Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Munising during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
Failure to Report and Investigate Resident-to-Resident Abuse: The facility did not fully implement its abuse policy or immediately report multiple resident-to-resident abuse allegations and incidents to the SA. Charting and staff interviews described a resident with dementia and repeated physical and verbal aggression toward other residents and staff, including grabbing, hitting, kicking, spitting, threats, and entering rooms uninvited. Other residents with varying cognitive status reported fear, unsafe conditions, and unwanted intrusions, while staff stated that incidents were known but incident reports, SA reports, and investigations were not consistently completed.
Insufficient nursing staffing led to delayed resident assistance and unmet needs. A resident with a history of falls and mild cognitive impairment reported call lights often took 30 minutes or longer to be answered, staff sometimes turned the light off and did not return, and transportation to a dental appointment was delayed because of staffing and a broken van. Multiple residents reported waits of 20 minutes to an hour for help, and CNAs described short staffing on weekdays and weekends, with only one person per hall at times and residents being neglected because there were not enough staff.
Evening Snacks Not Available for Residents: A confidential resident group reported that snacks were sometimes not provided at night, and one resident said staff told them there were no snacks available when requested. A CNA stated the facility often did not have any snacks or food available during late evening or night hours, and the NHA was unaware of the issue. The facility policy required snacks and nutritious convenience foods to be available for residents who wanted to eat outside scheduled meal times.
Food Handling and Kitchen Sanitation Deficiencies: Kitchen staff was observed handling an uncovered drink in the prep area and later touching a beard net with bare hands before using a utensil to stir food, with no hand hygiene observed in between. Surveyors also found a slicer and can opener bracket with food debris, degraded rubber spatulas, and food debris buildup on the floor and cove base molding in the kitchen.
Infection control practices were not followed for two residents, and multiple IPC policies were not reviewed annually. A CNA touched a resident’s urinary catheter tubing and drainage bag with bare hands, then continued propelling the wheelchair without hand hygiene, while an LPN observed and did not intervene. In another event, an LPN carried towels against his uniform, placed them on a treatment cart, then used the same towels in a resident’s room, donned gloves without hand hygiene, wore an untied gown, and handled a catheter drainage bag and dressing supplies. The IP and NHA confirmed several IPC policies had not been updated since the dates listed on them.
Poor Premises Cleanliness and Maintenance: A resident room had peeled paint on the wall and baseboard heat cover, the exterior back door had a damaged door-sweep with daylight visible below part of the door, and the kitchen had soiled floors, peeled cove base molding, and grease buildup. A soiled privacy curtain was also observed in the shower room, and staff stated curtains are changed when notification is received.
Failure to Identify, Report, and Investigate Resident Abuse: Multiple residents with dementia or behavioral symptoms were involved in repeated verbal and physical altercations, including hitting, grabbing, yelling, spitting, and entering other residents’ rooms. One resident with severe cognitive impairment sustained a forehead laceration during a dining room incident, while other residents reported fear, intimidation, and keeping their doors closed because aggressive residents wandered into their rooms. Staff interviews and chart review showed incidents were often documented only in nursing notes and were not consistently reported or thoroughly investigated as abuse.
A resident with Alzheimer's Disease and severe cognitive impairment did not have advance directive information or a completed advance directive in the EMR. The SSD said she completes these on admission and annually for residents with a DPOA, but she could not find one for the resident, and the NHA acknowledged it was missing. Facility policy stated staff should verify an advance directive or CPR wishes upon admission.
Missing transfer, bed-hold, and Ombudsman notifications: The facility did not provide complete written transfer notices or bed-hold forms for multiple residents transferred to the ED, and one resident’s transfer was not included on the Ombudsman notification list. Several documents were blank or incomplete, including missing reasons for transfer, unchecked bed-hold choices, and absent signatures or proof that bed-hold information had been provided.
A resident with bipolar disorder, schizoaffective disorder, and dementia had a positive Level I PASARR screening, but the facility did not have evidence of a completed Level II PASARR determination. Interviews showed the SS Director lacked a formal monitoring process for Level II returns, and the DON could not locate the required determination in the EMR when surveyed.
Failure to update a resident’s person-centered care plan led to an outdated plan that still focused on dementia-related verbal aggression and psychotropic use, while missing her hospice/end-of-life status, fear of dying, loneliness, grieving, and recent UTI-related behavior changes. Staff noted the resident was cognitively intact, tearful, and distressed about being alone and not wanting psychiatric medications, yet the care plan did not reflect revisions for her current needs or the new antipsychotic medication.
Failure to provide meaningful activities for a resident with severe cognitive impairment. The resident, who had Alzheimer’s disease and non-Alzheimer’s dementia, was repeatedly observed sitting alone in her room with no TV, music, lights, or sensory items, and no staff interaction. The resident’s care plan and activity evaluation identified a need for staff-supported cognitive stimulation and preferred activities such as music, TV, and sensory activities, but a CNA and LPN reported she was not offered activities and activity staff were not seen providing room-based activities.
Inaccurate wound documentation and failure to follow compression stocking orders. A resident with diabetes, edema, and heel wounds was repeatedly observed without ordered compression stockings even though the TAR showed them as applied. Staff could not explain why the stockings were missing, and documentation did not consistently reflect the resident’s edema or notify the MD. Wound records were also inconsistent, with the R heel described as both a stage 3 pressure injury and a diabetic ulcer, and the L heel documented as healed before later notes and observation showed an uncovered wound with eschar.
The facility failed to keep residents’ drug regimens free from unnecessary drugs when an antipsychotic was started for a resident with dementia and hospice status without documented non-pharmacological interventions or use of ordered PRN anti-anxiety medication first. It also failed to discontinue duplicate inhaled therapy after a pharmacist recommendation and physician order, and staff administered PRN pain meds to two residents without documenting non-pharmacological interventions before use.
A medication pass resulted in a 9.68% error rate, with an LPN failing to follow required inhaler and insulin administration procedures for a resident. The LPN did not instruct the resident to rinse and spit after Trelegy or Advair, did not properly position or coach the Advair inhaler use, and gave Humalog and Lantus injections at the same abdominal site despite the resident’s request for a different location and the MAR documenting a different Humalog site.
A resident who was fully dependent on staff for transfers suffered bruising and a toe injury when staff used an incorrectly sized sling and mechanical lift, contrary to the care plan. Staff were unable to identify the correct sling size, and the storage area lacked clear instructions, resulting in the use of a sling that was too small and caused significant discomfort and injury.
Two residents were admitted without timely transcription and receipt of physician orders for essential medications and treatments. One resident with severe cognitive impairment and glaucoma did not receive prescribed ophthalmic medications for nearly two weeks, while another with respiratory failure and COPD did not have a physician order for supplemental oxygen despite low oxygen saturation and documented need. Facility leadership confirmed the absence of required orders at admission.
A resident dependent on staff for personal care did not receive required assistance with denture use and timely incontinence care. The resident's dentures were found improperly stored and covered in mold, and the resident was left in a urine-soaked brief and clothing for several hours without regular checks, contrary to care plan and facility policy. Staff were unable to account for the dentures' whereabouts and did not document incontinence checks unless a change was made.
A resident with severe visual and hearing loss, cognitive impairment, and dependence on staff was left without meaningful engagement or appropriate activities, despite care plan interventions. Observations showed the resident was left alone for long periods, positioned away from sources of stimulation, and staff did not interact with her during care. Documentation of activities was unclear, and the resident's preferences were not addressed, resulting in social isolation.
Two residents with complex wounds did not receive physician-ordered wound care on multiple occasions, as documented in the TAR. Nursing staff and the DON confirmed that wound treatments were missed, despite facility policy requiring adherence to physician orders for wound management.
Several residents with conditions such as diabetes and peripheral vascular disease were found to have thick, long, and curled toenails that had not been trimmed for an extended period, resulting in pain and difficulty wearing shoes. CNAs confirmed the lack of recent nail care, and staff interviews revealed that only residents with certain insurance received podiatry services, leaving others without necessary foot care. The facility's policy for regular nail assessment and trimming was not followed, and nail care was not consistently provided on shower days as required.
A facility failed to securely store medications, as an insulin pen was left on a cognitively impaired resident's bedside table, and a treatment cart was found unlocked with prescription items accessible. An LPN admitted the oversight, and the facility's policy requires medications to be stored in locked compartments.
The facility failed to maintain and sanitize resident equipment, leading to an increased risk of infection spread. Observations showed multiple wheelchairs and hoyer lifts were heavily soiled, with damaged components and inadequate cleaning. Staff interviews revealed a lack of adherence to cleaning protocols, despite the facility's policy requiring regular cleaning and disinfection to prevent pathogen transmission.
