Medilodge Of Sterling Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Sterling Heights, Michigan.
- Location
- 14151 East 15 Mile Road, Sterling Heights, Michigan 48312
- CMS Provider Number
- 235263
- Inspections on file
- 45
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Medilodge Of Sterling Heights during CMS and state inspections, most recent first.
A resident with limited mobility and multiple chronic conditions did not consistently receive restorative therapy services as ordered, with only partial documentation of therapy sessions and missed opportunities for care. Staff interviews confirmed both missed treatments and incomplete documentation, contrary to facility policy.
A resident experienced ongoing discomfort due to an inadequate mattress and reported the issue to multiple staff members over several months. Despite these reports, no documentation or maintenance work order was submitted, and the mattress was not replaced, even though other mattress replacements were processed for different residents during the same period.
A resident with significant mobility limitations and a care plan requiring two-person assistance for bed mobility fell from bed when a hospice aide provided care alone, contrary to the documented intervention. Facility records and staff interviews confirmed the care plan was not followed, resulting in the resident's fall.
The facility failed to serve food in a palatable manner and at preferred temperatures for several residents, leading to dissatisfaction. Residents reported the food as cold, unappetizing, and sometimes difficult to chew. A lunch tray was found to have food items served at lukewarm temperatures, and group interviews highlighted food quality as a significant concern. The facility's policy on food preparation and serving temperatures was not consistently met.
The facility's kitchen dish machine area was not maintained in a clean manner, leading to a gnat infestation. Numerous gnats were observed due to wet, murky standing water and black slimy substances on pipes. Pest control reports from August 2024 to January 2025 highlighted heavy gnat activity due to poor cleanliness, particularly around the dish tank, sinks, corners, and drains.
The facility failed to ensure call lights were within reach for five residents, leading to a deficiency in call light accessibility. Observations showed call lights on the floor and out of reach, despite staff knowing the proper placement requirements. Residents had various medical conditions and required different levels of assistance, yet the issue persisted across multiple observations and interviews.
A facility failed to promptly investigate an abuse allegation involving a resident with severe cognitive impairment. The incident, where a staff member allegedly mocked the resident, was reported by a witness but not investigated until 13 days later. The delay and inconsistency in witness statements indicate a deficiency in following the facility's abuse policy.
The facility failed to complete an annual PASARR for two residents. One resident with severe cognitive impairment had no level II PASARR request, while another resident with intact cognition had no updated PASARR available. The facility's policy requires coordination with the PASARR program, which was not followed.
A resident with PTSD and Major Depressive Disorder was admitted to the facility, but the care plan failed to address the PTSD diagnosis and known triggers. Despite the resident's intact cognition and acknowledgment of PTSD, the mood/behavior care plan lacked necessary details. Interviews with staff revealed communication lapses, as the PTSD diagnosis was not included in the care plan during the behavior meeting, contrary to facility policy.
The facility failed to provide timely ADL assistance to two residents. One resident experienced delays in receiving care, including being left on a bedpan for two hours. Another resident, who requires 1:1 feeding assistance, was observed eating without help despite having impaired cognition and shaking hands. The facility's policy mandates necessary services for residents unable to perform ADLs.
A resident with Down's syndrome, Schizophrenia, and Chronic kidney disease expressed concerns about long toenails causing discomfort. Despite having intact cognition, the resident's medical records lacked a current podiatry consultation. Facility staff acknowledged the need for nail care, but the social services team was still establishing connections with ancillary services, resulting in a deficiency in timely podiatry care.
A resident with quadriplegia and gastrostomy was observed with an unlabeled and undated tube feeding bottle. An LPN confirmed that the tube feeding is set up during the evening shift and should be labeled. The DON also stated that the tube feeding should be labeled and dated when set up. However, the facility's policy on Feeding Tubes did not address labeling and dating requirements.
The facility failed to discard expired medications from a medication cart, as observed by an LPN. Two expired medications, Glucosamine Chondroitin and Oyster Shell Calcium, were found in the cart. The DON confirmed that expired medications should be removed, but the facility did not provide a Medication Storage policy.
The facility failed to maintain resident equipment in a clean and safe condition, affecting three residents with severe cognitive impairments. Observations revealed issues with a bedside dresser and overbed table, and the Maintenance Director found no submitted orders for repair or cleaning. The facility's Preventative Maintenance Program policy was not effectively implemented, as no maintenance requests were documented for the observed issues.
