Medilodge Of Marshall
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshall, Michigan.
- Location
- 879 East Michigan Ave, Marshall, Michigan 49068
- CMS Provider Number
- 235495
- Inspections on file
- 32
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Medilodge Of Marshall during CMS and state inspections, most recent first.
A resident with necrotizing fasciitis, depression with anxiety, and type 2 DM, who was cognitively intact, reported concerns about late pain medication. The resident had a physician order for oxycodone 10 mg every 4 hours, scheduled six times daily, but controlled substance records showed multiple instances of administration intervals that were shorter or longer than 4 hours. An RN reported that nurses often covered two halls, leading to late medication administration, and the DON confirmed that the oxycodone was not consistently signed out according to the every-4-hour order.
A resident with multiple comorbidities and intact cognition developed several facility-acquired pressure ulcers on the right heel and medial malleolus, including an unstageable heel wound attributed to a brace and another heel wound that progressed to a stage 3 ulcer. The record showed multiple overlapping and conflicting wound care orders for the same wound sites and repeated missed treatments on several ordered days. During observation, dressings that had not been changed for several days were removed, revealing unstageable and stage 3 pressure ulcers with increased size, drainage, foul odor, and slough, while the resident reported significant pain despite the wound nurse using appropriate infection control during the dressing changes.
A resident with severe cognitive impairment and dementia, known to have a history of physical aggression toward others, was left in a dining room without documented, active interventions to prevent altercations. While another cognitively impaired resident with significant neurological and psychiatric conditions was shouting, the aggressive resident grabbed the resident’s clothing and struck the resident multiple times in the face, causing a scratch, before a CNA intervened. Facility records showed multiple prior aggressive incidents by the same resident, particularly in the dining room, yet the care plan lacked ongoing, specific strategies to prevent such behaviors in that setting, and leadership could not provide evidence of appropriate behavioral interventions despite a policy requiring assessment and care planning for residents with behaviors that might lead to conflict.
Nursing staff failed to follow professional standards for medication administration when an RN preceptor pulled a full set of morning medications, including insulin and antihypertensives, for one resident and handed them to an LPN on orientation who lacked access to the electronic MAR. The LPN did not verify the five rights of medication administration and gave the medications to a different resident with multiple comorbidities, while that resident’s own scheduled morning medications were held. Interviews confirmed that the person who removed the medications from the cart did not administer them and that standard medication verification practices were not followed.
A resident with multiple chronic conditions was given another resident’s full morning medication regimen, including insulin and cardiovascular medications, after an RN preceptor removed and documented the medications in the EHR for a different resident and then handed them to an orienting LPN who lacked MAR access. The LPN did not verify the five rights of medication administration and administered the medications to the wrong resident, while the resident’s own scheduled morning medications were held. A regional clinical consultant later identified that the person who pulled the medications was not the one who administered them and that standard professional practices and the five rights were not followed.
A resident with severe cognitive impairment was the subject of a suspected abuse allegation involving possible non-consensual sexual activity, as reported by a roommate. The allegation was initially communicated by a CNA to an LPN, but there was no immediate follow-up or investigation. Subsequent staff, including an RN, delayed reporting while waiting for clarification from the LPN, resulting in a late notification to the State Agency.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident receiving hospice care, who was cognitively intact, reported being verbally and physically abused by a CNA during an argument about a room change. The resident stated the CNA yelled, called him names, and struck him on the head with a roll of an object. Multiple staff members confirmed witnessing the CNA being verbally and physically aggressive with other residents and reported these behaviors to management, but the CNA continued to work in the facility.
A resident who was bed bound, non-verbal, and dependent on staff for all ADLs did not receive scheduled showers or bed baths, and had excessively long fingernails and toenails with no documentation of nail care or podiatry consult. The resident was observed with matted hair and an unpleasant odor, indicating a failure to provide necessary grooming and hygiene services as required by facility policy.
A resident with multiple complex medical conditions who was totally dependent on staff for toileting did not have required two-hourly toileting and shift-based bowel elimination documented for several periods. The DON confirmed that documentation was missing and could not provide evidence that the resident received necessary assistance, following a complaint that the resident was left in a wet brief for an extended time.
A resident with multiple chronic conditions did not receive prescribed Hydrocodone-Acetaminophen for pain management as ordered by the physician. Documentation showed missed doses due to issues with medication supply and delays in reordering, and the DON confirmed that staff did not reorder the medication before it ran out.
A resident with severe cognitive impairment and multiple comorbidities was not accurately assessed or monitored for pressure ulcers. Wound documentation was inconsistent, with measurements for separate wounds sometimes combined and assessments not matching photographic evidence. The wound nurse could not explain these discrepancies, and the plan of care did not accurately reflect the resident's wound status. The DON confirmed the inaccuracies in both wound assessments and care planning.
The facility failed to maintain a clean and functional environment, affecting 91 residents. Observations revealed leaking sinks, soiled light covers, and non-cleanable surfaces in the laundry rooms. Common areas and resident rooms had accumulated dust, non-functional lights, and damaged fixtures. The facility's cleaning and maintenance protocols were not followed, increasing the risk of cross-contamination and bacterial harborage.
A resident with cognitive intactness and multiple diagnoses experienced ongoing frustration due to constant yelling from nearby residents. Despite informing staff, grievances were not documented or resolved, leading to increased frustration and uncharacteristic behavior from the resident. CNAs confirmed the issue was reported to the Unit Manager, but no changes were made.
A facility failed to accurately complete MDS assessments for a resident, resulting in incorrect documentation of insulin injections. The resident's MDS indicated insulin administration, but physician orders showed no record of such treatment. The MDS Coordinator confirmed the inaccuracies but could not explain the discrepancies.
A resident with multiple health issues was not provided with the 1:1 activities outlined in her care plan, leading to unmet care needs and increased frustration among other residents. Despite being cognitively intact, she was observed repeatedly yelling for help without staff intervention. Interviews with CNAs confirmed the lack of engagement, and documentation was insufficient to show that activities were offered as planned.
A resident with cognitive intactness and multiple health conditions was not provided with meaningful, individualized activities as per her care plan. Despite being at risk for altered activity patterns, the resident was often found in bed yelling for help, with no staff engaging in 1:1 activities. CNAs reported that the resident did not get out of bed and was not observed participating in activities, causing frustration among other residents. The facility's documentation showed limited 1:1 activity offerings, and the administrator acknowledged the lack of adherence to the care plan.
A resident developed a stage 3 pressure ulcer due to the facility's failure to adhere to care plans and policies. The resident, admitted with multiple health issues, did not initially have pressure ulcers. However, inconsistent documentation and failure to implement interventions like regular turning and use of pressure redistribution mattresses led to the ulcer's development. The Wound Nurse missed the initial assessment and incorrectly staged the wound, while documentation showed the resident was not turned every two hours as required.
The facility failed to document the size of tracheostomy cannulas in physician orders for two residents, leading to a deficiency in professional standards for respiratory care. One resident's tracheostomy care was inconsistent, and the size of the cannula was known by staff familiarity rather than documented orders. The issue was confirmed by facility staff, who acknowledged the need for clearer documentation.
