Medilodge Of Capital Area
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansing, Michigan.
- Location
- 2100 E Provincial House Drive, Lansing, Michigan 48910
- CMS Provider Number
- 235653
- Inspections on file
- 31
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Medilodge Of Capital Area during CMS and state inspections, most recent first.
A resident with multiple psychiatric and medical diagnoses, who was cognitively intact, was issued immediate involuntary discharge paperwork for alleged repeated threats toward staff and other residents. Police were involved after the resident called 911, and the resident was later transported to the ED under a court-appointed petition. When the hospital attempted to return the resident, facility staff stated the resident would not be readmitted and could instead go to a local motel, and the hospital ultimately discharged the resident to the community. Although facility forms cited danger to the safety and health of others as the reason for transfer/discharge, the medical record lacked physician documentation that the transfer/discharge was necessary for these safety concerns.
A resident with a history of major depressive disorder and traumatic brain injury, who was cognitively intact, underwent an x‑ray performed by a contracted technician. During the procedure, the interaction escalated into a heated verbal altercation in which the technician used profanity, spoke aggressively, and, according to multiple staff, antagonized and challenged the resident while continuing the x‑ray. Staff responded after hearing the resident call for help and observed the technician yelling, cursing, and making disrespectful and threatening remarks, leading the resident to request that the technician be removed from the room. The facility’s investigation confirmed the incident and the heated verbal exchange between the technician and the resident.
The facility did not report multiple allegations of abuse and misappropriation involving several residents, including an incident where a resident's debit card was allegedly misused by staff and physical altercations between residents with severe cognitive impairment. Despite initial notifications and documentation, required reports to the State Agency were not made, and investigations were not initiated as per facility policy.
The facility did not investigate or report multiple incidents of physical altercations between residents with severe cognitive impairment, despite documented injuries and pain. Incident reports were signed by the NHA after the events, but no investigations or required notifications to state agencies were initiated, contrary to facility policy.
The facility did not follow its abuse and neglect policies when multiple residents with severe cognitive impairment were involved in physical altercations, resulting in pain and minor injury. Incident reports were completed, but the NHA was not notified, did not investigate, and did not report the incidents to the state agency as required by facility policy.
A resident with moderate cognitive impairment and a legal guardian had a signed and witnessed DNR advanced directive, including a physician signature, but the facility did not have a physician order in place to implement the DNR. Staff interviews indicated a breakdown in communication regarding updating orders after the advanced directive was signed.
Two residents did not receive accurate or timely MDS assessments related to pressure ulcers. One resident was incorrectly coded as requiring tracheostomy care, while another developed a new pressure ulcer without a required change in condition assessment being completed. Staff interviews and record reviews confirmed these assessment failures.
A resident with severe cognitive impairment and multiple diagnoses was transferred from a secure dementia unit to another hall, but the care plan was not updated to reflect this change. The LPN confirmed the oversight, which was identified during a survey through observation, interview, and record review, resulting in the potential for unmet care needs.
A resident who required one-person assistance for hygiene was repeatedly observed with greasy, uncombed hair, an excessively long mustache, and wearing the same soiled clothing over multiple days. Staff interviews confirmed the resident was cooperative and had not refused care, but the facility had not provided needed grooming or clothing changes, and had been without a beautician for several months. The ADON was unaware of the resident's condition and acknowledged the facility's responsibility to meet care needs.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
Two residents, one cognitively intact and one with severe cognitive impairment, consistently received meals that were not at safe or appetizing temperatures. Food items, including hot entrees and beverages, were served below recommended temperatures, and cold items were not sufficiently chilled. Despite residents expressing dissatisfaction, staff did not take steps to address the temperature concerns during meal service.
A resident with multiple medical conditions and a regular diet order repeatedly did not receive requested or preferred food items, instead receiving items on their dislike list, despite submitting multiple complaints and meal tickets showing the discrepancies. Facility staff confirmed the resident's food preferences were not consistently honored and could not explain the ongoing errors.
A facility failed to administer medications as ordered for a resident with diabetes and liver cirrhosis. The resident's medications, including Lactulose, Glimepiride, and Isosorbide Dinitrate, were not consistently given due to unavailability. The issue was discovered after a family member raised concerns, and the DON confirmed the medications were not pulled from backup supply or delivered timely.
A facility failed to follow professional guidelines by using PDI Sani-Cloth Germicidal Disposable Wipes for a resident's incontinent bowel care. The resident, with a history of multiple medical conditions, was cleaned with bleach wipes by a Staff Development Coordinator, despite the wipes being unsuitable for skin contact. The incident was reported by a CNA, and the SDC admitted to the inappropriate use of the wipes, initially intended for cleaning the mattress.
A cognitively impaired resident was sexually assaulted by another resident with a known history of sexual offenses. The facility failed to monitor the offender adequately and did not activate the missing resident policy when the victim was unaccounted for over an hour. The incident was captured on surveillance, but the footage was not saved, and the facility's abuse prevention policies were not effectively followed.
The facility failed to maintain plumbing and refrigeration equipment, risking foodborne illness for residents. A leak was observed from the coffee maker's water filter, and the Arctic Air cooler was holding food at 52°F, above the safe threshold. The CDM discarded the food as the temperature did not decrease. Additionally, the atmospheric vacuum breaker for the mop sink was under constant pressure, violating FDA standards.
