Medilodge Of Gaylord
Inspection history, citations, penalties and survey trends for this long-term care facility in Gaylord, Michigan.
- Location
- 508 Random Lake, Gaylord, Michigan 49735
- CMS Provider Number
- 235350
- Inspections on file
- 21
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Medilodge Of Gaylord during CMS and state inspections, most recent first.
A resident with chronic conjunctivitis and MRSA in the left eye experienced months of worsening symptoms, including redness, purulent drainage, pain, crusting, and swelling, while the facility failed to act on a provider’s ophthalmology referral and did not timely schedule a specialty eye appointment. A provider documented a referral for ophthalmology after minimal response to treatment, but no corresponding order appeared in the EMR, and the former scheduler reported likely never being informed of it amid ongoing issues with missed orders. Nursing notes over subsequent months repeatedly described persistent and escalating signs of infection, yet an ophthalmology appointment was not ordered "ASAP" until much later, and the eye clinic confirmed the first contact from the facility occurred only shortly before the resident was finally sent by EMS. By the time the resident was evaluated, outside providers documented a months-long history of worsening eye infection and diagnosed severe ocular infection with sepsis, and later observations still showed left eye swelling and blurred vision.
A resident on hospice with lung cancer, COPD, vertebral fracture, and post-laminectomy syndrome became unable to eat, drink, or swallow, yet continued to receive lorazepam oral tablets as documented on the MAR. After an episode where the resident reportedly choked when a tablet was given with water, nursing staff began dissolving lorazepam tablets into atropine solution without a corresponding provider order to change the medication form. An RN stated this was customary practice for end-of-life care, while the consulting pharmacist reported that dissolving a tablet into another medication’s solution is not standard practice and that a liquid lorazepam formulation exists. The DON referenced supposed standing orders allowing medications to be crushed and dissolved, but later the DON and NHA acknowledged that no such standing orders policy existed.
A resident admitted with lung cancer, vertebral fracture, post-laminectomy syndrome, COPD, and urinary retention did not receive multiple first doses of ordered medications for pain, BPH, nausea/vomiting, and airway patency because the drugs were documented as "on order" and not yet available. A complainant reported the resident waited a significant time for physician orders and missed initial doses. The DON acknowledged that delays in prescriptions and limited back-up stock could lead to missed doses and that discharge orders were not always available before arrival, despite policies requiring immediate-care medication orders and timely pharmacy services with 24/7 emergency coverage.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility failed to properly store and dispose of expired medications and did not maintain accurate temperature logs for the medication refrigerator. Observations revealed expired supplements, improperly dated vaccines, and medication carts with undated insulin pens and inhalers. An unlocked medication cart was found unattended with loose pills and an unidentified pill container. Staff interviews indicated a lack of awareness and adherence to medication storage policies.
The facility failed to implement an effective IPCP, lacking a designated IP and relying on external personnel for infection control. The MDS nurse, RN D, was unable to provide comprehensive information about infection tracking and monitoring. Specific cases, such as a resident with a persistent respiratory infection and two residents testing positive for COVID-19, highlighted the deficiencies. Additionally, infection control policies were not updated annually, and the DON acknowledged the problem.
The facility did not employ a qualified Infection Preventionist (IP) to manage the Infection Prevention and Control Program (IPCP). The DON admitted that infection control was managed by someone from another building, and RN D, the MDS nurse, lacked training and knowledge about infection control policies. The facility's policy required a qualified IP to coordinate and manage the IPCP onsite.
The facility failed to provide written transfer notifications to residents, their representatives, and the LTC Ombudsman for four residents transferred to the hospital. The medical records lacked documentation of the required notifications, and the binder meant to hold these notices was empty for two months. Administrative staff confirmed the inconsistency in receiving necessary information from nursing staff, leading to the deficiency.
The facility failed to provide written notice of the bed hold policy to four residents or their representatives during hospital transfers. Medical records lacked documentation of the policy issuance, and Administrative Staff F confirmed inconsistencies in maintaining notifications. The facility's policy required timely notification, which was not adhered to in these cases.
A facility failed to maintain resident privacy by leaving a medical cart computer open, displaying a resident's Physician Orders, and a visible 'Controlled Substance Log'. This breach was confirmed by the DON, who stated that the information should have been securely locked and closed.
