Medilodge Of Portage
Inspection history, citations, penalties and survey trends for this long-term care facility in Portage, Michigan.
- Location
- 7855 Currier Dr, Portage, Michigan 49002
- CMS Provider Number
- 235399
- Inspections on file
- 27
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Medilodge Of Portage during CMS and state inspections, most recent first.
A resident with a history of stroke, left-sided hemiplegia, and intact cognition was documented as needing one-person assistance with eating and was identified on admission as being at risk for hot liquid spills due to upper extremity weakness. Despite this, the care plan and Kardex did not include specific hot-liquid precautions or assistive devices, and staff left the resident alone with hot coffee on two separate occasions. In the first incident, a CNA, after confirming with an RN, placed a lidded cup of hot coffee at the bedside and left; the resident spilled it and sustained a painful burn with open skin on the left forearm, which was treated with triple antibiotic ointment rather than immediate cooling as described in external burn-care guidance cited in the report. In the second incident, another CNA, unaware of the prior burn and without any hot-liquid precautions documented, provided coffee at the resident’s request and left; the resident again spilled the coffee and food, resulting in a burn to the left hand. Interviews showed that multiple staff knew the resident required assistance with meals and had a shaky right hand, yet the facility’s hot liquids and assistive device policies were not effectively implemented or communicated, leading to inadequate supervision and two burn injuries.
A resident with a history of intracerebral hemorrhage and left-sided hemiplegia, who was left-handed and required assistance with ADLs, experienced two separate hot coffee burns to the left arm/hand after being given coffee without adequate assistance despite being assessed as at risk for hot liquid spills. The care plan and Kardex only reflected a one-person assist for eating and did not include specific interventions for hot liquid safety or special equipment, even though CNAs and an RN recognized the resident needed help with drinks and that lids and straws were used due to frequent spills. After the first burn, no additional interventions or communication of hot liquid risk were incorporated into the care plan or Kardex, and the incident was not reported as neglect, contrary to the facility’s abuse/neglect policy that defines neglect as failure to provide necessary care to avoid physical harm and discomfort.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards.
Surveyors found that appropriate care was not consistently provided for residents with bowel or bladder continence or incontinence, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
The facility was cited for failing to meet food service safety standards, including an inaccessible handwashing sink due to blocked access, and dietary staff not following hand hygiene protocols. Staff were observed wearing artificial fingernails and jewelry, handling food without gloves, and not washing hands after leaving and re-entering the kitchen or using personal items, all in violation of FDA Food Code requirements.
Residents repeatedly reported delayed call light response, staff turning off call lights before needs were met, and inconsistent water pass during RC meetings. Despite these ongoing concerns, documentation of actions taken was often incomplete or absent, and residents felt their grievances were not taken seriously by facility leadership, leading some to stop reporting issues.
Multiple residents reported that hot foods were consistently served cold, with group interviews confirming widespread dissatisfaction regarding food temperature, quality, and missing items. Observations during meal service showed that while food started at safe temperatures, it cooled significantly before reaching residents, and there was no ongoing temperature monitoring during tray delivery.
A resident with moderate cognitive impairment and diabetes was not provided with facial hair grooming despite expressing her desire for it and facility policy requiring such care on shower days. Staff interviews confirmed the expectation to offer grooming, but documentation and follow-through were lacking, resulting in the resident's needs not being met.
A resident with reduced mobility and decreased strength did not receive the ordered restorative range of motion (ROM) program, as confirmed by interviews and a lack of documentation for the past month. Staff cited inconsistent scheduling and poor oversight as reasons for the missed services, and the resident expressed a desire to participate in the program. The facility's policy requiring daily review and documentation of restorative care was not followed.
A resident's care plan was not updated to reflect changes in adaptive equipment needs, despite communication from the occupational therapist. The resident, with severe cognitive impairment and other health issues, continued to receive outdated equipment, as the nursing and dietary departments did not implement the communicated changes.
A resident was supposed to receive Norco for pain management, but the order was incorrectly entered as Percocet in the EHR. The error was identified when the resident's family member reported the discrepancy. Staff confirmed the clerical error, and the resident was actually given Norco, which was available in the medication cart.