The facility failed to control a gnat infestation in the kitchen, affecting all 99 residents. Gnats were observed in various areas, including the dry storage room, grease trap, dish machine area, and dining room. The Certified Dietary Manager noted that the pest control operator provided floor and drain cleaner, but service reports did not mention treatment for gnats. This failure violates the 2017 FDA Food Code, which requires premises to be free of pests.
The facility's Activities Director on the memory care unit lacked the necessary qualifications and experience, resulting in residents being left unengaged and inactive. Observations showed that scheduled activities were either not conducted or inadequately executed, with many residents observed sleeping or passively watching television. The director admitted to not being certified and was still completing her training.
A facility failed to serve meals at the preferred temperature and provide necessary condiments and utensils, causing dissatisfaction among residents. One resident experienced delays due to cold food and missing items, while a group of residents reported ongoing issues with meal accuracy and preferences. A test tray revealed inadequate food temperatures, highlighting the facility's deficiencies in food service.
A resident at the facility was found with a bruise on her forehead, which was not immediately reported as an injury of unknown origin. Staff provided conflicting accounts of the resident's behavior and the bruise's appearance, leading to inconsistencies in documentation. The facility's internal determination that the bruise was self-inflicted resulted in the incident not being reported to the state agency, highlighting a deficiency in the reporting and investigation process.
A resident at the facility was found with a bruise on her forehead, and the facility failed to conduct a thorough investigation. Staff provided inconsistent accounts of the resident's behavior and the bruise's appearance, with some suggesting it resulted from the resident leaning her head against a bathroom wall. The facility's DON and Administrator were informed, but the investigation was incomplete, lacking comprehensive documentation and follow-up. This raises concerns about the facility's ability to protect residents from potential abuse.
A resident admitted with multiple health conditions, including a stage 3 pressure ulcer, was not accurately assessed in the MDS. Despite the ulcer being documented in the medical record, it was omitted from the MDS assessment, as confirmed by the MDS Coordinator and Nurse, leading to potential unmet care needs.
The facility failed to implement adequate care plans for two residents, leading to potential health risks. One resident with severe cognitive impairment and a Stage 3 pressure ulcer was not consistently provided with required interventions, such as the correct sling size for transfers. Another resident with moderate cognitive impairment experienced delays in dental care due to a lack of a comprehensive care plan addressing oral issues. These deficiencies highlight the facility's failure to ensure comprehensive and effective care plans.
A resident with severe cognitive impairment was not engaged in meaningful activities as per their care plan. Despite enjoying music, walking, and pet visits, the resident was observed wandering alone without staff intervention to participate in scheduled activities. The activity director noted the resident's interest in sensory activities, yet records did not reflect pet visits, highlighting a disconnect between the resident's interests and provided activities.
A resident with severe cognitive impairment and multiple health issues was improperly transferred using a mechanical lift, resulting in a hematoma and bruises. The staff involved were not adequately trained or assessed for competency, and the sling used was inappropriate for the resident's weight. The incident was linked to a failure to follow the facility's mechanical lift transfer policy.
A resident in an LTC facility experienced three medication errors, resulting in an 11.11% error rate. An LPN administered a full tablet of Metoprolol instead of a half tablet, gave Senna Plus without an order, and incorrectly measured ClearLax using a pill cup instead of the bottle's measuring cap. The DON confirmed the errors and was unaware of the improper measurement method.
A resident with moderate cognitive impairment experienced continued pain due to the facility's failure to promptly schedule a dental referral. Despite a dental visit recommending an oral surgeon referral for nodules removal, the appointment was not scheduled in a timely manner. The resident's care plans did not initially address dental issues, and even after the dental visit, the care plan was not updated to include the nodules or the goal of receiving dentures.
A resident with multiple health conditions, including a history of stroke, was not provided with a necessary built-up knife for meal preparation, despite it being part of their care plan. Observations showed the resident had to use inappropriate utensils to prepare food, and the Dietary Manager confirmed the oversight, acknowledging the expectation for the knife to be included with meals.
A facility failed to communicate and document hospice services for a resident with severe cognitive impairment, leading to uncoordinated care. The resident's DPOA was not informed about the hospice disciplines or visit schedules, and hospice calendars were inconsistently updated in the medical record. Staff interviews confirmed the absence of a hospice admission meeting with the DPOA, violating the facility's policy for coordinated care planning.
A facility failed to administer the PCV20 vaccine to a resident as recommended by CDC guidelines, despite the resident's age and medical history indicating the need for it. The resident had previously received PCV13 and PCV23 vaccines, but the Infection Preventionist was unaware of the requirement for PCV20, leading to a deficiency in care.
A resident with multiple medical conditions and a history of PTSD and anxiety reported that the facility's policy of requiring two caregivers for all care violated her rights and privacy. Despite being cognitively intact and expressing her wishes, the facility enforced the policy, leading to increased anxiety and distress for the resident. The ombudsman confirmed that the resident's rights were not being honored.
