Medilodge Of East Lansing
Inspection history, citations, penalties and survey trends for this long-term care facility in East Lansing, Michigan.
- Location
- 1843 N Hagadorn Road, East Lansing, Michigan 48823
- CMS Provider Number
- 235283
- Inspections on file
- 31
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Medilodge Of East Lansing during CMS and state inspections, most recent first.
Two residents experienced significant weight loss after not consistently receiving prescribed nutrition, either through tube feeding or oral intake. One resident with complex medical needs did not receive the full volume of tube feeding on multiple occasions, while another had multiple undocumented or unverified meals. The registered dietician and DON confirmed gaps in both nutrition delivery and documentation, leading to unaddressed weight loss.
A resident with complex medical needs, including a gastrostomy and ventilator dependence, did not consistently receive the prescribed tube feeding volumes as ordered by the physician. Medication records showed missed and incomplete feedings over an extended period, leading to significant weight loss. The issue was identified by the RD and reported to the DON, but no corrective action was documented.
The facility did not maintain adequate nursing staff levels according to its own staffing grid, resulting in repeated shortfalls across multiple shifts. Residents with complex medical needs experienced long delays in care, missed showers, and unmet requests for assistance, including feeding. Surveyors observed staff failing to respond to call lights despite being present and able to hear them, and concerns about staffing and call light response were raised multiple times by residents without resolution.
Two residents did not receive scheduled showers as required, with one resident and their family reporting ongoing missed showers and lack of response to grievances. Staff interviews and documentation review confirmed that showers were not consistently provided, and there was no documentation of refusals or postponements.
Two residents with complex medical needs were not properly monitored or treated for constipation, despite prolonged periods without bowel movements. Facility staff failed to follow protocols for notifying physicians and administering interventions, and documentation was incomplete. One resident was hospitalized after developing aspiration pneumonia and abdominal distension related to untreated constipation.
A resident's medication, including multiple pills and a nasal spray, was found unattended in a medication cup on top of an isolation cart outside a room, with no staff or residents nearby. The medication was later identified as belonging to a resident with moderate cognitive impairment and several chronic conditions. Facility policy requires medications to be under direct observation or locked during administration, but this protocol was not followed.
A resident with multiple complex medical conditions did not receive several scheduled doses of prescribed medications, including an antibiotic, antipsychotic, and anticonvulsant, despite these being available in the facility's back-up supply. The nurse did not retrieve the medications from the back-up supply, and there was no documentation of provider notification or adjustment of orders for the missed doses, as confirmed by the DON and facility records.
A resident with chronic respiratory failure and a tracheostomy did not consistently receive physician-ordered cough assist therapy three times daily, as documented in the medical record. Multiple scheduled treatments were missed due to reasons such as lack of tolerance, refusal, or the resident being asleep, and staff interviews indicated inconsistent attempts to administer the therapy.
A resident with multiple complex medical conditions and total dependence on staff developed new pressure ulcers and experienced worsening of an existing sacral ulcer due to the facility's failure to implement and follow care plan interventions, such as regular turning, use of heel boots, and timely wound assessments. The resident was repeatedly observed in the same position without necessary protective devices, and new wounds were not promptly identified or treated, resulting in preventable skin breakdown.
A facility failed to provide adequate nursing staff on ventilator and tracheostomy units, resulting in residents not being turned or repositioned as required, the development and worsening of pressure ulcers, and an unwitnessed fall. Staff reported being unable to complete all care tasks due to high resident acuity and insufficient staffing, with most residents requiring two-person assistance for ADLs. Necessary interventions such as heel boots and pressure-relieving mattresses were not consistently used, and staff worked extended shifts without breaks.
Three residents with high risk for skin breakdown did not receive consistent turning, repositioning, or wound care as ordered, leading to worsening pressure ulcers, infections, and hospitalizations. Documentation showed multiple missed wound treatments and gaps in repositioning, with staff and family reports confirming lapses in care and incomplete records.
The facility did not consistently provide required ADL care, including bathing, oral hygiene, and repositioning, for several dependent residents with complex medical needs. Multiple residents missed showers and oral care, and documentation showed lapses in turning and repositioning. Staff and resident interviews, as well as grievance forms, indicated that chronic understaffing led to these deficiencies, with care needs not being met on multiple shifts.
The facility failed to maintain sufficient nursing staff, resulting in multiple residents experiencing missed care such as showers, oral care, repositioning, and wound treatments. This led to worsening pressure ulcers, avoidable falls, and unmet basic care needs, as confirmed by staff, resident, and family interviews, as well as documentation and grievance reports.
A resident with a history of recent hip fracture, confusion, and multiple comorbidities experienced a fall with injury after staff failed to implement care planned fall prevention interventions, including use of positioning wedges, floor mat, and proper bed height. The resident was found on the floor with injuries, and documentation and staff interviews confirmed that required interventions were not in place at the time of the incident.
A facility failed to implement a comprehensive care plan for a resident, resulting in the development and worsening of pressure ulcers. The resident, with knee contractures, was observed without required offloading boots, leading to pressure ulcers on the left trochanter and coccyx. Staff interviews revealed confusion about responsibilities, and the care plan lacked updated interventions. The facility did not conduct a root cause analysis or interdisciplinary meetings to address the issue.
A resident with knee contractures was not provided with adequate pressure ulcer care, leading to worsening wounds. Despite the care plan requiring offloading boots to be worn at all times, staff failed to ensure this intervention was implemented. Observations revealed pressure ulcers on the resident's left trochanter and coccyx, with the resident's feet resting on the mattress without pressure relief. Misidentification of wounds and lack of communication among staff contributed to the deficiency.
The facility failed to maintain proper infection control surveillance for its 62 residents, as no monitoring, mapping, or documentation was conducted for November 2024. The absence of the ICP led to a lack of staff performing infection control duties, with the DON and ADON only reviewing new antibiotic orders without tracking infection clusters.
A resident admitted for respite care was assessed as high risk for falls but did not receive a person-centered care plan addressing specific needs like wandering and confusion. Despite experiencing falls, the care plan was inadequately revised, leading to another fall and hospital transfer. Staff interviews confirmed the need for close supervision, which was not documented in the care plan.
The facility failed to accurately complete MDS assessments for three residents. One resident's MDS incorrectly indicated insulin administration, another's did not reflect significant weight loss, and a third's inaccurately documented discharge to a hospital instead of home. These discrepancies were confirmed by facility staff.
The facility failed to implement comprehensive care plans for three residents, leading to potential unmet care needs. A resident with malnutrition did not receive double meal portions as ordered, another with renal disease did not receive required dietary supplements, and a third with a pressure ulcer had a non-functioning air mattress despite documentation indicating otherwise. These deficiencies were confirmed through observations and staff interviews.