A resident was involuntarily discharged from an LTC facility without proper preparation or documentation, leading to homelessness. The resident, who was on a pre-approved vacation, was informed he could not return due to unpaid bills. The facility failed to follow its discharge policy, resulting in the resident being unable to re-enter the facility and eventually becoming homeless.
A resident with severe cognitive impairment and type 2 diabetes had numerous expired food items in their personal mini-fridge, including yogurt, cheese, and sausage with mold. Interviews with staff revealed confusion over who was responsible for monitoring the food, and the facility's policy on refrigerator maintenance was not followed, as no temperature log was present. This oversight posed a risk of foodborne illness.
A resident admitted for osteomyelitis treatment did not receive prescribed IV antibiotics for several days due to transcription errors at the LTC facility. The resident's condition worsened, leading to hospitalization. Staff interviews revealed missed orders due to unfamiliar discharge paperwork.
The facility failed to prevent and manage pressure ulcers for three residents, leading to severe outcomes. A resident with cognitive impairment developed a heel ulcer that deteriorated due to inadequate documentation and intervention, resulting in amputation. Another resident's wound vac was frequently turned off, worsening a stage four ulcer. A third resident developed a stage three ulcer due to improper repositioning and support.
A resident with cognitive impairment and a history of falls suffered a major injury due to inadequate supervision, as staff were spread thin and left the resident unattended. Another resident with a history of smoking and falls was observed smoking unsupervised, contrary to the care plan and facility policy requiring supervision. Staff confirmed ongoing issues with low staffing levels and inadequate supervision.
The facility failed to provide adequate staffing, resulting in unmet care needs and safety concerns for all 65 residents. A resident reported long wait times for toileting assistance, leading to incontinence, and often receiving bed baths instead of showers. Another resident expressed difficulty in receiving showers, while a third resident reported not being repositioned as required, leading to discomfort. Additionally, a resident with moderate cognitive impairment experienced an unwitnessed fall due to insufficient supervision. Staff confirmed the ongoing issue of low staffing levels.
The facility failed to adhere to food safety standards, with cold foods like potato salad and cottage cheese held at improper temperatures, and a lack of proper labeling and monitoring in nourishment rooms. Additionally, roast beef was not reheated to the required temperature, and a cross-connection issue with the ice machine's drain line was identified, posing potential contamination risks.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling catheter, despite multiple observations noting the absence of EBP outside the resident's room. The resident, admitted with several medical conditions including cellulitis and lymphedema, did not have EBP included in her care plan, putting her at risk for MDRO infection over a six-day period.
The facility failed to ensure resident privacy and dignity by not knocking or waiting for permission before entering rooms. Multiple residents reported staff entering without proper acknowledgment, causing embarrassment and lack of privacy. Observations confirmed staff entering rooms without knocking, violating the facility's policy on resident dignity.
The facility failed to provide written notifications for hospital transfers for four residents, as required by policy. Residents were transferred due to various medical conditions, including unresponsiveness, sepsis, a deteriorating wound, and a fall with injury. Interviews revealed that the interim social worker was not sending the required notifications, and the Nursing Home Administrator was unaware of this oversight.
The facility failed to provide written bed-hold notifications to residents or their representatives before hospital transfers, affecting five residents. Interviews and record reviews revealed missing documentation in clinical records, and the Nursing Home Administrator confirmed the oversight. The facility's policy requires written information on bed-hold duration and conditions for readmission to be given prior to transfers.
The facility failed to destroy discontinued schedule two medications in a timely manner and improperly used another resident's medication. A resident had another's acetic acid solution used for wound care, and expired lorazepam orders were not removed from medication carts, violating facility policies.
The facility failed to ensure dementia training was completed by four CNAs as required by annual training requirements. A review of training logs showed that the course 'Dementia Care: Normal Aging vs. Alzheimer's/Dementia' was incomplete for three CNAs and not listed for one. The ADON was unaware of the course and assumed dementia training was included in 'Challenging Behaviors,' which did not cover dementia care. This deficiency could potentially affect all residents with dementia in the facility.
A resident with multiple medical conditions reported verbal abuse by a nurse, who suggested the resident should end his life. The nurse had a history of inappropriate communication, and despite previous warnings, continued to work at the facility. This resulted in mental distress for the resident.
The facility failed to report alleged abuse timely for two residents, leading to potential ongoing abuse. A cognitively intact resident reported an inappropriate comment by a nurse, which was acknowledged as abuse by an LPN but not reported immediately. Another resident experienced alleged abuse when a nurse spoke harshly after multiple falls, which was not reported until later. Both incidents were reported to the State Agency days after occurring, violating the facility's policy on timely reporting.
The facility failed to assess the clinical need for urinary catheterization for two residents, leading to potentially unnecessary catheter usage. One resident had a catheter placed post-surgery without a documented diagnosis of urinary retention, and a requested urology referral was not made. Another resident was admitted with a catheter, but their care plan did not reflect its presence or care instructions. The facility lacked a policy for evaluating catheter necessity, contributing to the deficiency.
The facility failed to monitor weight fluctuations for two residents, one with multiple diagnoses including diabetes and heart failure, and another with protein-calorie malnutrition and dysphagia. Significant weight changes were not documented, and weights were not obtained upon readmission after hospitalizations, contrary to the facility's policy requiring weekly monitoring for new admissions and weight loss cases.
The facility failed to obtain informed consent and physician orders for psychotropic medication, leading to unauthorized administration of lorazepam to two residents. Additionally, a resident did not receive timely gradual dose reduction (GDR) for psychotropic medications despite recommendations, due to a breakdown in communication between the behavioral health provider and facility physician.
The facility failed to effectively implement its QAPI program, as the NHA could not explain the process for identifying, analyzing, correcting, or monitoring medical errors or adverse events. Despite monthly QAPI meetings and a policy requiring systematic data collection and investigation, the NHA relied on emails from the regional clinical nurse and DON for information, indicating a lack of understanding and execution of the QAPI process.
A resident was given a laxative without proper assessment, despite having regular bowel movements, leading to diarrhea and incontinence. The nurse responsible did not document the administration on the MAR, and the facility's PRN medication policy was not followed.
A resident with multiple health issues, including hemiplegia and dementia, received only one shower during a 17-day stay, despite requiring moderate assistance and the facility's policy of twice-weekly showers. The care plan lacked interventions for showering, and the DON could not explain the deficiency.
A resident with a stage 4 pressure injury did not receive proper care due to the facility's failure to transcribe hospital discharge orders and follow wound clinic recommendations. The resident's wound, which developed at the facility and led to hospitalization for sepsis, was not treated as instructed upon their return. The wound clinic's recommendation to reapply a wound VAC was not followed, and the attending physician was not informed, resulting in a lack of appropriate wound care.
The facility failed to provide adequate staffing, resulting in unmet care needs for residents. A resident with intact cognition reported urinating in bed due to delayed assistance, while another experienced long wait times for help. A resident with severe cognitive impairment was found soaked in urine. CNAs reported being overwhelmed and unable to provide necessary care. Staffing records showed insufficient CNA numbers, and the facility's policies lacked clarity on required staffing levels.
The facility failed to post daily nurse staffing information, as required, impacting transparency about staff availability for resident care. The NHA could not locate the staffing posting, and missing information was noted for several dates. The DON confirmed that the information should be posted daily near the entrance.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to fully implement and operationalize its Abuse Program Policy and Procedure and failed to immediately report allegations and actual resident-to-resident abuse to the State Agency for 9 residents reviewed for abuse. The report states that resident-to-resident altercations involving residents #4, #10, #52, #55, #R63, #100, #101, #102, and #103 were documented in nursing notes and behavioral charting, but incident reports, State Agency reports, and facility investigations were not made available for review for multiple events. Resident #4 had dementia and a BIMS score of 00/15, indicating cognitive impairment. MDS assessments and charting showed repeated physical and verbal behavioral symptoms directed toward others. Nursing notes documented that the resident grabbed another resident’s arm, raised a fist, and used profanity toward staff and a resident; attempted to kick a cup out of a blind resident’s hands and then tried to kick him in the head; attempted to enter another resident’s room and became aggressive when told to leave; hit a CNA in the face; threw a wheelchair, shoes, and cups; spit; and entered another resident’s room through the bathroom and threatened to beat him if he did not shut up. Another note documented an incident in which the resident was found with a forehead laceration after an altercation in the dining room involving other residents. Other residents reported fear and unsafe conditions related to aggressive resident behavior. Resident #10, who was cognitively intact with a BIMS score of 15/15 and had an amputation, reported that a pacing, yelling, and spitting resident entered his room, sat on his roommate’s bed, and ate his roommate’s lunch, and that he felt fearful because he could not move quickly. Resident #55, with a history of falls and mild cognitive impairment, reported keeping his door shut because aggressive residents wandered into rooms and bathrooms, yelled, grabbed clothing and arms, pushed residents in wheelchairs, and caused frustration because of limited staffing. Resident #63 had a care plan for verbal aggression, and charting documented a verbal altercation with another resident. Staff interviews confirmed that residents with aggressive behaviors were well known in the facility, that altercations were occurring, and that staff were supposed to report allegations of abuse to the NHA, but reports and investigations were not consistently completed.