A resident with a history of depression and anxiety experienced increased distress due to constant yelling from other residents. Despite reporting frustrations, the facility failed to address the issue, leading to the resident's decreased social interaction and increased withdrawn and angry behaviors. Incomplete mood assessments and ineffective interventions contributed to the deficiency.
A resident identified as a high fall risk was found injured on the floor due to the absence of a fall protection mat, as required by their care plan. Despite being able to move independently, the resident was unsteady and unsafe without assistance. The lack of the mat, confirmed by the DON and admitted by an LPN, led to the resident sustaining head and leg injuries.
A resident with dementia and major depressive disorder experienced discrepancies in the controlled medication count for ABHR Cream. The facility's records showed inconsistent remaining amounts of the medication, with no documentation explaining the discrepancies. The DON suggested air in the container as a cause, but a pharmacy technician confirmed that air would not affect the count. The facility lacked ABHR gel/cream at the time of the investigation.
The facility failed to respect resident dignity and privacy, as staff entered rooms without knocking and referred to a resident disrespectfully. A resident was observed without a meal, and a CNA referred to them as 'whatever, whatever,' which the resident found disrespectful. The resident was new to the facility and expressed feeling disrespected by the comment.
A resident with hemiplegia experienced a delay in receiving a necessary x-ray for left hand pain, ordered on October 1, 2024, but not completed until October 12, 2024. The delay was attributed to an imaging company issue and miscommunication among staff. The resident reported severe pain, and staff interviews confirmed the expectation for quicker x-ray completion.
A resident with a full code status was found unresponsive in a facility, but CPR was not initiated by staff until EMS arrived. Despite the facility's policy requiring immediate CPR, staff delayed action, checking the code status and calling 911 instead. The resident had a history of Obstructive Sleep Apnea and Morbid Obesity, and the delay in CPR initiation resulted in Immediate Jeopardy.
A facility failed to create a comprehensive care plan for a resident with severe cognitive impairment and a history of swallowing non-food items. The care plan lacked specific interventions to prevent the resident from ingesting non-food items, despite previous hospitalizations for such behavior. The deficiency was identified during a survey, and the issue was acknowledged by facility administrators.
A resident with cerebral atherosclerosis, legal blindness, and dementia experienced a fall, resulting in a lack of documented neurological assessments in the facility's records. Despite the fall, the facility did not have a specific neurological assessment policy, and the Director of Nursing believed the standard of care was followed with daily neuro checks. However, the documentation showed outdated vital signs and no detailed neurological assessments, raising concerns about the thoroughness of the assessments.
A resident with Obstructive Sleep Apnea and Morbid Obesity was not reassessed for respiratory status after a hypoxic episode, despite having used a CPAP machine in the hospital. An LPN administered oxygen, but no further assessments were documented. The resident was later found unresponsive and pronounced dead after CPR efforts. The DON acknowledged the need for follow-up assessments, and the facility did not provide additional information on CPAP use.
The facility failed to provide written notice before room changes for four residents, violating their rights. Room changes were related to payor source transitions from Medicare to Medicaid, but no written notices were documented, affecting residents with conditions such as dementia, anxiety disorder, cerebral infarction, anemia, COPD, diabetes, bipolar disorder, and major depressive disorder.
The facility failed to maintain cleanliness and repair in resident bathrooms, with observations of dried feces on toilet surfaces and structural issues like peeling wall molding and worn door frames. The Maintenance Manager was unaware of these issues due to reliance on the TELS system for maintenance communication, indicating a lapse in the facility's preventive maintenance program.
The facility failed to maintain accurate medical records for two residents. One resident had a DNR order, but CPR was performed without documentation of the event. Another resident's transfer to the hospital was inadequately documented, lacking details about their condition and necessary forms. These deficiencies highlight lapses in record-keeping and communication.
Failure to Administer Oxycodone as Ordered Every 4 Hours
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication as ordered for a cognitively intact resident with necrotizing fasciitis, major depressive disorder with anxiety, and type 2 diabetes. The resident was admitted with these diagnoses and had an MDS BIMS score of 13/15, indicating intact cognition. During an observation, the resident reported concerns that their pain medications were occasionally administered late. The physician’s order dated 12/30/25 directed that oxycodone 10 mg be given every four hours, and the MAR showed scheduled administration times at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM daily. Review of the controlled substance records for the resident’s oxycodone 10 mg showed multiple instances where the medication was signed out at intervals shorter or longer than the ordered four hours. Examples included doses given approximately 2 hours and 18 minutes apart, 4 hours and 45 minutes apart, 4 hours and 50 minutes apart, over 5 hours apart, and as close as 1 hour and 45 minutes apart on various dates. In an interview, an RN stated that nurses often worked two halls, resulting in late medication administration. The DON stated that the controlled substance records should reflect the time the medication was pulled for administration and that, for an every-4-hour order, staff were expected to sign it out every four hours unless refused. The DON reviewed the records and agreed that the oxycodone had been signed out outside of the ordered every-4-hour schedule.
Failure to Prevent and Properly Treat Pressure Ulcers on Resident’s Right Foot
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and progression of pressure ulcers and to consistently provide ordered wound care for one resident with multiple right foot pressure injuries. The resident was admitted with multiple medical conditions including COPD, obesity, anxiety, mild neurocognitive disorder, neuromuscular bladder dysfunction, depression, anemia, hypothyroidism, insomnia, hypertension, sleep apnea, GERD, and osteoarthritis, and was cognitively intact per a recent MDS. The MDS documented one stage 3 pressure ulcer present on admission and one unstageable pressure ulcer that was not present on admission. Facility records identified three facility-acquired wounds on the right foot: an unstageable right heel wound attributed to a brace, an initially unstageable right superior heel wound that progressed to a stage 3 pressure ulcer, and an unstageable right medial malleolus wound, all with documented increases in size over time. The medical record showed multiple overlapping and conflicting treatment orders for the right heel and right medial malleolus, including different instructions for cleansing, use of betadine, iodine, calcium alginate, Medihoney, and various dressings, with several orders remaining active simultaneously. During interview, the wound nurse responsible for pressure wound oversight acknowledged that some of these orders should have been deleted and was unable to identify which orders were correct for either the right heel or the right medial malleolus. Review of the treatment records revealed that ordered wound care was not completed on multiple specified dates for both the right heel and right medial malleolus wounds, despite the orders being in effect. On observation, the resident was found in bed on an alternating air mattress with the right foot elevated, and reported having several pressure wounds on the right foot caused by a boot previously worn at the facility. During a wound care observation, dressings dated three days prior were removed from the right heel, right superior heel, and right medial malleolus. The right heel wound was observed as unstageable with eschar; the right superior heel wound had a large amount of yellowish/greenish drainage with foul odor and was measured and classified as a stage 3 pressure ulcer with a pink granulating wound bed; and the right medial malleolus wound appeared unstageable with slough tissue and increased dimensions. The wound nurse performed cleansing and dressing changes using wound wash, betadine, calcium alginate, Medihoney, and bordered gauze, and used appropriate infection control technique. The resident reported pain rated between 7 and 9 out of 10 at the conclusion of the dressing changes.
