Medilodge Of Leelanau
Inspection history, citations, penalties and survey trends for this long-term care facility in Suttons Bay, Michigan.
- Location
- 124 West 4th Street, Suttons Bay, Michigan 49682
- CMS Provider Number
- 235209
- Inspections on file
- 22
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Medilodge Of Leelanau during CMS and state inspections, most recent first.
A resident was given oral medications along with two identical, unlabeled cups of clear liquid—one containing water and the other acetic acid intended for a catheter flush—by an RN who was still in orientation. The RN left the resident alone without identifying which cup was water and did not observe the medication pass. The resident took his medications using the acetic acid before realizing it was not water and reported prior concerns about the same nurse bringing incorrect medications. Interviews indicated the acetic acid was not prepared in a sterile manner, the orienting RN had only explained (not observed) the catheter flush procedure, and the orientee RN lacked documented competency for urinary catheter flushing.
Surveyors observed multiple medication administration errors resulting in a 14% error rate. One resident’s RN mishandled oral medications by touching pills with bare hands while searching for a diuretic, administered the diuretic after the resident had requested it be held, documented it as held on the MAR, and omitted an ordered nasal spray that was not available on the cart. The same RN failed to follow insulin lispro pen instructions, including not cleaning the rubber seal, priming the pen incorrectly, and not holding the injection site for the recommended time. For another resident, an RN initially prepared the wrong aspirin formulation (enteric-coated instead of chewable) before recognizing the discrepancy. These events occurred despite a policy requiring adherence to professional standards and accurate MAR documentation.
A cognitively intact male resident inappropriately touched a non-communicative female resident with cerebral palsy and speech/language developmental disorders on two separate occasions, including squeezing her breast over clothing, rubbing her thigh, and lifting her shirt to touch and bounce her breast. Another resident reported witnessing these events to a CNA, and the male resident later admitted to lifting the female resident’s top and touching her breasts. The facility’s failure to prevent this conduct violated its abuse, neglect, and exploitation policy and resulted in sexual abuse and mental trauma to the female resident.
The facility failed to maintain adequate staffing levels, affecting resident care. A resident reported a decline in care quality due to insufficient nursing staff, leading to inadequate meal assistance and long wait times for call light responses. During a resident council meeting, attendees raised concerns about staffing shortages impacting meal assistance and safety. An LPN confirmed the staffing inadequacies, stating that corporate management dismissed concerns about staffing levels.
The facility did not conduct and document an annual facility-wide assessment, leading to a potential inadequacy in resources for resident care. The NHA provided an outdated Facility Assessment Tool, and confirmed no updates were made to meet annual review requirements. The assessment indicated an average resident population of 63, not reflecting the current 68 residents, showing a discrepancy in population assessment.
The facility did not update its infection control policies annually, affecting all 68 residents. Policies for COVID-19, influenza, and pneumococcal vaccinations, among others, were outdated. An LPN/IP was unaware of the annual update requirement, and the NHA confirmed the policies were the most recent. Frequent changes in IP managers contributed to this oversight.
The facility failed to ensure proper medication security and assessment for self-administration for two residents. One resident had unsecured medication and lacked comprehensive physician orders for self-administration, while another resident self-administered water flushes without a physician's order or assessment. The facility's policy requirements for documentation and storage were not met, leading to unsecured medications and unauthorized self-administration.
The facility failed to provide written bed-hold information to two residents or their representatives during hospital transfers. One resident was hospitalized due to hypoxia, and another due to aggressive behavior, but neither received the required Bed Hold Authorization form. Interviews confirmed the absence of these notices, despite the facility's policy requiring them at the time of transfer.
The facility failed to provide timely showers and baths for residents, leading to a deficiency in ADL care. A resident with diabetes experienced delays due to a malfunctioning boiler, resulting in late or refused showers. Another resident reported staff shortages affecting their ability to receive preferred bed baths, while a third resident received fewer showers than scheduled. The facility's policy on ADLs was not adhered to, contributing to the deficiency.
A resident with a neck fracture and history of falls was found wearing non-grip socks, contrary to her care plan, which specified gripper socks for fall prevention. The resident's daughter noted the absence of the socks she provided, raising concerns about fall risks. The DON acknowledged the care plan should have been updated to reflect the resident's preferences, highlighting a deficiency in the facility's adherence to its Fall Prevention Program and Accidents and Supervision policy.