A resident with diabetes and chronic kidney disease experienced a delay in the collection of a urinalysis, which was ordered due to symptoms of cloudy urine and burning with urination. Despite the order being placed, the urinalysis was not collected until several days later, resulting in a deficiency in timely care.
A resident with a stage 4 pressure ulcer experienced a deficiency in care due to a non-functioning air mattress, which was part of her care plan to aid in wound healing. Despite documentation indicating the mattress was functioning, observations revealed it was not, leading to a slight worsening of the wound. The issue was only addressed after surveyor intervention.
A resident with multiple health conditions, including respiratory failure, was observed using oxygen therapy without a physician's order. Facility staff confirmed the expectation for such an order, but it was not documented, highlighting a lapse in the transcription of orders post-hospital readmission.
A resident with severe cognitive impairment was verbally abused by an RN, who yelled and blamed the resident for an ostomy bag issue. The incident was witnessed by a CNA and confirmed by a SW through limited communication with the resident. The facility substantiated the abuse claim and terminated the RN's employment.
A resident with severe obesity and a suspected femoral artery bleed was not transferred to the ER as ordered due to weight limitations of EMS equipment. The facility failed to notify the physician that the transfer did not occur, as confirmed by the physician and the resident's medical record.
A resident with respiratory failure and morbid obesity experienced a suspected femoral artery bleed. Despite a physician's order for hospital transfer, EMS could not transport the resident due to weight limitations. The facility failed to notify the physician of the situation and did not adequately monitor the resident's condition, leading to a significant drop in blood pressure and delayed hospital transfer.
A resident with a facility-acquired pressure ulcer on the sacrum received inconsistent treatment orders, leading to improper application of wound care. The ulcer, characterized by slough and granulation tissue, increased in size over several weeks. Treatment orders included collagen, hydrofera blue, Dermasyn AG, and Medihoney, but were applied concurrently and inconsistently. The DON acknowledged the confusion in treatment application, contributing to the deficiency.
A resident developed a deep tissue injury (DTI) due to improper management of catheter tubing, despite being at risk for pressure injuries and dependent on all care. Initial assessments noted a bruise on the left buttock, later identified as a DTI. Staff education on proper catheter placement was provided, but the wound worsened, leading to reclassification and updated care plans.
Failure to Prevent Significant Weight Loss Due to Inadequate Nutrition and Documentation
Penalty
Summary
The facility failed to prevent significant weight loss in two residents who were reviewed for weight loss. One resident, who had multiple complex medical conditions including chronic respiratory failure, protein-calorie malnutrition, cerebral palsy, and dependence on a ventilator, experienced a substantial weight loss of 31.1 pounds over four months. This resident was prescribed tube feedings to meet caloric and nutritional needs, but medication and feeding records showed that the resident did not consistently receive the prescribed volume of tube feeding solution on numerous occasions. The registered dietician confirmed that the resident did not receive the required caloric intake for extended periods, and the director of nursing was aware of the issue but could not provide any corrective action that had been taken at the time. Another resident, with a history of stroke, diabetes, heart failure, and dysphagia, lost 14.6 pounds, representing a 13% weight loss in 90 days. Review of this resident's food acceptance records revealed multiple instances where no food acceptance was documented for several meals over the preceding 30 days. The registered dietician could not verify whether the resident had received dietary trays for the meals with missing documentation. The director of nursing confirmed that there were multiple dates and mealtimes without documentation of food acceptance and could not explain the lack of documentation. Both cases demonstrate that the facility did not ensure residents consistently received adequate nutrition and hydration as ordered, either through tube feeding or oral intake. The lack of consistent documentation and follow-through on prescribed nutritional interventions contributed directly to significant weight loss in both residents.
Failure to Administer Prescribed Tube Feedings Resulting in Significant Weight Loss
Penalty
Summary
The facility failed to follow physician orders for the administration of tube feeding solution for one resident, resulting in significant weight loss. The resident, who had multiple complex medical conditions including chronic respiratory failure, protein-calorie malnutrition, cerebral palsy, and dependence on a ventilator, was admitted with a gastrostomy and required tube feeding as per physician orders. Observations and record reviews revealed that the resident was very active at night, often crawling on the floor and chewing on the feeding tube, which led nursing staff to disconnect the tube feeding. Despite these challenges, the prescribed tube feeding volumes were not consistently administered as ordered. Medication records showed multiple instances where the resident did not receive the full prescribed amount of tube feeding solution, and on several occasions, feedings were missed entirely. The resident's weight history indicated a significant decrease, with a loss of 31.1 pounds over four months. The registered dietician confirmed that the resident had not received the required caloric intake from tube feedings during the reviewed period and that this issue had been reported to the Director of Nursing. However, there was no documentation or explanation provided for why the resident did not receive the prescribed nutrition, nor was there evidence of corrective action taken by facility leadership following the incident. The failure to administer tube feedings as ordered directly contributed to the resident's significant weight loss.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple days where staffing levels did not meet the facility's own staffing grid requirements. Staffing records reviewed with the Nursing Scheduler showed repeated shortfalls in both CNA and nurse coverage across various shifts, with some days being up to three staff short. These shortages were documented for several dates and shifts, despite the facility census indicating the need for more staff. Residents reported significant delays in receiving care, including long wait times for call light responses and missed showers. One resident stated she had not received a shower in over a week and often waited up to an hour for assistance, with staff sometimes turning off her call light without returning. Another resident, who required assistance with feeding due to quadriplegia, reported being denied food because staff did not have time to help him. Both residents indicated that these issues were ongoing and had been raised multiple times with facility management and in Resident Council meetings, but no improvements were observed. Direct observations by surveyors confirmed that staff frequently failed to respond to call lights, even when multiple staff members were present and the call lights were audible. On several occasions, staff were seen ignoring call lights while sitting at the nurse's station or walking by without responding. The facility's policy requires any staff member who sees or hears a call light to respond, but this was not followed. Additionally, the facility was unable to produce concern forms related to staffing or call light response issues raised in Resident Council meetings.
Failure to Provide Routine Showers and Maintain Resident Hygiene
Penalty
Summary
The facility failed to provide routine showers and maintain hygiene for two residents who were unable to perform activities of daily living independently. One resident, a cognitively intact female with chronic medical and psychiatric conditions, reported not receiving a shower for over ten days and stated this was a recurring issue despite multiple complaints to nursing management. Review of her shower records for the month showed only three showers provided, with only one documented refusal. A CNA confirmed that there was no dedicated staff for showers and that workload sometimes made it impossible to provide showers as scheduled. Another resident, who was nonverbal and had severe cognitive and physical impairments, also did not receive scheduled showers. The resident's family reported ongoing concerns and filed a grievance regarding missed showers, which was not responded to by facility staff. Documentation showed significant gaps between showers with no refusals recorded. The ADON confirmed that all residents were scheduled for showers twice weekly but could not provide documentation for refusals or postponements for these two residents.
