Medilodge Of Gtc
Inspection history, citations, penalties and survey trends for this long-term care facility in Traverse City, Michigan.
- Location
- 2950 Lafranier Road, Traverse City, Michigan 49686
- CMS Provider Number
- 235243
- Inspections on file
- 21
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Medilodge Of Gtc during CMS and state inspections, most recent first.
A resident with cancer, dysphagia, and pneumonitis had a documented full code order, intact cognition, and had signed a CPR consent requesting resuscitation. One morning, a CNA found the resident unresponsive and not breathing and alerted an RN, who delayed going to the room, assessed for a pulse, concluded the resident was dead, and covered him with a sheet without initiating CPR or calling a code. The RN left to retrieve a stethoscope, administered medications to another resident, then returned and again failed to start CPR, later stating she did not know the resident’s code status and believed he was already dead. Another RN subsequently discovered the resident’s full code status, directed that CPR be started, and called a code blue and 911; when staff entered the room, the resident was pulseless and not breathing but did not exhibit clear signs of irreversible death. During the code, the first RN told staff to stop CPR, citing the DON, and also contacted an on-call provider who documented a change in code status to DNR based on nursing reports, despite state law and facility policy requiring the resident’s consent and specific signatures for a DNR. Multiple staff reported that too much time elapsed between finding the resident unresponsive and initiating CPR, and the facility’s CPR/BLS policy and AHA BLS algorithm, which required immediate CPR for a pulseless, non-breathing full code resident without obvious signs of irreversible death, were not followed.
A cognitively intact male resident with cancer, dysphagia, and pneumonitis had a documented full-code status and had signed a CPR consent requesting resuscitation. When he was found unresponsive, staff initiated CPR after confirming his full-code status, but during the code an RN entered the room and instructed staff to stop, stating the code status had been changed to DNR based on direction from the DON. The DON later denied ordering CPR to stop and stated that a full code should be fully run, while the RN reported she had contacted an on-call provider who changed the code status to DNR due to suspected imminent death. A PA documented that nursing reported the resident had passed, CPR was started, and the code status was changed to DNR, and acknowledged changing the status based solely on nursing information, while an NP and the cited Michigan Do-Not-Resuscitate Procedure Act described that a valid DNR requires the declarant’s and physician’s signatures and two witnesses, which had not been obtained.
A resident with cancer, dysphagia, and pneumonitis was found unresponsive by a CNA, and an RN assessed the resident and later called a code blue, after which the resident was determined to be deceased. The IDT progress note describing the sequence of events was entered by the NHA, and a separate code blue report in the EMR listed the DON as the person preparing it, even though the DON was not on-site and did not document the event. The RN involved stated she had charted the incident but could not identify where in the EMR, and the DON suggested another staff member may have opened the assessment for the RN because the RN did not know how to do it, resulting in documentation not being entered under the correct staff member’s name and failing to meet professional standards for accurate medical records.
A facility failed to implement effective infection control and surveillance measures following a scabies diagnosis in a resident, resulting in the spread of scabies to multiple residents. Despite clinical recommendations and physician orders for treatment and contact precautions, the facility did not document the infection, initiate transmission-based precautions, or monitor other residents for symptoms, leading to several residents developing pruritic rashes and discomfort.
A resident with a new colostomy was discharged home without adequate preparation or support, despite being unable to independently manage colostomy care and requiring assistance with daily activities. The facility did not schedule necessary surgical follow-up or provide sufficient education, leading to repeated ER visits for complications including wound infection and colostomy management issues.
Two residents experienced lapses in care when staff failed to coordinate post-surgical follow-up and did not implement a bowel protocol as ordered. One resident did not have surgical staples removed or a follow-up appointment scheduled as required, while another went seven days without a bowel movement and did not receive prescribed interventions. Staff interviews and record reviews confirmed that established protocols were not followed.
Two residents were observed self-administering medications without proper assessments or documentation by the facility's interdisciplinary team. One resident was using a nebulizer without a documented assessment or care plan, while another had an outdated and incomplete assessment. The Director of Nursing acknowledged the lack of regular assessments, contrary to the facility's policy.
A resident with severe cognitive impairment and multiple health conditions was diagnosed with influenza, but the facility failed to document and assess the resident's respiratory status and changes in condition. Staff did not follow protocols for documenting signs and symptoms, and the resident's need for supplemental oxygen was not communicated to the provider in a timely manner. The resident was eventually transferred to the emergency department for further evaluation.