A facility failed to conduct weekly skin checks for a resident, leading to gangrene in the right great toe and hospitalization. The resident, with multiple health conditions, was at risk for impaired skin integrity, but an eight-week gap in assessments allowed the condition to worsen. The issue was discovered by a family member, and the facility's DON acknowledged the lapse in care.
The facility failed to provide adequate incontinence care, repositioning, and hydration for three dependent residents. Two residents were left without water and timely incontinence care, while another was found in a soiled state for hours without intervention. Despite staff presence, necessary care was not provided, leading to deficiencies in adherence to care plans and facility policies.
The facility failed to ensure a homelike environment in resident rooms and common areas, with issues such as non-functional lights, exposed wires, and cluttered shower rooms. Observations revealed safety hazards like sharp metal objects in hallways and inadequate maintenance of resident rooms, including missing light covers and rusting sink repairs. Maintenance logs showed unresolved issues, and interviews indicated delays in providing necessary items to residents.
A resident with a history of falls and moderate cognitive impairment experienced nine falls without adequate interventions being implemented in their care plan. Despite multiple incidents, the facility failed to consistently update the care plan to prevent further falls, contrary to their fall prevention policy.
The facility failed to serve food in a palatable manner and at the preferred temperature for three residents, leading to dissatisfaction during meals. A complaint was submitted, and a surveyor's taste test revealed issues with food temperature and flavor. Interviews with the Dietary Manager and residents confirmed these issues, despite the facility's policy stating that food should be palatable and served at an appetizing temperature.
The facility failed to maintain adequate lighting in the East Dining Room, as observed by surveyors and reported by a resident. Five lights were not functioning, and attempts to operate them were unsuccessful. The NHA was unaware of the issue until informed by the Activities Director, despite the facility's policy requiring maintenance requests to be documented in an electronic system.
The facility failed to maintain sanitary conditions of a steam table in the East Dining Room, where loose crusted material and mold were observed. The Nursing Home Administrator acknowledged the expectation for cleanliness, and the facility's cleaning policy highlights the importance of removing debris and bacteria.
The facility failed to maintain a clean and comfortable environment for two residents, leading to feelings of anger and frustration. A complaint revealed bugs and a black substance leaking from the air conditioner in their rooms. Despite reporting the issue, it persisted for months without resolution. Housekeeping confirmed the presence of bugs and the unsuccessful removal of the black substance, which was reported to maintenance. The Maintenance Director was unaware of the issues, and pest control had not been conducted. Facility policies on maintaining a safe environment were not followed.
The facility failed to notify the guardian of a resident's transfer to the hospital. The resident, with severe cognitive impairment and multiple diagnoses, required immediate medical intervention and was transferred via EMS. Despite the facility's policy and expectations, the responsible party was not informed of the change in the resident's condition.
Failure to Provide and Document Ordered Restorative Therapy Services
Penalty
Summary
A deficiency occurred when the facility failed to provide restorative therapy services as ordered for a resident with diagnoses including spinal stenosis, multiple sclerosis, and fibromyalgia. The resident, who was alert and oriented and required extensive assistance with bed mobility and transfers, was observed lying in bed and confirmed not receiving consistent restorative therapy during the week. Physician orders specified skilled restorative nursing three times a week for 12 weeks, focusing on active range of motion (ROM) exercises for both upper and lower extremities. However, a review of the clinical record over a 14-day period showed that restorative therapy was only documented as provided on three out of six possible occasions. Further investigation revealed discrepancies in documentation, as a CNA reported providing restorative therapy on additional dates that were not recorded in the medical record. The Assistant Director of Nursing acknowledged the lack of accurate documentation and stated that the restorative program was under review. Facility policy requires that implementation of restorative nursing programs be documented in the delivery record or electronic medical record, but this was not consistently done for the resident in question.