Failure to Prevent Resident-on-Resident Physical Abuse in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by another resident, despite a known history of aggressive behaviors. One resident (R2) had multiple neurological and psychiatric diagnoses, including pseudobulbar affect, severe intellectual disabilities, cognitive impairment, bipolar disorder, and conversion disorder with seizures, and was documented as rarely or never understood on the most recent MDS. Another resident (R6) had severe cognitive impairment with a BIMS score of 3, along with Alzheimer’s disease, dementia, depression, morbid obesity, and other medical conditions. Both residents were present in the dining room at the time of the incident. On the date of the incident, an incident report documented that R6 approached R2 in the dining room while R2 was shouting, became upset, yelled at R2, and then hit R2 in the face multiple times, leaving a scratch on R2’s nose. A CNA witness stated that she entered the dining room to report off to another CNA, observed R6 standing beside R2, heard R2 begin to yell, and then saw R6 grab R2 by the sweatshirt and hit R2 three to four times on the forehead before the CNA separated them. The CNA reported that she was aware R6 had a history of altercations with other residents and believed R6 was not to be left unattended in the dining room or placed next to other residents there, and she did not see any other staff member observing R6 in the dining room at the time. Record review showed that R6 had multiple prior documented incidents of physical aggression toward other residents, including accusations of physical aggression, altercations and hitting in the dining room, slapping another resident in the dining room, throwing a plastic bottle at another resident in the dining room, and hitting a roommate. R6’s care plan identified behavioral issues such as physical aggression toward staff and other residents, yelling, hitting, wandering into other residents’ rooms, and resistance to care, but the interventions listed were time-limited (such as 1:1 care until infection ruled out and frequent checks) and had been resolved before the incident. The care plan did not include interventions specifically aimed at preventing altercations in the dining room. The Nursing Home Administrator confirmed R6’s prior altercations in the dining room and could not provide evidence of care plan interventions implemented after each altercation or in place prior to the incident to prevent R6’s behaviors and potential physical altercations, despite a facility policy requiring identification, ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or neglect.
Medication Error During LPN Orientation Leads to Wrong-Resident Administration
Penalty
Summary
The deficiency involves nursing staff failing to follow professional standards for medication administration, resulting in one resident receiving another resident’s medications. Resident #1 was admitted with multiple diagnoses including depression, thyroiditis, GERD, osteoporosis, dementia, sleep apnea, insomnia, chronic pain, dysphagia, and hypercholesterolemia. On the date of the incident, Resident #1 received a full set of morning medications that had been ordered for Resident #7, including Farxiga 10 mg, hydrochlorothiazide 25 mg, furosemide 20 mg, loratadine 10 mg, a multivitamin, potassium chloride 10 mEq, Tylenol 650 mg, Lantus 22 units subcutaneous, and metoprolol tartrate 25 mg. Resident #1 later recalled receiving the wrong medication but could not recall the specific drugs or the date, and reported no negative outcome. Resident #7 had been admitted with chronic respiratory failure, type 2 diabetes, depression, PTSD, hypercholesterolemia, anxiety, adjustment disorder, mild cognitive impairment, dementia, dysphagia, hypertension, and a cognitive communication deficit, and had a BIMS score of 12, indicating moderate cognitive impairment. The medications administered to Resident #1 were those ordered for Resident #7. Review of Resident #1’s medical record showed that blood sugars were monitored following the event, with readings of 126 mg/dL, 150 mg/dL, 218 mg/dL, and 123 mg/dL over the subsequent hours. Resident #1’s October MAR showed that all of her own 0800 medications, including alendronate, cholecalciferol, duloxetine, fenofibrate, hydrochlorothiazide, losartan, clonidine, and famotidine, were held that morning. Interviews revealed that the error occurred during orientation of a new LPN. The Nursing Home Administrator and Regional Clinical Consultant stated that an RN preceptor pulled the medications for Resident #7 from the medication cart and then handed them to the LPN, who was on orientation and did not have access to the electronic MAR in PointClickCare. The LPN then administered these medications to Resident #1 instead of Resident #7 and acknowledged not following the five rights of medication administration (right patient, right medication, right dose, right time, right route). The Regional Clinical Consultant stated that professional practice dictates that the person who pulls the medication should be the one to administer it, and that this standard, as well as the five rights, were not followed in this incident.
Medication Error When Precepting Nurse Prepares Medications for Another Nurse
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when one resident received another resident’s medications, including insulin and antihypertensive medication. The affected resident had multiple diagnoses, including depression, thyroiditis, GERD, osteoporosis, dementia, hypercholesterolemia, sleep apnea, insomnia, chronic pain, and dysphagia. The resident and a family member both reported that the resident had been given the wrong medications, with the family member specifically noting insulin and a blood pressure medication. The resident recalled receiving the wrong medication but could not identify which medications or when the incident occurred. Record review showed that on the morning in question, the resident was administered a full set of medications that were ordered for another resident with chronic respiratory failure, type 2 diabetes, depression, PTSD, hypercholesterolemia, anxiety, mild cognitive impairment, dementia, dysphagia, hypertension, and cognitive communication deficit. The medications given in error included Farxiga 10 mg, hydrochlorothiazide 25 mg, furosemide 20 mg, loratadine 10 mg, a multivitamin, potassium chloride 10 mEq, acetaminophen 650 mg, Lantus 22 units subcutaneously, and metoprolol tartrate 25 mg. The resident’s blood sugars were monitored and documented following the error, and the medication administration record showed that the resident’s own scheduled 0800 medications were held that day. Interviews with facility staff revealed that the error occurred during orientation of a new LPN. The precepting RN pulled and documented the medications for the other resident in the electronic system because the orienting LPN did not yet have access to the electronic MAR. The RN then handed those medications to the LPN to administer. The LPN reported that she did not follow the five rights of medication administration and mistakenly gave the medications to the wrong resident. The regional clinical consultant identified that the root cause was the LPN not pulling the medications herself and not following the five rights, and that professional practice standards requiring the same person to both pull and administer medications were not followed.
Failure to Timely Report Suspected Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the State Agency involving a resident with severe cognitive impairment. A resident with a low BIMS score, indicating severe cognitive impairment and inability to consent, was alleged by their roommate to be involved in sexual activity with another person. The initial allegation was reported by a CNA to an LPN, but the LPN did not follow up to gather more information. The CNA reported the allegation again to the charge nurse and an RN during a subsequent shift, but the RN delayed action, waiting for the LPN to arrive before proceeding. The Nursing Home Administrator was not notified until the following morning. The incident was ultimately reported to the State Agency, but not until several hours after the initial allegation was made. The delay in reporting was due to a lack of immediate follow-up and communication among staff, including the LPN not investigating further and the RN waiting for confirmation from the LPN before taking action. The facility's failure to promptly report the suspected abuse as required resulted in a deficiency.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Resident from Verbal and Physical Abuse by CNA
Penalty
Summary
A resident under hospice care, who was cognitively intact, reported being verbally and physically abused by a Certified Nursing Assistant (CNA) approximately a year prior to the survey. The resident described an incident where the CNA argued with him about a room change, yelled at him, called him names, and struck him on the head with a roll of an object, possibly a paper towel. The resident stated he reported the incident at the time, and the CNA continued to work at the facility, though was not assigned to his care. The facility's incident report corroborated the resident's account, and staff interviews revealed that multiple staff members were aware of the CNA's aggressive behavior toward residents, including both verbal and physical abuse, which had been reported to management. Several staff members, including CNAs and LPNs, confirmed witnessing the CNA being verbally and physically aggressive with other residents and reported these incidents to management. One LPN specifically recalled witnessing the CNA being verbally abusive toward the resident in question and other residents, and stated that management responded by moving the CNA to another hall. The Director of Nursing and Nursing Home Administrator indicated that the abuse prevention coordinator at the time handled the investigation. The facility's policy on abuse, neglect, and exploitation lists resident or staff reports of abuse and observed verbal or physical abuse as possible indicators, all of which were present in this case.