A resident developed a stage 2 pressure injury that was inaccurately documented and not properly assessed by a physician. The facility failed to implement Enhanced Barrier Precautions (EBP) and complete wound treatments as ordered. Staff did not wear appropriate PPE during high-contact activities, and there was no physician's order or care plan for EBP. The Director of Nursing confirmed these deficiencies.
A resident with an indwelling catheter was observed with their urinary collection bag uncovered and on the floor, with the drainage tube touching the ground, posing a risk of infection. The facility's catheter care policy did not specify that bags should remain off the floor, and both the DON and an RN acknowledged the infection risk associated with this practice.
The facility failed to provide proper respiratory care for two residents. One resident received supplemental oxygen without a documented order or assessment, and another received oxygen at a higher rate than prescribed. The facility did not ensure completion of respiratory assessments or proper documentation and communication with providers.
The facility failed to provide adequate supervision during mealtimes for three residents, resulting in severe consequences, including the death of one resident. Despite clear care plans and medical recommendations, residents with a history of choking and dysphagia were left unattended, leading to choking incidents and hospitalization.
A resident did not receive her prescribed Nifedipine for four days, leading to increased anxiety, chest pain, and fatigue. The facility failed to follow its policy on medication administration and errors, resulting in delayed communication with the pharmacy and physician, and inadequate documentation.
Failure to Initiate Timely CPR and Improper Code Status Handling for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely emergency medical care and CPR to a resident who had a documented full code status. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis, and had an advance directive and physician order indicating “Full Resuscitate.” His BIMS score showed intact cognition, and he had signed a CPR consent form requesting resuscitation in the event of cardiac arrest. Therapy and rehabilitation documentation indicated he had good rehab potential and personal goals to walk again and relocate, and staff, including the Director of Rehabilitation and a Nurse Practitioner, later stated they were surprised by his death. On the morning of the incident, a CNA entered the resident’s room to obtain vital signs and found him unresponsive, appearing not to be breathing and not responding to touch or name. The CNA immediately alerted the RN assigned to the hall, who was at the medication cart. The CNA reported that the RN initially responded verbally from a distance, then took approximately two minutes to secure medications before going to the room. Upon arrival, the RN assessed for a pulse at the wrist and ankle, concluded the resident had passed, and covered him completely with a sheet. The RN then left the room to retrieve a stethoscope from the medication cart, administered another resident’s medications, and later returned to listen for an apical pulse and again covered the resident, without initiating CPR or calling a code blue at that time. The RN stated she did not know the resident’s code status during this initial assessment and believed the resident was “very cold and very dead,” and reported observing mottling of the legs. Subsequently, another RN on a different unit learned there had been a death and questioned the situation. This RN asked the first RN for the resident’s code status and observed that the chart being referenced was for a different patient. After directing the first RN to the correct chart, the second RN identified the resident as full code and instructed that CPR be started, a code blue be called, and 911 be contacted. When the second RN entered the room, the resident was fully covered with a sheet, pulseless, and not breathing, but without observed rigor mortis, lividity, or mottling, and not recalled as cold to the touch. CPR and BVM ventilation were initiated, and multiple nurses and CNAs responded to the code. During the code, the first RN contacted the DON by phone; staff in the room reported that the first RN entered and instructed them to stop CPR, stating the DON had ordered it, although the DON later denied giving an order to stop and stated that for a full code, staff were to run the code until EMS arrived or a physician order was obtained. Another nurse recalled the first RN saying she thought the resident had been dead for a couple of hours. During the resuscitation efforts, the first RN also contacted an on-call provider and requested a change in the resident’s code status to DNR because imminent death was suspected. A PA documented being notified that the resident had passed away and that CPR had been started, and recorded that the code status changed to DNR. When questioned later, both the RN and the PA were unable to explain how the code status could be changed from full code to DNR without the resident’s consent and without the statutory requirements for a DNR order being met. A Nurse Practitioner stated that such a change was impossible without the declarant’s signature, a physician signature, and two witnesses, and that qualified staff were obligated to perform CPR on full code residents until an order to stop was received from an on-site physician or medical control. Multiple staff, including a CNA who was a CPR instructor, indicated that too much time elapsed between finding the resident unresponsive and initiating CPR. The facility’s own CPR/BLS policy and the American Heart Association BLS algorithm, as cited in the report, required initiation of CPR for a pulseless, non-breathing full code resident in the absence of obvious signs of irreversible death, which were not consistently observed or documented by responding