A resident with severe cognitive impairment and incontinence was not provided appropriate care for Moisture Associated Skin Damage (MASD) as per professional standards. The resident was found soaked in urine and had scratched herself, leading to blood under her fingernails. The facility staff failed to document check and change procedures consistently, and record sheets were improperly shredded, contrary to the facility's policy.
The facility failed to provide proper respiratory care for three residents by not following physician orders and infection control protocols. A resident had a nasal cannula that was not changed weekly, and incorrect oxygen settings were noted on a Bipap machine. Another resident's nasal cannula was undated, and there were no clear parameters for oxygen flow rate. Additionally, respiratory equipment for a third resident was improperly stored and undated. The DON admitted to not being trained on proper procedures, and facility policies were not adhered to.
The facility failed to manage medications properly for two residents, leading to deficiencies in administration and documentation. A resident received Lorazepam after discontinuation, with discrepancies in the eMAR and controlled substance log. Another resident's Alprazolam lacked a required stop date. The DON confirmed that discontinued medications should be removed promptly, and medications should not be dispensed without a physician's order.
A facility failed to document non-pharmacological interventions before administering PRN anxiolytics to a resident with dementia, administered an antipsychotic without a documented indication, and did not consider a GDR for an antidepressant. The DON confirmed the lack of documentation, and the NHA acknowledged the absence of a GDR, contrary to facility policy.
A facility failed to maintain accurate wound documentation for a resident with skin failure, leading to inconsistencies in the classification and staging of wounds. Staff interviews revealed that management instructed the wound care nurse to classify pressure injuries as 'Other' due to the resident's diagnosis, resulting in potential ineffective treatment plans. The MDS Coordinator confirmed that comprehensive assessments relied on EMR documentation, which inaccurately reflected the resident's condition.
The facility did not post daily nurse staffing information, as required, leading to outdated information being displayed. The Staffing Coordinator was absent, and nursing staff were responsible for posting but did not do so due to confusion with the form. The NHA was aware of the requirement but noted the form's lack of user-friendliness.
Two residents with cardiac and respiratory conditions did not receive timely and comprehensive assessments at an LTC facility. One resident, post-heart surgery, lacked vital sign monitoring upon admission and experienced a decline, leading to death. Another resident with chronic heart issues had delayed cardiac evaluations and insufficient monitoring for orthostatic hypotension, resulting in multiple falls and eventual death. Staffing shortages and incomplete documentation contributed to these deficiencies.
Failure to Act on Ophthalmology Referral and Coordinate Timely Eye Care
Penalty
Summary
The deficiency involves the facility’s failure to act upon a provider’s ophthalmology referral and to timely coordinate specialty eye care for one resident with a chronic and worsening left eye infection. The resident had a history of schizoaffective disorder, morbid obesity, and prior stroke, with moderately impaired decision-making requiring cues and supervision. In early April 2025, a physician documented bilateral eye irritation and redness consistent with conjunctivitis. On 5/13/2025, an NP/PA documented chronic conjunctivitis and ordered a culture of the left eye drainage before starting antibiotics. A physician order dated 5/17/2025 directed staff to obtain the left eye drainage culture that day, and the 5/22/2025 bacteriology report showed 3+ MRSA in the eye culture. On 6/26/2025, a physician progress note documented continued management of conjunctivitis with recent treatment having no to minimal effect and indicated that new orders and an ophthalmology referral were given. However, review of the EMR showed no corresponding physician order for an ophthalmology referral at that time. The facility’s own staff later acknowledged that the 6/26/2025 referral was not found in the EMR and that there had been an ongoing issue with missed orders around that period. The former scheduler stated he likely was not informed of the June referral, and the Unit Manager/RN stated she was unsure where in the process the June referral broke down, but confirmed that the ophthalmology appointment was not attempted to be scheduled until months later. During the months following the June referral, nursing documentation showed persistent and progressively worsening signs and symptoms of left eye infection. Between early July and mid-September, multiple infection/signs and symptoms notes described green mucus drainage at the inner canthus, crusting despite cleansing and eye drops, bilateral eye redness with drainage, ongoing redness with drainage, repeated scleral injection, increased redness, tenderness, and purulent drainage, the eye being closed shut with thick yellow drainage and pain, and swelling around the eye. On 9/15/2025, a physician order was entered for an ophthalmology appointment “ASAP” related to chronic eye infections. The ophthalmology clinic later confirmed that the first contact from the facility to schedule this resident was not until 9/25/2025, despite the clinic’s ability to see acute eye pain cases within about three days. When the resident was finally transported by EMS to the ophthalmology clinic, staff there documented a months-long history of red, irritated eye with purulent discharge, worsening pain and redness, and immediate concern for bacterial cellulitis and possible sepsis, leading to referral to an ER. The ER documented septic shock and severe eye infection, and the specialty hospital discharge summary confirmed preseptal cellulitis, bacterial keratitis of the left eye, and sepsis present on admission. At the time of the surveyor’s observations in February 2026, the resident’s left eye remained swollen, limiting visualization of the eye and partially blocking vision, and the resident reported that vision in the left eye was still “a little blurry.” The facility’s DON could not explain why there were two separate ophthalmology referrals, one in June and one in September, and acknowledged uncertainty about what happened with the earlier referral. The Unit Manager/RN described the facility’s process as requiring that referrals be transcribed into the EMR as orders so that the transport driver can schedule appointments, but confirmed that the June referral was missed. The ophthalmology clinic’s receptionist confirmed that the facility did not contact the clinic about this resident until late September, despite the chronic and worsening eye condition documented over the preceding months.