Failure to Timely Replace Uncomfortable Mattress After Resident Complaints
Penalty
Summary
A deficiency was identified when a resident reported having an uncomfortable mattress that felt as though it had a hole and caused them to feel the bed frame. The resident stated this issue had persisted since their admission approximately six months prior and that they had informed various staff members about the problem during this time. Despite these reports, the mattress was not replaced, and the resident continued to experience discomfort. Observations confirmed the mattress had a visible wrinkle and a compressed, softer center, supporting the resident's complaint. Interviews with staff, including a CNA and an LPN, confirmed that the resident had repeatedly voiced concerns about the mattress over several months. However, there was no documentation in the resident's progress notes regarding these complaints, and a review of the facility's maintenance reporting system (TELS) showed no work order had been submitted for a mattress replacement for this resident. Administrative staff confirmed that all staff are trained to enter work orders into TELS, and other mattress replacements had been processed for different residents during the same period. Maintenance staff also indicated that no work order had been received for this issue.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Primary Generalized Osteoarthritis, Spinal Stenosis, and Muscle Weakness, who was receiving hospice services, experienced a fall from their bed during care. The resident reported that the hospice aide was providing care alone and, while turning the resident in bed, the resident rolled off onto the floor. The resident's care plan specifically required two staff members to assist with bed mobility due to their fall risk, an intervention that was documented and in place prior to the incident. Facility records, including the incident/accident report and progress notes, confirmed that the hospice aide provided care without the required second staff member. The Director of Nursing acknowledged awareness of the incident and stated that the expectation was for care to be provided with two-person assistance, as outlined in the resident's care plan. The facility's policy also required care plans to be developed and implemented based on fall risk assessments.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food was served in a palatable manner and at the preferred temperature for several residents. Multiple residents, including those with intact cognition and various medical conditions such as COPD, osteomyelitis, and heart failure, reported dissatisfaction with the food quality. They described the food as cold, unappetizing, and sometimes difficult to chew. Specific instances included a resident noting that the food was better when surveyors were present, and another resident expressing that the food was cold and sometimes burnt. During the survey, a lunch tray was temperature checked, revealing that the food items were served at temperatures below what might be considered hot, with the chicken at 119.8°F, Brussels sprouts at 121.3°F, and rice pilaf at 122.1°F. The survey team also taste-tested the food and found it to be lukewarm and lacking flavor. The facility's dietary manager and corporate manager indicated that food temperatures were based on resident preferences, but no specific temperature guidelines were provided. A group interview with seven residents highlighted that food quality was a significant concern, with reports of the food being mostly warm rather than hot. The facility's food committee notes indicated mixed feedback, with 60% of residents finding the food tasty, but 35% reporting that it was not hot enough. The facility's policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served at a safe and appetizing temperature, but the observations and resident feedback suggest these standards were not consistently met.
Gnat Infestation Due to Poor Kitchen Cleanliness
Penalty
Summary
The facility failed to maintain the dish machine area in the kitchen in a clean manner, resulting in the presence of gnats. On March 10, 2025, numerous gnats were observed underneath the dish machine tank and drainboard, where the flooring was wet with murky standing water, and the pipes were coated with a black slimy substance. The Dietary Manager was unable to provide an explanation for the presence of gnats. Pest control service reports from August 2024 to January 2025 consistently noted heavy gnat activity due to poor cleanliness in the kitchen, particularly around and underneath the dish tank, sinks, corners, and drains. According to the 2017 FDA Food Code section 6-501.111, premises should be maintained free of insects, rodents, and other pests by eliminating harborage conditions.
Deficiency in Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents, leading to a deficiency in call light accessibility. Observations revealed that residents' call lights were often found on the floor and out of reach, despite staff being aware of the proper placement requirements. For instance, Resident 612's call light was observed on the floor, and staff confirmed it should be within hand reach. Similarly, Resident 613's call light was repeatedly found on the floor, even after staff entered and exited the room. Interviews with staff, including a unit manager and the administrator, confirmed that call lights should be accessible to residents. The residents involved had various medical conditions, such as end-stage renal disease, type 2 diabetes, osteomyelitis, cerebral infarction, sepsis, respiratory failure, hemiplegia, muscle weakness, and dysphagia. Some residents had intact cognition, while others had impaired cognition, requiring different levels of assistance with activities of daily living. Despite these needs, the facility's failure to ensure call light accessibility was consistent across multiple observations and interviews, indicating a systemic issue in maintaining proper call light placement.
Delayed Investigation of Abuse Allegation
Penalty
Summary
The facility failed to timely complete an investigation for an allegation of abuse involving a resident with severe cognitive impairment. The incident in question occurred when a staff member allegedly mocked the resident, leading to the resident becoming visibly upset and crying. The Maintenance Director witnessed the incident and reported it to the Nursing Home Administrator. However, the investigation was not initiated until 13 days after the incident, and witness statements were not obtained until the same day the investigation began. The facility's policy requires immediate investigation of any allegations of abuse, neglect, or exploitation, but this protocol was not followed. The delay in obtaining witness statements and the inconsistency in the Maintenance Director's account of the incident highlight deficiencies in the facility's response to the allegation. The Nursing Home Administrator considered the incident a customer service concern, which may have contributed to the delay in addressing the issue according to the facility's abuse policy.