staff. The Immediate Jeopardy was determined to have begun when the RN first found the resident without pulse or respirations and failed to initiate emergency life-sustaining measures despite his full code status, and the resident was later pronounced dead by a hospital physician. Interviews and record review documented conflicting accounts regarding the resident’s physical condition (coldness, mottling, and signs of irreversible death), the timing of assessments and interventions, and the communication between the RN, DON, and on-call provider about stopping CPR and changing code status. Staff statements consistently described a delay in initiating CPR, initial misidentification of the resident’s code status, and the resident being fully covered with a sheet before a code was called, all in the context of a documented full code order and signed CPR consent. The report also cites state law requirements for executing a DNR order, including that an individual of sound mind or a patient advocate may execute a DNR, and that the order must be dated, voluntary, and signed by the declarant or patient advocate, the attending physician, and two witnesses. These statutory requirements were contrasted with the events in which the resident’s code status was documented as changed to DNR during or immediately after the code, based solely on nursing staff communication to the PA, without evidence of the required signatures or the resident’s participation. Facility policy required staff to provide basic life support, including CPR, for full code residents who did not show obvious clinical signs of irreversible death, and to coordinate rescue efforts until EMS arrival, but the actions described in the report show that these procedures were not followed for this resident. Overall, the deficiency centers on the failure of nursing staff to promptly verify the resident’s full code status, initiate CPR immediately upon finding him pulseless and not breathing, and maintain life-sustaining efforts in accordance with facility policy, professional guidelines, and state law governing resuscitation and DNR orders. The sequence of events, as corroborated by multiple staff interviews and documentation, shows delays in response, premature assumption of death, miscommunication about code status, and an improper attempt to change the resident’s code status to DNR without the required legal process, all occurring before and during the emergency response that ended with the resident’s death.
Removal Plan
- Provide education to licensed nurses on the CPR policy, including confirming code status in the medical record, assessing when to initiate CPR, when CPR can be stopped, and pronouncing death.
- Educate licensed nurses on properly assessing prior to initiating CPR (check for pulse, observe chest rise, listen and feel for breathing, observe skin and body findings).
- Educate licensed nurses on the facility Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) policy, including that full code residents must receive BLS/CPR prior to EMS arrival unless obvious clinical signs of irreversible death are present, and defining those signs (rigor mortis, dependent lividity, decapitation, transection, decomposition).
- Educate licensed nurses that the licensed nurse on each shift is responsible for coordinating the rescue effort and directing other team members during the rescue effort until EMS has arrived.
- Educate licensed nurses that a resident may be declared dead by a Licensed Physician or Registered Nurse with physician authorization in accordance with state law per policy.
Failure to Obtain Informed Consent Before Changing Code Status During CPR Event
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent before changing a cognitively intact resident’s code status from full code to DNR. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis. His EMR showed a physician’s advance directive order for full resuscitation initiated on 11/17, and a BIMS score of 15 on 11/22 indicating intact cognition. An advance directives/CPR consent form signed by the resident on 11/17 documented that he requested CPR in the event of cardiac arrest. On the morning of 12/7, staff discovered the resident unresponsive. An IDT progress note by the NHA documented that a CNA found the resident unresponsive, RN Q assessed him and believed he was deceased, and later RN M verified the resident’s full code status and initiated CPR at approximately 9:30 AM. Multiple staff, including CNAs and nurses, participated in the code. Witness statements and interviews indicated that during the code, RN Q entered the room and instructed staff to stop CPR, stating that the resident’s code status had changed to DNR and that this direction came from the DON. Staff reported confusion about how the code status had changed and stopped CPR based on RN Q’s statements. Interviews with the DON and RN Q revealed conflicting understandings of the instructions given during the event. The DON stated she told RN Q that if the resident was a full code, staff should run the code and stop only when EMS arrived or a physician order was received, and denied ordering cessation of life-sustaining efforts. RN Q later acknowledged she misunderstood the DON and also reported that she contacted an on-call provider during the code to change the resident’s status to DNR. A telehealth note by PA BB documented that nursing staff notified her the resident had passed away, that CPR was started, and that the code status was changed to DNR; PA BB stated she changed the code status based on nursing’s report of imminent death and did not address how this could occur without the resident’s consent. NP L stated that such a code status change was impossible without the declarant’s signature, a physician’s signature, and two witnesses, and the report cites the Michigan Do-Not-Resuscitate Procedure Act requirements, underscoring that no proper DNR order process was followed before the code status change.