Improper Alteration and Administration of PRN Lorazepam at End of Life
Penalty
Summary
The deficiency involves the facility’s failure to administer a medication in the prescribed form for one resident receiving end-of-life care. The resident was admitted with diagnoses including malignant neoplasm of the lung, vertebral fracture, post-laminectomy syndrome, COPD, and urinary retention. Documentation in the EMR showed that nursing staff noted the resident was not drinking or eating and was on hospice, and later documented that the resident could no longer swallow. Despite these entries, the Medication Administration Record showed that lorazepam oral tablets continued to be administered multiple times after it was documented that the resident could no longer eat, drink, or swallow. During interviews, the complainant reported that near the end of the resident’s life, he was unable to swallow and that a nurse attempted to give a tablet with water, which caused the resident to choke. The complainant further stated that after this, staff dissolved the resident’s pills in other medication liquids to form a solution. The nurse who provided care confirmed that she dissolved lorazepam tablets into atropine solution to administer the medication and stated she did not believe a physician’s order was needed to change the form of the medication, indicating this was a common practice for end-of-life residents. The facility’s pharmacy consultant stated it was not standard practice to dissolve a tablet into another medication’s solution and noted that lorazepam is available in a liquid formulation. The DON initially stated that standing orders allowed medications to be crushed and dissolved into another medication unless contraindicated, but later the DON and NHA acknowledged the facility did not have a standing orders policy.
Failure to Ensure Timely Availability of Admission Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure prescribed medications were readily available for a newly admitted resident, resulting in multiple missed first doses. The resident was admitted with diagnoses including malignant neoplasm of the lung, T7–T8 vertebral fracture, post-laminectomy syndrome, COPD, and urinary retention. Physician orders dated for the admission included Morphine Sulfate ER 30 mg (2 tablets every 12 hours for cancer-related pain), Flomax 0.4 mg at bedtime for benign prostatic hyperplasia related to urinary retention, Prochlorperazine 10 mg every 8 hours for nausea/vomiting related to lung cancer, and Budesonide-Formoterol 160/4.5 mcg (2 puffs every 12 hours) for COPD-related airway patency. Review of the MAR showed that the evening dose of Morphine ER, the bedtime dose of Flomax, the evening and next-morning doses of Prochlorperazine, and the evening dose of Budesonide-Formoterol on the first days after admission were not administered, with the reason documented as “on order.” During a telephone interview, the complainant reported that the resident waited a significant amount of time for physician orders and missed the first dose of several medications as a result. In an interview, the DON stated that depending on the medication, it was not uncommon to have a delay in prescriptions arriving at the facility, which could result in a missed dose, and explained that the facility maintained only a limited back-up supply and that controlled substances could be delayed if there were issues getting the physician’s order to the pharmacy. The DON also stated that the facility did not always have discharge orders before the resident arrived. Facility policies reviewed indicated that admission orders must include medication orders for immediate care and that the provider pharmacy was required to provide routine and timely pharmacy service, including 24/7 emergency service.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all forms of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these types of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to properly store and dispose of expired medications and did not maintain accurate temperature logs for the medication refrigerator. During an observation, a registered nurse was unaware of the requirement to check refrigerator temperatures, and it was found that temperature logs were incomplete or missing for several months. Additionally, expired therapeutic nutrition powder supplements were found in the medication room, and multi-use vials of vaccines were not properly dated after being opened. Further inspection of medication carts revealed several issues, including insulin pens and inhalers that were opened without expiration dates, loose pills that were not identified, and a pill container without a resident's name. One medication cart was found unlocked and unattended, with loose pills and an unidentified pill container inside. The staff responsible for these carts were either unaware of the need to date medications or admitted to forgetting to lock the cart. Interviews with nursing staff and the Director of Nursing highlighted a lack of awareness and adherence to the facility's policies regarding medication storage and handling. The Director of Nursing acknowledged that medications should be dated when opened, medication carts should be regularly cleaned, and refrigerator temperatures should be checked twice daily. However, these practices were not being consistently followed, leading to the deficiencies observed during the survey.