A resident with a cervical vertebra fracture was not properly managed during a transfer, as a CNA removed the Aspen collar before the transfer, contrary to care plan instructions. The CNA was unaware of the requirement to keep the collar on during transfers, as it was not specified in the Kardex. This deficiency was confirmed by an RN and UM/LPN, who stated the collar should remain on to prevent further injury.
A resident's medical records inaccurately documented an order for Percocet instead of Norco due to a clerical error by a nurse. The resident, who was cognitively intact, had diagnoses including pain and muscle weakness. The error was confirmed by facility staff and had the potential to affect the resident's medical outcome.
During a COVID outbreak, staff at the facility failed to wear face masks correctly, with multiple instances of masks worn below the nose or chin. Despite signage and re-education efforts by the Infection Preventionist, non-compliance was observed among various staff members, including dietary aides, RNs, CNAs, and housekeepers, posing a potential risk for infection spread.
Failure to Supervise Resident With Hot Liquids Resulting in Repeated Burns
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and protection from accident hazards related to hot liquids for a resident with significant functional limitations, resulting in two burn injuries. The resident had a history of nontraumatic intracerebral hemorrhage with flaccid hemiplegia affecting the left dominant side, chronic pain, and depression. On admission, the nursing evaluation documented that the resident was at risk of hot liquid spills due to weakness/paresis and reduced mobility in the upper extremities, and the care plan and Kardex both indicated the resident required one-person assistance with eating. The MDS also reflected that the resident needed partial/moderate assistance with eating. Despite this, there was no documentation in the care plan or Kardex that the resident was at risk for hot liquid spills or required special equipment to reduce that risk. On the first incident date, staff provided the resident with hot coffee in her room. A CNA reported that the resident had previously spilled soda on herself and the bed and asked an RN if the resident could have coffee; the RN allowed it. The CNA placed a lidded cup of coffee on the bedside table and left the resident alone. Later, staff found that the resident had spilled the coffee and sustained a burn on her left lower forearm. The resident’s family member stated that the resident had a stroke, had left-sided paralysis, used only her right (non-dominant) hand, and needed assistance with meals and drinks, and that she had informed staff of this. The resident herself reported that the coffee lid was on the cup but fell off when she took a drink, and that she needed help with meals and drinks. Clinical documentation and photographs showed an in-house–acquired burn on the left inner forearm with open skin, redness, pain, and later blistering consistent with a second-degree burn. The nurse who first treated the burn did not apply cool water and instead used triple antibiotic ointment and a non-adherent dressing, contrary to external burn first-aid guidance cited in the report and to the expectations later described by facility clinical leadership. A second burn incident occurred a few days later, again involving hot coffee. On that day, a CNA brought the resident a cup of coffee at her request, not knowing about the prior burn. The Kardex indicated the resident was a one-person assist for meals, but there were still no specific interventions regarding hot liquids or assistive devices documented or communicated to staff. The resident was again left alone with hot coffee and subsequently spilled her lunch plate and coffee on herself and the floor. When another CNA responded to the call light, the resident’s left hand was noted to be red, and cool water was poured over the area. The unit manager observed spilled coffee on the bed and floor and redness of the left hand. Staff interviews confirmed that the resident was known to need assistance with meals due to left-sided weakness and a shaky right hand, and that she was considered a one-to-one assist at meals. However, the hot liquid safety assessment process described in facility policy was not effectively implemented: although the admission assessment identified the resident as at risk for hot liquid spills, this risk was not translated into specific, documented interventions on the care plan or Kardex, and there was no systematic communication to direct care staff about hot liquid precautions prior to the second burn. The facility’s own Hot Liquids/Food Assessment Policy required that when a resident is identified as having concerns with handling hot liquids, a hot liquids safety evaluation should be completed and immediate interventions such as cooling liquids, use of lids, avoidance of hot liquids until evaluation, therapy evaluation, IDT review, and an immediate plan of care should be implemented and added to the care plan and Kardex. The Use of Assistive Devices Policy required IDT collaboration to provide and support assistive devices and staff training. Despite these policies, the unit manager stated that the facility did not do anything different for residents at risk for hot liquid spills because all residents received plastic lids, and that such risk would not be specifically communicated. The administrator acknowledged that no interventions were put in place after the first burn and that no full staff education occurred. Dietary staff monitored coffee temperatures but not all hot liquids, and there was no separate documentation line for hot water temperatures. Therapy only formally evaluated the resident for assistive devices and dining-room supervision after the second burn. Collectively, these actions and inactions led to the resident twice being left unsupervised with hot coffee despite known physical limitations and documented assistance needs, resulting in two burn injuries and the resident’s expressed fear of being burned again.