Insufficient Nursing Staffing and Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. Review of the facility’s Mandatory Submission of Staffing Information Payroll Based Journal (PBJ) Staffing Data Report showed the facility was triggered for low weekend staffing for the 4th quarter of 2025. During interviews, staff reported that staffing was short at times, especially on weekends, and that the facility did not use agency staff. The LPN/scheduler stated the facility had open positions for FT nurses and CNAs, and that unit managers, the DON, and other qualified staff were filling staffing gaps, particularly over the last month due to bad weather and the holidays. Resident #55, who had a history of falling and a BIMS score of 11/15 indicating mild cognitive impairment, reported that call lights took a very long time to be answered, often about 30 minutes or longer on nights and weekends. The resident stated staff sometimes turned off the call light and said they would return but did not come back, and reported frustration about delayed assistance, missed follow-up on concerns, and difficulty getting transportation to a dental appointment because of staffing and a broken van. In a confidential group interview, multiple residents reported long waits for help, including 20 minutes to an hour, and described incidents such as a colostomy bag coming off with stool everywhere while waiting for assistance. CNA interviews also described staffing as bad during the week and weekend, with only one person per hall at times and residents being neglected because there were not enough staff to provide needed care.
Evening Snacks Not Available for Residents
Penalty
Summary
The facility failed to ensure evening snacks were offered to residents who requested food outside of scheduled meal times. During a confidential resident group interview, six of eight residents reported that snacks were sometimes not provided at night, and one resident stated that staff told them there were no snacks available when they asked for something. A CNA reported that the facility sometimes did not have any snacks or food available at night for residents and that there were many nights when residents could not have anything to eat during the late evening or night. The NHA acknowledged the importance of having snacks for residents and was unaware that snacks were not available. The facility policy stated that for residents who desire to eat at non-traditional times or outside scheduled meal service times, snacks will be provided and nutritious snacks and convenience foods shall be available.
Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety. During a kitchen tour, kitchen staff H was observed taking an uncovered drink from a small counter space next to the office where employees store personal food and drinks and then going to the prep table with the uncovered drink. When asked, kitchen staff H stated it was his drink, and the Dietary Manager had him put a lid on it. The report also notes that staff are required to drink only from a closed beverage container handled to prevent contamination of hands, the container, exposed food, clean equipment, utensils, linens, and unwrapped single-service and single-use articles. Later that day, kitchen staff H was observed adjusting his beard net with bare hands and then going to the stove and using a utensil to stir food being cooked in a stock pot, with no handwashing observed after touching the beard net. The report further documents that a slicer was covered with a clear plastic bag but still had food debris under the blade and on the casing, the can opener bracket had a buildup of food debris, two rubber spatulas were dried out and degraded with flakes missing, and the floor around the vegetable wash sink and cooking range line had food debris buildup. The cove base molding behind the range was peeled away from the wall and very soiled with food debris buildup.
Infection control practices were not followed and policies were not reviewed annually
Penalty
Summary
The facility failed to safely transport linen, failed to review and update infection control policies annually, and failed to ensure infection prevention and control practices were followed for two residents. Resident #3 was admitted with Alzheimer’s disease and had a urinary catheter for urinary retention. On 1/7/26, R3 was observed in a wheelchair with the urinary catheter drainage bag partially connected to the bottom of the wheelchair seat, while the rest of the drainage bag and tubing were on the floor. A CNA then propelled the wheelchair after reaching under it with bare, uncleaned hands to pick up the catheter tubing and drainage bag, secured them under the seat, and continued pushing the resident without performing hand hygiene. An LPN observed the interaction and did not direct the CNA to perform hand hygiene or don gloves. Resident #51 was admitted with diabetes, had a urinary catheter for urinary retention, and had a stage 3 pressure injury on the right heel. On 1/7/26, an RN was preparing to change the heel dressing while an LPN carried towels against his uniform down the hall and placed them on the treatment cart. The LPN then picked up the towels again and carried them against his uniform into the resident’s room, spread them on the overbed table as a barrier, and put on gloves without first performing hand hygiene. He also donned a gown but did not tie it at the neck and waist, then assisted the resident with transfer, removed the catheter drainage bag from the wheelchair, and adjusted his gown with the same gloves before continuing to handle dressing supplies. The Infection Preventionist stated staff had been educated on PPE use and that gowns should be secured at the neck and waist, towels should not be held against uniforms, and hand hygiene should be performed before donning gloves and after touching a catheter drainage bag. The Infection Preventionist also said he was not sure when infection prevention and control policies had last been reviewed or updated. Record review showed multiple infection prevention and control policies, including Hand Hygiene, Enhanced Barrier Precautions, Influenza Vaccination, Pneumococcal Vaccine, Personal Protective Equipment, Antibiotic Stewardship Program, and Infection Surveillance, were not dated as reviewed or revised annually. The Administrator confirmed the policies provided were the most recent and had not been reviewed or updated since the dates listed on the policies.
Poor Premises Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises and proper storage of clean and sanitary supplies. On 1/5/2026 at 9:10 AM, peeled paint was observed on the wall in a resident room behind the bed, with an area approximately one and a half feet wide by 3 feet high, and the baseboard heat cover in the same room also had paint loss in several places. On 1/5/2026 at 11:12 AM, the exterior back door in the maintenance hall was observed with a damaged door-sweep on the bottom of the door, and daylight was visible below part of the door. In the kitchen, on 1/5/2026 at 3:25 PM, the floor under the vegetable wash 2 bin sink was observed soiled with a built-up accumulation of food debris and grime. The Dietary Manager stated the cleaning and to-do lists are reviewed by staff on a regular basis. On 1/5/2026 at 3:31 PM, the cove base molding behind the cook line was observed peeled away from the wall and floor in one section and had a buildup of grease and grime. On 1/6/2026 at 8:50 AM, the privacy curtain beside the toilet in the shower room on the 300 Wing was visibly soiled. A housekeeping employee stated it was housekeeping's responsibility to check the curtains and notify the Environmental Services Director when they needed to be changed, and the Environmental Services Director stated the curtains are changed when notification is received and that there are 10 extra curtains per hall to replace soiled ones.
Failure to Identify, Report, and Investigate Resident Abuse
Penalty
Summary
The facility failed to fully implement and operationalize its Abuse Program Policy and Procedure to immediately identify, report, and thoroughly investigate repeated incidents of physical and verbal abuse involving multiple residents. The report identified 9 residents involved in abuse-related events, including residents with dementia, cognitive impairment, and behavioral symptoms, and described repeated resident-to-resident altercations, verbal aggression, and physical aggression that were documented in nursing and behavior notes but not consistently reported or investigated as abuse incidents. Resident #4 had dementia and a BIMS score of 0/15, indicating severe cognitive impairment. Charting and staff interviews described repeated aggressive behaviors toward residents and staff, including yelling, chasing a PT employee, attempting to kick another resident, hitting staff in the throat, hitting a CNA in the face, grabbing another resident’s arm, and throwing objects and a wheelchair. On 10/5/25, R4 was found in the dining room with a laceration to the forehead and blood on his face after an incident involving other residents, but no incident reports, facility-reported incidents, or state agency reports were made available for that event. Staff interviews also indicated that incidents involving R4 were not consistently reported to the Abuse Coordinator or investigated beyond routine nursing or behavioral notes. Other residents reported fear, intimidation, and unsafe conditions related to aggressive residents entering rooms, yelling, spitting, and grabbing others. Resident #10, who was cognitively intact with a BIMS of 15/15, reported keeping the room door closed because residents with dementia and behavioral issues entered rooms without permission, including one resident who sat on a roommate’s bed and ate the roommate’s lunch. Resident #55, with mild cognitive impairment, reported keeping the room door shut because aggressive residents wandered into rooms and bathrooms, yelled, hit at each other, and grabbed or pushed other residents. Additional charting documented verbal altercations involving residents #52 and #63, and staff acknowledged that resident-to-resident altercations were known but not consistently reported, with one CNA stating prior concerns had gone unanswered and that incidents should have been reported to the NHA.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information for an advance directive and did not have an advance directive formulated for Resident #74, who was admitted with Alzheimer's Disease and had severe cognitive impairment with a BIMS score of 3 out of 15. Review of the EMR did not show that the resident or responsible party had received advance directive information or completed an advance directive. The Social Services Designee stated she completes advance directives on admission and annually for residents with a DPOA, but she could not find one for Resident #74 and it was not in the EMR. The Nursing Home Administrator acknowledged that Resident #74 did not have advance directive information and had not formulated an advance directive. The facility policy stated that staff should verify the presence of an advance directive or the resident's wishes regarding CPR upon admission.
