resident, a male with a history of stroke and other medical conditions, was admitted with existing wounds documented by the hospital. However, the facility did not identify or document these wounds accurately during the admission assessment, and there was a lack of treatment orders for certain areas, such as the reddened area on the right outer ankle and bilateral heels. The facility also failed to notify the physician and the Durable Power of Attorney (DPOA) of new and deteriorating pressure injuries. There were multiple instances where wound treatments were not completed as ordered, and there was no documentation of a rationale for the lack of wound care. The resident's care plans were not updated to reflect the multiple pressure injuries following skin assessments, wound assessments, or hospitalization. Additionally, the facility's wound management program was found to be lacking, with late and incomplete assessments and inconsistent documentation. The resident was eventually admitted to the hospital with severe sepsis due to an infected sacral decubitus ulcer, and multiple pressure ulcers were identified. The facility's failure to provide timely and appropriate wound care, along with inadequate communication and documentation, contributed to the deterioration of the resident's condition. Interviews with staff and family members confirmed the lack of notification and communication regarding the resident's worsening condition and new wounds.
Lack of Routine Monitoring of Patient Care Equipment
Penalty
Summary
The facility failed to have a system in place to ensure routine monitoring of patient care equipment for safe and functional condition, potentially affecting the safety of all residents. During an interview, the Director of Nursing (DON) reported that there is no log of resident care equipment being monitored. Mechanical lifts are checked once or twice a year by an external company, but the maintenance department does not maintain a log for routine monitoring of other patient care equipment such as wheelchairs, shower chairs, mechanical lifts, and bed rails. Although an electronic communication program exists to report equipment needing repairs, there is no formal system for preventative maintenance and monitoring. A review of the facility's Preventative Maintenance Program policy, last revised in March 2022, revealed that a program should be developed and implemented to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Failure to Follow Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during meal tray delivery and incontinence care, leading to potential cross-contamination and the spread of illness. During observations on the Northwest Hallway, staff members, including a Registered Dietitian, Certified Nursing Aides, and a Social Worker, were seen delivering meal trays without performing hand hygiene before or after entering resident rooms. This was confirmed by the Director of Nursing, who stated that staff are expected to wash their hands after resident contact and before handling another resident's tray. Additionally, a Certified Nursing Assistant was observed providing incontinence care to a resident with generalized weakness and colitis without changing gloves or performing hand hygiene between handling soiled items and clean surfaces. The CNA admitted in an interview that she should have changed her gloves and performed hand hygiene when transitioning from dirty to clean tasks.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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