Failure to Complete Annual PASARR for Two Residents
Penalty
Summary
The facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for two residents, R70 and R139, out of six residents reviewed for PASARR screening. R70 was admitted with diagnoses including dysphagia, intellectual disabilities, and functional quadriplegia, and had a severe cognitive impairment as indicated by a BIMS score of 00. The medical record for R70 showed a PASARR dated 11/27/24, but there was no request for a level II PASARR, which is required for residents with mental illness or intellectual disabilities. R139, who was observed in bed watching television and expressed a desire to meet with a social worker regarding a change in guardianship, was admitted with diagnoses including adjustment disorder with anxiety and depressed mood, bipolar disorder, and chronic respiratory failure with hypoxia. R139 had an intact cognition as indicated by a BIMS score of 15. The medical record for R139 showed a PASARR dated 7/08/24 with a hospital exemption for 30 days, but no updated PASARR was completed or available at the time of the survey. The facility's policy requires coordination with the PASARR program to avoid duplicative testing and mandates preadmission screening for all individuals with mental illness or intellectual disabilities, which was not adhered to in these cases.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing Post-Traumatic Stress Disorder (PTSD) for a resident, identified as R62, who was admitted with diagnoses of Major Depressive Disorder and PTSD. The resident's medical record and the most recent Minimum Data Assessment (MDS) indicated an intact cognition with a score of 15/15. Despite the resident's acknowledgment of having PTSD and experiencing triggers, the mood/behavior care plan did not include the PTSD diagnosis or known triggers. Interviews with facility staff revealed lapses in communication and documentation. The Social Worker (SW) stated that the PTSD diagnosis and known triggers should have been included in the mood care plan upon the resident's admission. The Director of Nursing (DON) acknowledged that the PTSD diagnosis was not communicated during the behavior meeting, which resulted in the care plan not being developed as required. The facility's policy on Comprehensive Care Plans mandates that the care planning process should assess the resident's strengths and needs, incorporating personal and cultural preferences, and should be trauma-informed, which was not adhered to in this case.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance for two residents in need of help with Activities of Daily Living (ADLs). Resident R24 reported that over a weekend, they requested ADL care at 6:15 AM, but did not receive assistance until 9:45 AM. On another occasion, they activated the call light at 7:00 PM and did not receive care until 9:30 PM. R24's medical records indicate they require assistance due to muscle weakness and limited mobility. The facility's concern forms documented multiple instances of delayed care, including an incident where R24 was left on a bedpan for two hours during the midnight shift. The Director of Nursing acknowledged issues with the midnight shift and stated that residents should be checked on hourly. Resident R154 was observed struggling to eat due to shaking hands and reported not receiving assistance with meals, despite having a physician's order for 1:1 feeding assistance. R154's medical records show they have impaired cognition and require assistance with eating. A nutrition note indicated that R154 benefits from supervision or assistance with meals. The Assistant Director of Nursing stated that R154 should receive help with meal setup and cueing, but observations showed R154 eating without assistance. The facility's policy on ADLs states that residents unable to perform these activities should receive necessary services to maintain good nutrition and hygiene.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide timely podiatry care for a resident, identified as R201, who expressed concerns about their toenails being too long and causing discomfort. During an observation, R201's toenails were noted to extend past the tips of their toes. The resident, who has a diagnosis of Down's syndrome, Schizophrenia, and Chronic kidney disease, could not recall their last podiatry visit. A review of R201's medical records did not show a current podiatry consultation, despite the resident having intact cognition as indicated by a BIMS score of 14. Interviews with facility staff revealed that R201 was on a list to be seen by podiatry, but the social services team was new and still working to establish connections with ancillary services. The Director of Nursing confirmed the need for R201's toenails to be cut. The facility's policy on nail care, revised in August 2024, requires assessments of residents' nails upon admission and readmission, and mandates reporting unusual nail conditions to a physician. However, this policy was not effectively implemented for R201, leading to the deficiency.