Failure to Monitor and Treat Constipation Resulting in Hospitalization
Penalty
Summary
The facility failed to appropriately monitor and treat constipation for two residents, resulting in significant negative outcomes, including hospitalization for one resident. For one resident with multiple complex medical conditions, including chronic respiratory failure, COPD, tracheostomy, and diabetes, the medical record showed no bowel movement for several consecutive days. Despite the facility's protocol to notify a physician after three days without a bowel movement, there was no evidence that medication was administered until the sixth day, and the Assistant Director of Nursing (ADON) could not explain the delay in intervention. Another resident, who was non-verbal and had severe cognitive impairment, experienced prolonged periods without documented bowel movements, with gaps of up to ten days. The only intervention noted was the administration of a suppository, which was ineffective. The resident was later found unresponsive with signs of vomiting and respiratory distress, requiring emergency intervention and hospitalization. Hospital records indicated the resident suffered an aspiration event, aspiration pneumonia, and abdominal distension related to constipation, with enteral nutrition being altered due to the event. Interviews with facility staff revealed a lack of clear responsibility and follow-through regarding bowel monitoring and intervention. The ADON and Director of Nursing (DON) both indicated that alerts for missed bowel movements could be cleared by nurses without action, and there was no facility policy or procedure for bowel elimination or constipation management. Additionally, a grievance filed by the resident's family regarding constipation concerns was not addressed or documented with findings or actions, and staff interviews suggested that family involvement may have led to missed communication about bowel movements.
Unattended Medication Left in Hallway
Penalty
Summary
A deficiency occurred when medication intended for a resident with multiple diagnoses, including stroke, hypertension, dementia, and prostate cancer, was found unattended in a medication cup on top of an isolation cart outside the resident's room. The unattended medication included several pills and a bottle of nasal spray. At the time of discovery, no staff or residents were present in the vicinity of the medication. The medication was later identified as belonging to the resident, who had moderate cognitive impairment as indicated by a BIMS score of 10 out of 15. Facility policy requires that medications be under the direct observation of the person administering them or locked in a storage area or cart during medication administration. However, the medication was left unattended, in violation of this policy. The resident was later observed in the dining room and could not confirm whether he had received his medication that morning. The incident was confirmed through observation, interview, and record review.
Failure to Administer Medications per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident. The resident, who had a complex medical history including chronic respiratory failure with hypoxia, asthma, tracheostomy status, and spastic quadriplegic cerebral palsy, was observed to have missed multiple scheduled doses of critical medications. Specifically, the resident did not receive the prescribed evening dose of Bactrim DS, an antibiotic ordered for pneumonia, as well as scheduled doses of Olanzapine and Klonopin. The medication administration records and incident reports indicated that although these medications were available in the facility's back-up supply, the nurse did not retrieve them for administration. Progress notes reflected that the pharmacy had been called, but there was no documentation of provider notification or consideration of changes to the medication orders to address the missed doses. The Director of Nursing confirmed that the medications in question were present in the back-up supply and acknowledged that the nurse should have administered them from this supply. The resident's medical record lacked documentation regarding any discussion with the provider about extending or adjusting the medication orders due to the missed doses. The failure to administer these medications as ordered was identified through observation, record review, and staff interview, and was corroborated by facility documentation and the resident's medication administration records.
Failure to Provide Ordered Respiratory Care for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician's orders for a resident with chronic respiratory failure, tracheostomy status, and other significant medical conditions. The resident was nonverbal and had limited ability to communicate or understand. Physician orders and hospital discharge instructions required the resident to receive cough assist therapy three times daily to maintain airway patency and lung inflation. Documentation in the Respiratory Administration Record (RAR) showed that the resident missed multiple scheduled cough assist treatments, with reasons cited including lack of tolerance, refusal, being asleep, or being out of the facility. Observations confirmed the presence of a tracheostomy and cough assist machine in the resident's room. Interviews with respiratory therapy staff revealed inconsistent administration of the ordered therapy, with one therapist unable to recall the last time the treatment was attempted. The records indicated at least 20 missed opportunities for cough assist therapy in one month, and additional missed treatments following the resident's hospital readmission, despite ongoing physician orders for the therapy.
Failure to Implement Pressure Ulcer Prevention and Care Interventions
Penalty
Summary
A resident with significant cognitive impairment and total dependence on staff for activities of daily living was admitted with multiple complex medical conditions, including an anoxic brain injury, respiratory failure with tracheostomy, gastrostomy, and a sacral pressure ulcer. Upon admission, the resident was identified as being at risk for skin impairment, and a care plan was developed that included interventions such as turning and repositioning, use of heel boots, application of barrier cream, and use of a pressure redistribution mattress. Despite these planned interventions, repeated observations showed the resident consistently positioned on their back with their head and neck leaning to the left, left ear pressed against the pillow, and heels directly against the mattress. Documentation and interviews revealed that these interventions were not consistently implemented, as the resident was often found without both heel boots in place and was not regularly turned or repositioned as required. The resident developed new pressure ulcers during their stay, including a deep tissue injury on the right heel and an open area on the left ear, both of which were determined to be facility-acquired. The sacral pressure ulcer also worsened, increasing in size and depth, and was noted to have visible bowel movement in the wound image. There were no treatment orders or interventions in place for the new wounds on the right heel and left ear, and the care plan was not updated to address these new areas of skin breakdown. Family members reported that staff were not responsive to concerns about the resident's wounds and that the resident was rarely turned or repositioned during their visits. Staff interviews confirmed a lack of awareness and follow-through regarding the resident's wound care needs and the absence of required equipment, such as heel boots. Record review further indicated inconsistencies and omissions in documentation, including the lack of initial assessment and documentation of the right heel wound upon admission, despite prior hospital records indicating its presence. The DON and Administrator were unable to provide explanations for the lack of implementation of care plan interventions, the absence of timely wound assessments, and the failure to provide necessary treatments for new pressure ulcers. The facility's failure to operationalize its policies and procedures for pressure ulcer prevention and care, as well as the lack of comprehensive assessment and intervention, directly resulted in the development and worsening of pressure ulcers for this resident.