A facility failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. Despite discharge instructions recommending monthly catheter changes and assessment for sensation to void, the facility did not change the catheter monthly and lacked documentation of a voiding trial. Interviews with the DON revealed no specific policy for Foley catheter insertion, and the existing policy was not followed, contributing to the deficiency.
A facility failed to ensure that MRRs were addressed by the physician and documented in a resident's clinical record. The pharmacist's recommendations from two MRRs were not found in the record, and the DON was unaware of the need to provide these to the physician. The facility's policy requires documentation of irregularities and physician responses, which was not followed in this instance.
The facility failed to provide evening snacks to three residents with diabetes, as per their needs and preferences. Residents reported not receiving snacks on multiple occasions and expressed dissatisfaction with the limited and unhealthy options available. The snack distribution process was inconsistent and unsanitary, with the dietary manager acknowledging that the snack list had not been updated for some time.
A resident requested a COVID-19 vaccination in September but did not receive it due to delivery issues from the contracted pharmacy. The resident contracted COVID-19 in November, and the facility did not attempt to secure the vaccine from alternative sources, despite having a policy that allows for such measures.
A facility failed to report an allegation of sexual abuse involving a resident and an occupational therapist to the State Agency. Despite a CNA reporting the incident to the NHA, the facility's legal team advised against reporting, believing the resident was on leave. The facility's policy requires immediate reporting of such allegations, which was not followed.
The facility failed to thoroughly investigate a sexual abuse allegation involving a resident and an OT. A CNA reported the incident to the NHA, but no further statements were collected, and the investigation did not comply with the facility's abuse policy. The OT was transferred, but the investigation remained incomplete.
Resident Ingests Acetic Acid Due to Unsupervised, Unlabeled Medication Setup
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe medication administration and observation of medication consumption, resulting in a resident ingesting acetic acid intended for catheter flushing. A complaint filed with the State Agency alleged that a nurse gave the resident acetic acid in a regular cup without informing him what it was, and he drank it, believing it was his fluid for taking medications. During interviews, an RN explained that another RN who was in training brought the resident’s oral medications along with two identical glasses containing clear liquid—one with water and one with acetic acid—both in the same type of glass. The RN in training then left the resident alone with the medications and both unlabeled glasses, without instructing the resident which glass contained water and without witnessing the medication administration. The resident reported that the nurse placed two glasses of clear liquid and a cup of medications on his bedside table and left the room without observing him take his medications. While taking his medications, he realized that what he was drinking was not water and then discarded it, later becoming upset about the incident. The resident also stated that the same nurse had previously brought him the wrong medications and that he did not trust her. Additional interviews revealed that the acetic acid was not drawn up in a sterile manner, contrary to the expected use of a syringe or sterile collection cup, and that the orienting RN had only explained the catheter flush procedure verbally and had not witnessed the trainee RN perform an indwelling catheter flush. Review of the trainee RN’s competencies showed no documented check-off for flushing urinary catheters, and the RN was noted to be on an extended orientation process at the time of the incident.
Medication Administration Errors Resulting in 14% Error Rate
Penalty
Summary
Surveyors identified a medication error rate of 14% (4 errors out of 29 opportunities), exceeding the 5% threshold, related to medication administration practices for two residents. For one resident, an RN prepared oral medications and subcutaneous insulin and brought them to the resident’s room. When the resident asked if her diuretic was in the cup and requested that it be removed so she could take it later, the RN stated that it was present, left the room, and then searched through the medication cup at the cart, touching three pills with bare hands while attempting to identify the diuretic. The RN then returned and administered all medications, including the diuretic, without informing the resident that the diuretic remained in the cup. During the same medication pass, the RN was unable to locate the resident’s ordered nasal spray, stated she would obtain a new one from backup supply, and did not administer the nasal spray. Medication reconciliation later showed the diuretic was documented as “held” even though it was given, and the nasal spray was omitted and not given, and the medication cart lacked the nasal spray. During preparation and administration of the resident’s insulin lispro, the RN did not follow manufacturer instructions: she failed to clean the pen’s rubber seal with alcohol, primed the pen while holding it horizontally instead of with the needle pointing up, and held the injection site for only two seconds, after which a drop of blood appeared at the site. The DON confirmed these steps were inconsistent with expectations and standards of practice. For a second resident, another RN prepared medications and initially dispensed an enteric-coated aspirin 81 mg instead of the ordered chewable aspirin 81 mg, placing it in the medication cup with other medications. When questioned, the RN reviewed the order and acknowledged the aspirin form was incorrect and needed to be replaced with the chewable form. These observed errors and omissions occurred despite a facility policy requiring medications to be administered as ordered, in accordance with professional standards, and with proper verification and documentation on the MAR.