Failure to Implement Effective Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program (IPCP), which resulted in the potential spread of infectious organisms and disease to all 82 residents. The Director of Nursing (DON) admitted that the facility did not have a designated Infection Preventionist (IP) and relied on someone from another building to manage infection control information. The MDS nurse, RN D, who had some training in infection prevention, was unable to provide comprehensive information about the IPCP, including tracking and monitoring of infections. The IPCP binder for December 2024 was empty, and RN D was unaware of how infections were documented or tracked. Specific cases highlighted the deficiencies in the IPCP. A resident was prescribed Doxycycline for a respiratory infection, but the symptoms persisted, and the same antibiotic was re-prescribed without apparent effectiveness. RN D was unfamiliar with the infection control policies and did not know the details of the infection cases or the testing procedures for other residents. Additionally, the facility's infection control policies, including those for vaccinations, had not been updated annually as required. The DON acknowledged the problem with infection control in the facility.
Lack of Qualified Infection Preventionist in Facility
Penalty
Summary
The facility failed to ensure a qualified Infection Preventionist (IP) was employed at least part-time and present to manage the Infection Prevention and Control Program (IPCP). During an interview, the Director of Nursing (DON) admitted that the facility did not have an IP and that someone from another building, who was not employed at the facility, was handling infection control information. The DON indicated that a Registered Nurse (RN) D, who was the MDS nurse, had training in infection prevention and control, but any questions regarding the IPCP should be directed to RN D. However, during an interview with RN D, it was revealed that RN D was unable to answer questions about the processes for identifying, monitoring, tracking, correlating, reporting, documenting, and controlling infections and communicable diseases within the facility. RN D stated that they primarily handled MDS and had never been trained on the infection control policies, indicating a lack of knowledge about the infection control program. The facility's policy required a qualified individual to be designated as the IP, whose primary role was to coordinate and be accountable for the IPCP, including the antibiotic stewardship program, and to work onsite at the facility.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written transfer notifications to residents, their representatives, and the Office of the State Long-Term Care Ombudsman for four residents who were transferred to the hospital. The medical records for these residents did not indicate that written notifications of transfer, including the reason, effective dates, and the location to which the residents were being transferred, were given. This deficiency was identified for four out of seven residents reviewed for transfers out of the facility. The residents involved were transferred to the hospital and readmitted without the required documentation being provided to them or their representatives. Administrative Staff F confirmed that the written notifications of bed holds and transfers were not maintained as expected. The binder, which was supposed to contain these notifications, was found to be empty for the months of November and December. Staff F stated that it was inconsistent whether she received the necessary information from the nursing staff, and no written transfer notices were sent for the residents on the ombudsman log for those months. The facility's Transfer Discharge Policy required that transfer notices be provided as soon as practicable, but this was not adhered to, leading to the deficiency.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to four residents or their representatives when they were transferred to the hospital. This deficiency was identified during a review of the medical records for these residents, which revealed that no documentation of the bed hold policy issuance was present. Specifically, the records for residents transferred on various dates throughout the year did not include the required notifications, indicating a lapse in the facility's adherence to its own Transfer Discharge Policy. Administrative Staff F confirmed that the written notifications of bed holds and transfers were not maintained as expected. The staff member stated that the notifications were supposed to be filed in a binder organized by month, but the months of November and December were empty. Staff F acknowledged that the process was inconsistent, as notifications were not always received from the nurses. The facility's policy required that the bed hold policy be provided to the resident and their representative at the time of transfer or within 24 hours, but this was not followed in the cases reviewed.