Failure to Provide Scheduled Bathing and Nail Care
Penalty
Summary
A resident with diagnoses including aphasia and cerebral infarction was admitted and readmitted to the facility, and was described as rarely or never understood, bed bound, incontinent, and unable to make her needs known. The resident required staff assistance for all activities of daily living, including bathing and personal hygiene, and was scheduled to receive showers on Sundays and Wednesdays. Observations revealed that the resident's fingernails and toenails were excessively long, her hair was matted, and she had an unpleasant odor. Review of facility records showed that the resident did not receive a shower or bed bath on her scheduled days, and there was no documentation of completed nail care. Additionally, there was no evidence that a podiatry consult had been requested to address the long toenails. Facility policy required that residents unable to perform activities of daily living receive necessary services to maintain grooming and hygiene, but these services were not provided as scheduled for this resident.
Failure to Provide and Document Required Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically toileting and incontinence care, for a resident who was totally dependent on staff for these needs. The resident, who had multiple complex medical conditions including COPD, morbid obesity, pulmonary fibrosis, and congestive heart failure, was admitted and required one-person assistance for toileting. Documentation revealed that required two-hourly toileting and shift-based bowel elimination records were missing for several time periods during the resident's stay. This lack of documentation indicated that the resident may not have been offered or provided toileting assistance as required by facility policy. The Director of Nursing confirmed during an interview that it was the facility's expectation and practice to offer and document toileting every two hours for newly admitted residents, and to document bowel movements once per shift. Upon review, the DON acknowledged the absence of documentation for the specified periods and could not provide any alternative records to demonstrate that the resident received the necessary assistance. The deficiency was identified following a complaint that the resident had been left in a wet brief for an extended period.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to implement physician orders for the administration of pain medication for one resident. The resident was admitted with multiple chronic conditions, including rheumatoid arthritis, and had a series of physician orders for Hydrocodone-Acetaminophen to be administered at specific intervals for pain management. Review of the medical administration record (MAR) showed that the pain medication was not documented as given according to the physician's orders. Progress notes indicated ongoing issues with obtaining the medication from the pharmacy and the facility's emergency drug kit (EDK), resulting in missed doses. Interviews with the Director of Nursing (DON) confirmed awareness of the issue and revealed that the resident's pain medication supply had run out, necessitating a new order for the pharmacy to provide additional medication or approve use from the facility's backup supply. The DON stated that it was expected for staff to reorder the medication before it ran out, but could not explain why this was not done. As a result, the resident did not receive pain medication as ordered by the physician.
Failure to Accurately Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and monitor pressure ulcers for a resident with multiple medical conditions, including severe cognitive impairment, COPD, dementia, and a history of falls. The resident was admitted with significant risk factors for skin breakdown and was documented to have pressure injuries on the left gluteus and coccyx. Multiple Skin and Wound Evaluation forms were completed over several weeks, but the documentation was inconsistent and inaccurate. Wound measurements were sometimes combined for separate wounds, and at times, the assessments did not match the photographic evidence, with some wounds not being individually measured or properly classified. Interviews with the wound nurse revealed a lack of clarity and understanding regarding the documentation and assessment process. The wound nurse was unable to explain why wounds were recorded as a single injury when photographs showed two distinct wounds, or why some wounds were not measured separately. Additionally, the wound nurse could not account for discrepancies between the documented wound locations and the actual wounds observed in photographs. The plan of care for the resident was also found to be inaccurate, as it did not reflect the presence of both pressure ulcers or indicate when a wound had healed. The Director of Nursing confirmed that the wound assessments and the resident's plan of care were not completed accurately. Observations of wound care revealed that only the coccyx wound was present and treated, while the left gluteal area was intact. The documentation, however, did not consistently reflect these findings, and the plan of care was not updated to accurately represent the resident's current wound status.
Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to effectively clean and maintain its physical plant, affecting 91 residents. During an environmental tour of the facility's laundry service, it was observed that the clean laundry room had a leaking hand wash sink cold water supply valve and soiled overhead light assembly lens covers. In the soiled laundry room, transport carts were found to be etched and scored, creating non-cleanable surfaces. Additionally, the common areas, including the nurses' station and staff restrooms, were noted to have accumulated dust and dirt deposits, and several light assemblies were non-functional. In various units, multiple deficiencies were observed, including stained ceiling tiles, loose commode supports, and non-functional resident call systems. The nursing supply closets had bare and unsealed shelving units, and the emergency water supply closet was in disarray with soiled containers. Resident rooms across different units had non-functional light assemblies, missing pull string extensions, and damaged drywall surfaces. The commode base caulking in many restrooms was etched and scored, and several hand sink basins were draining slowly. The facility's policies and procedures for cleaning schedules and preventative maintenance were reviewed, revealing that routine cleaning and maintenance were not performed according to the predetermined schedule. The Direct Supply TELS work orders for the last 60 days showed no specific entries related to the maintenance concerns identified during the survey. This lack of adherence to cleaning and maintenance protocols increased the likelihood of cross-contamination and bacterial harborage, posing a risk to the safety and comfort of residents, staff, and the public.