Failure to Protect Resident From Sexual Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by another resident. During routine morning care on 12/30/25, a CNA was informed by a resident witness that he had observed a male resident (R1) fondling a female resident (R2) on two separate occasions approximately four weeks earlier, two days apart. The witness reported that the first incident occurred at a puzzle table, where R1 squeezed R2’s breast over her clothes and then rubbed her thigh. The second incident reportedly occurred in a hallway near the therapy gym, where R1 again squeezed R2’s breast over her clothes, then lifted her shirt and bounced her breast. R1 later admitted in an interview with the NHA and DON that he had lifted R2’s top and touched her breasts, describing the incident as very quick. R1’s EMR showed he was cognitively intact, responsible for his own medical and financial decisions, and had been admitted with diagnoses including hydronephrosis. R2’s EMR documented that she had cerebral palsy, developmental disorders of speech and language, was non-communicative, and had a legal guardian/conservator for medical and financial decisions. A personal protection order was issued on behalf of R2, citing that she had a reasonable apprehension of sexual assault because R1 had sexually assaulted or threatened her with sexual assault. The facility had an Abuse, Neglect and Exploitation policy intended to prohibit and prevent abuse, neglect, and exploitation, but the events described show that R2 was subjected to inappropriate sexual touching by R1, resulting in mental trauma based on the reasonable person concept.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing levels, impacting the care of several residents. Resident #37 reported a decline in care quality, noting that often only one nurse was available for large sections of the facility, leading to inadequate assistance during meal times. Resident #41 experienced long wait times for call light responses and was only receiving one shower per week, contrary to the facility's policy of a 15-minute maximum wait time for call light responses. Observations confirmed that call lights were left unanswered for extended periods, and staff were not available to assist residents promptly. During a resident council meeting, attendees expressed concerns about staffing shortages, which affected meal assistance and overall safety. Resident #63 highlighted the lack of staff in the dining room, resulting in inadequate feeding assistance for their blind spouse, Resident #11. Additionally, Resident #8 observed that some residents were eating off others' plates due to the lack of assistance. An LPN confirmed the staffing inadequacies, stating that the facility's corporate management dismissed concerns about staffing levels, which were insufficient to meet the residents' needs and acuity.
Failure to Update Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document an annual facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. During the entrance conference, the Nursing Home Administrator (NHA) provided a Facility Assessment Tool covering the period from July 2023 through June 2024. However, upon inquiry, the NHA confirmed that there were no updates to the facility assessment to meet the requirement of being reviewed and updated annually. Additionally, the review of the Facility Assessment tool revealed that the section titled Average Daily Census Analysis indicated an average patient population of 63, which did not reflect the current resident population of 68, highlighting a discrepancy in the facility's assessment of its resident population.
Failure to Update Infection Control Policies Annually
Penalty
Summary
The facility failed to update its infection control policies annually, which has the potential to affect all 68 residents regarding infection control practices. During a review of the infection control policies, it was found that several policies, including those for COVID-19, influenza, and pneumococcal vaccinations, as well as the water management program, transmission-based precautions, laundry, and handling clean linen, were not updated annually. The COVID-19, influenza, and pneumococcal vaccination policies were last updated in October 2023, while the transmission-based precautions policy was last updated in May 2023. The water management program was undated, and the laundry and handling clean linen policies were last updated in October 2023. An interview with the LPN/Infection Preventionist revealed a lack of awareness that the policies needed to be updated annually, citing frequent changes in IP managers and involvement from other management and corporate personnel. The Nursing Home Administrator confirmed that the provided policies were the most recent updates available.