Failure to Obtain Physician Documentation for Involuntary Transfer/Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician documented the necessity of a resident’s transfer/discharge based on safety concerns. The resident was admitted with multiple diagnoses including a left leg fracture, epilepsy, anxiety disorder, depression, schizophrenia, and PTSD, and was documented as cognitively intact on the MDS BIMS assessment. On one day, social services and the nursing home administrator attempted to issue immediate involuntary discharge paperwork citing repeated threats toward staff and other residents, and the resident requested appeal paperwork but refused to physically accept the documents. Nursing notes indicated that police came to the facility after the resident called 911, and the DON gave the police the involuntary discharge letter. The resident was documented as being aware he needed to leave the next day, based on what the police told him. The following day, nursing documentation showed the resident was unexpectedly discharged via police car to the ED under a court-appointed petition. Multiple staff interviews confirmed that the facility was in the process of an involuntary discharge and had not yet received State Agency approval. The NHA, DON, ADON, SSD, and an RN all reported that when the hospital called seeking to return the resident, facility staff stated the resident would not be readmitted and instead could go to a local motel, and the hospital ultimately discharged him to the community when he refused the motel. The involuntary discharge forms and notice cited endangerment to the safety and health of others due to the resident’s clinical/behavioral status, but review of the medical record revealed there was no physician documentation that the transfer/discharge was necessary for these safety reasons.
Failure to Protect Resident From Verbal Abuse by X‑Ray Vendor
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by an outside x‑ray technician. The resident had a history of major depressive disorder and traumatic brain injury and was cognitively intact per a recent MDS assessment. The resident had an order for an x‑ray, and the contracted x‑ray technician entered the resident’s room to perform the procedure. During the encounter, the technician and the resident engaged in a heated verbal exchange that escalated beyond a simple disagreement. According to the facility’s own incident investigation and multiple staff interviews, the technician used profanity toward the resident, stood over the resident, and engaged in an aggressive, confrontational manner. The resident reported that the technician got in his face, threatened him with a closed fist, and used profanity. Nursing staff documented hearing the resident yell for help and, upon entering the room, observed a verbal altercation in progress. Staff reported that the technician told the resident he did not care who the resident told, that he was going to finish his “f*cking job,” and that he antagonized the resident by challenging him to get out of bed and try to hit him, while continuing to yell and curse. Additional staff corroborated that the technician spoke aggressively and disrespectfully, made statements such as “this is why you’re in here” and “I wish you could get up and hit me,” and that the resident asked staff to remove the technician from his room because he felt threatened and disrespected. The technician himself acknowledged that the interaction became extremely heated, that cursing went back and forth, and that he warned the resident to watch his mouth or he would leave, while continuing to perform the x‑ray. The facility’s investigation substantiated that the incident occurred and that there was yelling and words exchanged between the resident and the technician, but the facility concluded it could not substantiate that verbal abuse occurred, despite the consistent staff accounts of aggressive, profane, and threatening behavior toward the resident by the vendor.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or misappropriation of property to the State Agency for four residents, as required by regulation and facility policy. In one case, a resident with a history of alcohol dependence and anxiety disorder was alleged by a family member to have had her debit card taken and used by a staff member. The resident initially confirmed the allegation to the Nursing Home Administrator (NHA) and Director of Nursing (DON), resulting in the suspension of the accused staff member. However, after the family member left, the resident retracted her statement, claiming she felt pressured to make the accusation. Despite the retraction, both the DON and NHA acknowledged that the initial allegation constituted a reportable event, but it was not reported to the State Agency. Additional incidents involved residents with severe cognitive impairment. Two separate altercations occurred between residents, resulting in physical contact and complaints of pain. Incident reports documented these events, including one where a resident's arm was grabbed and another where residents swung at each other, making contact. The NHA, who was responsible for abuse investigations, was not initially notified of these incidents. Upon later review of the incident reports, the NHA agreed that these events met the criteria for abuse allegations and should have been reported and investigated, but no such actions were taken at the time. Facility policy clearly defined abuse to include staff-to-resident and resident-to-resident altercations, and required immediate investigation and reporting of all allegations to the appropriate authorities. Despite this, the NHA signed off on incident reports without ensuring that the required notifications and investigations were completed. The failure to report these incidents as required resulted in a deficiency related to the timely reporting and investigation of suspected abuse, neglect, or misappropriation.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving three residents with severe cognitive impairment. Incident reports documented physical altercations between residents, including one event where a resident removed another's hat, leading to both residents swinging at each other and one making contact with the other's back. Another incident involved a resident becoming agitated, grabbing another resident's arm, and a physical struggle ensued, resulting in pain and minor injury to both residents and a CNA who intervened. Despite these documented events, there was no evidence that the facility initiated investigations or reported the incidents to the appropriate state agency as required by policy. Interviews with the Nursing Home Administrator (NHA), who also served as the facility abuse coordinator, revealed that she was not notified of the incidents at the time they occurred. Upon review of the incident reports during the survey, the NHA acknowledged that the events constituted allegations of abuse and should have been investigated and reported. The NHA also confirmed that she had signed the incident reports after the fact but had not initiated any investigation or reporting process prior to the surveyor's inquiry. Facility policy required immediate investigation and reporting of any suspicion or report of abuse, including resident-to-resident altercations. The policy defined physical abuse to include actions such as hitting, slapping, and grabbing. Despite this, the facility did not follow its own procedures, as the incidents were neither investigated nor reported in accordance with state and federal regulations. The failure to act was confirmed through record review, staff interviews, and the absence of investigation documentation.