Inaccurate and Misattributed Documentation of Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medical records were accurately documented in accordance with professional standards for one resident. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis. On the morning in question, an IDT progress note authored by the Nursing Home Administrator (NHA) documented that at 9:15 AM a CNA entered the resident’s room to obtain vital signs and found the resident unresponsive, with eyes and mouth open, no response to touch or name, dry oral mucosa, and mottling from the waist to the feet. The note further stated that RN Q assessed the resident by checking for a pulse, feeling the ankles, and listening for respirations with a stethoscope for one minute, and that at 9:24 AM RN Q notified the NHA and DON that the resident was deceased and that it was an irreversible death. During a subsequent telephone interview, RN Q confirmed she was the primary nurse responsible for the resident’s care that morning and that she ultimately called a code blue. When asked if the event was documented in the resident’s medical chart, RN Q stated she remembered charting it somewhere in the EMR but was unsure of the exact location. A separate report titled “#1154 Code Blue,” dated the same morning at 9:30 AM, listed the resident and identified the DON as the person preparing the report. In an interview, the DON stated she was not in the facility at the time of the incident and had not documented that report, assuming instead that it was RN Q’s documentation and suggesting that another staff member may have opened the assessment for RN Q because RN Q did not know how to do so herself. In another interview, the NHA stated that all staff are required to document under their own name in the medical record, highlighting that the code blue documentation was not accurately attributed to the staff member who provided care.
Failure to Implement Infection Control Measures During Scabies Outbreak
Penalty
Summary
The facility failed to implement effective infection control measures and comprehensive infection surveillance to prevent the transmission of scabies among residents. A resident with a history of anoxic brain damage and cognitive communication deficit was diagnosed with scabies following dermatology appointments, with clinical notes indicating a spreading, itchy, and bleeding rash. Despite a physician's order for scabies treatment and recommendations for contact precautions, the facility did not document the resident's treatment for scabies, implement transmission-based precautions, or monitor other residents for symptoms as part of their infection control program. The Assistant Director of Nursing acknowledged that CDC guidelines recommend contact precautions after initiation of therapy but stated these were not enacted due to the belief that the treatment was prophylactic rather than for an active infection. Subsequent dermatology evaluation confirmed crusted scabies and recommended enacting scabies protocols according to facility and state guidelines, including isolation of contaminated clothing and treatment of household contacts. The Director of Nursing reported that after this diagnosis, skin assessments were conducted on all residents, and 19 additional residents with rashes were treated with a scabicidal. However, prior to this, there was no evidence of early detection, isolation, or infection control practices being implemented following the initial diagnosis, as required by both facility policy and CDC guidelines. Multiple residents developed symptoms consistent with scabies, including pruritic rashes, severe itching, and discomfort. Progress notes for several residents documented exposure to a confirmed scabies case and the presence of rashes consistent with scabies infestation. Interviews with affected residents confirmed ongoing symptoms and discomfort. The facility's infection prevention and control program policy required surveillance, early detection, and control of communicable diseases, but these measures were not effectively carried out, resulting in the transmission of scabies among residents.
Failure to Ensure Safe Discharge and Adequate Preparation for Colostomy Care
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident who required ongoing care for a new colostomy following abdominal surgery. The resident was admitted for subacute rehabilitation after surgery and had limited family support, living alone with only one relative nearby who was unable to provide daily assistance. Despite clear hospital discharge instructions for a surgical follow-up within 10-14 days, the facility did not schedule the necessary appointment for staple removal or arrange for adequate post-discharge support. The resident was discharged home while still requiring supervision or assistance for activities of daily living, including colostomy care, transfers, and ambulation, as documented by therapy assessments. Multiple staff interviews and medical record reviews revealed that the resident expressed concerns about her ability to manage colostomy care independently at home. Nursing and therapy staff noted that the resident was not able to perform all aspects of colostomy care without significant cues and was not at her functional baseline for mobility, with an increased fall risk. The resident and her family both reported feeling unprepared for discharge, and the resident was only provided with a single colostomy care education session, which was insufficient for her to achieve independence in this area. The facility's social services director confirmed that only limited home health services were arranged, and not all necessary follow-up appointments were scheduled. Following discharge, the resident required repeated emergency room visits due to complications related to her colostomy, including staple removal, wound infection, and inability to manage the colostomy appliance. Emergency department documentation and provider notes indicated that the resident was unable to care for her colostomy, experienced leakage and skin issues, and was not safe to be living independently. The facility's failure to ensure the resident was adequately prepared and supported for discharge resulted in repeated hospitalizations and ongoing health complications.