Plan Of Correction
Element 1: Resident 117 areas to right rear malleolus and left outer ear were assessed by the nurse on 5/9/25 with orders for treatments put in place to include heel boots, low air loss mattress, and care plan updated. Resident 117 was discharged on 05/13/2025. Element 2: A skin sweep of current residents, including current residents admitted since 4/25/25, was completed by the Director of Nursing/Designee by 5/14/25 for any new skin areas or skin areas missed on admission. Any new areas noted were assessed, had treatment orders entered, and care plans updated for interventions to prevent and promote healing of wounds. A one-time audit of current residents with wounds was completed to ensure the wounds have appropriate treatment orders and interventions to prevent and promote healing of wounds, including being turned and repositioned. This was completed by the Director of Nursing/Designee by 5/14/25. A one-time audit of residents' most recent Braden score was completed by the Director of Nursing/Designee by 5/14/25, and anyone with a Braden of 10 or below was placed on the yellow dot program for turning and repositioning. Element 3: The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 5/14/25. The Director of Nursing and/or designee re-educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 5/14/25, with emphasis on turning and repositioning, ensuring wound treatments are being completed, and appropriate interventions are in place to prevent and promote healing of wounds. Also, that all admissions need to have their skin assessed by 2 nurses. Nurse Aides were re-educated on the yellow dot program for turning and repositioning and checking residents' Kardex to ensure interventions are in place. This was completed by Staff Development Coordinator/Designee by 5/14/25. Wounds will be reviewed daily in the morning clinical Monday through Friday to ensure treatments are being completed and weekly in the standard of care meeting to ensure appropriate interventions are in place to prevent and promote wound healing. Admissions will be reviewed daily in the morning clinical Monday through Friday to ensure admission skin assessments are accurate and have been assessed by 2 nurses. Element 4: The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure interventions are in place and treatments are being completed to prevent and promote healing of wounds. The Director of Nursing/designee will audit residents with a Braden of 10 or less and residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure they are being turned and repositioned appropriately to prevent and promote healing of wounds. The Director of Nursing/designee will audit admission skin assessments weekly for 4 weeks, then monthly thereafter, to ensure all skin issues present on admission are documented appropriately and their skin has been assessed by 2 nurses. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.
Failure to Provide Sufficient Nursing Staff Resulting in Unmet Care Needs and Pressure Ulcers
Penalty
Summary
The facility failed to provide sufficient nursing staff with appropriate competencies and skill sets to meet the care needs of residents, particularly those residing on the ventilator and tracheostomy hallways. Staffing records and interviews revealed that, at times, only three CNAs and three RNs were present to care for all residents on these high-acuity units, with most residents requiring two-person assistance for activities of daily living (ADLs). Staff reported working extended shifts, sometimes up to 18 hours, and being unable to take breaks or complete all required care tasks, such as turning and repositioning residents every two hours. Multiple CNAs confirmed that it was not possible to provide all necessary care due to the heavy workload and insufficient staffing levels. Several residents experienced negative outcomes as a result of inadequate staffing. One resident, who was dependent on staff for all ADLs and assessed as a fall risk, suffered an unwitnessed fall after attempting to get out of bed when incontinent, as they were unable to use the call light and staff could not provide timely assistance. Another resident, also fully dependent and rarely understood, was observed multiple times in the same position in bed and developed a stage 4 pressure ulcer that worsened during their stay. Staff interviews confirmed that residents were not being turned and repositioned as required, and necessary equipment such as heel boots was not consistently available or used. A third resident, admitted with a stage 3 sacral pressure ulcer, developed additional facility-acquired pressure ulcers, including a deep tissue injury on the heel and a pressure ulcer on the ear. Observations and interviews with family and staff indicated that this resident was not being turned or repositioned regularly, and care plan interventions such as the use of heel boots and pressure-relieving mattresses were not consistently implemented. The DON and Administrator acknowledged the worsening of wounds and the lack of consistent interventions but did not provide explanations for the failures. Staff repeatedly stated that the high acuity and total care needs of residents, combined with insufficient staffing, made it impossible to meet required care standards.
Plan Of Correction
Element 1: The facility assessment has been updated by 5/14/25 and reviewed by the QAPI Committee to ensure staffing levels are appropriate to meet the current resident population needs. Current residents with a BIMS of 9 or above and responsible parties for residents with a BIMS of 8 or below were interviewed for any negative outcomes related to needs not being met by the Director of Nursing/Designee by 5/14/25. Residents' concerns were placed on a Quality Assurance form and ran through the Quality Assurance process by 5/14/25. Element 2: Current residents and/or responsible parties have been interviewed to ensure that their needs are being met by the Director of Nursing and/or designee by 5/14/25. Any concerns identified have been addressed immediately. Element 3: The QAPI Committee reviewed the policy, Nursing Services and Sufficient Staff, and deemed it appropriate by 5/14/25. The Regional Director of Operations has re-educated the Administrator, Director of Nursing, and the Scheduler on the Nursing Services and Sufficient Staff Policy, including sufficient staff resident needs. This education will be completed by 5/14/25. During the morning stand-up meeting and as needed, staffing will be reviewed to ensure supervision. Adjustments will be made as needed. Element 4: A weekly audit of 10 residents will be conducted by the Administrator and/or designee to ensure needs are being met timely for 4 weeks and then monthly thereafter until substantial compliance is sustained. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.
Failure to Prevent and Treat Pressure Ulcers Resulting in Worsening Wounds and Hospitalization
Penalty
Summary
The facility failed to provide adequate care and services to prevent and promote healing of pressure ulcers for three residents, resulting in worsening wounds, infections, and hospitalizations. All three residents were dependent on staff for all care and were identified as high risk for skin breakdown. The facility did not consistently implement or document required interventions such as turning and repositioning, and there were multiple missed wound treatments as evidenced by gaps in the Treatment Administration Record (TAR) and CNA task documentation. For example, one resident had 42 eight-hour shifts without documented turning and repositioning, and 20 missed wound treatments for facility-acquired pressure wounds. Another resident had 23 eight-hour shifts without documented repositioning and four missed wound treatments for a worsening coccyx pressure wound. A third resident had 37 eight-hour shifts without documented repositioning and 21 missed wound treatments for pressure wounds, with incomplete turning logs maintained by family members as further evidence of lapses in care. The residents involved had significant medical histories, including traumatic brain injury, cerebral vascular accident, acute respiratory failure, and comatose states, making them highly susceptible to pressure injuries. Despite care plans and physician orders specifying frequent turning, repositioning, and wound care, these interventions were not reliably carried out or documented. Wound assessments showed progression of pressure ulcers from initial stages to unstageable or stage 4, with some wounds developing slough, odor, and signs of infection. In several cases, the wounds deteriorated to the point of requiring hospital transfer for advanced wound management, debridement, and treatment of sepsis or osteomyelitis. Interviews with staff confirmed that documentation was incomplete and that staffing shortages contributed to the inability to provide required care. Unit managers and wound nurses acknowledged that there were holes in the TAR and CNA documentation, and that some wound treatments were not recorded as completed. Staff also reported that, at times, there were not enough CNAs to turn residents every two hours as required by care plans. There was no evidence provided by the facility to demonstrate that the worsening or facility-acquired pressure ulcers were unavoidable, despite the presence of appropriate interventions in the care plans.