Plan Of Correction
Element #1 Clean Laundry Room: Hand wash sink leak was fixed. Overhead light assembly clear plastic protective lens covers cleaned. Soiled Laundry: 6 new laundry transport carts were ordered. Nurses station: 6 new chairs were ordered. Staff Restroom: return-air-exhaust cleaned Shower Room (A): wand assembly corrected light assemblies functioning, hand sink basin re-secured. Call light system corrected. Nursing Supply Closets ALL now have painted, sealed shelves. Stained ceiling tiles replaced. Womens Locker Room: sink drain repaired, cove base reinstalled, Emergency Water Supply area cleaned with new shelving purchased. Staff Breakroom was cleaned including the toaster and refrigerator freezer unit. A11 - The restroom overhead light assembly was fixed. The restroom commode base perimeter was also cleaned and caulked. B1 - The restroom over sink light assembly was fixed. The restroom commode base perimeter caulking was redone. The interior and exterior commode base surfaces were cleaned. The window ledge drywall surface was repaired. The floor mounted heating grill assembly was replaced. B7 - The commode base caulking was redone. B9 - The floor mounted heating grill plate was replaced. C2 - Commode base caulking was repaired. The restroom sink was unclogged and is draining normally. C3 - The Bed 1 over bed light assembly pull string was replaced. The Bed 2 floor mounted anti-skid strips were replaced. The restroom over sink light assembly corrected and is functioning. The restroom commode base caulking was replaced. The restroom bathtub interior surface and perimeter surround was cleaned. The Bed 1 over bed light assembly pull string was added. C6 - The Bed 2 over bed light assembly pull string extension was replaced. The restroom overhead light assembly was also fixed. The restroom commode base caulking was redone. The restroom commode base seat was replaced. C-7 - The restroom commode base caulking was repaired. The restroom over sink light assembly was also corrected. The restroom overhead light assembly protective lens cover was cleaned and replaced. The Bed 2 drywall surface was further observed (etched, scored, particulate), adjacent to the footboard. The damaged drywall surface measured approximately 4-feet-wide by 4-feet-long. C9 - The restroom commode base caulking was redone. The restroom overhead light assembly was also corrected. C-10 - The restroom commode base caulking redone. The restroom hand sink basin was unclogged and is draining normally. The restroom perimeter wall/flooring coving strip was reinstalled and is no longer loose. D2 - The restroom commode base caulking was redone. The restroom over sink light assembly was also corrected. The restroom commode support was additionally tightened. D-3 - The restroom commode base caulking was replaced. The restroom overhead light assembly was also corrected. The Bed 2 drywall surface was repaired. D7 - The commode base caulking was replaced. The restroom and sink basin caulking was also replaced. The drywall surface was repaired. D-9 - The restroom commode base caulking was replaced. The restroom commode base was also tightened. The restroom commode support was additionally tightened. The restroom over sink light assembly was repaired. The restroom overhead light assembly lens cover was also cleaned. The Bed 1 over bed light assembly pull string extension was replaced. D-11 - The restroom commode base caulking was repaired. The restroom commode base was also tightened. The restroom commode support was additionally tightened. The restroom over sink light assembly was fixed. The restroom overhead light assembly lens cover cleaned. The Bed 1 over bed light assembly pull string extension was added. D-13 - The Bed 1 over bed light assembly pull string extension was added. The restroom commode base caulking was also replaced. D-17 - The restroom commode base caulking was redone. The restroom overhead light assembly lens cover was cleaned. Element 2 Residents who reside in facility are considered at risk. Facility-wide audit was completed to ensure a safe and sanitary environment is possible for all residents. Findings were entered into TELS and corrected by facility maintenance. Element 3 The Administrator has reviewed the Preventative maintenance policy and cleaning schedules policy and deemed them appropriate. Staff have been educated on the use of the TELS work order system. Staff will utilize TELS daily to submit needed work orders. Element 4 NHA or designee will audit 10 areas each week x4 weeks, then monthly to ensure proper maintenance needs have been met, and surfaces are cleanable. Results will be reviewed monthly by QAPI until substantial compliance achieved. Administrator is responsible for overall compliance.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances were promptly documented, investigated, tracked, and resolved for a resident, resulting in ongoing frustration and unresolved grievances. The resident, a cognitively intact female with diagnoses including hypertension, Guillain-Barre Syndrome with paraplegia, major depression, and anxiety disorder, expressed repeated frustration over the constant yelling of nearby residents. Despite informing staff of her grievances, no changes were made, and the resident was not familiar with the facility's grievance process. Observations and interviews revealed that the resident and her roommate preferred to keep their door closed due to the noise, and the resident resorted to using ear buds to cope with the situation. Certified Nurse Aides (CNAs) working on the hall confirmed that complaints about the yelling were common and reported to the Unit Manager. However, the grievances were not documented or resolved, leading to increased frustration for the resident, who even began yelling back, which was uncharacteristic for her.
Plan Of Correction
Element 1: Resident #52 no longer resides in the facility. Resident #52 concerns were addressed with the Assistant Administrator. A white noise machine was purchased to assist with the noise level in the hall. Follow-up visit was completed, and the resident states the machine has helped. Concern form signed and completed by the Administrator. Element 2: The Administrator/Designee will complete an audit of residents to ensure concerns have been documented on grievance forms. Any new concerns will be documented per the QA policy and addressed. Element 3: The QAPI Committee will review the Quality Assistance Procedure policy and deem it appropriate. The Administrator and Director of Nursing have been educated by Regional Director of Operations on the QA Policy. Staff will be educated on the QA policy/grievance policy to ensure concerns are addressed appropriately. Staff to turn concern forms to the administrator daily. Administrator will follow up with appropriate departments to ensure concerns are addressed. Element 4: Administrator/Designee will complete random weekly audits for 4 weeks and then monthly until substantial compliance is achieved, ensuring concern forms and follow-up are completed. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. The Administrator is responsible for achieving and maintaining compliance.
Inaccurate MDS Assessments for Insulin Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for a resident, resulting in inaccurate documentation. The resident, who was admitted with multiple diagnoses including type 2 diabetes, hypertension, and vascular dementia, had discrepancies in the MDS assessments regarding insulin injections. The MDS with an Assessment Reference Date (ARD) of 02/28/2025 indicated that the resident received one insulin injection during the seven-day look-back period, while the MDS with an ARD of 12/24/2024 indicated seven injections. However, a review of the resident's physician orders showed no record of insulin injections during the entire stay at the facility. The MDS Coordinator, responsible for completing the MDS, confirmed the inaccuracies in the assessments. Despite reviewing the physician orders, the coordinator could not explain why the MDS assessments contained incorrect information about insulin administration. This discrepancy highlights a failure in accurately documenting the resident's medical treatment, which is crucial for ensuring appropriate care and treatment plans.
Plan Of Correction
Element 1: Resident #8 MDS assessment was modified to ensure correct coding of section N of the MDS. Element 2: All current residents with insulin coded on the most recent MDS were reviewed to verify accurate drug class coded, and modifications were made as necessary. Element 3: Regional MDS Coordinator to provide facility MDS coordinator and MDS nurse education on RAI manual Chapter 3, pages N1-N28, for accurate coding of Section N. Facility MDS staff provided with pharmacy reference material to identify proper drug classes of medications. MDS will verify MDS coding of section N to ensure appropriate coding of insulin medication class prior to completion. Element 4: MDS coordinator or designee will audit Section N for accurate insulin coding for 5 residents weekly x4 weeks, and then 5 residents monthly x 3 months. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Administrator is responsible for overall compliance.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered care plan for a resident, resulting in unmet care needs and increased frustration among other residents. The resident, a cognitively intact female with multiple diagnoses including hypertension, heart failure, kidney failure, lung cancer, depression, and anxiety disorder, was observed repeatedly yelling for help from her room without receiving attention from staff. Despite having a care plan that included 1:1 visits and activities to engage her, there was no evidence of these activities being carried out, as the resident was observed in bed without interaction or engagement from staff over several days. Interviews with Certified Nurse Aides (CNAs) revealed that the resident did not get out of bed and that they had never observed staff conducting 1:1 activities with her. The resident's yelling was noted in nurse progress notes as a daily occurrence, causing frustration and sleep disruption for other residents. The Nursing Home Administrator (NHA) acknowledged the lack of documentation in the resident's medical record regarding offered activities, which were only noted on five occasions over a 60-day period. There was also no evidence that the resident had been invited to participate in group activities or taken outside.