Failure to Report and Care Plan for Resident at Risk for Hot Liquid Burns
Penalty
Summary
The deficiency involves the facility’s failure to report an incident of neglect related to hot liquid burns and to implement appropriate interventions after an initial burn, resulting in a second burn to the same resident. The resident had a history of nontraumatic intracerebral hemorrhage with flaccid hemiplegia affecting the left dominant side and was assessed on admission as being at risk for hot liquid spills due to upper extremity weakness and reduced mobility. The resident’s MDS showed intact cognition, and the care plan and Kardex identified a one-person assist for eating but did not include any interventions or information regarding risk for hot liquid spills or special equipment to reduce that risk. On one occasion, the resident’s family member found the resident covered in dried coffee with a burn on the left forearm that was red, swollen, with peeled skin, and the resident complained of pain. An incident report documented that staff notified an LPN that the resident had spilled coffee and burned herself, and the daughter stated the resident was not supposed to be left alone with hot drinks. CNAs reported that the resident was a one-to-one assist with meals because her right (non-dominant) hand was shaky and that the Kardex should indicate if assistance with hot beverages was needed. The resident herself reported having two burns on her left arm/hand, described the first burn as severe with blisters, and stated that although the coffee lid was on the cup both times, it fell off when she took a drink; she also stated she was left-handed, had to use her right hand due to left-sided neglect, and needed help with meals and drinks. A second incident report documented another hot coffee spill in which a CNA responded to the resident’s call light and found coffee spilled on the bed and floor, with the resident’s left hand noted to be red and blanching. The Unit Manager confirmed that a hot liquid safety assessment completed on admission identified the resident as at risk for hot liquid spills, but stated that the facility did not do anything specific with these assessments for high-risk residents beyond providing lids on cups, and that this risk was not otherwise communicated. The Nursing Home Administrator stated the first burn was not reported because it was not considered an injury of unknown origin, despite the facility’s abuse/neglect policy defining neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and listing failure to provide care needs such as comfort and safety as a possible indicator of abuse or neglect.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions, are provided in the report.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the cited deficiency.
Food Service Safety Deficiencies Due to Inaccessible Handwashing Sink and Staff Noncompliance
Penalty
Summary
The facility failed to prepare and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations during kitchen operations. The only handwashing sink in the kitchen was blocked by a large dietary cart full of dirty dishes, making it inaccessible to staff. Interviews with facility staff revealed ongoing concerns about the lack of a conveniently located handwashing sink, with discussions about adding another sink but no resolution due to space and plumbing constraints. The placement of dietary carts further contributed to the inaccessibility of the handwashing sink, impeding regular hand hygiene practices. During lunch service, dietary staff were observed violating food safety protocols, including wearing artificial fingernails and jewelry while handling food without gloves, and failing to wash hands after activities that could contaminate them, such as leaving and re-entering the kitchen or handling personal items like cell phones. The Certified Dietary Manager was also observed assisting with food items without washing hands after entering the kitchen. These actions were not in compliance with the 2022 FDA Food Code requirements for hand hygiene, fingernail maintenance, and jewelry restrictions for food employees.