Failure to Coordinate Post-Surgical Care and Follow Bowel Protocol
Penalty
Summary
The facility failed to coordinate post-surgical care and follow established bowel protocol for two residents. For one resident with a recent colostomy and abdominal surgery, the facility did not ensure timely removal of surgical staples or schedule a required follow-up appointment with the surgeon, as directed in the hospital discharge instructions. Despite multiple staff being aware of the need for post-operative follow-up and staple removal, there was no documentation of communication with the surgeon’s office, and the staples remained in place for 28 days post-surgery. The resident was ultimately sent to the emergency department for staple removal after being seen by her primary care provider, who noted the lack of follow-up and the presence of redness and inflammation at the surgical site. For another resident with a history of anoxic brain damage and chronic constipation, the facility did not follow physician orders or its own bowel management protocol. The resident went seven days without a bowel movement, during which time there was no documentation of abdominal or bowel assessments, and prescribed interventions such as Milk of Magnesia, Dulcolax suppository, or Fleet enema were not administered as ordered. The facility’s policy required nursing staff to assess residents and administer interventions after three days without a bowel movement, but this was not done, and the resident was eventually transferred to the hospital for evaluation of possible bowel impaction. Interviews with facility staff confirmed that protocols for post-surgical care and bowel management were not followed. Staff members were either unaware of the need for certain interventions or failed to document and communicate necessary actions, resulting in lapses in care for both residents. The deficiencies were identified through record review, staff interviews, and review of facility policies.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess and determine the clinical appropriateness of self-administration of medications for two residents. Resident #18 was observed using a nebulizer alone in his room without any documented interdisciplinary team (IDT) assessment or care plan indicating his ability to self-administer medications. His admission assessment indicated that he did not wish to self-administer medications, yet there was no further documentation or comments regarding this decision. Resident #49 was also observed using a nebulizer without supervision, and the most recent assessment for self-administration was dated several months prior, with a critical section left blank. The Director of Nursing confirmed that assessments for self-administration were not conducted regularly, only if there was a physical decline, which contradicts the facility's policy requiring regular assessments and documentation in the resident's medical record.
Failure to Document and Notify Change in Resident's Condition
Penalty
Summary
The facility failed to ensure appropriate assessments and timely notification of a change in condition for a resident diagnosed with influenza. The resident, who had severe cognitive impairment and multiple health conditions including esophageal cancer and heart failure, was observed with signs of respiratory infection but did not receive timely documentation or assessment of these symptoms. The resident's electronic medical record lacked documentation of the influenza diagnosis, signs, symptoms, and the need for droplet precautions. On multiple occasions, staff failed to document the resident's respiratory status and changes in condition, such as the development of a severe cough and the need for supplemental oxygen. The Director of Nursing was unaware of the lack of documentation, and the Infection Preventionist noted that pertinent charting was not completed as required. The resident's oxygen saturation levels dropped, and there was no documentation of a complete respiratory assessment or provider notification until the resident's condition worsened. The resident was eventually transferred to the emergency department for evaluation after a nurse practitioner was informed of the change in condition. The facility's policy required notification of changes in a resident's condition, including the need for new treatments like oxygen administration, but these protocols were not followed. The lack of timely assessment and documentation potentially delayed necessary treatment for the resident's influenza and respiratory issues.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident. The resident was admitted without any wounds or pressure injuries, but later developed a stage 2 pressure injury on the right lateral malleolus. The wound was not accurately documented, as it was initially recorded as a stage 2 pressure injury despite the presence of slough, which should have classified it as unstageable. The wound nurse acknowledged the inconsistency but continued to document it as a stage 2 pressure injury without further evaluation or physician notification. The facility did not ensure proper physician assessment and documentation of the wound. There was no physician's order or care plan for Enhanced Barrier Precautions (EBP), and the resident's room lacked signage indicating EBP were in place. The Treatment Administration Record showed a missed treatment on one occasion, with no documentation to confirm its completion. Additionally, the physician did not assess the wound unless there was an infection or changes, which was not documented in this case. Staff failed to implement EBP and complete wound treatments as ordered. Certified Nurse Aides and a Registered Nurse were observed not wearing appropriate personal protective equipment (PPE) during high-contact activities, such as incontinence care, transferring the resident, and dressing changes. The Director of Nursing confirmed that PPE should be worn during these activities and that residents with wounds should be placed on EBP, but this was not done for the resident in question.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to implement proper infection control measures for a resident with an indwelling catheter, leading to a potential risk of infections. The resident, who was cognitively intact with a BIMS score of 15/15, was observed on multiple occasions with their urinary collection bag uncovered and placed on the floor, with the drainage tube touching the ground. This was noted during observations on two consecutive days, with approximately 300 cc of urine visible in the bag during one observation. The facility's Director of Nursing and a Registered Nurse confirmed that the catheter bag should not be on the floor due to infection concerns. However, the facility's catheter care policy did not specify that urinary catheter bags should remain off the floor, indicating a gap in the policy that could contribute to the deficient practice. The observations and interviews highlight a failure to adhere to infection control protocols, potentially compromising the resident's health.