Plan Of Correction
Element 1: Resident 7 no longer resides in facility. Element 2: Residents in facility were reviewed to ensure their care plans were implemented appropriately to reflect activities, interests, and preferences. If missing, interests and preferences were added to care plans. Element 3: Education was provided to Activity Director and staff to ensure care plans are implemented timely to include interests. Activities staff will ensure comprehensive care plans are updated upon completing the activities assessment. Element 4: Act dir/designee will audit 10 random residents weekly to ensure activity comprehensive care plan is completed and individualized. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide meaningful, individualized, and engaging activities to a resident, identified as R7, who was cognitively intact and had a history of hypertension, heart failure, kidney failure, depression, and anxiety disorder. Despite having a care plan that included 1:1 visits from staff and volunteers, and a preference for activities such as keeping up with the news, watching TV, coloring, word searches, and reading, there was no evidence of 1:1 activity visits being conducted. Observations revealed that R7 was often found in bed, yelling for help, and no staff were observed entering the room to engage with the resident. The resident's care plan also indicated a risk for altered activity patterns due to anxiety and disinterest, yet the facility did not adhere to the plan. Interviews with Certified Nurse Aides (CNAs) revealed that R7 did not get out of bed and staff were not observed conducting activities with the resident. The CNAs reported that residents on the same hall often complained about yelling, which caused frustration and sleep disruption. The facility's documentation showed that R7 was only offered 1:1 activities on five occasions over a 60-day period, and there was no documentation of R7 being invited to or refusing group activities or outdoor programs. The facility's administrator acknowledged the lack of documentation in the medical record and the failure to follow the resident's care plan.
Plan Of Correction
Element 1: Resident 7 no longer resides in facility. Element 2: Residents in facility were reviewed to ensure their care plans were updated appropriately to reflect interests and preferences. If missing, interests and preferences were added to care plans. Element 3: Education was provided to Activity Director and staff to ensure likes/dislikes are followed, care plans are updated, and a meaningful and diverse calendar was offered. Activities staff will ensure residents get equal opportunity to participate in activities each week. Element 4: Act dir/designee will audit 10 random residents weekly to ensure activity likes and dislikes are in place and care planned. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer for a resident, identified as R81, who was admitted with multiple health issues including a fracture of the left femur, dementia, and nutritional deficiencies. Upon admission, R81 did not have any pressure ulcers, but later developed a stage 3 pressure ulcer on the left gluteal fold. The facility's documentation was inconsistent, as the initial skin assessment did not record the pressure ulcer, and subsequent assessments failed to accurately stage the wound, which was covered with slough tissue and should have been classified as unstageable. The facility's policy required weekly skin assessments and documentation of pressure ulcers, but these were not consistently followed. The Wound Nurse admitted to missing the pressure ulcer in the initial assessment and incorrectly staging the wound. Additionally, the facility's plan of care for R81 included interventions such as the use of pressure redistribution mattresses and regular turning and repositioning, but these were not effectively implemented. Observations revealed that the alternating air mattress was not plugged in, rendering it ineffective, and documentation showed that R81 was not turned every two hours as required, but rather only once per shift or less on several occasions. Interviews with Certified Nursing Aides confirmed the expectation of turning residents every two hours, yet the documentation did not support this practice. The failure to adhere to the care plan and facility policies contributed to the development and progression of R81's pressure ulcer. The lack of consistent and accurate documentation, along with the failure to implement prescribed interventions, highlights significant deficiencies in the facility's care practices for preventing pressure ulcers.
Plan Of Correction
Element 1 Resident #81 was assessed by a licensed nurse to ensure wound assessment was completed to include measurements and correct staging. The APM was assessed to ensure proper function. And resident has been turned and repositioned per care plan. Element 2 Residents in facility with impaired skin integrity are considered at risk. Residents in facility have had a full skin assessment completed. If any new skin areas found, they were measured, and assessed, with appropriate interventions in place. Braden assessments were completed to identify the residents at risk for skin breakdown. The DON/designee to ensure accurate staging of the wound was documented and measurements completed. Any identified concerns were addressed. Care plans were reviewed by IDT for Residents with pressure ulcer or at risk for developing to ensure interventions were in place including turning and repositioning to promote healing. Element 3 The Administrator and DON have reviewed using the NPUAP Guidelines for Pressure Injury Staging, Pressure injury prevention and Management and Pressure Injury Prevention Guidelines Policies and deemed them appropriate. Wound Nurse will receive education from the DON/Designee on staging and the documentation required for a pressure ulcer using the NPUAP Guidelines for Pressure Injury Staging. This education also includes who to contact if assistance is needed. Licensed nurses will receive education on Pressure Ulcer/Skin Breakdown Clinical Protocol including who to notify if a new area is observed or a change in injury is noted, also educated on documenting nutritional supplement intake. Clinical staff including Nurses Aides will be educated on Pressure Ulcer Prevention and Management including where to find the turn and reposition schedule in the kardex for each resident, as well as ensuring interventions are in place. Daily (Monday-Friday) during the morning clinical meeting, all new admissions and clinical alerts will be reviewed to identify any new skin conditions. New admissions and residents with pressure ulcers will be observed weekly during wound rounds to ensure that the staging of the wound remains accurate. Changes in the pressure ulcer will be reported to the provider for further recommendations as needed. Element 4 DON/Designee will audit 10 residents with pressure ulcers or with a decreased Braden score per week ensuring care plan is appropriate and being implemented, wound notes, and provider notes accurately reflect the status of the pressure injury weekly for 4 weeks and then monthly to ensure that interventions are in place and appropriate for resident. Results will be reviewed monthly by the QAPI Committee. The Administrator is responsible to maintain compliance.
Deficiency in Tracheostomy Care Documentation
Penalty
Summary
The facility failed to adhere to professional standards for tracheostomy care by not ensuring physician orders included the size of the tracheostomy cannulas for two residents. Resident #87, who had a tracheostomy due to respiratory failure and other medical conditions, did not have physician orders specifying the size of the inner and outer cannula. During an observation, it was noted that the resident's tracheostomy was clean, but the absence of specific orders was confirmed by the Unit Manager, who could not explain the oversight. The Regional Respiratory Therapist emphasized that it is a professional standard to have such orders, including the manufacturer's details, as sizes may vary. Similarly, Resident #38, who also had a tracheostomy, did not have the size of the tracheostomy specified in the physician orders. The resident reported inconsistent tracheostomy care, and during an observation, an LPN replaced the inner cannula with a size 6 Shiley, knowing the size from familiarity rather than documented orders. The Clinical Regional Consultant confirmed that the size should be part of the physician orders and acknowledged that changes were being made to clarify the orders for this resident.
Plan Of Correction
Element 1: Resident #38 and 87 physician orders reviewed and updated to reflect correct trach orders, including sizing. Element 2: Residents with trachs are like residents. No other residents in the facility have a trach. Element 3: The Trach Policy has been reviewed by the NHA and DON and deemed appropriate. The facility-licensed nursing staff have been re-educated on the Trach care policy, and appropriate orders are required. During daily clinical stand-up, nurse managers will ensure orders are in place for Trach. Element 4: Residents who have a Trach will have their orders reviewed weekly for 4 weeks to ensure the orders are correct and match the trach currently being used for each resident. Audits will then be completed monthly for 3 months, or until substantial compliance is obtained or discontinued by the QAPI team. Results will be reviewed monthly by the QAPI Committee. The Administrator is responsible for maintaining compliance.