Failure to Address and Resolve Resident Grievances Regarding Call Light Response and Water Pass
Penalty
Summary
The facility failed to ensure that grievances raised by residents during Resident Council (RC) meetings were promptly documented, investigated, and resolved. Over several months, RC meeting minutes consistently recorded concerns regarding delayed call light response times, particularly on the third shift, staff turning off call lights before addressing residents' needs, and inconsistent water pass. Despite these recurring issues being documented as both old and new business in multiple RC meetings, the 'Actions taken' sections were frequently left blank or marked as 'ongoing,' with no clear evidence of resolution or follow-up. During an RC meeting, all nine participants confirmed that assistance was not provided in a timely manner on the third shift, with one resident reporting a wait of several hours for help after activating the call light. Residents expressed frustration that their repeated complaints were not being taken seriously by facility leadership, with some stating they had stopped voicing concerns to the Nursing Home Administrator (NHA) or Director of Nursing (DON) due to a lack of meaningful response. Several residents described receiving generic assurances without observable improvement, and the issues would temporarily improve before recurring. The NHA acknowledged awareness of the concerns and described a staffing schedule change, but the report does not indicate that these actions effectively addressed the residents' grievances.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature for multiple residents. Two residents with cognitive intactness, one with anemia, diabetes, depression, and anxiety, and another with a history of sepsis, reported that hot foods were often served cold, with one specifically mentioning a cold pork chop at dinner. Both residents had previously communicated their concerns to staff, including the registered dietitian, but continued to experience the same issues. Additionally, a group interview with nine residents revealed unanimous dissatisfaction, with all participants stating that food was always cold, vegetables were overcooked and mushy, and items were frequently missing from trays. The group also reported that their food preferences and requests were not honored, and that a food committee had not led to any improvements. Observations during meal service confirmed the deficiency. While hot food items on the steam table were initially at appropriate temperatures (over 175°F), the process of delivering trays to different halls resulted in significant temperature drops. A test tray placed on the last cart delivered to a hall was found to have mashed potatoes at 119°F, Salisbury steak at 109°F, and carrots at 118°F, well below the recommended serving temperatures. No additional food temperatures were recorded during the meal service, indicating a lack of ongoing monitoring to ensure food remained at a safe and appetizing temperature until served.
Failure to Provide Dignified Grooming for Resident
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment and a history of type 2 diabetes and muscle weakness was observed to have long gray facial hairs on her chin. The resident reported that facial hair grooming was performed regularly at her previous group home, but since admission to the facility, this grooming had not occurred. Despite expressing her desire to have her facial hair shaved, the grooming was not provided. Multiple staff interviews confirmed that the facility's standard practice is to offer shaving or plucking of facial hair on shower days or upon resident request. However, the resident stated that even after a recent shower, her facial hair was not addressed as expected. Review of the resident's care records showed that her bathing schedule was documented, but the shower sheets only indicated whether skin checks were performed and did not include a section for grooming tasks. The facility's written expectations require staff to attend to facial hair for both men and women during each shower, and to inform the nurse if a resident refuses grooming. In this case, the lack of documentation and follow-through resulted in the resident's grooming needs not being met, impacting her dignity and personal preferences.
Failure to Implement and Document Ordered Restorative ROM Program
Penalty
Summary
The facility failed to implement and document an ordered restorative program for a resident with reduced mobility and decreased strength in both upper and lower extremities. The resident had a physician's order for a Level 2 restorative ADL/hygiene and range of motion (ROM) program, and the care plan specified the need for restorative ROM interventions. Despite this, there was no documentation of restorative services being provided for the last 30 days. Interviews with the resident, restorative aide, and the restorative director confirmed that the resident had not been consistently seen for restorative care, with staff citing the resident's preference for spending time outside and lack of set scheduling as reasons. The restorative director also admitted to not ensuring proper documentation or oversight of the program. The facility's own policy required daily review and documentation of restorative services, including time spent, resident tolerance, and reasons for missed sessions. However, these requirements were not met, as evidenced by the absence of documentation and staff acknowledgment of lapses in both service delivery and record-keeping. The resident expressed awareness of the missed services and a desire to participate in the restorative program, further confirming the deficiency in care.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to revise a person-centered care plan for a resident, resulting in an inaccurate reflection of the resident's current care needs. The resident, who had diagnoses including adult failure to thrive, restlessness and agitation, and severe protein calorie malnutrition, was assessed with a severe cognitive impairment. The care plan initially included the use of adaptive equipment such as a plate guard, built-up utensils, and a 2-handled cup with a straw. However, the occupational therapist had upgraded the resident to regular silverware and communicated these changes to the nursing and dietary departments, but the care plan was not updated to reflect these changes. Observations revealed that the resident was still being provided with built-up utensils and other adaptive equipment that were no longer necessary according to the occupational therapist's assessment. Despite the communication of changes in December, the care plan and meal tickets continued to list outdated equipment needs. The unit manager acknowledged that the updates had not been made in the nursing department, which also affected the dietary department's adherence to the resident's current needs.