Plan Of Correction
Element 1 Resident 105 no longer resides in the facility and was discharged to the hospital on 3/26/25. Resident 106 no longer resides in the facility and was discharged to the hospital on 4/1/25. Resident 111 continues to reside in the facility. Her wounds, treatment orders, and care plans were reviewed by the Director of Nursing, Wound Nurse, and wound care provider by 4/25/25 and deemed to be appropriate. An unavoidable assessment was completed due to the resident's wound being expected to decline on admission due to comorbidities and assessment of periwound. Element 2 A skin sweep of current residents was completed by the Director of Nursing/Designee by 4/25/25 for any new skin areas. Any new areas noted were assessed, had treatment orders entered, and care plans updated for interventions to prevent and promote healing of wounds. A one-time audit of current residents with wounds was completed to ensure the wounds have appropriate treatment orders and interventions to prevent and promote healing of wounds. This was completed by the Director of Nursing/Designee by 4/25/25. A one-time audit of residents' most recent Braden score was completed, and anyone with a Braden score of 10 or below was placed on the yellow dot program for turning and repositioning. Element 3 The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 4/25/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 4/25/25, with emphasis on the yellow dot program for turning and repositioning, ensuring wound treatments are being completed, and appropriate interventions are in place to prevent and promote healing of wounds. Nurse Aides were educated on the yellow dot program for turning and repositioning and checking the resident kardex to ensure interventions are in place. This was completed by the Staff Development Coordinator/Designee by 4/25/25. Wounds will be reviewed daily in the morning clinical Monday through Friday to ensure treatments are being completed and weekly in the standard of care meeting to ensure appropriate interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure interventions are in place and treatments are being completed to prevent and promote healing of wounds. The Director of Nursing/designee will audit residents with a Braden score of 10 or less weekly for 4 weeks, then monthly thereafter, to ensure they are being turned and repositioned appropriately to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.
Failure to Provide Required ADL Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary Activities of Daily Living (ADL) care, including bathing, showering, oral care, grooming, and repositioning, for four dependent residents. Documentation and interviews revealed that multiple residents missed several showers, with some going up to 20 days without bathing or showering. Oral care was also frequently omitted, with one resident missing oral care on 51 shifts. In addition, required turning and repositioning for pressure wound prevention was not consistently performed, as evidenced by 42 eight-hour shifts without documentation of this care for a dependent resident. Residents affected had significant medical needs, including traumatic brain dysfunction, cerebral vascular accident, partial paralysis, and dependence on staff for all or most ADLs. One resident with a tracheostomy and contractures was not turned or repositioned as required, and another resident with dentures did not have oral care addressed in their care plan. Documentation reports and care plans confirmed these omissions, and interviews with residents and staff corroborated the lack of consistent ADL care, citing missed showers, oral care, and incontinence care. Staff interviews and grievance forms indicated that chronic understaffing contributed to the deficiencies, with reports of only three to four CNAs on certain shifts, including on units with high-acuity residents. Staff described being unable to meet basic care needs, such as incontinence care and repositioning, at the required frequency. Residents and staff reported submitting grievances and concern forms regarding missed care and staffing shortages, with some improvement only noted in the two weeks prior to the survey.
Plan Of Correction
Element 1 Resident 103 no longer resides in the facility. Resident was discharged home on 3/24/2025. Resident 104 no longer resides in the facility. Resident 104 discharged home on 3/27/2025. Resident 106 no longer resides in the facility. Resident 106 discharged to the hospital on 4/1/2025. Resident 110 continues to reside in the facility. Resident was offered a shower and ADL's including oral care was completed by 4/25/2025. Element 2A A one-time audit of the last 3 days of current residents was conducted to verify that they have received or been offered a shower/bed bath. If a shower/bed bath had not been offered at time of audit, it would be immediately offered and given or documented if refused. This was completed by the Director of Nursing/Designee by 4/25/25. A one-time audit of current residents was conducted to ensure residents received ADL care including oral care by 4/25/25. Anyone that had not received ADL care including oral care was immediately completed and documented on by 4/25/25. This was completed by the Director of Nursing/Designee. Element 3 The QAPI Committee reviewed the policy, Activities of Daily Living and deemed it appropriate by 4/25/25. The Director of Nursing has re-educated the certified nursing assistants and the licensed nurses on the Activities of Daily Living policy with emphasis to showers and ensuring residents are being offered and given showers on their shower days and completing and documenting ADL care including oral care every shift. This education will be completed by 4/25/25. Element 4 The Director of Nursing or Designee will conduct random audits weekly for four weeks and then monthly thereafter until substantial compliance is sustained, to verify that showers/bed baths and ADL care including oral care is being offered, given and/or documented if refused. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.
Deficiency Due to Insufficient Nursing Staff Levels
Penalty
Summary
The facility failed to ensure sufficient nursing staff with appropriate competencies and skill sets to meet the needs of its residents, as evidenced by multiple observations, interviews, and record reviews. The census was reported at 69, with a significant portion of residents dependent on staff for care, including a ventilator unit. Several complaints were received by the State Agency alleging insufficient staffing, which resulted in unmet care needs such as failure to prevent worsening of pressure ulcers and avoidable falls with injury. The CMS PBJ Staffing Report also indicated excessively low weekend staffing. Specific resident cases highlighted the impact of insufficient staffing. One resident, with a history of hip fracture and high fall risk, suffered a fall resulting in rib fractures. Staff reported that necessary safety equipment, such as positioning wedges, was not in place at the time of the fall, and the resident's wife had to remain at the bedside due to concerns for safety and confusion. Another resident, dependent on staff for all care, experienced worsening and new pressure ulcers, with documentation showing missed wound treatments and incomplete turning and repositioning logs. Additional residents experienced missed showers, oral care, and repositioning, with documentation reflecting numerous shifts where required care was not provided or not documented as completed. Interviews with staff, residents, and family members consistently reported ongoing staffing shortages, particularly on second and third shifts, leading to basic care needs not being met. Staff described being unable to provide care as frequently as required, with restorative staff being pulled to cover floor duties and managers picking up shifts to meet minimum requirements. Resident council and grievance forms further corroborated concerns about missed care and insufficient staffing, with reports of residents being left in soiled conditions and not receiving scheduled showers or repositioning.