Failure to Investigate and Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to implement its own written policies and procedures for abuse and neglect for multiple residents. Specifically, the facility did not initiate investigations or report incidents of resident-to-resident altercations as required by its policy. For example, one incident involved a resident with severe cognitive impairment who was involved in a physical altercation with another resident over a personal item, resulting in physical contact. The incident report documented the altercation, but the Nursing Home Administrator (NHA), who is also the facility abuse coordinator, was not notified and did not investigate or report the event to the appropriate state agency. Another incident involved a resident with severe cognitive impairment and multiple comorbidities who was physically grabbed by another resident, leading to pain and minor injury. The incident report documented the event, including the resident's complaints of pain and the involvement of a certified nursing aide (CNA) who intervened. Despite the documentation and the facility's policy requiring immediate investigation and reporting of suspected abuse, the NHA was not aware of the details and did not initiate an investigation or report the incident to the state agency. Record review confirmed that the NHA signed the incident reports days after the events occurred, but there was no evidence of timely investigation or reporting as required by the facility's abuse, neglect, and exploitation policy. Interviews with the NHA revealed a lack of awareness of the incidents and a failure to follow the facility's procedures for investigating and reporting allegations of abuse, particularly in cases involving resident-to-resident altercations resulting in physical contact and injury.
Failure to Obtain Physician Order for DNR Status
Penalty
Summary
The facility failed to obtain a physician order to implement an advanced directive/Do Not Resuscitate (DNR) for one resident. The resident, who had moderate cognitive impairment and a full legal guardian authorized to make health and medical care decisions, had an advanced directive form signed by the guardian and witnessed, with a physician signature present on the form. However, upon review of the clinical record, it was found that there was no corresponding physician order in place to enact the DNR status. Interviews with facility staff revealed that the process for updating orders relies on notification from the social worker, but the Assistant Director of Nursing was not notified that the advanced directive had been signed, and the responsible social worker was unavailable for interview during the survey.
Failure to Complete Accurate and Timely MDS Assessments for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to complete accurate and timely Minimum Data Set (MDS) assessments for two residents with pressure ulcers. For one resident, the MDS inaccurately indicated the presence of a tracheostomy and the need for tracheostomy care, despite direct observation, resident interview, and staff confirmation that the resident did not have a tracheostomy or require related care. The error was acknowledged by the MDS nurse, who confirmed the assessment was incorrect. For another resident, staff interviews and record review revealed that a new pressure ulcer developed on the resident's left heel, but a required change in condition MDS assessment was not completed within the mandated timeframe. The MDS nurse confirmed that the development of a new pressure ulcer should have triggered a change in condition assessment, but this was not done. The failure to complete accurate and timely assessments was confirmed through interviews with nursing and MDS staff, as well as review of the residents' medical records.
Failure to Update Care Plan After Resident Transfer
Penalty
Summary
The facility failed to update and revise the individualized, person-centered care plan for one resident following a significant change in the resident's care environment. The resident, who had severe cognitive impairment with a BIMs score of 1 out of 15 and diagnoses including dementia, anxiety, and depression, was observed resting in bed on the 300-unit hall with a perimeter mattress and bilateral fall mats. Despite being moved from the secure dementia unit (100-unit hall) to the 300-unit hall on July 17th, the resident's care plan continued to state that the resident resided on the secure care unit for a therapeutic environment related to dementia. This discrepancy was identified during a survey through observation, interview, and record review. The LPN managing the 300-hall unit confirmed that the care plan had not been updated to reflect the resident's new location and care needs, despite the facility's policy requiring comprehensive, person-centered care plans to be developed, implemented, and revised as needed. The failure to update the care plan resulted in the potential for unmet care needs for the resident.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to ensure that a resident who required assistance with activities of daily living (ADLs) received appropriate care to maintain personal hygiene and grooming. The resident, who was cognitively intact and required one-person assistance for hygiene according to the care plan, was repeatedly observed over several days with greasy, uncombed hair, an excessively long mustache that extended into his mouth, and wearing the same soiled clothing with food and debris. There was no documentation indicating that the resident refused or was resistant to care. Interviews with staff confirmed that the resident was cooperative with care and had not refused showers, clothing changes, or grooming. Staff also reported that the resident had been requesting a haircut, but the facility had been without a beautician for approximately six months. The Assistant Director of Nursing was unaware of the resident's unkempt appearance and soiled clothing, and acknowledged that, despite the family's wishes for the resident to be independent, it was ultimately the facility's responsibility to ensure care needs were met.
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 residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food at the preferred temperature for two residents, resulting in dissatisfaction during meals. One resident, who was cognitively intact and had multiple medical diagnoses including kidney failure and heart disease, reported never receiving a hot meal since admission, with meals described as only warm at best. This resident also noted that hot tea was rarely hot, iced tea was rarely cold, and meats were inconsistently cooked, sometimes overcooked or undercooked. Another resident, with severe cognitive impairment and a history of stroke, diabetes, and dysphagia, frequently received meals in his room and stated that the food was never really warm. Direct temperature checks of this resident's food trays revealed that hot items such as quiche, peas, and coffee were served well below the expected temperature of 165°F, and ice cream was above the recommended cold temperature. On another occasion, breakfast items like hash browns, biscuits, and coffee were also served below appropriate temperatures, and the resident expressed dissatisfaction with the temperature of the food. Staff did not offer to provide warmer food when concerns were raised.