Missing transfer, bed-hold, and Ombudsman notifications
Penalty
Summary
The facility failed to provide residents and/or responsible parties with written transfer notifications and bed-hold notifications, and failed to notify the Office of the State Long-Term Care Ombudsman for a facility-initiated transfer, for three residents reviewed for hospitalizations. Resident #9 was transferred to the ED on 10/3/25, 10/18/25, and 12/17/25. For the 10/18/25 transfer, there was no written notification of transfer or bed-hold notice provided. For the 12/17/25 transfer, the written transfer notice did not include a reason for transfer, and the bed-hold form did not have any boxes checked to show acceptance or declination of bed hold. The October 2025 Ombudsman notification list did not include notification of R9’s 10/3/25 transfer. Resident #70 was transferred to the ED on 11/15/25, but the facility did not provide a written transfer notice. The bed-hold form in the EMR was blank where the resident or representative would accept or decline bed hold, did not contain a signature, and the EMR did not show that bed-hold information had been provided. Resident #1 was transferred to the ED on 10/10/25 and 10/11/25; the 10/11/25 transfer notice contained blank boxes where the reason for transfer should have been documented, and no bed-hold notice was located in the EMR. During interviews, the NHA confirmed missing transfer and bed-hold documentation for some events and was unable to explain the missing Ombudsman notification.
Failure to Complete Level II PASARR After Positive Screening
Penalty
Summary
The facility failed to complete a Level II PASARR for one resident after a Level I PASARR screening was positive for multiple criteria. The resident had active diagnoses of bipolar disorder, schizoaffective disorder, and dementia, and the Level I screening indicated yes to four of six questions, including a current diagnosis of mental illness and dementia, treatment for mental illness and dementia, use of one or more prescribed antipsychotic medications within the past 14 days, and presenting evidence of mental illness or dementia. Record review and interviews showed no evidence that a Level II PASARR determination had been completed after the positive Level I screening. The Social Services Director stated she forwarded monthly lists to the Regional Social Worker because she was not a licensed social worker, and reported there was no formal process in place for monitoring return of Level II determinations. The DON also could not locate a Level II PASARR or determination in the EMR and later reported the resident's Level II determination was still awaiting physician review and signature, while the state designated authority said the resident was exempt from the full Level II evaluation.
Failure to Update Care Plan for Hospice Resident’s Behavioral and Psychosocial Needs
Penalty
Summary
The facility failed to revise and update Resident #5’s person-centered care plan after changes in her condition and treatment. Resident #5 was admitted with colon cancer and had an MDS BIMS score of 12/15, indicating she was cognitively intact. During an observation and interview, she was sitting upright in her room and became tearful when discussing her illness, stating that her colon cancer had spread throughout her body, that she was dying, and that she wished to be at home with her family when she passed away. She also stated that she did not need the medications she was receiving, identified them as psychiatric medications, and said she was not crazy. She reported feeling afraid, terrified of being alone, and more anxious because of the holidays and weather limiting family visits. Her care plan still reflected behaviors related to dementia, including verbal aggression and psychotropic/mood stabilizer medication use, with interventions focused on administering medications as ordered and monitoring for adverse effects. The care plan did not reflect revisions for her current condition, including her hospice/end-of-life status, her expressed hopelessness, fear of death and dying, grieving, loneliness, or her stated desire to be with family. The record also showed no care plans in place for UTIs, no compassion visits considered in care planning, and no non-pharmacological focus areas or interventions updated to address her mood or behaviors. During interviews, RN staff stated that residents starting an antipsychotic should have a care plan specific to that medication and noted that R5’s prior behaviors were associated with a UTI and that she was fearful of dying and missed her family. A behavioral health psychiatry follow-up note documented that she was on hospice care for colon cancer, had recently started Aricept, and that her family was interested in adding Namenda. The note also stated that she had previously experienced increased agitation and aggression related to confusion from dementia during a UTI, but the care plan reviewed by surveyors did not show revisions for the new antipsychotic medication, the recent UTI-related behaviors, or her end-of-life emotional concerns.
Failure to Provide Meaningful Activities for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide meaningful activities for Resident #74, who had Alzheimer’s disease, non-Alzheimer’s dementia, and a BIMS score of 3 out of 15 indicating severe cognitive impairment. The resident’s activities evaluation identified preferred activities including movies/TV and music/talk radio, and the care plan stated the resident was dependent on staff for activities, cognitive stimulation, and social interactions, with preferred activities listed as sensory activities, reading, and music. Observations showed the resident repeatedly sitting alone in her room with no lights on, no TV or music, and no activity or sensory items available to interact with. On multiple occasions, the resident was observed sitting on the edge of the bed staring at the wall or floor, with no stimulation or interaction from staff, and later yelling out incoherently while still without activities. A CNA reported the resident was not offered activities and that there were many behaviors down the wing with no activities. An LPN stated activity staff were never seen going into resident rooms to do activities and that residents who did not go to group activities did not receive any activities. The Activity Director could not describe activities offered to residents who stayed in their rooms and could not explain what was offered to this resident when she sat alone all day.
Inaccurate wound documentation and failure to follow compression stocking orders
Penalty
Summary
The facility failed to accurately document wounds, determine wound etiology, and follow the physician’s order for bilateral lower extremity compression stockings for one resident with diabetes, a diabetic foot ulcer, and an unhealed stage 3 pressure injury. The resident was observed multiple times sitting in a wheelchair with both feet on the floor and without the ordered compression stockings, despite an order to ensure the stockings were worn on both lower extremities at all times. The resident stated she was supposed to wear special stockings but they had not been put on in a while, and staff acknowledged the stockings should have been on the resident but did not know why they were not being worn as ordered. The January 2026 TAR showed the stockings were signed out as applied on multiple days even though direct observations showed they were not on the resident. A progress note documented the stockings were missing and that vascular changes and pooling edema were present, but there was no further documentation after that regarding the missing stockings, the increased edema, or notification of the physician about the missing stockings. The resident’s lower calves and feet were observed with a purple hue and edema, and staff documented the resident spent large portions of the day in a dependent position with pooling edema. The wound record was also inconsistent. The right heel wound was documented in assessments as a facility-acquired stage 3 pressure injury, while some progress notes described it as a diabetic ulcer. The left heel wound was documented as resolved on 12/8/25, but later progress notes continued to describe a left heel diabetic ulcer and treatments in place. On 1/7/26, staff stated the left heel had healed, but when the heel was lifted, an uncovered wound approximately 1.5 cm by 1.5 cm with eschar was found, and staff said it looked like it had reopened. The nurse and LPN stated they had believed the left heel wound was healed and did not know when it reopened.
Unnecessary drugs and PRN medication administration failures
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when it started risperidone for a resident with dementia and hospice status without documented non-pharmacological interventions or use of the resident’s ordered PRN anti-anxiety medication first. The resident had diagnoses including dementia and colon cancer on hospice, and during an interview she was observed sitting upright in her room, speaking coherently, and expressing fear, loneliness, and distress about dying alone. She stated that she did not need the medications because she was not crazy and was dying, and she reported that she became frustrated and spoke loudly to staff because they did not visit as much as she wanted. The resident’s physician orders included risperidone 0.5 mg daily for adjustment disorder with depressed mood, started after hospice reported that she had been very upset and angry. A psychiatry note documented that she had recently started Aricept, was on Celexa, and had previously experienced agitation and aggression primarily related to confusion from dementia, including during a prior UTI. During interview, an RN stated that a resident starting an antipsychotic should have a complete assessment and documented behaviors to show the medication was necessary, and that the resident had PRN anti-anxiety medication that should have been used when she was struggling with mood, behaviors, aggression, and anxiety. The facility also failed to discontinue an inhaled medication for another resident after the consultant pharmacist recommended stopping duplicate therapy and the physician signed the order to discontinue it. The resident continued to receive both Trelegy and Advair daily, and the DON confirmed the Advair was not discontinued because the wrong fluticasone product had been stopped instead. In addition, the facility failed to document non-pharmacological interventions before administering PRN pain medications to two residents. One resident received PRN oxycodone on multiple days with no documentation of non-pharmacological interventions before administration, and another resident was observed receiving PRN acetaminophen without being asked about pain or having non-pharmacological interventions attempted first.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate at or below 5 percent, with three errors out of 31 opportunities for a rate of 9.68%, affecting one resident reviewed. During observation on 1/6/2025, an LPN administered Trelegy Ellipta and then handed the resident oral medications without instructing her to rinse and spit after the inhaler; the resident swallowed water after the inhaler and then swallowed the oral medications. The same LPN then administered Advair while the inhaler was held in a vertical position, assisted with loading the dose, and did not instruct the resident to keep the inhaler level, hold her breath for 10 seconds, or rinse and spit after use. The same medication pass also included insulin administration errors. After giving Humalog 15 units by subcutaneous injection into the resident’s right mid-abdomen, the LPN returned with Lantus and prepared 60 units. Although the resident requested the second injection be given on the left side of her abdomen, the LPN injected the Lantus into the right mid-abdomen at the same site used for the Humalog. The MAR documented the Humalog injection as being given in the left upper quadrant, which did not match the observed site. The DON stated the resident had not been assessed for self-administration of medications, nursing should load inhalers and instruct residents accordingly, insulin injection sites should be rotated, and two insulins should be injected in different locations.