Breach of Resident Privacy Due to Unsecured Medical Information
Penalty
Summary
The facility failed to maintain the personal privacy of medical information for one of the four hallways reviewed. During an observation, the D-hall medical cart computer was found with an open display showing the Physician Orders for a resident, making the information visible to unauthorized individuals. Additionally, a 'Controlled Substance Log' for the same resident was clearly visible on the cart. This breach of privacy was confirmed by the Director of Nursing, who acknowledged that the computer display and documentation should have been securely locked and closed.
Inadequate Care for Resident with MASD
Penalty
Summary
The facility failed to provide appropriate care for a resident with Moisture Associated Skin Damage (MASD) according to professional standards of practice. The resident, who was admitted with diagnoses including cerebral infarction, neurogenic bladder, and type 2 diabetes, was found to have severe cognitive impairment and was always incontinent of bowel and bladder. Observations and interviews revealed that the resident was not being checked and changed every two hours as required, leading to the resident being found soaked in urine and scratching herself, resulting in blood under her fingernails. The resident's Durable Power of Attorney (DPOA) reported these issues, which were supposed to be addressed in the care plan. The facility's staff failed to document the check and change procedures consistently in the electronic medical record (eMAR), and the record sheets were being shredded at the end of each day, contrary to the facility's policy. The Director of Nursing (DON) confirmed that staff should document every check and change in the eMAR and that the destruction of record sheets was not in line with the facility's procedures. The facility's incontinence policy stated that all residents who are incontinent should receive appropriate treatment and services to prevent infections, which was not adhered to in this case.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents by not adhering to physician orders and infection control protocols. Resident #331 was observed with a nasal cannula that had not been changed since 12/3/24, despite physician orders requiring weekly changes. Additionally, the resident's Bipap machine had a note indicating incorrect oxygen settings, and the nebulizer mask was improperly stored and undated. Resident #330's nasal cannula was undated, and there were no clear parameters for oxygen flow rate, leaving nurses without guidance on adjusting oxygen levels. Licensed Practical Nurse B confirmed the lack of parameters and the improper storage and dating of respiratory equipment. Resident #43 also had improperly stored and undated respiratory equipment, with a nebulizer and nasal cannula left unbagged and without a barrier. The Director of Nursing admitted to not being trained on the proper procedures but acknowledged the standard practice of weekly changes and proper storage. The facility's policies on oxygen administration, nebulizer therapy, and CPAP/BiPAP support were not followed, leading to deficiencies in the care provided to these residents.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to properly manage pharmaceutical services for two residents, leading to deficiencies in medication administration and documentation. For one resident, a prescribed antianxiety medication, Lorazepam, was not reevaluated after 14 days as required by regulation, and doses were administered after the medication had been discontinued. Additionally, the medication was not signed out on the electronic medication administration record (eMAR) on multiple occasions, and the controlled substance log did not match the eMAR entries. The discontinued medication remained in the narcotic controlled lock box for approximately three months, contrary to the facility's policy that requires timely removal of discontinued medications. Another resident was prescribed Alprazolam without a discontinuation date, which is against the regulation that requires a stop date after 14 days for PRN psychotropic drugs. The Director of Nursing confirmed that controlled substances should be removed promptly once discontinued and that medications should not be dispensed without a physician's order. The facility's policies on medication destruction, controlled substance administration, and medication administration were not adhered to, resulting in these deficiencies.