Failure in Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents receiving supplemental oxygen. For one resident, there was a lack of completion of respiratory assessments and documentation of vital signs, as well as a failure to notify the provider about the need for supplemental oxygen. This resident, who had multiple diagnoses including esophageal cancer and heart failure, was observed receiving supplemental oxygen without a documented order or assessment, indicating a lapse in the facility's protocol for managing changes in the resident's condition. Another resident with chronic obstructive pulmonary disease was found to be receiving supplemental oxygen at a rate higher than the physician's order. Despite multiple observations of the incorrect oxygen flow rate, there was no documentation of any amended orders to justify the increased rate. The facility's Director of Nursing confirmed that oxygen should be administered according to physician orders and that there were no standing orders allowing nurses to modify oxygen delivery rates without a physician's directive. This oversight highlights a failure to adhere to prescribed treatment plans and ensure accurate documentation and communication regarding residents' respiratory care.
Failure to Provide Adequate Supervision During Mealtimes
Penalty
Summary
The facility failed to provide adequate supervision during mealtimes for three residents, resulting in severe consequences, including the death of one resident. Resident #508, who had a history of traumatic brain injury, dysphagia, and severe cognitive impairment, experienced two choking incidents due to lack of supervision. Despite clear instructions from the hospital and speech therapy evaluations recommending direct supervision during meals, the resident was left unattended on multiple occasions. The first incident involved choking on a hot dog, and the second, more severe incident involved choking on a tuna fish sandwich, leading to hospitalization and subsequent death due to acute hypoxic respiratory failure and aspiration pneumonia. Resident #509, who had a history of cerebral infarction, dysarthria, and dysphagia, was observed eating lunch without the required 1:1 supervision. Despite being care planned for 1:1 supervision during mealtimes, the resident was left unsupervised, which could have led to potential harm. The staff members present in the dining room were not providing the necessary supervision or assistance, indicating a lack of communication and adherence to care plans. Resident #510, diagnosed with dysphagia, cognitive communication deficit, and schizophrenia, was also left unsupervised during breakfast. The resident's care plan required 1:1 assistance due to a history of choking and aspiration pneumonia. However, the Assistant Director of Nursing placed the meal tray in front of the resident and walked away, leaving the resident to eat without supervision. This repeated failure to implement care-planned interventions for residents requiring supervision during meals highlights significant lapses in communication and staff training within the facility.
Failure to Provide Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceuticals for a resident, resulting in the resident going without a prescribed medication for an extended period. The resident, who had diagnoses including achondroplasia, PTSD, recurrent depressive disorder, adjustment disorder, anxiety disorder, and Raynaud's syndrome, did not receive her prescribed Nifedipine for four days. This led to increased anxiety, chest pain, and fatigue for the resident. The missed doses were documented in the Medication Administration Regimen (MAR) and progress notes, indicating the medication was unavailable and on order from the pharmacy. The facility's correspondence history with the pharmacy supplier revealed that the Unit Manager/Registered Nurse first called to inquire about the missing prescription three days after the initial missed administration. The Director of Nursing (DON) was unaware of the pharmacy issue until the resident's guardian contacted the Nursing Home Administrator (NHA) with concerns. The DON admitted a system failure, including delayed communication with the pharmacy supplier, delayed communication with the facility physician, and lack of staff education regarding escalation protocol for missed prescriptions, notification procedures, and documentation of medication omissions. The facility's policy on medication administration and errors was not followed, as evidenced by the lack of timely action to rectify the issue and inadequate documentation. The policy required immediate notification of the physician, obtaining alternative treatment orders, and detailed documentation of efforts to obtain the medication. The facility also failed to complete a medication error incident report and monitor the resident for adverse reactions to the medication omission.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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