Plan Of Correction
Element 1: The facility assessment has been updated by 4/25/25 and reviewed by the QAPI Committee to ensure staffing levels are appropriate to meet the current resident population needs. Current residents with a BIMS of 9 or above and responsible parties for residents with a BIMS of 8 or below were interviewed for any negative outcomes related to delay in call light response time by the Director of Nursing/Designee by 4/25/25 and did not have any negative outcomes. Residents’ concerns were placed on a Quality Assurance form and ran through the Quality Assurance process by 4/25/25. Element 2: Current residents and/or responsible parties have been interviewed to ensure that their needs are being met by the Director of Nursing and/or designee by 4/25/25. Any concerns identified have been addressed immediately. Element 3: The QAPI Committee reviewed the policy, Nursing Services and Sufficient Staff, and deemed it appropriate by 4/25/25. The Regional Director of Operations has re-educated the Administrator, Director of Nursing, and the Scheduler on the Nursing Services and Sufficient Staff Policy, including staffing to meet resident needs. This education will be completed by 4/25/25. During the morning stand-up meeting and as needed, staffing will be reviewed to ensure supervision. Adjustments will be made as needed. Element 4: A weekly audit of 10 residents will be conducted by the Administrator and/or designee to ensure needs are being met timely for 4 weeks and then monthly thereafter until substantial compliance is sustained. Audits will be reviewed by the QAPI committee monthly for 3 months until substantial compliance is met. The Administrator is responsible to maintain compliance.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and implement care planned interventions for a resident with a known high risk for falls. The resident, an 82-year-old male with a recent left hip fracture, post-surgical revision, and multiple comorbidities including peripheral vascular disease, hypertension, diabetes, and anemia, was admitted to the facility. The resident's care plan included specific fall prevention interventions such as a low bed, floor mat, non-skid footwear, and placement of wedges at the right shoulder and knee when resting in bed. Despite these interventions being documented, they were not in place at the time of the incident. On the day of the incident, the resident experienced an unwitnessed fall from bed. Staff interviews and documentation revealed that the positioning wedges were not in use and were found on a chair or nightstand, the floor mat was not in place, and the bed was not at its lowest position. The resident was found on the floor, confused, with bleeding from the surgical incision and signs of injury. Staff confirmed that the care planned interventions were not followed, and the resident's confusion and restlessness were known risk factors that had been communicated to the facility by the family. Following the fall, the resident required emergency room treatment and hospital admission, where additional injuries including rib and pelvic fractures were identified. The failure to implement and maintain the prescribed fall prevention measures directly contributed to the resident's fall and subsequent injuries. Staff interviews confirmed a lack of adherence to the care plan and an inability to provide one-on-one supervision despite the resident's high risk status and family concerns.
Plan Of Correction
Element 1: Resident 102 no longer resides in the facility. Resident was discharged to the hospital on 12/15/25. Element 2: A one-time audit of current residents' fall interventions was completed by the Director of Nursing / Designee by 4/25/25 to ensure fall interventions are in place and reflect residents' current needs. Element 3: The QAPI Committee reviewed the Falls Clinical Protocol policy and deemed it appropriate by 4/25/25. The Director of Nursing and/or designee educated the Nurses and C.N.As on the Falls Clinical Protocol policy, with an emphasis on ensuring interventions are in place and that the interventions are noted on the incident reports. This education will be completed by 4/25/25. Element 4: The Director of Nursing/designee will audit 10 residents to ensure fall interventions are in place and will audit residents with falls to ensure that fall interventions in place at the time of the fall were documented on the incident report and that the care plan is updated with new interventions. These audits will be conducted weekly for 4 weeks, then monthly thereafter. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible for maintaining compliance.
Failure to Implement Comprehensive Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure a comprehensive care plan was in place and properly executed for a resident, leading to the development and worsening of pressure ulcers. The resident, who was admitted with diagnoses including knee contractures, was observed without offloading boots, which were supposed to be on at all times as per the care plan. The boots were found on the floor, and staff members were unclear about their responsibility for ensuring the boots were worn, leading to the resident's feet resting directly on the mattress. The resident was observed to have a pressure ulcer on the left trochanter and a coccyx pressure ulcer, both of which were not properly documented or staged in the care plan. The left foot was initially documented as a hematoma but was later identified as a deep tissue injury (DTI). The care plan did not include updated interventions for the pressure ulcers, and there was no evidence of a root cause analysis or interdisciplinary team meetings to address the skin breakdown. Interviews with staff, including CNAs, a COTA, an LPN, and the wound nurse, revealed a lack of clarity and communication regarding the care plan and interventions for the resident's pressure ulcers. The Director of Nursing confirmed that the resident's Kardex indicated the need for offloading boots at all times, but this was not consistently followed. The facility's failure to implement and revise the care plan contributed to the resident's pressure ulcers not being properly managed or prevented.
Plan Of Correction
Element 1 Resident 7 continues to reside in the facility. The skin care plan was reviewed and updated to include the correct classification and staging of current wounds and include appropriate interventions to prevent and promote healing of wounds by the Director of Nursing/Designee by 3/14/25. Element 2 A one-time audit of current residents with wounds was completed to ensure their skin care plans have the correct classification and staging of current wounds and they include appropriate interventions to prevent and promote healing of wounds. This was completed by the Director of Nursing/Designee by 3/14/25. Element 3 The QAPI Committee has reviewed the Comprehensive Care Plan policy and has deemed it to be appropriate by 3/14/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Comprehensive Care Plan policy by 3/14/25 with emphasis on ensuring skin care plans have correct classification and staging of wounds and that they include appropriate interventions to prevent and promote healing of wounds. Nurse Aides were educated on checking resident kardex s and ensuring interventions are in place. This was completed by the Staff Development Coordinator/Designee by 3/14/25. Wounds will be reviewed weekly in standard of care meeting to ensure wounds are classified and staged correctly and interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit Skin care plans of residents with wounds weekly x4 weeks then monthly thereafter to ensure wounds are classified and staged correctly and interventions are in place to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible to maintain compliance.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and services to prevent and promote the healing of pressure ulcers for one resident, resulting in worsening wounds. The resident, who was admitted with diagnoses including knee contractures, was observed without offloading boots, which were supposed to be on at all times as per the care plan. The boots were found on the floor, and staff members, including CNAs and a COTA, were unclear about their responsibility to ensure the boots were worn. Observations revealed pressure ulcers on the resident's left trochanter and coccyx, with the resident's feet resting directly on the mattress without pressure relief. The resident's care plan indicated the need for padded boots to be worn at all times, but this intervention was not consistently implemented. Interviews with staff, including CNAs, LPNs, and the wound nurse, revealed a lack of clarity and communication regarding the responsibility for ensuring the boots were worn. The wound nurse acknowledged that the resident's left foot wound was misidentified as a hematoma instead of a deep tissue injury, and the left trochanter wound was incorrectly documented as a blister rather than an unstageable pressure ulcer. The facility's failure to conduct a root cause analysis or hold care conferences to address the resident's pressure ulcers further contributed to the deficiency. The resident's coccyx pressure ulcer, initially documented as a stage 4, worsened over time, with increased drainage and slough covering the wound bed, rendering it unstageable. The Director of Nursing confirmed that the resident's care plan required the boots to be worn at all times, but this was not effectively communicated or enforced among the staff.