Failure to Ensure Proper Medication Security and Assessment for Self-Administration
Penalty
Summary
The facility failed to ensure proper medication security and assessment for self-administration for two residents, R14 and R46. For R14, a clear plastic medication cup with tablets was left unsecured on the over-bed table, and a bottle of acetaminophen was found on the nightstand, contrary to the requirement for locked storage. R14's medical record indicated a self-administration evaluation, but it lacked a comprehensive physician's order for self-administration throughout the day, only covering evening medications. The care plan did not adequately address storage expectations or specify procedures for day shift medication administration, and the MAR lacked documentation for self-administration during the day. For R46, the resident was observed self-administering water flushes through a feeding tube without a physician's order or a self-administration assessment. R46's MAR did not include an order for self-administration of water flushes, and the care plan indicated that all fluids should be provided by staff. The DON acknowledged the facility's difficulty in preventing R46 from accessing syringes and confirmed the absence of a physician's order or assessment for self-administration. The facility's policy on resident self-administration of medication required documentation of the resident's preference and capability to follow directions, as well as proper storage arrangements. However, these requirements were not met for R14 and R46, leading to unsecured medications and unauthorized self-administration. The DON confirmed the deficiencies in physician orders, MAR documentation, and storage practices, contributing to the facility's failure to comply with self-administration protocols.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written bed-hold information to two residents or their representatives during transfers to a hospital, as required by their policy. Resident #22 was hospitalized due to hypoxia and oxygen needs from 9/15/24 to 9/25/24, but no Bed Hold Authorization form was completed or scanned into the electronic medical record (EMR). Interviews with the Nursing Home Administrator and Medical Records Staff confirmed the absence of the bed hold notice for Resident #22 at the time of transfer. Similarly, Resident #57 was transferred to a hospital for further evaluation following aggressive behavior, including attempting to attack staff and other residents. This resident was hospitalized from 9/1/24 to 9/9/24, yet no Bed Hold Authorization form was completed or scanned into the EMR. The Director of Nursing stated that nurses are responsible for providing the bed hold policy and completing necessary forms at the time of transfer, but this was not done for Resident #57. The facility's policy, dated 2/1/22, requires written notice of the bed-hold policy to be provided at the time of transfer.
Failure to Provide Timely Showers and Baths
Penalty
Summary
The facility failed to provide necessary showers during preferred times for two residents, leading to a deficiency in the care provided for Activities of Daily Living (ADLs). Resident #6, who has diabetes mellitus and intact cognition, reported issues with the facility's boiler, resulting in cold water and delayed showers. This resident prefers morning showers on specific days but had to wait due to the boiler malfunction, leading to refusals or late showers. The task list for this resident showed multiple instances of late or refused showers over a period of several weeks. Resident #22, also with diabetes mellitus and intact cognition, expressed concerns about staff shortages affecting their ability to receive preferred bed baths twice a week. This resident reported having to beg for a bed bath and experienced inconsistencies in receiving them. The task list indicated missed showers or baths over several weeks. Additionally, Resident #41, who requires assistance due to left-sided hemiplegia, reported receiving only one shower per week on several occasions, contrary to their care plan. The facility's policy on ADLs emphasizes minimizing the loss of residents' functional abilities, but the facility failed to adhere to this policy, resulting in the deficiency.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement effective interventions to prevent falls for a resident who had a history of falls and was at risk for further injury. The resident, who had a neck fracture and was on hospice care, experienced a fall resulting in a head laceration and high blood pressure. Despite the resident's care plan indicating the use of gripper socks as a fall prevention measure, the resident was observed wearing regular socks without grips, which were not the ones purchased by her daughter. The daughter expressed concern about the absence of the gripper socks she had provided, which were intended to prevent further falls. The Director of Nursing confirmed that the care plan should have been updated to reflect the resident's preference for different socks, as the resident did not like the facility-provided gripper socks. The facility's Fall Prevention Program and Accidents and Supervision policy require that each resident's risk factors and environmental hazards be evaluated, and interventions be monitored and revised as needed. However, the facility did not adhere to these policies, resulting in a deficiency in providing adequate supervision and assistive devices to prevent accidents.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate catheter care and maintenance for a resident with an indwelling urinary catheter. The resident, who was admitted to the facility after hospitalization, had discharge instructions recommending monthly catheter changes and assessment for sensation to void due to Guillain-Barre syndrome. However, the facility did not change the catheter monthly in August, September, and October, and there was no documentation of a voiding trial or monitoring of the resident's sensation to void. The resident's treatment administration record and progress notes lacked detailed documentation of catheter changes, including the procedure tolerance, equipment used, and urinary return following insertion. Interviews with the Senior Director of Nursing revealed that the facility did not have a specific policy for Foley catheter insertion, and the existing policy for suprapubic catheter changes was not followed. The DON acknowledged that the discharge recommendations should have been completed monthly and documented, and that the physician should have been monitoring the resident's sensation to void. The lack of adherence to the discharge instructions and inadequate documentation contributed to the deficiency in catheter care for the resident.