Failure to Use Correct Sling and Lift During Transfer Causes Resident Injury
Penalty
Summary
The facility failed to ensure the use of an appropriately sized sling and mechanical lift during resident transfers, resulting in injury to a resident who was totally dependent on staff for all transfers. During an observed transfer, staff used a blue sling with green binding, presumed to be a large size, with a [Name Brand] 450 mechanical lift, despite the resident's care plan specifying the use of an XXL blue or black sling with a [Name Brand] 600 lift. The sling used was too small, causing the resident's abdominal area to extend out the sides and exerting significant pressure on her back, arms, and legs. Staff were unable to confirm the correct sling size, and the sling's labels were missing or illegible. The resident expressed discomfort and reported that the incorrect equipment pinched her during transfers. The resident had a complex medical history, including debility, cardiorespiratory conditions, heart failure, peripheral vascular disease, anxiety, PTSD, COPD, and morbid obesity. She was also at risk for abnormal bleeding due to anticoagulant and aspirin therapy. Multiple progress notes and incident reports documented deep purple bruises on her arms and legs, which matched the shape of the sling, as well as a skin tear on her right second toe sustained when a CNA bumped her toe on a door frame during a shower transfer. The care plan had been updated previously to specify the correct sling and lift, but staff failed to follow these interventions, and there was no clear system in place for identifying or selecting the correct sling size in the storage area. Interviews with staff and review of facility policies revealed a lack of knowledge and adherence to the resident's care plan and safe lifting procedures. Staff were unsure of the correct sling size, and the storage area lacked instructions for assessing sling size. The facility's policy required ongoing assessment of residents' transfer needs and availability of appropriately sized slings, but these requirements were not met. The deficiency resulted in harm to the resident, including bruising, an injured toe, and discomfort during transfers.
Failure to Obtain and Transcribe Physician Orders for Immediate Care on Admission
Penalty
Summary
The facility failed to ensure the timely receipt and transcription of physician orders for immediate care upon admission for two residents. For one resident with Alzheimer's disease and visual loss, there was a 12-day delay in obtaining and administering prescribed ophthalmic medications, including Timolol-Dorzolamide-Latanoprost and Latanoprost, which were documented as necessary for the resident's glaucoma and visual loss. Despite the medications being listed in the pre-admission physician note and the family inquiring about them, the orders were not transcribed or administered until nearly two weeks after admission. Progress notes indicate that staff were aware of the need for these medications and communicated with the resident's ophthalmologist, but the actual orders and administration were delayed. Another resident with acute and chronic respiratory failure, pneumonia, and COPD was admitted without a physician order for supplemental oxygen, despite having a care plan intervention for oxygen and being observed with low oxygen saturation levels. The resident was seen in the dining room without oxygen, and staff later provided an oxygen tank holder and tubing after observing low oxygen saturation readings. However, review of the medical record confirmed that no physician order for oxygen was present from admission through the time of the survey, even though oxygen was administered when low saturation was detected. Interviews with facility leadership confirmed that the required physician orders for both medications and oxygen were not present or transcribed at the time of admission for these residents. The facility's own policy requires documentation and verification of physician orders for care and treatment, but this process was not followed, resulting in a lack of necessary medications and treatments for the affected residents.
Failure to Provide Timely Denture and Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Alzheimer's disease, non-Alzheimer's dementia, depression, visual and hearing loss, and dependence on staff for personal care did not receive proper denture and incontinence care. The resident's care plan required staff to encourage and assist with denture use and to provide regular incontinence checks and changes. However, the resident's dentures were found by a complainant in a cup on a discolored paper towel, covered in what appeared to be white mold, and not in the resident's mouth as required. Staff were unable to locate the dentures in the resident's room and later found them in the Staff Development Coordinator's office, with no explanation for their placement there. Observations revealed that the resident was left sitting in a wheelchair and later in a recliner for extended periods without incontinence checks or changes. Staff did not interact with the resident during these periods, and no incontinence care was provided between 10:15 a.m. and 4:15 p.m., despite the facility's policy of checks every two hours. When finally checked, the resident was found to be wet with urine, and both the resident's clothing and recliner were soiled. Staff admitted that documentation only occurred when a resident was changed, not when checked and found dry, leading to uncertainty about the timing of care provided. The facility's own policies and the resident's care plan required regular assistance with oral hygiene and incontinence care, but these were not followed. The Director of Nursing confirmed that the observed lapse in incontinence care was unacceptable and acknowledged the poor condition of the dentures as shown in photographs. The deficiency was substantiated by direct observation, staff interviews, and review of care plans and facility policies.
Failure to Provide Meaningful Activities for Resident with Sensory Impairments
Penalty
Summary
The facility failed to provide meaningful activities to promote psychosocial well-being for a resident with severe visual and bilateral hearing loss, as well as cognitive impairment and dependence on staff for daily care. Despite care plan interventions that included escorting the resident to activity programs, providing friendly visits, and offering an activity calendar, observations revealed the resident was left alone for extended periods without engagement. The resident was seen sitting slumped in a wheelchair or recliner, with no staff interaction, and was positioned with her back to a television, which was not an appropriate activity given her blindness. Staff were observed performing care tasks without speaking to the resident, and the resident was left in silent environments without stimulation. Interviews and documentation review further indicated a lack of individualized activity provision. The activity director was unable to explain what activities had been provided, as documentation was unclear and included ambiguous entries such as "other" without specifics. The resident's preferences for music and conversation were not addressed, and there was no evidence of staff actively engaging the resident in meaningful activities tailored to her sensory impairments. This resulted in social isolation for the resident, contrary to the facility's policy to support residents' psychosocial well-being through individualized activities.
Failure to Complete Physician-Ordered Wound Care for Two Residents
Penalty
Summary
The facility failed to follow physician orders for wound care for two residents with complex medical conditions. One resident, admitted with peripheral vascular disease and heart failure, had a venous/arterial ulcer and was prescribed a specific wound care regimen, including dressing changes every other day and the application of various topical treatments. Review of the Treatment Administration Record (TAR) showed that the ordered wound care was not completed on multiple specified dates across several months. Interviews with nursing staff confirmed that the treatments were missed as documented in the TAR. Another resident, admitted with diagnoses including cancer, cirrhosis, and neurogenic bladder, had multiple pressure ulcers, including a stage 3 ulcer and unstageable wounds. This resident had physician orders for daily application of Santyl ointment and specific wound care procedures. The TAR indicated that the prescribed treatments were not completed on two documented dates. Both the wound care nurse and the Director of Nursing acknowledged that the physician-ordered wound care was not completed as required. Facility policy requires wound treatments to be provided in accordance with physician orders, but this was not followed for these residents.