Plan Of Correction
Element 1 Resident 7 wounds were reviewed by the Director of Nursing, Wound Nurse, and wound care provider by 3/14/25, and it was determined reclassification of wounds was appropriate. The Coccyx Wound was reassessed on 3/13/25 by the wound care provider and determined that the wound needed to be reclassified again back to a stage 4 due to the resolving of slough in the wound bed from the previous week. Skin/Wound evaluations and care plans were updated to reflect the correct classification and staging of current wounds and include appropriate interventions to prevent and promote healing of wounds. Element 2 A one-time audit of current residents with wounds was completed to ensure the wounds are classified and staged correctly, and the care plans are updated and include appropriate interventions to prevent and promote healing of wounds. Any wounds not classified correctly were immediately reclassified and care plans updated. This was completed by the Director of Nursing/Designee by 3/14/25. Element 3 The QAPI Committee has reviewed the Pressure Ulcer Prevention and Management policy and has deemed it to be appropriate by 3/14/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Pressure Ulcer Prevention and Management policy by 3/14/25, with emphasis on correct classification and staging of wounds and ensuring that the care plans are updated and include appropriate interventions to prevent and promote healing of wounds. Nurse Aides were educated on checking resident kardexes and ensuring interventions are in place. This was completed by the Staff Development Coordinator/Designee by 3/14/25. Wounds will be reviewed weekly in the standard of care meeting to ensure wounds are classified and staged correctly, care plans are updated, and appropriate interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit residents with wounds weekly for 4 weeks, then monthly thereafter, to ensure wounds are classified and staged correctly, care plans are updated, and interventions are in place to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible to maintain compliance.
Inadequate Infection Control Surveillance
Penalty
Summary
The facility failed to ensure proper infection control surveillance for all 62 residents, as it was not monitored, mapped, and documented monthly. The deficiency was identified when the facility was unable to provide complete infection control line listings and color-coded maps for the months of August through December 2024. Specifically, only the line listings for August, September, and October 2024 were available, and only the map for September 2024 was provided. During interviews, it was revealed that no nurse had been performing the duties of the infection control program since November 1st, 2024, due to the absence of the Infection Control Preventionist (ICP). The Director of Nursing (DON) and Assistant Director of Nursing (ADON) admitted that no staff was monitoring the infection control program, and they only reviewed new antibiotic orders during morning meetings without tracking infection clusters. Consequently, there was no infection control monitoring for November 2024.
Failure to Implement Adequate Care Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop and implement a person-centered baseline care plan for a resident admitted for a 10-day respite stay. Upon admission, the resident was assessed as a high risk for falls due to various factors, including altered perception, disorganized speech, restlessness, and the use of multiple medications. Despite these identified risks, the care plan only included general interventions such as educating the resident on safety, encouraging the use of a call light, and ensuring the room was free from hazards. However, these interventions were not adequately tailored to address the resident's specific needs, such as wandering, confusion, and improper footwear. The resident experienced a fall on 8/21/2024, which highlighted the inadequacy of the care plan. The interdisciplinary team updated the care plan five days later, but the revisions were insufficient as they did not address the resident's wandering, confusion, or need for proper footwear. Subsequently, the resident had another fall on 8/28/2024, resulting in a hospital transfer due to hip pain. Interviews with facility staff revealed that the resident required close supervision and should have been kept in view in common areas, but these needs were not reflected in the care plan or Kardex, contributing to the resident's falls and injuries.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for three residents. For Resident #36, the MDS indicated that the resident received insulin injections during the seven-day look-back period, but a review of the medical record revealed that the resident did not receive insulin during that time. This discrepancy was confirmed by the Regional Director of Assessment Coordination. For Resident #59, the quarterly MDS did not reflect a significant weight loss of 5.8% in one month, despite a Nutrition Evaluation indicating this weight loss. The Regional Director of Assessment Coordination noted that the medical record's weights and vital signs section would show triggers for weight loss. Additionally, Resident #68's MDS inaccurately documented a discharge to a short-term hospital, while a progress note indicated the resident was discharged home with family. The Nursing Home Administrator confirmed the resident was discharged home.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans for three residents, resulting in potential unmet care needs. Resident #22 was admitted with major depressive disorder and moderate protein calorie malnutrition. Despite a physician's order for a mechanical soft diet with double portions, observations revealed that the resident's meals were not being consumed, and the registered dietician confirmed that the resident should have received double portions, which were not provided. Resident #28, diagnosed with end-stage renal disease and gastroparesis, was observed to have meals lacking the ordered double protein portions and butter/margarine packets, which were necessary due to his increased needs from dialysis. The resident reported weight loss and frequent nausea and vomiting, and the registered dietician confirmed the dietary orders were not being followed, as the resident's meal trays did not include the required items. Resident #4, with a history of dementia, schizophrenia, and a stage 4 pressure ulcer, was found to have a non-functioning air mattress, which was a critical intervention for her wound care. Despite documentation indicating the mattress was functioning, observations and interviews revealed it was not operational, contributing to the resident's reported pain and potential decline in wound healing. The unit manager confirmed the malfunction and replaced the pump only after the surveyor's inquiry, highlighting a lapse in the implementation of care plan interventions.
Delayed Urinalysis Collection for Resident
Penalty
Summary
The facility failed to ensure the timely collection of an ordered urinalysis for a resident with diagnoses including diabetes and chronic kidney disease. The resident, who was cognitively intact, reported symptoms of cloudy urine and burning with urination on a Monday. A Nurse Practitioner noted the need for a urinalysis, complete blood count, and basic metabolic panel on the following Wednesday. However, the urinalysis result was rejected due to 'Supplies Unavailable,' and the laboratory did not receive the urine sample until the following Sunday night. During interviews, a registered nurse was unsure of the meaning behind the 'Supplies Unavailable' note, and a laboratory representative confirmed the delay in receiving the urine sample. The resident's urinalysis was eventually sent for further testing due to the presence of leukocytes. This delay in collecting and processing the urinalysis represents a deficiency in providing timely care according to the resident's needs and medical orders.