Failure to Address Resident's Psychosocial Distress Due to Environmental Noise
Penalty
Summary
The facility failed to adequately assess and address a resident's expressions of distress, leading to decreased social interaction and increased withdrawn, angry, and depressive behaviors. The resident, a cognitively intact female with a history of major depression and anxiety disorder, expressed frustration due to the constant yelling of other residents in her hall. Despite reporting these frustrations to staff, no effective measures were taken to alleviate the situation, resulting in the resident's increased distress and uncharacteristic behavior. Observations revealed that the resident preferred to keep her door closed and use ear buds to block out the noise, yet she continued to experience frustration and anxiety. The facility's psychiatric consults noted the resident's sleep disturbances and recommended non-pharmaceutical interventions, but these were not effectively implemented. The resident's mood assessments were incomplete, further indicating a lack of comprehensive evaluation and intervention by the facility. Interviews with staff confirmed that the issue of residents yelling was well-known, yet no grievance forms were completed, and the problem persisted. The facility's decision to place several residents who frequently yelled in the same area exacerbated the situation, affecting the resident's mental well-being. The Social Service Director acknowledged the resident's recent behavioral changes, which were uncharacteristic and linked to the ongoing disturbances.
Plan Of Correction
Element 1: Resident 52 no longer resides in facility. Element 2: Residents on C hall with a Brief Interview of Mental Status of 9 or greater had a Patient Health Questionnaire-9 completed to ensure residents have had no expressions of distress, developed decreased social interaction, increased withdrawal, anger, and depressive behaviors. Any changes in Patient Health Questionnaire-9 have had referrals made to psychology services. Element 3: CNAs and Nurses were re-educated on proper documentation of behaviors including depression, agitation, withdrawal, distress, anger, etc. Interdisciplinary Team will review clinical documentation M-F to ensure any changes in behaviors are followed up on. Element 4: The Administrator will complete an audit reviewing 6 residents per week to evaluate Patient Health Questionnaire-9 scores and ensure appropriate interventions are in place if eligible. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a fall protection mat was placed at the bedside of a resident, as specified in the care plan, to prevent injury from falls. The resident, who was admitted with diagnoses including pneumonia, emphysema, paroxysmal atrial fibrillation, and arthropathy, was identified as a high fall risk upon admission. The care plan, updated shortly after admission, included interventions such as educating the resident on safety, encouraging the use of a call light, and ensuring a fall protection mat was placed on the floor next to the bed. However, on the morning of February 7, the resident was found on the floor with injuries, and it was noted that the fall protection mat was not in place. Interviews with staff revealed that the resident had the ability to move independently but was unsteady and unsafe without assistance. The Director of Nursing confirmed the care plan's requirement for a fall protection mat, and a Licensed Practical Nurse admitted that the mat was not present at the time of the fall. The incident resulted in the resident sustaining bleeding from the head and leg, as well as several skin tears. The absence of the fall protection mat, as required by the care plan, directly contributed to the resident's fall and subsequent injuries.
Controlled Medication Discrepancy for Resident
Penalty
Summary
The facility failed to ensure an accurate account of controlled medications for a resident diagnosed with dementia and major depressive disorder. The resident was prescribed ABHR Cream, a controlled drug, to be applied topically every 12 hours as needed. A review of the Control Substance Record revealed discrepancies in the medication count. Initially, 30 grams of ABH gel were received, and the first dose was signed out on 1/23/25, with a remaining count of 28 mL instead of the expected 29 mL. Subsequent records showed further discrepancies, with the count on 2/1/25 being 24 mL when it should have been 27 mL. There was no documentation explaining these discrepancies. Interviews conducted during the investigation revealed that the Director of Nursing (DON) could not account for the discrepancies and suggested that air in the medication container might have contributed to the issue. However, a pharmacy technician confirmed that the facility received 30 mL of ABH cream and that each click of the dispenser equaled 0.25 mL, requiring four clicks for a 1 mL dose. The pharmacy technician also stated that air in the bottle would not cause a discrepancy in the medication count. The facility did not have any ABHR gel/cream available at the time of the investigation.
Plan Of Correction
Element 1: Resident 17 controlled substance sheets were reviewed by the Director of Nursing. There are no inaccurate counts on current controlled medications. Element 2: A one-time audit was completed by the clinical team of active controlled substance orders to ensure accurate counts. No inaccurate counts were found during this audit. Element 3: The Director of Nursing was re-educated on medication administration and accurate counts for controlled substances by the Regional Director of Clinical Services. Licensed nurses have been re-educated on ensuring accurate counts when administering and documenting controlled substances. At shift change, nurses will review counts, and if any inaccuracy is noted, the DON or designee will be notified. A daily review, Monday through Friday, will be completed by nurse managers to ensure controlled substance use sheets are accurate. The QAPI Committee reviewed the policy, "Medication Administration," and deemed it appropriate. Element 4: An audit will be completed weekly for four weeks, then monthly, of nine residents with controlled substance orders to ensure accurate counts. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. The Administrator is responsible for achieving and sustaining compliance.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor residents' rights to be treated with respect and dignity, as evidenced by staff members entering resident rooms without knocking on multiple occasions. This was observed on three separate instances on January 8, 2025, where staff entered rooms without knocking. Additionally, a resident, identified as Resident 13, was observed in the dining room without a lunch meal, and a CNA referred to the resident as 'whatever, whatever' when requesting a meal tray, which the resident found disrespectful. The resident, who was new to the facility, expressed feeling disrespected by the comment but chose to ignore it. Another instance of a staff member entering a resident's room without knocking was observed on January 9, 2025.
Delay in X-ray Completion for Resident
Penalty
Summary
The facility failed to obtain a timely x-ray for a resident, leading to a delay in care. The resident, who was admitted with hemiplegia and hemiparalysis following a stroke, reported pain and swelling in the left hand. Despite a physician's order for an x-ray on October 1, 2024, the x-ray was not completed until October 12, 2024. The resident expressed that the pain was severe, initially rated as 10 out of 10, and later as 6 out of 10, with no improvement over time. Interviews with facility staff revealed that the delay was due to an issue with the imaging company and a miscommunication regarding the order. The Licensed Practical Nurse acknowledged the delay, stating that x-rays should typically be completed within a day or two. The Director of Nursing indicated that the order was incorrectly entered by the physician, contributing to the delay. This deficiency highlights a lapse in the facility's process for ensuring timely diagnostic testing for residents.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) for a resident who was a full code, resulting in Immediate Jeopardy. The resident, identified as R200, was found unresponsive with no pulse or respirations. Despite being a full code, CPR efforts were not initiated by the facility staff at the time the resident was discovered. Instead, the staff checked the code status and called 911, but did not begin CPR until Emergency Medical Services (EMS) arrived. The incident involved Licensed Practical Nurse (LPN) M, who was notified by a Certified Nurse Assistant (CNA) that the resident was not breathing. LPN M documented that upon finding the resident unresponsive, she checked the code status and called 911, but did not start CPR. LPN D, another nurse, confirmed that CPR was not in progress before EMS arrived and noted that LPN M was not actively participating in the resuscitation efforts. The delay in initiating CPR was estimated to be about 5 to 10 minutes from the time the resident was found unresponsive to the arrival of EMS. The resident, R200, had a history of Obstructive Sleep Apnea and Morbid Obesity, and was cognitively intact according to the Minimum Data Set (MDS). The facility's policy required staff to provide basic life support, including CPR, prior to the arrival of emergency medical services, but this was not followed. The failure to initiate CPR immediately upon finding the resident unresponsive was a significant deviation from the facility's policy and contributed to the adverse outcome.