Failure to Honor Resident Food Preferences Results in Repeated Meal Errors
Penalty
Summary
The facility failed to provide food in accordance with a resident's documented preferences, resulting in repeated instances where the resident did not receive requested or preferred food items. The resident, who was cognitively intact and had multiple medical diagnoses including kidney failure, heart disease, and mood disorders, reported ongoing issues with meal accuracy. Specific examples included not receiving items such as tossed salad, hot tea, yogurt, cold cereal, 2% milk, potato chips, ketchup, and homestyle turkey and gravy, and instead receiving items on his dislike list, such as coffee and beef products. The resident had documented these issues through multiple Quality Assistance Forms, noting frequent discrepancies between meal tickets and actual meals received. Despite the resident's ongoing communication with the dietary manager and submission of concerns, the problems persisted over several weeks, as evidenced by saved meal tickets and repeated complaints. Interviews with facility staff, including the Nursing Home Administrator and Dietary Account Manager, confirmed that the resident's food preferences were not consistently honored and that staff could not explain the repeated errors. The facility's own review of the situation acknowledged noncompliance with meeting the resident's food preferences as documented.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to follow physician's orders for medications for a resident who was admitted with diagnoses including type two diabetes and cirrhosis of the liver. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Physician orders included Lactulose, Glimepiride, and Isosorbide Dinitrate, which were not consistently administered on specific dates. A family member raised concerns about the unavailability of these medications, which were confirmed by a review of the medication administration record. The Director of Nursing discovered the issue when the family filled out a Quality Assurance form. Despite attempts to contact the staff responsible for the medication administration, no responses were received by the time of the survey exit. The facility's failure to ensure the timely delivery and administration of the prescribed medications led to the deficiency, as the medications were not available from the pharmacy and were not pulled from the backup supply as expected.
Improper Use of Disinfectant Wipes for Resident Care
Penalty
Summary
The facility failed to adhere to professional guidelines by using PDI Sani-Cloth Germicidal Disposable Wipes for incontinent bowel care on a resident. The resident, who had a history of traumatic brain injury, schizoaffective disorder, dementia, and other medical conditions, was admitted to the facility in 2020. During an incident in early 2025, a Certified Nurse Aide (CNA) reported that a Staff Development Coordinator (SDC) used bleach wipes to clean the resident after a bowel movement, despite knowing it was inappropriate for skin contact. The incident was observed and reported by the CNA, who witnessed the SDC using the wipes on the resident's buttocks, groin, legs, and penis. The resident later confirmed that bleach wipes were used on him, although he could not recall specific details about the incident. The SDC admitted to using the wipes, initially intended for cleaning the mattress, on the resident's skin, acknowledging it was a mistake. The facility's incident report corroborated the CNA's account, detailing the use of disinfectant wipes during the resident's care. The SDC's witness statement explained the decision to use the wipes due to the resident's condition and the difficulty in cleaning him. The Safety Data Sheet for the wipes clearly stated they were not intended for skin use, highlighting the deviation from proper care protocols.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, R505, from sexual abuse by another resident, R501, resulting in a sexual assault. R505, who was cognitively impaired, was ushered into R501's room, where she remained for over an hour. The incident was captured on surveillance video, but the facility did not save the footage. Staff later found R505 with soiled underwear, leading to her being sent to the emergency room for examination. The Director of Nursing confirmed the incident after reviewing the video, which showed R501 barricading his room to prevent entry. R505 was diagnosed with Alzheimer's disease and dementia, with a BIMS score indicating severe cognitive impairment. She was unable to make decisions for herself and had a legal guardian. The facility's staff did not report her missing for over an hour, and the missing resident policy was not activated. R501, who had a history of sexual offenses, was not under any special monitoring or supervision, and his care plan did not reflect any precautions related to his past behavior. The facility's failure to implement adequate monitoring and supervision for R501, despite his known history, and the lack of timely reporting and intervention by staff, contributed to the incident. The facility's policies on abuse prevention and missing residents were not effectively followed, leading to the sexual assault of R505 and the subsequent investigation by law enforcement.
Removal Plan
- Resident was transferred to hospital and was provided a SANE examination.
- Resident was placed on 1:1 supervision until discharged from the facility.
- Female residents with a BIMS 10 or less had skin assessments completed with no concerns identified.
- Female residents with a BIMS 10 or higher were interviewed regarding any concerns with other residents in the facility and if they feel safe.
- Social Services Director completed an audit of sex offender registry for residents in facility.
- Three additional residents identified as sex offenders were placed on one to one supervision and assessed regarding risk factors.
- Resident's interventions/supervision updated as deemed appropriate based on risk factors.
- Care plans updated for residents identified as sex offenders.
- Facility staff were re-educated on the facility Abuse, Neglect and Exploitation Policy to include Criminal Sexual Abuse.
- Administrator, Director of Nursing and Social Services Director educated on ensuring that active sex offenders within the facility have appropriate supervision and interventions initiated and have ongoing monitoring.
- Facility staff were educated on signs of potential sexual abuse and actions to take if sexual abuse is suspected or has occurred.
- Facility staff were educated on following the kardex / care plan regarding interventions placed for residents who are active registered sex offenders.
- Sexual Abuse education will be completed during ongoing facility orientation.
- Residents who are on the sex offender list will be care planned with discussion and agreement, to allow entry when staff has a need to verify the whereabouts of another resident.
- Should a suspected or confirmed sexual abuse occur, the facility staff will immediately intervene and stop contact between residents.
- Perpetrator will be placed on one to one supervision in the interim.
- Notify the Administrator and Police as appropriate.
- Nurse will complete a physical assessment.
- Ad hoc QAPI initiated.
- Current residents in facility with a sex offender history will be reviewed by the Social Services Director or designee and IDT weekly for any new behaviors and to ensure current interventions remain in place and are appropriate.
- The Medical Director/designee was notified of the event.