Failure to Ensure Functioning Pressure Relief Equipment
Penalty
Summary
The facility failed to implement necessary interventions to promote the healing of a pressure ulcer and prevent its worsening for a resident. The resident, a cognitively intact female with multiple diagnoses including a stage 4 pressure ulcer, was observed with a non-functioning air mattress, which was supposed to be a part of her care plan to relieve pressure and aid in wound healing. Despite the care plan requiring the air mattress to be checked each shift, the nursing staff documented that it was functioning even when it was not, as observed by the surveyor over three shifts. The resident reported significant pain associated with the pressure ulcer, and the wound was noted to have worsened slightly over a week. The air mattress pump was found to be non-functional, and the issue was only addressed after the surveyor's inquiry. The facility's staff, including the LPN and Unit Manager, confirmed the malfunction and took steps to replace the pump. However, the failure to ensure the air mattress was functioning as intended contributed to the deficiency in care provided to the resident.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for oxygen for a resident, identified as R4, who was observed using oxygen therapy without a documented order. R4, a female resident with a history of respiratory failure, dementia, schizophrenia, cardiac disease, hypertension, kidney disease, stage 4 pressure ulcer, anxiety, and depression, was admitted to the facility and most recently readmitted on 10/15/24. During observations on 10/27/24 and 10/28/24, R4 was seen using a nasal cannula connected to an oxygen concentrator set at 4 liters, without humidified air, and reported discomfort due to dryness. A review of R4's physician orders from 10/15/24 to 10/29/24 showed no evidence of an order for oxygen therapy. Interviews with facility staff, including the Nursing Home Administrator, Registered Nurse, Unit Manager, and Director of Nursing, confirmed the expectation that residents using oxygen should have a physician's order. The Nursing Home Administrator acknowledged the lack of an order for R4 and indicated that the issue would be addressed. The Unit Manager, who had been in the position for only two weeks, was expected to ensure all orders were correctly transcribed following hospital readmissions, but this oversight occurred.
Verbal Abuse Incident by RN
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by staff. The incident involved a resident with severe cognitive impairment, who was able to make herself understood and comprehend others. The resident had a history of cerebral infarction, major depressive disorder, and anxiety disorder. On the day of the incident, a Registered Nurse (RN) was reported to have yelled at the resident and blamed her for an ostomy bag that had come off. The RN allegedly grabbed the resident's arm forcefully, causing the resident to cry. A Certified Nurse Assistant (CNA) who witnessed the incident reported it to the Social Worker (SW), who confirmed the resident's account through limited communication. The RN involved in the incident was interviewed and acknowledged being in the room with the resident and the CNA but denied yelling, stating instead that she was firm with the resident. The CNA, however, provided a detailed account of the RN's actions, including yelling and blaming the resident. The SW corroborated the CNA's report by confirming the resident's non-verbal affirmation of the incident. The facility substantiated the abuse claim and terminated the RN's employment following the investigation.
Failure to Notify Physician of Unfulfilled ER Transfer Order
Penalty
Summary
The facility failed to notify the physician of a change in treatment orders when a resident, who was suspected to have a femoral artery bleed, was not transferred to the emergency room as ordered. The resident, who was cognitively intact and responsible for their own care, was admitted with diagnoses including respiratory failure, tracheostomy status, and severe obesity. On the day of the incident, the nurse observed profuse bleeding from the resident's lower right abdomen and a large blood clot, prompting a physician's order for the resident to be sent to the ER. However, the EMS was unable to transport the resident due to weight limitations, and an alternate ambulance service could not transfer the resident until later. Despite the situation, the Assistant Director of Nursing did not inform the physician that the resident was not transported to the hospital as initially ordered. The medical record did not reflect any notification to the physician about the failure to transfer the resident, and the physician confirmed that they were not made aware of the situation beyond the initial call about the bleeding.
Failure to Monitor and Transfer Resident with Hemorrhage
Penalty
Summary
The facility failed to routinely assess and monitor a change in condition for a resident who was admitted with diagnoses including respiratory failure, tracheostomy status, and morbid obesity. The resident experienced a suspected femoral artery bleed, which was documented in an SBAR on 6/8/24. The nurse observed profuse bleeding and a large blood clot in the resident's abdominal fold, and the physician ordered the resident to be sent to the emergency room. However, due to the resident's weight, EMS was unable to transport him, and an alternate ambulance service was not available until later in the afternoon. Despite the physician's order for hospital transfer, the resident remained in the facility without further orders for treatment, assessment, or monitoring of his condition. The medical record did not reflect that the physician was notified of the failed transfer. The resident's condition worsened, and he began hemorrhaging again early on 6/9/24. Staff frequently checked for bleeding and changed towels, but the resident's blood pressure continued to drop, indicating a lack of adequate monitoring and intervention. The resident's medical record showed a significant drop in blood pressure from 117/70 mmHg on 6/8/24 to 70/42 mmHg on 6/9/24, with corresponding changes in pulse rate. EMS was eventually able to transport the resident to the hospital using a flatbed truck, but the delay and lack of appropriate monitoring and intervention contributed to the deficiency. The physician later stated that if she had been informed of the situation, she would have expected more frequent monitoring of vital signs.
Inconsistent Treatment Orders for Pressure Ulcer
Penalty
Summary
The facility failed to ensure appropriate treatment orders for a resident with a facility-acquired pressure ulcer on the sacrum. The resident, who had a history of cardiac arrest, respiratory arrest, and anoxic brain damage, developed an unstageable pressure ulcer characterized by slough and granulation tissue. Over the course of several weeks, the ulcer increased in size, and the treatment orders were inconsistent and overlapping. Initially, the treatment involved cleansing the wound, applying collagen, and covering it with hydrofera blue and bordered foam, to be changed every other night. Subsequent orders introduced different treatments, including Dermasyn AG and Medihoney, which were to be applied daily at bedtime. These orders ran concurrently with the original treatment plan, leading to confusion and improper application of treatments. The Director of Nursing acknowledged that the staff was applying treatments incorrectly, with hydrofera being used on an old wound and collagen and Medihoney on the new sacral wound. This inconsistency in treatment orders and application contributed to the deficiency identified during the survey.
Failure to Prevent Medical Device-Related Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a medical device-related pressure ulcer for a resident, resulting in a deep tissue injury (DTI). The resident was readmitted with multiple diagnoses, including acute respiratory failure and protein-calorie malnutrition, and was dependent on all care. The resident had an indwelling catheter and was at risk for developing pressure injuries but was not on a turning/repositioning program. Initial assessments noted several stage 1 pressure injuries and a bruise on the left buttock, which was later identified as a DTI related to the catheter tubing placement. Observations and interviews revealed that the resident was frequently repositioned due to incontinence and existing wounds. However, the catheter tubing was not properly managed, leading to pressure on the left buttock. The wound nurse and DON assessed the area and initially documented it as a bruise. Despite staff education on proper catheter placement, the area worsened, opening and presenting with deep reddish/purple discoloration. The wound nurse updated the physician and received treatment orders, but the wound continued to deteriorate. Further assessments and interdisciplinary team discussions led to the reclassification of the wound as a DTI. The facility's wound management program included weekly assessments and staff education, but the improper management of the catheter tubing resulted in the development of the pressure ulcer. The resident's care plan was updated to reflect the new wound classification, and the facility continued to monitor and treat the wound.
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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
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