Removal Plan
- Documentation of the amount of residents at risk.
- The facility identified CPR was not initiated immediately.
- The Director of Nursing and/or designee began education of facility staff on initiating CPR immediately to include: checking of code status utilizing the electronic medical record on the laptop or kiosk or utilizing the paper chart; the timeline and steps for assessing pulse and respirations when a resident is found unresponsive and initiating CPR immediately to include placing on floor if needed. Initiating CPR includes checking airway, breathing, circulation and beginning compressions while someone verifies the code status and 911 is called. Identify a team leader to assign duties and scribe. Ensure crash cart is with patient and AED is applied. Compressions will continue until EMS arrives and verbalizes they will take over.
- The facility has 26 Licensed Nurses. The facility has educated 25 of the 26 Licensed Nurses.
- Any staff not educated will not be permitted to work a shift until education has been completed.
- The facility Medical Director was notified.
- The Director of Nursing and/or designee completed a chart audit on 85 charts and verified the advanced directives to the physician order for accuracy.
- An audit was completed of Licensed Nurses to ensure CPR certifications were up to date. The identified nurse was recertified.
- The QAPI committee has reviewed the Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) policy and has deemed them appropriate.
- The facility had an Adhoc QAPI meeting including the Medical Director and deemed this removal plan appropriate.
- The Director of Nursing is responsible for continued compliance.
Failure to Develop Comprehensive Care Plan for Resident with Pica Behavior
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R201, who had a history of swallowing non-food items. This deficiency was identified during a survey where it was noted that the care plan did not include specific interventions to prevent the resident from picking up and swallowing non-food items. The resident, who had severe cognitive impairment and diagnoses including unspecified intellectual disabilities, generalized anxiety disorder, and schizophrenia, had previously been hospitalized twice for ingesting non-food items, including quarters and AAA batteries. The care plan for R201, dated 10/17/24 and updated on 10/30/24, addressed the behavior of swallowing non-food items but only included interventions such as approaching the resident in a calm manner, communicating with him, and observing his mental status and situational stressors. However, it lacked specific safeguards against the behavior of picking up and swallowing non-food items. This omission was discussed with the Nursing Home Administrator, Director of Nursing, and Regional Nurse Consultant, who acknowledged the lack of specific interventions in the care plan.
Failure to Conduct Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to provide ongoing clinical assessments, specifically neurological assessments, for a resident who was reviewed for such assessments. The resident, who had diagnoses of cerebral atherosclerosis, legal blindness, and dementia, experienced a fall that resulted in redness and a red mark on the forehead. Despite this incident, there was a lack of documented neurological assessments in the progress notes following the fall. The facility's Director of Nursing (DON) acknowledged that the neurological assessment portion of the fall follow-up forms required manual entry each time, yet the forms contained outdated vital signs from previous days, indicating a lack of current assessments. The facility did not have a specific neurological assessment policy, relying instead on a general fall policy. This policy stated that residents who have fallen and were suspected to have hit their head should have neuro checks per medical order or protocol. However, the facility's documentation did not reflect adherence to this protocol, as there were no detailed neurological assessments recorded after the fall. The DON believed that the standard of care was followed, stating that neuro checks were done daily, but the lack of documentation and the reliance on outdated vital signs raised concerns about the thoroughness of the assessments conducted.
Failure to Reassess Respiratory Status Leads to Resident's Death
Penalty
Summary
The facility failed to reassess the respiratory status of a resident, identified as R200, who had a history of Obstructive Sleep Apnea and Morbid Obesity. Upon admission, it was noted that the resident had been using a CPAP machine during sleep in the hospital, but there was no documentation of CPAP use during the facility stay. An incident occurred where the resident was found in a supine position, appearing hypoxic and cyanotic, prompting an LPN to administer oxygen and elevate the head of the bed, which improved the resident's oxygenation. However, there was a lack of follow-up documentation or reassessment of the resident's respiratory status after this episode. Later, the resident was found unresponsive and was pronounced dead after CPR efforts. Interviews with facility staff revealed uncertainty about the timeline of events and a lack of documentation regarding the resident's respiratory assessments. The Director of Nursing acknowledged that follow-up assessments should have been conducted after the initial hypoxic episode, and the absence of documentation suggested that assessments may not have been performed. The facility did not provide additional information regarding the CPAP use prior to the end of the survey.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice prior to room changes for four residents, which is a violation of the residents' rights. Resident #2, who was admitted with dementia and anxiety disorder, experienced a room change due to a payor source change from Medicare to Medicaid on 8/21/24, without any written notice provided to the responsible party. Similarly, Resident #5, admitted with a cerebral infarction, had a room change on 10/14/24 for the same reason, again without written notice. Resident #6, with acute posthemorrhagic anemia and COPD, underwent room changes on 9/12/24 and 10/8/24. Although discussions were held with the family regarding room rates and Medicaid coverage, no written notice was documented. Resident #11, with diabetes, bipolar disorder, and major depressive disorder, had room changes on 6/28/24 and 8/12/24, and reported not being informed in advance. The Nursing Home Administrator confirmed that these changes were related to transitions from Medicare to Medicaid rooms, yet no written notices were provided.
Facility Fails to Maintain Cleanliness and Repair in Resident Bathrooms
Penalty
Summary
The facility failed to maintain cleanliness and repair in resident bathrooms, as observed during a survey. On multiple occasions, the bathroom shared by three residents was found with dried feces on the toilet seat riser and in the toilet bowl. This unsanitary condition persisted over two days, indicating a lack of timely cleaning and maintenance. Additionally, another bathroom was observed with a bent and rusted metal vent/register on the floor, further highlighting the facility's failure to maintain a clean and safe environment. Structural issues were also noted in several bathrooms. One bathroom had a section of wall molding peeled away, exposing a cracked and crumbling wall. Another bathroom had metal door frames with sections worn away, revealing a black interior. Additionally, molding was seen hanging off the wall behind the toilet in another bathroom. The Maintenance Manager was unaware of these issues, as they were not included in the work orders submitted through the TELS system, which the facility relies on for communication of maintenance needs. The facility's preventive maintenance program, as outlined in their policy, was not effectively implemented to ensure a safe and sanitary environment.
Deficiencies in Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical record documentation for two residents, leading to deficiencies in care and services provided. For Resident #1, the electronic medical record indicated a signed Do Not Resuscitate (DNR) order and an Advanced Directive. Despite this, when the resident was found not breathing, a code was called, and CPR was initiated. The Registered Nurse involved did not document the code event or the subsequent discovery of the DNR status, resulting in a lack of documentation regarding the resident's change in condition and the actions taken. For Resident #3, the facility failed to document the resident's transfer to the hospital adequately. The progress notes lacked details about the resident's condition at the time of transfer, vital signs, and the time of departure. The nurse responsible for the resident's care did not document the transfer or complete the necessary forms, such as the SBAR change in condition form and the Transfer V2 form. This omission resulted in incomplete records regarding the resident's transfer and condition.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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