Inaccurate Physician Orders Lead to Potential Medication Error
Penalty
Summary
The facility failed to maintain professional standards of nursing practice related to physician orders for a resident, resulting in inaccurate physician orders and the potential for medication error. The resident, who was cognitively intact, was supposed to receive Norco for pain management as per the physician's verbal order. However, the order was incorrectly entered into the Electronic Health Record (EHR) as Percocet. This clerical error led to a discrepancy between the medication order and the medication administered. The error was identified when the resident's family member reported that the facility dispensed Percocet instead of Norco, which was not ordered by the physician. Interviews with the Director of Nursing, Nursing Home Administrator, and other staff confirmed that the order for Percocet was entered inaccurately and that the resident was actually given Norco, which was available in the medication cart. The incident was documented as a near miss, as the wrong medication was not administered to the resident.
Improper Aspen Collar Use During Resident Transfer
Penalty
Summary
The facility failed to ensure the proper placement of an Aspen collar during a transfer for a resident with a fracture of the second cervical vertebra. The resident, who was severely cognitively impaired, had specific orders to wear the Aspen collar when up in a wheelchair and during transfers. However, during an observation, a CNA removed the resident's Aspen collar before assisting with a transfer from a wheelchair to a bed, contrary to the care plan instructions. The CNA was unaware of the importance of keeping the collar on during transfers, as this information was not specified in the Kardex, which she relied on for resident care instructions. The RN and UM/LPN confirmed that the collar should remain on during transfers to prevent further injury. The deficiency was identified through observation, interviews, and record reviews, highlighting a gap in communication and adherence to the resident's care plan.
Inaccurate Medication Order Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to an incorrect documentation of medication orders. The resident, who was cognitively intact with a BIMS score of 15/15, had pertinent diagnoses including pain, muscle spasm, contracture of the left foot, and muscle weakness. A discrepancy was found in the medication orders where the resident's record inaccurately documented an order for Percocet instead of Norco. This error was identified during a review of the resident's medical records and confirmed through interviews with the resident's family member and facility staff. The error originated from a verbal order given by the resident's primary care physician, which was incorrectly transcribed by a registered nurse. The nurse mistakenly entered the order for Percocet into the electronic health record (EHR) instead of the correct medication, Norco. This clerical error was acknowledged by the Director of Nursing and the Education Training Director, who confirmed that there was no written prescription or verbal order for Percocet. The inaccurate documentation of the medication order had the potential to impact the resident's medical outcome.
Improper PPE Usage During COVID Outbreak
Penalty
Summary
The facility failed to ensure that personal protective equipment, specifically face masks, was worn correctly by staff during a COVID outbreak. Observations revealed multiple instances where staff members, including a dietary aide, registered nurse, certified nurse assistants, housekeepers, and a floor tech, were not wearing their face masks properly, with masks positioned below their noses or chins. This occurred despite signage indicating a COVID outbreak and the requirement for face masks to be worn throughout the building. Interviews with staff confirmed that they were aware of the requirement to wear masks covering both the nose and mouth, yet non-compliance was observed. The Infection Preventionist confirmed that during a COVID outbreak, all staff were required to wear face masks correctly, covering the nose and mouth. Despite having a laminated picture illustrating the proper way to wear a face mask and re-educating staff, the issue persisted. The report highlights that the facility's failure to enforce proper mask-wearing practices among staff during a COVID outbreak posed a potential risk for the spread of infection and disease transmission among residents.
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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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