Failure to Maintain Plumbing and Refrigeration Equipment
Penalty
Summary
The facility failed to maintain its plumbing and refrigeration equipment, which could potentially increase the risk of foodborne illness for all residents consuming food from the kitchen. During an observation, a leak was noted from the in-line water filter for the coffee maker, resulting in water accumulation on the floor. This is a violation of the 2017 FDA Food Code Section 5-205.15, which requires plumbing systems to be repaired according to law and maintained in good repair. Additionally, the Arctic Air reach-in cooler was observed to be holding a temperature of around 52 degrees Fahrenheit, which is above the safe temperature threshold for cold holding as per the 2017 FDA Food Code Section 3-501.16. This section mandates that time/temperature control for safety food should be maintained at 41 degrees Fahrenheit or less. The Certified Dietary Manager (CDM) acknowledged the issue and discarded the food from the cooler as the temperature was not decreasing. Furthermore, the atmospheric vacuum breaker for the mop sink was under constant pressure, which is against the 2017 FDA Food Code Section 5-202.14, requiring backflow prevention devices to meet specific standards.
Facility Fails to Control Gnat Infestation in Kitchen
Penalty
Summary
The facility failed to control pests in the kitchen, resulting in a swarm of gnats affecting the entire facility with a census of 99 residents. Observations on multiple occasions revealed gnats in various areas of the kitchen, including the dry storage room, the grease trap by the three-compartment sink, the dish machine area, and the dining room. The presence of gnats was particularly noted around food storage and preparation areas, such as the bread rack next to a drainage pipe and breakfast trays in the dining room, which were attracting gnats. The Certified Dietary Manager (CDM) acknowledged the issue, stating that the pest control operator had provided floor and drain cleaner to address the gnats. However, the pest control service reports from previous months did not mention any treatment for gnats, drain flies, or fruit flies. The facility's failure to eliminate harborage conditions and effectively control pests is in violation of the 2017 FDA Food Code, which mandates that premises be maintained free of insects and other pests through routine inspections and appropriate pest control methods.
Unqualified Activities Director Leads to Resident Disengagement
Penalty
Summary
The facility failed to ensure that the Activities Director on the memory care unit was qualified to perform the duties effectively. Observations over several days revealed that residents were often left unengaged, with many observed sleeping or passively watching television. Scheduled activities, such as 'Coffee and Cocoa' and 'Dance to Dine,' were either not conducted as planned or were inadequately executed. For instance, during a scheduled activity, the Activities Director engaged residents in a brief two-minute balloon toss before leaving them with an aide who did not attempt further engagement. The Activities Director admitted to not being a recreational or occupational therapist and was still in the process of completing the MEPAP class to become certified in Activities. She had no prior experience as an Activity Director, having only three months of experience as an Activity Aide at a sister facility. The director's lack of qualifications and experience contributed to the deficiency, as she was unable to provide meaningful and individualized activities for the residents, many of whom were observed to be disengaged and inactive.
Deficiencies in Food Service and Temperature Control
Penalty
Summary
The facility failed to serve food at the preferred temperature and provide necessary condiments and utensils, leading to dissatisfaction among residents. One resident, identified as R57, consistently received cold meals and was informed by staff that reheating was not allowed. Instead, a new tray had to be requested from the kitchen, which took additional time. On one occasion, R57's breakfast tray was replaced, but it lacked hash browns and included a plastic spoon instead of metal silverware, further delaying her meal consumption by 27 minutes. A confidential group of six residents reported ongoing issues with food service, including cold food, soggy bread, and inaccuracies in meal trays. They noted that their preferences were often not followed, such as missing condiments or utensils. During a test tray observation, a resident's lunch was found to be served at inadequate temperatures, with meatloaf at 113 degrees F, mashed potatoes at 133 degrees F, and corn at 125 degrees F. The Dietary Manager acknowledged awareness of these issues and mentioned ongoing audits to address them.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin for one resident, resulting in the potential for further injuries of unknown origin to not be reported and facility corrective action to not be taken. The resident, who had been at the facility since November 2023 with a recent readmission in January 2024, was noted to have a small bruise on her forehead. The incident report indicated that the resident often leaned her head on the wall while being changed in the bathroom, but the report lacked details on the color or stage of healing of the bruise. Interviews with staff provided conflicting accounts of the resident's behavior and the timeline of the bruise's appearance. Some staff members reported that the resident would rest her head on the wall, while others stated they had not observed this behavior. The bruise was described by different staff members as being yellow, purple, or blue at various times, indicating inconsistencies in observations and documentation. The facility's Administrator and DON were notified of the bruise, but the report was not made to the state agency as it was determined internally that the bruise was caused by the resident's behavior. However, the investigation and reporting process was unclear, with discrepancies in who reported the incident and when. The lack of immediate reporting and thorough investigation of the injury of unknown origin highlights a deficiency in the facility's handling of such incidents.
Inadequate Investigation of Resident's Bruise
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident, identified as R25, who was found with a bruise on her forehead. The incident report dated 6/20/2024 noted a small bruise on R25's forehead, but lacked details such as the color or stage of healing. Statements from staff, including a CNA and an LPN, suggested that R25 had a habit of leaning her head against the bathroom wall, which was believed to be the cause of the bruise. However, there was inconsistency in the staff's accounts regarding the timing and nature of the bruise, with some staff reporting it as a newer bruise and others as an older one. The facility's Director of Nursing (DON) and Administrator were notified of the bruise, but the investigation was incomplete. The Administrator could not recall who reported the incident to her, and there was no documentation of further investigation or assessment of other residents for similar injuries. Interviews with various staff members revealed discrepancies in their observations and recollections about R25's behavior and the bruise's appearance. Some staff members reported that R25 did not tap her head on the wall, while others stated she did. The lack of a comprehensive investigation and documentation raises concerns about the facility's ability to protect residents from potential abuse. The incident report was the only document available regarding the bruise, and it contained only two staff witness statements. There was no follow-up documentation or assessment of the bruise after 6/20/2024, indicating a failure to ensure resident safety and compliance with reporting requirements for injuries of unknown origin.