Deficiencies in Medication Management and Documentation
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted and documented before administering as-needed anxiolytic medication to a resident with severe cognitive impairment and multiple diagnoses, including dementia and depression. The resident was given diazepam on multiple occasions without any record of attempted non-pharmacological interventions, as confirmed by the Director of Nursing (DON). This lack of documentation hinders the physician's ability to make informed decisions about the resident's medication regimen and affects the staff's ability to revise the care plan effectively. Another deficiency was identified in the administration of an antipsychotic medication to a resident without a documented diagnosis or indication for its use. The resident, admitted for therapy services following hospitalization for a cutaneous abscess, was prescribed Seroquel for sleep without any psychotic-related issues noted in the medical record. The DON and Regional DON were unable to provide a reason for the medication's use, highlighting a failure to review and justify the medication regimen as per the facility's policy. Additionally, the facility did not consider a gradual dose reduction (GDR) for an antidepressant medication prescribed to a resident with major depressive disorder. The resident's care plan indicated a risk for psychosocial well-being alterations, yet there was no documentation of GDR attempts or contraindications in the social service progress reviews. The Nursing Home Administrator acknowledged the absence of a GDR for the medication, which is contrary to the facility's policy requiring GDR attempts within the first year of admission or after initiating a psychotropic medication.
Inaccurate Wound Documentation for Resident with Skin Failure
Penalty
Summary
The facility failed to maintain accurate wound documentation for a resident receiving hospice care, resulting in an inaccurate reflection of the resident's condition. The resident, identified as having skin failure, was observed with a large dark purple area on the right hip, indicative of a deep tissue injury. The Licensed Practical Nurse (LPN) reported the resident had three wounds, but the classification of these wounds was inconsistent with the documentation in the electronic medical record (EMR). The EMR showed discrepancies in the classification and staging of the wounds, with some wounds documented as 'Other - Not Set' instead of being accurately classified as pressure injuries. Interviews with staff revealed that the facility's regional management instructed the wound care nurse to classify the resident's hip wounds as 'Other' due to the diagnosis of skin failure, despite the wounds being pressure injuries. The Certified Wound and Ostomy Nurse confirmed the importance of accurate wound assessments for effective treatment planning. However, the nurse admitted to changing the wound classification based on management's direction, which led to the potential for ineffective treatment plans due to incorrect documentation. Further interviews indicated that clinical staff were sometimes directed to avoid documenting pressure injuries for residents with a diagnosis of skin failure. The MDS Coordinator confirmed that comprehensive assessments relied on the EMR documentation, and if wounds were not documented as pressure injuries, they would not be included as such in the assessments. This practice resulted in the inaccurate communication of the resident's medical condition to healthcare providers, potentially affecting the continuity of care and the formulation of effective interventions.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of nurse staffing information, which resulted in the inability of residents, their representatives, and visitors to determine the number of staff available to provide resident care. On December 15, 2024, the Daily Nurse Staffing Form was observed to be outdated, showing a date of December 12, 2024, three days prior to the observation. During an interview, the Staffing Coordinator, Staff A, reported that she was responsible for completing and posting the daily staffing levels but had not worked from December 13 to December 16, 2024. In her absence, the nursing staff were responsible for this task. The Nursing Home Administrator acknowledged awareness of the requirement for daily posting and indicated that the nursing staff did not complete the staff posting due to the form being not user-friendly and causing confusion.
Inadequate Cardiac and Respiratory Assessments Lead to Resident Deaths
Penalty
Summary
The facility failed to ensure comprehensive and timely cardiac and respiratory assessments for two residents with cardiac and respiratory conditions. Resident 1, who had a history of heart surgery, heart failure, and other cardiac issues, was admitted to the facility but did not receive vital sign monitoring upon arrival. The resident's cardiac and respiratory assessments were delayed, with the first comprehensive assessment occurring two days after admission. During the resident's stay, there was a lack of communication between nursing and therapy staff regarding vital signs, and the resident's condition deteriorated, leading to their death without timely intervention. Resident 2, who had a history of atrial fibrillation, ventricular tachycardia, and chronic heart failure, also experienced inadequate monitoring. The resident's cardiac evaluation was completed four days after admission, and there was a lack of comprehensive vital sign monitoring, particularly for orthostatic hypotension, which was a known issue for the resident. The resident experienced multiple falls and low blood pressure episodes, which were not adequately addressed or documented, leading to their eventual death from cardiac arrest. The report highlights systemic issues within the facility, including staffing shortages and incomplete documentation, which contributed to the lack of timely and comprehensive assessments for both residents. The facility's failure to carry over hospital discharge orders, such as the use of compression stockings for Resident 1, further exacerbated the situation, leading to preventable complications and ultimately the deaths of both residents.
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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.
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