Failure to Provide Routine and Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot and nail care, including toenail trimming, for four residents who were reviewed for nail care. Observations revealed that multiple residents had thick, long, yellowed, and curled toenails, with some residents reporting pain and difficulty wearing shoes due to the condition of their nails. Certified Nursing Assistants (CNAs) acknowledged that the toenails had not been cut for a significant amount of time and that they were unable to trim certain residents' toenails due to their condition. The facility's nail care policy requires regular assessment and trimming of nails, with specific provisions for residents with diabetes or circulation problems, but these procedures were not followed for the affected residents. Interviews with residents and staff indicated that nail care was not consistently provided, with some residents stating they could not recall the last time their toenails were trimmed or that it had been almost a year since their last nail care. Staff interviews further revealed that access to podiatry services was limited to residents with certain insurance coverage, and the affected residents were not on the list to receive mobile medical podiatry. The DON stated that nail care was supposed to be provided on shower days, but this was not consistently implemented, resulting in untrimmed toenails and unnecessary pain for the residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to securely store medications and treatment supplies, leading to potential misuse. An insulin pen belonging to a resident with type 2 diabetes was found on the resident's bedside table, with approximately 150 units of insulin remaining. The resident was severely cognitively impaired, as indicated by a BIMS score of 00/15. A Licensed Practical Nurse (LPN) acknowledged that the insulin pen was likely left there from an earlier medication pass and admitted that medications should not be left on residents' bedside tables. Additionally, a treatment cart near the nurse's station was observed unlocked, containing various prescription powders, creams, and medical supplies. The cart was accessible to unauthorized individuals, and the LPN interviewed was unsure who last used the cart. The facility's policy mandates that all medications be stored in locked compartments and that medication carts be locked when unattended, which was not adhered to in these instances.
Failure to Maintain and Sanitize Resident Equipment
Penalty
Summary
The facility failed to maintain equipment in good working order and to clean and sanitize resident equipment, which increased the potential for the spread of infections among residents. Observations revealed that multiple wheelchairs were heavily soiled with food crumbs, dried spillage, and had damaged components such as seat cushions with holes. Additionally, a motorized wheelchair was noted to be in a similar state of disrepair and uncleanliness. Hoyer lifts were also observed to be soiled with dust, debris, and dried crusted substances, and the bags holding sanitizing wipes were heavily soiled. A vital sign machine and its components, including a pulse oximetry probe and a thermometer, were found to be soiled and sticky. Interviews with staff, including a CNA and an LPN, indicated that CNAs and nursing staff were responsible for cleaning and sanitizing resident equipment before and after use, with a specific emphasis on the 3rd shift for thorough cleaning. However, the observations contradicted these statements, as the equipment was not maintained according to the facility's policy on cleaning and disinfection of resident-care equipment. The policy outlined the importance of cleaning and disinfecting reusable equipment to prevent the transmission of pathogens, yet the facility failed to adhere to these guidelines, as evidenced by the condition of the equipment observed during the survey.
Inadequate Discharge Planning Leads to Resident's Homelessness
Penalty
Summary
The facility failed to implement and follow their policy to ensure a safe and orderly discharge for a resident, resulting in an involuntary discharge into the community without sufficient preparation and orientation. The resident, who was cognitively intact and had pertinent diagnoses including type 2 diabetes, was originally admitted to the facility and had a history of cellulitis requiring antibiotics and wound care. The resident left the facility for a pre-approved vacation to Texas, with the understanding that there would be no issue with returning as he was self-pay. However, during his absence, the acting Nursing Home Administrator informed him that he would not be able to return due to an unpaid bill, and he was officially discharged without any discharge paperwork or medications. The facility's electronic medical record indicated that a Notice of Involuntary Discharge was served to the resident, citing non-payment of services. Despite this, the facility's legal department advised that the involuntary discharge process was not properly followed, and the appeal was lost. The resident was not provided with appropriate follow-up and discharge instructions, and upon returning from vacation, he was unable to re-enter the facility and had to stay at a hotel. Eventually, a local hospital social worker reported that the resident was homeless, highlighting the lack of proper discharge planning and communication. Interviews with staff revealed that there was confusion and miscommunication regarding the resident's status, with the facility failing to document the discharge process adequately. The acting Nursing Home Administrator acknowledged that the previous management had not properly documented the involuntary discharge process and that the resident's discharge was not planned or executed according to policy. The facility's policy on involuntary transfer and discharge was not adhered to, resulting in the resident's unplanned discharge and subsequent homelessness.
Expired Food Items Found in Resident's Mini-Fridge
Penalty
Summary
The facility failed to remove expired foods from the mini-fridge of a resident who was severely cognitively impaired and had type 2 diabetes. During an observation, numerous expired food items were found in the resident's personal mini refrigerator, including expired yogurt, cheese, mustard, butter, and sausage with visible mold. Additionally, there were expired snacks and drinks on a shelf and in a nightstand drawer, along with soiled and open protein shakes on the bedside table. Interviews with various staff members, including an LPN, housekeeping staff, and a CNA, revealed a lack of clarity regarding who was responsible for monitoring and maintaining the cleanliness and safety of the resident's food items. The LPN and other staff members were unsure if it was the responsibility of the kitchen, housekeeping, or floor staff to track the food items. The resident herself was unaware of the expired items and reported receiving snacks from her daughter through the mail. The facility's policy on resident refrigerators stated that housekeeping staff should record refrigerator temperatures daily and clean the refrigerators, discarding any non-compliant foods. However, there was no temperature log present, and the housekeeping manager confirmed that the department was not responsible for the mini-fridges. This lack of adherence to the facility's policy resulted in the potential for expired food to be consumed, increasing the risk of foodborne illness.
Failure to Administer IV Antibiotics and Transcribe Orders
Penalty
Summary
The facility failed to properly transcribe and administer medications according to physician orders for a resident who was admitted with osteomyelitis in the left ankle and foot. Upon admission, the resident was supposed to receive intravenous antibiotics and wound care, but the facility did not administer the prescribed IV antibiotics for approximately five days. This oversight resulted in the resident's condition worsening, leading to hospitalization. The resident, who was severely cognitively impaired, reported that the facility's nursing staff did not administer the IV antibiotics or properly clean the wound. The resident's guardian noticed the resident's foot and leg were swollen and red, prompting a visit to the hospital where the resident was treated for the worsened infection. The hospital discharge paperwork included specific orders for antibiotic administration and PICC line flushes, which were not followed by the facility. Interviews with facility staff, including a registered nurse and the Director of Nursing, revealed that the transcription of the physician's orders was missed due to differences in the hospital's discharge paperwork. The staff did not notice the orders for the IV antibiotics and PICC line flushes, resulting in a delay in treatment. The facility's incident report confirmed that the staff failed to initiate the IV antibiotic treatment until several days after the resident's admission.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three residents. Resident #29, who had severe cognitive impairment and multiple health conditions, developed a pressure injury on the left heel that was not properly documented or treated in a timely manner. Despite orders to offload pressure from the heel, the care plan was not updated, and staff were not informed of the correct interventions. This led to the deterioration of the wound, resulting in gangrene, sepsis, and ultimately, a below-knee amputation. Resident #22 developed a stage four pressure ulcer, and the facility failed to ensure the proper functioning of a wound vac device. The wound vac was frequently turned off due to alarms, and staff did not consistently perform dressing changes as ordered. The lack of timely intervention and proper wound care management contributed to the worsening of the resident's condition. Resident #36 developed a stage three pressure ulcer on the spine, which was not present upon admission. The resident was often observed in a slouched position in bed without proper support or repositioning. Despite the presence of a care plan that included repositioning interventions, these were not consistently implemented, leading to the development and deterioration of the pressure ulcer.
Inadequate Supervision Leads to Resident Injuries and Safety Risks
Penalty
Summary
The facility failed to provide adequate supervision, resulting in a fall with major injury for a resident with a history of osteoporosis, repeated falls, stroke, and toxic encephalopathy. The resident, who had moderate cognitive impairment, experienced an unwitnessed fall from a wheelchair, leading to a head laceration and a cervical fracture. Staff interviews revealed that the resident was placed at the nurse's station for better supervision due to low staffing levels, but was left unattended when staff were occupied elsewhere, contributing to the fall. Another deficiency was identified regarding a resident with a history of tobacco use, falls, COPD, and vascular dementia, who was observed smoking unsupervised outside the facility. Despite the resident's care plan requiring supervision during smoking, the resident was allowed to smoke alone, and facility management was unaware of the specific interventions outlined in the care plan. The facility's smoking policy mandates direct supervision for residents with smoking privileges, which was not adhered to in this case. Interviews with facility staff, including the Nursing Home Administrator and Director of Nursing, confirmed that low staffing levels and inadequate supervision were ongoing issues. The facility's policies on accidents, supervision, and smoking were not effectively implemented, leading to these deficiencies in resident care and safety.