Failure to Document Pressure Ulcer in MDS Assessment
Penalty
Summary
The facility failed to accurately complete a comprehensive assessment for a resident, resulting in the potential for unmet care needs. The resident was admitted with multiple diagnoses, including Parkinson's Disease, type 2 diabetes, COPD, epilepsy, schizoaffective disorder, atrial fibrillation, anxiety, insomnia, dementia, hypertension, depression, anemia, orthostatic hypotension, and stroke. Upon admission, a Skin & Wound Evaluation identified a stage 3 pressure ulcer on the resident's right ischial tuberosity. However, the Minimum Data Set (MDS) assessment, completed shortly after admission, did not document this pressure ulcer. During interviews, both the MDS Coordinator and the MDS Nurse confirmed the presence of the pressure ulcer in the resident's medical record but could not explain why it was omitted from the MDS assessment. The omission of the pressure ulcer from the MDS assessment indicates a failure in accurately completing the comprehensive assessment, which is crucial for addressing the resident's care needs effectively.
Deficiencies in Resident Care Plans and Implementation
Penalty
Summary
The facility failed to develop and implement adequate care plans for two residents, leading to potential health risks. Resident #34, who had severe cognitive impairment and was dependent on assistance for activities of daily living, was observed with a Stage 3 pressure ulcer. The care plan for this resident included specific interventions such as using a mechanical lift with a shower sling, orthotic boots, and a pillow between the knees. However, observations revealed that these interventions were not consistently implemented. The resident was transferred using an incorrect sling size, and staff failed to use the required shower sling, leading to a bruise on the resident's forehead. Additionally, there was no documented assessment of the correct sling size, and staff competency in using the mechanical lift was not validated. Resident #36, who had moderate cognitive impairment, complained of mouth sores and was supposed to see a dentist. However, there was no care plan addressing dental issues or oral care. The resident's dental visit notes indicated a need for a referral to an oral surgeon for the removal of nodules, but this referral was delayed. The Unit Manager confirmed that the referral was sent to the scheduler, but the appointment was not scheduled in a timely manner. The care plan developed after the surveyor's interview did not include the nodules noted by the dentist, and the resident's goal to receive dentures was not addressed. These deficiencies highlight the facility's failure to ensure that care plans were comprehensive and effectively implemented, resulting in potential harm to the residents. The lack of proper documentation, assessment, and follow-up on care plans contributed to the inadequate care provided to these residents.
Failure to Engage Resident in Meaningful Activities
Penalty
Summary
The facility failed to provide a meaningful, diverse, and engaging activity program for a resident with severe cognitive impairment residing in the secured memory care unit. The resident, who enjoys music, talk radio, walking, and pet visits, was observed wandering alone in the hallways on multiple occasions without staff intervention to engage them in scheduled activities. Despite having an activity care plan that included encouraging participation in group activities and providing sensory materials, the resident was not encouraged to join activities such as 'Coffee and [NAME]' or music sessions on the patio. The activity director, who has been with the facility for 10 months, acknowledged the resident's interest in sensory activities and pet visits, yet the activity participation record for June 2024 did not reflect any pet visits in the last 30 days. Additionally, the resident's activity care plan and the most recent activity assessment did not include pet therapy, indicating a disconnect between the resident's interests and the activities provided. This lack of engagement and failure to adhere to the resident's care plan contributed to the deficiency identified by the surveyors.
Improper Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in a hematoma and bruises. During an observation, a resident was lifted from her bed with a transfer sling that did not support her head or lower trunk adequately. The staff involved, including a Resident Aide and a Certified Nurse Aide, were not properly trained or assessed for competency in using the mechanical lift. The Staff Development Registered Nurse expressed concerns about the incorrect donning of the sling and the lack of proper assessments for sling size. The resident's care plan required a shower sling for transfers, but no specific size was recommended, and the sling used was inappropriate for the resident's weight. The resident, who had severe cognitive impairment and was dependent on assistance for activities of daily living, had a history of non-traumatic brain dysfunction, dementia, anxiety, depression, arthritis, and a hip fracture. An incident report noted a bump on the resident's forehead and bruising on her ear, which were not previously observed. The Nursing Home Administrator and Director of Nursing acknowledged that the injury could have been caused by a staff member not following the mechanical lift transfer policy, as the transfer was performed without the required two-person assistance. The staff member involved was suspended, but there was no confirmation that the resident's transfer was evaluated after the injuries were noted and before the surveyor's observation.
