Medilodge Of Munising
Inspection history, citations, penalties and survey trends for this long-term care facility in Munising, Michigan.
- Location
- 300 West City Park Drive, Munising, Michigan 49862
- CMS Provider Number
- 235410
- Inspections on file
- 31
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Medilodge Of Munising during CMS and state inspections, most recent first.
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.
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.
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 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.
The facility failed to provide adequate PPE and ensure its proper use in rooms under Transmission-Based Precautions for COVID-19. Staff, including an LPN and SSD, were observed entering these rooms without the required PPE. Interviews revealed a shortage of PPE supplies, with staff having to search for masks and other protective gear. Observations confirmed that PPE carts were inadequately stocked, lacking essential items such as gowns, N95 masks, and face shields.
The facility failed to investigate the root cause of falls for three residents with severe cognitive impairments, resulting in injuries such as fractures and lacerations. The DON did not complete root cause analyses or update care plans with necessary interventions, despite the facility's policy requiring such actions.
A resident with multiple health conditions, including legal blindness, experienced an incident where another resident yelled and cursed at him. Although initially addressed, there was no follow-up or care plan update by the Social Services Designee to address the incident's impact on the resident's well-being. This failure to provide adequate social services led to a deficiency citation.
A resident with multiple diagnoses experienced uncontrollable shaking and sought help from an LPN, who refused assistance, dismissing it as attention-seeking behavior. A CNA witnessed the event and comforted the resident. The DON confirmed the LPN did not assess the resident, and no documentation was made regarding the incident.
The facility failed to prevent and manage pressure ulcers for two residents, leading to severe deterioration and medical complications. The facility did not consistently follow wound care orders, document dressing changes, or implement timely interventions, resulting in worsened conditions and additional medical treatments.
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 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.
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.
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.
Inadequate PPE Availability and Usage in COVID-19 Precaution Rooms
Penalty
Summary
The facility failed to provide adequate Personal Protective Equipment (PPE) for staff and ensure its proper use when entering rooms under Transmission-Based Precautions (TBP) for COVID-19. Observations revealed that several resident rooms had signage indicating TBP due to active COVID-19 infections. However, staff members, including a Licensed Practical Nurse (LPN) and a Social Services Designee (SSD), were seen entering these rooms without donning the required PPE. Additionally, a Durable Power of Attorney (DPOA) reported that staff were not consistently wearing masks or gowns, and there was a lack of encouragement for visitors to wear masks. Interviews with staff, including Certified Nurses Assistants (CNAs) and a Registered Nurse (RN), highlighted a shortage of PPE supplies, particularly on weekends, with reports of having to search for masks and other protective gear. Observations confirmed that PPE carts on various wings were inadequately stocked, lacking essential items such as gowns, N95 masks, and face shields. The facility's policy mandates the use of specific PPE for residents with suspected or confirmed COVID-19, but the central supply clerk was not maintaining adequate supplies, leading to non-compliance with the policy.
Failure to Investigate Falls and Update Care Plans
Penalty
Summary
The facility failed to investigate the root cause of injuries for three residents who experienced falls, leading to deficiencies in resident safety and care planning. Resident #5, with severe cognitive impairment and multiple health conditions, was found on the bathroom floor with a hip fracture. The Director of Nursing (DON) did not provide answers regarding the root cause analysis or care plan interventions for this incident. The care plan lacked assessments for pain and interventions to minimize fall risks. Resident #3, also with severe cognitive impairment, experienced two falls. The first incident involved a CNA assisting the resident to the floor, and the second resulted in a nasal bone fracture. The DON acknowledged that no root cause analysis or care plan updates were completed for these falls. Similarly, Resident #4, with severe cognitive impairment and a history of traumatic brain injury, experienced two falls, one resulting in a laceration. The DON confirmed the absence of root cause analyses and care plan updates for these incidents. The facility's policy on falls required interventions based on assessed needs, which were not implemented.
Failure to Provide Adequate Social Services
Penalty
Summary
The facility failed to provide adequate medically-related social services to a resident, identified as R2, who was involved in an incident where another resident yelled and cursed at him. R2, who has multiple sclerosis, depression, legal blindness, and a neurogenic bladder, was admitted to the facility and is capable of understanding and being understood. Following the incident, R2 expressed feeling upset and worried about his safety. Although initially addressed by the staff, R2 reported that there had been no follow-up discussions or interventions added to his care plan to address the incident or its impact on his well-being. The Social Services Designee (SSD) admitted to not having conducted any trauma assessment or added any interventions to R2's care plan following the incident. The facility's policy on social services, which aims to provide medically-related social services to maintain residents' highest practicable physical, mental, and psychosocial well-being, was not adhered to in this case. The lack of follow-up and failure to update the care plan with necessary interventions for R2's psychosocial needs contributed to the deficiency identified by the surveyors.
Failure to Assess Change in Condition for Resident
Penalty
Summary
The facility failed to assess a change in condition for a resident, identified as R2, who was admitted with multiple active diagnoses including hereditary and idiopathic neuropathy, anxiety disorder, major depressive disorder, chronic pain, repeated falls, muscle weakness, and a compression fracture of the lumbar vertebra. R2, who had intact cognition, reported experiencing an uncontrollable shaking episode upon returning to the facility, which was a new and frightening experience for him. Despite seeking help from a Licensed Practical Nurse (LPN), the resident was denied assistance, as the LPN dismissed the situation as attention-seeking behavior and prioritized medication administration over assessing the resident's condition. A Certified Nursing Assistant (CNA) witnessed the resident's distress and attempted to seek help from the LPN, who refused to provide care. The CNA then comforted the resident until the episode subsided. The Director of Nursing (DON) confirmed that the LPN did not assess the resident for a change in condition, and there were no progress notes or assessments documented in the medical record regarding this incident. The resident had filed a grievance with the DON about the lack of assessment and care provided by the LPN.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer and provide appropriate care for two residents, R4 and R8. R4 developed an unstageable pressure ulcer on 2/18/24, which worsened to a stage IV ulcer by 3/11/24. The facility did not consistently measure wound care assessments, follow physician wound care orders, or ensure timely wound care interventions. R4's condition deteriorated, leading to a wound infection, hospitalization, and multiple medical interventions, including wound debridement and colostomy placement. The facility also failed to turn and reposition R4 consistently, as documented in the medical records, contributing to the worsening of the pressure ulcer. R4's medical history included muscle weakness, pneumonia, spinal stenosis, and rheumatoid arthritis, among other conditions. Despite these vulnerabilities, the facility did not provide timely and adequate wound care. The wound care consult was delayed, and there were multiple instances where dressing changes were not documented or performed as ordered. The facility's failure to implement a turning and repositioning schedule further exacerbated R4's condition, leading to severe pain and infection. Similarly, R8 developed an unstageable pressure ulcer to the coccyx area, which deteriorated over time. The facility did not document wound dressing changes consistently and failed to follow physician orders for wound care. R8's wound measurements showed significant deterioration, and the facility's care plan interventions were not effectively implemented. The facility's policies on wound treatment management and pressure injury prevention were not adhered to, resulting in the worsening of R8's condition and the need for additional medical interventions, including the placement of a urinary catheter to promote healing.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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