Staffing Shortages Lead to Unmet Care Needs and Safety Concerns
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care needs and ensure the safety of all 65 residents, as evidenced by multiple instances of unmet care needs and potential safety issues. A staff member reported that residents were being neglected, left in wet and soiled beds, and not receiving showers due to inadequate staffing. Resident #42, who requires assistance with personal care and has intact cognition, reported long wait times for toileting assistance, resulting in incontinence, and often receiving bed baths instead of preferred showers due to staffing shortages. Resident #15, also with intact cognition, expressed difficulty in receiving showers and suspected that the facility marked his shower opportunities as refused instead of offering alternative times. His care plan indicated a preference for showers twice a week, but records showed refusals or non-applicable statuses for several opportunities. Resident #61, with pressure ulcers and intact cognition, reported not being repositioned every two hours as required, leading to discomfort and potential worsening of his condition. The facility's records confirmed inconsistent repositioning, further highlighting the staffing inadequacies. Additionally, Resident #64, with moderate cognitive impairment, experienced an unwitnessed fall resulting in injuries, attributed to insufficient supervision due to staffing shortages. Staff interviews corroborated the challenges faced due to low staffing levels, with CNAs and RNs acknowledging the impact on resident care and supervision. The Nursing Home Administrator and Director of Nursing confirmed that low staffing levels have been an ongoing issue at the facility.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among the 65 residents. During a noon meal service, small bowl servings of potato salad and cottage cheese were observed at room temperature, with temperatures ranging from 46 F to 49 F, which is above the recommended 41 F or less for cold foods. The Kitchen Manager acknowledged the improper holding and disposed of the products. Additionally, a refrigerator in the nourishment room contained a package of rotisserie chicken without identifying information and a bottle of maple syrup past its expiration date, indicating a lack of proper monitoring and labeling. Further deficiencies were noted in the reheating process of roast beef, where the dietary staff failed to reheat the product to the required 165 F for 15 seconds. The staff member was unaware of the proper reheating temperature, and subsequent measurements showed the temperature ranged between 126 F and 146 F, below the required standard. This indicates a lack of knowledge and adherence to the FDA Food Code 2017 standards for reheating food for hot holding. Additionally, a cross-connection issue was identified with the ice machine's drain line, which was submerged into a floor drain and covered with a mold-like substance. The Kitchen Manager was aware of the issue but had not yet addressed it, and the Maintenance Director was only informed after the surveyor's observation. This situation presents a potential risk of contamination due to the improper configuration of the drain line, violating the FDA Food Code 2017 standards prohibiting cross-connections.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for one of the three residents reviewed for EBP, specifically for Resident 274 (R274). On multiple occasions, it was observed that there was no EBP outside of the room assigned to R274, who had an indwelling catheter. R274 was admitted with several diagnoses, including cellulitis, lymphedema, chronic diastolic heart failure, paroxysmal atrial fibrillation, morbid obesity, obstructive sleep apnea, essential hypertension, osteoarthritis, and a history of falls. Despite these conditions, R274's care plan did not include EBP for her catheter as per standards of care. The lack of EBP was noted over a period of six days, putting R274 at risk for a Multidrug Resistant Organism (MDRO) infection during her catheter care.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' right to a dignified existence by not ensuring privacy during care. This deficiency was identified through observations, interviews, and record reviews, where it was found that staff members frequently entered residents' rooms without knocking or waiting for permission. During a group meeting with the President of the Resident Council and seven other residents, several residents expressed their concerns about staff entering their rooms without proper acknowledgment, leading to feelings of embarrassment and a lack of privacy. Residents reported that staff would often knock quietly and enter immediately, not allowing residents time to prepare or cover themselves, which was particularly distressing during personal care activities. Further observations confirmed these reports, as staff members were seen entering rooms without knocking. For instance, housekeeping staff was observed entering a resident's room without knocking, and the resident confirmed that this was a frequent occurrence. Similarly, a CNA was also observed entering a room without knocking. The facility's policy on promoting and maintaining resident dignity, which emphasizes treating residents with respect and ensuring their privacy, was not adhered to, resulting in the identified deficiency.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notifications to residents and their representatives regarding transfers to hospitals, as required by policy. This deficiency was identified for four residents who were transferred out of the facility without receiving the necessary written notices. Resident 124 was sent to the hospital twice in October 2024 due to unresponsiveness and after a discussion with the on-call physician, but no written transfer notices were found in their electronic medical record. Similarly, Resident 22, who had a primary diagnosis of sepsis, was transferred multiple times to the emergency department for a deteriorating wound, yet did not recall receiving any transfer paperwork. Resident 29 was transferred to an acute care hospital due to a worsening left heel wound with necrotic tissue, but no written transfer notice was documented. Resident 64 was sent to the hospital following a fall with injury, and again, no written transfer notice was found in their records. Interviews with the Nursing Home Administrator and Regional Clinical Nurse revealed that the interim social worker was not sending the required notifications, and the Nursing Home Administrator was unaware that this task was not being completed. The facility's policy mandates that transfer or discharge notices be provided to the resident, their representative, the long-term care ombudsman, the state survey agency, and the physician, with a copy placed in the resident's file.
Failure to Provide Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to hospital transfers for five residents. This deficiency was identified through interviews and record reviews, revealing that the necessary documentation was missing from the clinical records of the affected residents. For instance, Resident #18 was transferred to the emergency department on two occasions without any bed-hold document in their clinical documentation. During an interview, the resident stated they were not informed about the bed-hold policy and assumed their bed would be available upon return. Similarly, Resident #124 was transferred to the hospital twice without receiving a written bed-hold notice, as confirmed by a review of their electronic medical record. Further investigation showed that Resident #22, who had been transferred multiple times due to medical conditions, did not recall receiving any bed-hold paperwork. Resident #29 and Resident #64 also experienced hospital transfers without documented bed-hold notifications. The Nursing Home Administrator acknowledged that bed-hold notifications were not being completed, indicating a lapse in adherence to the facility's policy. The facility's policy, revised in February 2022, mandates that written information about the bed-hold policy, including its duration and conditions for readmission, be provided to residents or their representatives before any transfer to a hospital or therapeutic leave.
Failure to Timely Destroy Discontinued Medications and Improper Use of Resident Medications
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not destroying discontinued schedule two medications in a timely manner and using another resident's medication on a different resident. During an observation, it was found that a resident had another resident's acetic acid solution in their room, which was being used on them for wound care. The resident confirmed that the solution was used on their lower legs. The Licensed Practical Nurse (LPN) acknowledged that the supplies should not have been in the room and should have been stored in the wound care cart, indicating a lapse in following proper procedures for medication storage and use. Additionally, the facility did not remove expired medications from the medication carts, as evidenced by the presence of expired lorazepam orders for multiple residents. The narcotic sign-out sheets for these medications were still present on the medication carts, despite the physician orders having expired and not being reordered. The facility's policy on discontinued medications requires that medications be removed from the active supply immediately upon receipt of a discontinuation order to prevent inadvertent administration. However, this policy was not followed, leading to the deficiency.
Deficiency in Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that dementia training was completed by four Certified Nursing Assistants (CNAs) as required by annual training requirements. This deficiency was identified through a review of CNA in-service training logs for CNAs F, V, U, and E. The training transcripts for CNAs F, V, and U indicated that the course titled 'Dementia Care: Normal Aging vs. Alzheimer's/Dementia' was incomplete and overdue, with a due date of 9/30/24. CNA E's transcript did not list any dementia training at all. An interview with the Assistant Director of Nursing (ADON) revealed that there was no specific dementia training provided to nurse aides, as it was assumed to be included in a course called 'Challenging Behaviors.' However, a review of the 'Challenging Behaviors' training transcript did not show any education regarding dementia care. The facility's most recent Facility Assessment Tool, covering the period from 7/2023 to 6/2024, stated that required in-service training for nurse aides must include dementia management training and resident abuse prevention training. The lack of specific dementia training for the CNAs resulted in the potential for unmet care needs and could potentially affect all residents with dementia in the facility, which had a current census of 65 residents.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, resulting in mental distress and anguish. A resident, who was cognitively intact and had multiple medical conditions including spinal stenosis, diabetes, heart failure, and kidney disease, reported an incident where a nurse made an inappropriate comment suggesting that the resident should end his life due to his health problems. The resident described the nurse and the circumstances of the incident, which he had reported to several staff members. The incident was documented by the facility and reported to the State Agency. Interviews with other staff members, including a CNA and an LPN, revealed that the nurse in question had a history of speaking inappropriately to residents and had been previously educated and nearly terminated for similar issues. Despite this, the facility allowed the nurse to continue working, which contributed to the deficiency in protecting residents from verbal abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report alleged abuse in a timely manner for two residents, resulting in a potential for ongoing abuse. Resident 61, who was cognitively intact with a BIMS score of 15, reported an inappropriate comment made by a nurse, suggesting that if she were in his position, she would end her life. This incident was reported to several staff members, including LPN M, who acknowledged the comment as abusive but failed to report it immediately to the Nursing Home Administrator (NHA) due to being preoccupied with other tasks. Additionally, Resident 124 experienced alleged abuse when a nurse, frustrated during her medication pass, spoke harshly after the resident fell out of bed multiple times. This incident was not reported to the administration until much later, when CNA F was questioned about another incident. Both events were not reported to the State Agency until several days after they occurred, violating the facility's policy that requires immediate reporting of abuse allegations within specified timeframes.