Medication Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed for one resident, resulting in an error rate of 11.11%. The errors were identified during the administration of medications to a resident with thoracic spine injuries and hypertension. The Licensed Practical Nurse (LPN) administered a full tablet of Metoprolol 25 mg instead of the prescribed half tablet (12.5 mg), two Senna Plus capsules without a corresponding physician's order, and an incorrect dosage of ClearLax, which was not measured using the appropriate measuring cap. The LPN admitted to administering a full tablet of Metoprolol due to the pharmacy providing full tablets and confirmed the resident's preference for Senna Plus, despite the lack of an order. Additionally, the LPN used a plastic pill cup to measure ClearLax instead of the bottle's measuring cap, which is marked for the correct dosage. The Director of Nursing (DON) acknowledged the errors related to Metoprolol and Senna Plus and was unaware of the improper measurement method for ClearLax.
Failure to Schedule Dental Referral Timely
Penalty
Summary
The facility failed to promptly schedule a dental referral for a resident, resulting in continued pain and a delay in meeting the resident's goals. The resident, who had a moderate cognitive impairment, was observed complaining of mouth sores and pain. Despite a dental visit on 3/28/24 recommending a referral to an oral surgeon for the removal of nodules on the maxillary anterior frenum, the referral was not scheduled in a timely manner. The unit manager confirmed that the referral was sent to the scheduler on 5/28/24, but the appointment had not been scheduled by 6/26/24. The resident's care plans did not initially address the dental issues or oral care, and even after the dental visit, the care plan was not updated to include the nodules or the goal of receiving dentures. The resident's goal to have reduced complications related to dental issues and to receive upper and lower dentures was not incorporated into the care plan. This oversight contributed to the delay in addressing the resident's dental needs and alleviating their pain.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, identified as R30, who required built-up eating utensils due to multiple health conditions, including osteomyelitis, type 2 diabetes, arthritis, and a history of stroke. R30 was admitted to the facility with a care plan that included the provision of built-up handles for utensils at meals. Despite this, observations on two separate occasions revealed that while R30 was provided with a built-up spoon and fork, a built-up knife was consistently missing from his meal tray. This omission required R30 to use inappropriate utensils to prepare his food, such as buttering toast and applying jam. Interviews with the Dietary Manager (DM) G confirmed that the facility had adaptive knives available and that the meal ticket for R30 indicated the need for built-up utensils. However, DM G was unable to explain why the built-up knife was not provided, despite acknowledging that it was expected to be included with every meal. This oversight in providing the necessary adaptive equipment as per the resident's care plan highlights a deficiency in the facility's adherence to ensuring residents' needs are met for meal preparation and eating.
Failure in Hospice Service Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was admitted with multiple diagnoses including dementia and Alzheimer's Disease, was receiving hospice care as indicated in their medical record. However, the Durable Power of Attorney (DPOA) for the resident was not informed about the specific hospice services being provided or the schedule of these services. Despite a physician's order for hospice services to begin, there was no evidence that the DPOA was notified about the hospice disciplines involved or the frequency of visits. Interviews with facility staff revealed that there was no documentation of a hospice admission meeting with the DPOA, and the hospice visit calendar was not consistently updated in the resident's medical record. The hospice calendar for certain weeks was not scanned into the medical record until after the visits had occurred, and there was no calendar for some weeks. The facility's policy required coordination of a care plan with the hospice provider, but this was not effectively implemented, as evidenced by the lack of communication with the resident's representative.
Failure to Administer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to administer pneumococcal immunizations in accordance with CDC recommendations for a resident, resulting in a potential risk for severe illness and complications from pneumococcal disease. The resident, identified as R25, was admitted to the facility with multiple diagnoses including dementia, chronic kidney disease, and severe protein-calorie malnutrition. The resident's medical record indicated that she had received the PCV13 vaccine in 2017 and the PCV23 vaccine in 2018, but there was no documentation of the PCV20 vaccine being administered, which is recommended by the CDC for individuals over the age of 65 at least five years after their last pneumococcal vaccination. During an interview, the Infection Preventionist (IP) confirmed that the resident had not been offered or received the PCV20 vaccine as per CDC guidelines. The IP admitted to being unaware of the specific CDC recommendation that the resident should receive the PCV20 vaccine. The facility's policy on pneumococcal vaccines, last revised in October 2023, stated that the type of vaccine offered should depend on the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines. However, this policy was not followed in the case of the resident, leading to the deficiency.
Violation of Resident's Rights and Privacy
Penalty
Summary
The facility failed to honor a resident's rights, resulting in increased anxiety, PTSD symptoms, decreased self-worth, and psychosocial wellbeing. The resident, who has a history of chronic obstructive pulmonary disease, acute kidney failure, pressure ulcers, malignant neoplasm, major depression, anxiety, PTSD, and other conditions, was cognitively intact and required assistance for personal care. Despite the resident's care plan emphasizing the need to offer choices and promote self-worth, the facility imposed a two-person assist for all care, including answering call lights, against the resident's wishes. The resident reported that the facility did not always staff two female caregivers on her hall, leading to delays in care. The resident also stated that the facility's decision to require two caregivers was a response to her allegation that an occupational therapist had left bruises on her arm. The facility investigated the allegation and found no wrongdoing, but continued to enforce the two-person assist policy, which the resident felt violated her rights and privacy. The resident expressed her concerns to the ombudsman, who confirmed that the resident's rights were not being honored. The facility's staff, including the Social Services Director, Unit Manager, and Nursing Home Administrator, maintained that the two-person assist was necessary for the resident's safety and to protect staff. However, the resident repeatedly expressed that this policy exacerbated her anxiety and PTSD, and she felt her autonomy and privacy were being compromised. The resident's refusal of care and verbal aggression were documented multiple times, highlighting her distress and the ongoing conflict between her wishes and the facility's policies.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