Failure to Document Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews (MRRs) were properly addressed by the physician and maintained in the clinical record for one resident. Specifically, the pharmacist's documentation for the resident revealed that monthly MRRs conducted on two occasions resulted in recommendations written to the physician. However, neither the pharmacist's written recommendations nor the physician's written responses were found in the resident's medical record. Upon inquiry, the Director of Nursing (DON) admitted to being unaware of the need to obtain and provide these written recommendations to the physician, resulting in the absence of the necessary documentation in the resident's record. The facility's policy on addressing medication regimen review irregularities requires that the pharmacist report any irregularities to the attending physician, medical director, and DON, and that these reports must be acted upon. The policy also mandates that the attending physician document in the resident's medical record that the identified irregularity has been reviewed and what actions, if any, have been taken. In this case, the lack of documentation indicates a failure to adhere to these established procedures.
Failure to Provide Evening Snacks as per Residents' Needs and Preferences
Penalty
Summary
The facility failed to offer evening snacks to three residents, all of whom have diabetes mellitus, as per their needs and preferences. Resident #6 reported not receiving a bedtime snack on multiple occasions and expressed concerns about the lack of healthy options and the potential infection control issues due to the way snacks were distributed. Resident #22 also did not receive a snack on several nights and expressed dissatisfaction with the limited variety and quality of the snacks offered. Resident #31 highlighted similar issues, noting the lack of healthy options and the unsanitary conditions of the snack distribution process. The facility's policy requires that snacks be offered in accordance with residents' needs and preferences, but this was not adhered to. The snack cart was not consistently distributed, and the options provided were limited and not updated regularly. The dietary manager confirmed that the snack list had not been updated for some time, and the current offerings did not align with the residents' preferences or dietary needs. The facility's failure to provide appropriate snacks as per the residents' needs and preferences constitutes a deficiency in care.
Failure to Administer COVID-19 Vaccine as Requested
Penalty
Summary
The facility failed to administer a COVID-19 vaccination to a resident who had requested it. The resident, identified as R14, asked for the COVID-19 vaccine when she received her influenza vaccination in September 2024. Despite her request, the vaccine was not administered, and she subsequently contracted COVID-19 in November 2024. The resident's medical record indicated that her COVID-19 vaccination status was pending, and her last documented COVID-19 vaccination was in January 2024. The Director of Nursing (DON) acknowledged that the COVID-19 vaccine was ordered from the facility's contracted pharmacy but was not delivered on multiple occasions. The DON did not attempt to secure the vaccine from a backup local pharmacy or contact the health department for alternative sources. The facility's policy allows for the vaccine to be administered directly or through arrangements with a pharmacy partner or local health department, but these options were not utilized in this case.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident sexual abuse to the State Agency (SA) as required by their policy. The incident involved a resident, identified as R900, and an occupational therapist (OT C). A complaint was filed with the SA, stating that the therapist had been having sexual relations with the resident, and it was alleged that everyone in the facility was aware of the situation. A certified nurse aide (CNA D) reported the allegation to the Nursing Home Administrator (NHA) on August 30, 2024, but the NHA initially stated that no abuse allegations had been reported in the last 30 days. Further interviews revealed that the Director of Nursing (DON) was aware of the allegation and had consulted the facility's legal team, who advised that the incident was not reportable because the resident was believed to be on a leave of absence when the alleged abuse occurred. However, the facility's policy mandates immediate reporting of such allegations to the SA and other relevant authorities within two hours if the events involve abuse or result in serious bodily injury. The facility did not adhere to this policy, as confirmed by the NHA, who acknowledged the failure to report the allegation to the SA.
Incomplete Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving a resident and a staff member. The complaint, filed with the State Agency, alleged that an Occupational Therapist (OT) was having a sexual relationship with a resident. A Certified Nurse Aide (CNA) reported the allegation to the Nursing Home Administrator (NHA) but was not asked to provide a written statement or further questioned about the incident. The Director of Nursing (DON) confirmed that the allegation was reported, and the facility's legal team was consulted due to the belief that the resident was on a leave of absence when the alleged incident occurred. The investigation file provided by the DON and NHA contained only one interview with the resident involved, with no additional interviews or witness statements collected. The NHA admitted that the investigation was incomplete and did not adhere to the facility's abuse policy, which requires identifying and interviewing all involved parties, including the alleged perpetrator and witnesses. The OT was transferred to another facility by the corporate therapy company, but no further investigative actions were documented.
Latest citations in Michigan
The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