Inadequate Assessment of Catheter Necessity
Penalty
Summary
The facility failed to properly assess the clinical need for urinary catheterization for two residents, leading to inappropriate or potentially unnecessary catheter usage. Resident #18 had an indwelling catheter placed after shoulder surgery, reportedly due to urinary urgency and the inability to get out of bed quickly without assistance. However, there was no documented diagnosis of urinary retention in the resident's chart, and a referral to a urologist, as requested by the resident, was not made. The resident's care plan indicated the catheter was for urinary retention, but this was not supported by the medical record. Resident #274 was admitted with an indwelling catheter from the hospital, reportedly due to the inability to reach the bathroom in time. However, the resident's care plan did not reflect the presence of a catheter or provide guidance on its care. The Assistant Director of Nursing was unaware of the resident having a catheter, and the facility lacked a policy for evaluating the medical necessity of catheter usage, relying only on catheter care procedures. This lack of standardized assessment and documentation contributed to the deficiency.
Failure to Monitor Resident Weight Fluctuations
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for weight fluctuations for two residents, resulting in the potential for inaccurate assessments and physical decline. Resident 61, who had multiple diagnoses including diabetes, heart failure, and a pressure ulcer, reported not being weighed as frequently as in the hospital. The medical record showed a significant weight drop from 175 pounds to 149 pounds, but no initial weights were recorded in the facility. The Registered Dietitian noted the absence of an admission weight and requested a current weight, but no further weights were documented. Resident 124, diagnosed with protein-calorie malnutrition and dysphagia following a stroke, was not weighed upon readmission after two hospitalizations. The only recorded weight was from before these hospitalizations, which was used to calculate nutritional needs. Despite the care plan's directive to periodically obtain and evaluate weights, no updated weights were recorded. The facility's policy required weekly weight monitoring for newly admitted residents and those with weight loss, but this was not adhered to, as confirmed by interviews with the Nursing Home Administrator and the Registered Dietitian.
Failure to Obtain Consent and Conduct Timely GDR for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent and physician orders for psychotropic medication for two residents, leading to the administration of lorazepam without proper authorization. One resident received nine doses of lorazepam without a physician order, and the consent for psychotropic medication was outdated and lacked specific dosage information. Another resident received five doses of lorazepam without a physician order, and the facility's policy on medication administration was not followed, as medications were given without a physician's order. Additionally, the facility did not conduct a timely gradual dose reduction (GDR) for psychotropic and anti-anxiety medications for a resident, despite recommendations from behavioral health providers. The resident, who had severe cognitive impairment and multiple psychiatric diagnoses, was on Paxil and Abilify for an extended period without adjustments. Recommendations for GDR were made but not acted upon in a timely manner, with significant delays in the facility physician's response to these recommendations. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed a breakdown in the process of reviewing and relaying GDR recommendations to the facility physician. The facility's policy on gradual dose reduction of psychotropic drugs was not adhered to, as there was a delay in evaluating and acting on the resident's medication needs, potentially leading to adverse side effects and excessive duration of medication use.
Ineffective QAPI Program Implementation
Penalty
Summary
The facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program, which is essential for the development, monitoring, and evaluation of adverse events to correct quality deficiencies. This deficiency was identified during an interview with the Nursing Home Administrator (NHA), who confirmed that QAPI meetings were held monthly but was unable to explain how medical errors or adverse resident events were identified, analyzed, corrected, or monitored through the QAPI process. The NHA relied on emails from the regional clinical nurse and the Director of Nursing for information on adverse events but lacked a clear understanding of the QAPI process. The facility's policy on QAPI, reviewed and revised in October 2022, mandates systematic data collection and investigation of medical errors and adverse events, yet these procedures were not effectively implemented.
Failure to Ensure Accurate Indication for Laxative Administration
Penalty
Summary
The facility failed to ensure an accurate indication for administering a laxative to a resident, leading to unnecessary medication use. The resident, who was always continent of bowel and bladder and required assistance for toileting, was given a laxative despite having regular bowel movements documented prior to the administration. The resident experienced diarrhea and bowel incontinence as a result of the laxative administration. The Medication Administration Record (MAR) showed that the laxative was not initialed as administered by a nurse, indicating a lack of proper documentation. Registered Nurse (RN) C, who was responsible for the resident's care on the day of the incident, admitted to administering the laxative without performing an assessment. RN C relied on a report that the resident had not had a bowel movement, which was later found to be inaccurate. The bowel elimination tracking record was updated after the laxative was given, showing bowel movements on previous days. The facility's policy on PRN medications requires an assessment for need and effectiveness, which was not followed in this case.
Failure to Provide Adequate Showering Services
Penalty
Summary
The facility failed to provide adequate showering services for a resident, identified as R5, who was admitted with multiple diagnoses including hemiplegia, urinary tract infection, dementia, cognitive communication deficit, and weakness. R5 required moderate assistance for showering and was occasionally incontinent of bladder. During the 17-day stay at the facility, R5 received only one shower, despite the facility's policy that residents should receive showers twice per week unless otherwise documented in the care plan. The care plan for R5 was revised after discharge and did not include interventions for showering or bathing. The Director of Nursing (DON) confirmed that showers are documented by CNAs and could not provide an explanation for the lack of showers provided to R5. The facility's policy on Activities of Daily Living (ADLs) states that residents unable to carry out ADLs should receive necessary services to maintain personal hygiene. However, the documentation showed that R5's showering needs were not adequately met, as evidenced by the CNA documentation and the lack of additional records in R5's health record.
Failure to Transcribe Treatment Orders and Follow Wound Clinic Recommendations
Penalty
Summary
The facility failed to transcribe treatment orders and follow up on wound clinic recommendations for a resident with a stage 4 pressure injury. The resident developed a severe pressure injury on the sacrum while at the facility, which later became infected, leading to hospitalization for sepsis. Upon returning to the facility, the hospital discharge instructions included specific treatment orders for the wound, which were not transcribed into the resident's electronic medical record (EMR). Consequently, the sacral wound was not documented as being treated until several days after the resident's return. Additionally, the facility did not follow up on the wound clinic's recommendation to reapply a wound VAC, which was noted in the resident's health record. The attending physician was not notified of these recommendations, and there was no documentation of an order to restart the wound VAC. Interviews with nursing staff revealed a lack of awareness regarding the wound clinic's recommendations, and the Director of Nursing acknowledged that the expected procedures for transcribing orders and following up on recommendations were not followed.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by the experiences of four residents who reported significant delays in receiving care. Resident #11, who has intact cognition, reported waiting excessively for assistance, resulting in an incident where they urinated in bed due to the lack of timely help. This resident also experienced delays in receiving medications and was unable to participate in activities due to insufficient staff. Similarly, Resident #7, also with intact cognition, expressed frustration over long wait times for assistance. Resident #1, with intact cognition, highlighted the issue of understaffing, particularly during night shifts, which affected their ability to receive timely care. Resident #3, who has severe cognitive impairment, was found soaked in urine due to inadequate staffing, as reported by their Durable Power of Attorney. Interviews with Certified Nursing Assistants (CNAs) revealed that they were overwhelmed with the number of residents they had to care for, often working alone and unable to provide necessary care such as transfers and showers. The facility's staffing records showed that the number of CNAs on duty was consistently below the required levels to adequately care for the residents, as per the facility's own staffing ratios. The facility's Emergency Staffing policy did not specify the number of staff needed to meet daily resident needs, and the Facility Assessment Tool did not indicate the required staffing levels. This lack of adequate staffing led to unmet care needs and compromised the quality of life and care for the residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to complete and post the daily nurse staffing information, which is a requirement for transparency regarding the number of staff available to provide resident care. This deficiency was identified during an interview with the Nursing Home Administrator (NHA), who was unable to locate the daily staffing posting. An observation revealed that the Regional Director of Clinical Services was filling out the staffing sheet for the current day and instructed staff to post it near the entrance of the facility. A review of the nursing staffing sheets showed missing information for several dates, including 7/13/24, 7/11/24, 6/23/24, 6/15/24, and 6/10/24. The NHA acknowledged that the staffing sheet was not posted at the beginning of the shift, and the Director of Nursing (DON) confirmed that the information should be posted daily by the nurses' station near the entrance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Munising
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dj Jacobetti Home For Veterans | 36.5 mi | ★★★★★ | 7 | 0 |
| Norlite Nursing Center | 36.7 mi | ★★★★★ | 22 | 0 |
| Schoolcraft Medical Care Facility | 37.3 mi | ★★★★★ | 1 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Medilodge Of Munising.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.