Failure to Label and Date Tube Feeding Bottle
Penalty
Summary
The facility failed to label and date a tube feeding bottle for a resident, identified as R75, who was observed on 3/11/2025 with an unlabeled and undated tube feeding bottle while laying in bed. Licensed Practical Nurse (LPN) A confirmed that the tube feeding is set up during the evening shift and acknowledged that it should be labeled. R75 was admitted with diagnoses of Quadriplegia and Gastrostomy and required staff assistance with bed mobility and transfers. The resident's recent Minimum Data Set assessment indicated a Brief Interview for Mental Status score of 99, showing they were unable to complete the assessment. The Director of Nursing (DON) also confirmed that the tube feeding should be labeled and dated when set up. However, a review of the facility's policy on Feeding Tubes revealed it did not address the requirement for labeling and dating.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure that medications were discarded when expired, as observed during a survey of one of the medication carts. On March 12, 2025, at 2:07 PM, an LPN identified two expired stock medications in the top drawer of Unit 100's lower numbered medication cart. The medications included Glucosamine Chondroitin, which had an open date of October 1, 2024, and a stamped expiration date of January 2025, and Oyster Shell Calcium 500mg, with an open date of September 25, 2024, and a stamped expiration date of August 2024. Later that day, at 4:15 PM, the DON confirmed that expired medications should be removed from use. Despite a request, the facility did not provide a policy for Medication Storage by the end of the survey.
Deficiency in Maintenance of Resident Equipment
Penalty
Summary
The facility failed to maintain resident equipment in a clean and safe condition, affecting three residents with severe cognitive impairments. Observations revealed that a bedside dresser for one resident had a two-inch gap between drawers, while another resident's overbed table was stained with dark circular marks. Additionally, a third resident's bedside dresser was stained, rough, and had uneven edges. These conditions were noted during observations conducted on March 10, 2025. The Maintenance Director reviewed the maintenance system and found no submitted orders for the repair or cleaning of the affected equipment. The facility's Preventative Maintenance Program policy, last reviewed in February 2022, requires the Maintenance Director to maintain a schedule of maintenance services to ensure equipment is safe and operable. However, the policy's implementation was lacking, as no maintenance requests were documented for the issues observed, indicating a failure in the facility's maintenance reporting and response system.
Failure to Conduct Weekly Skin Checks Leads to Gangrene
Penalty
Summary
The facility failed to complete weekly skin checks for a resident, resulting in the development of gangrene in the right great toe, right foot pain, and subsequent hospitalization. The resident, who had diagnoses including osteoarthritis, gout, adult failure to thrive, and end-stage renal disease requiring dialysis, was at risk for impaired skin integrity. The care plan for the resident included weekly skin inspections, but there was an eight-week gap between assessments, during which the condition of the resident's right foot deteriorated. The deficiency was identified when a family member visited the resident and discovered the gangrenous condition of the toe. The facility's Director of Nursing acknowledged the lapse in assessments and recognized the deficient practice. The resident was hospitalized for gangrene and sepsis, likely due to the gangrene, and continued to experience right foot pain even after returning to the facility.
Deficiencies in Resident Care: Incontinence, Repositioning, and Hydration
Penalty
Summary
The facility failed to provide adequate incontinence care, repositioning, and hydration for three dependent residents, leading to deficiencies in their care. Resident R703 and R707 were observed without water cups and reported not receiving timely incontinence care. R703 expressed concerns about not being turned as required, and both residents were left without water between meals, despite the availability of a water cart nearby. Staff were present in the hallway but did not address these needs, leaving the residents without necessary care for extended periods. Resident R706 was found in a soiled state, with a visible brown ring on the bed and gown, indicating a lack of timely incontinence care. Despite the presence of staff, R706 remained in the same position for several hours, with no intervention to change or reposition them. The resident's care plan indicated a need for assistance with toileting due to neuromuscular dysfunction, yet staff failed to provide the necessary care, leaving R706 in an unhygienic condition. The Director of Nursing acknowledged the need for repositioning, incontinence care, and hydration for dependent residents, confirming that no residents in the facility were fully independent. The facility's policies on Activities of Daily Living and Hydration were not adhered to, resulting in the observed deficiencies. The lack of staff intervention and adherence to care plans contributed to the inadequate care provided to these residents.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in resident rooms, common areas, and shower rooms on two nursing units. Observations revealed numerous deficiencies, including non-functional bathroom lights, unattached sink piping, and a burnt outlet. Sharp metal objects were found protruding from the hallway floor, posing a safety hazard. Resident rooms were observed with multiple white spackle patches on the walls, missing towel dispensers, and broken or missing light fixtures. Additionally, some rooms had exposed wires, rusting sink repairs, and missing light covers. Common areas and shower rooms were also found to be in disrepair and cluttered. The main hallway had a loose metal disc with bent edges, and baseboards were peeling away from the walls. Shower rooms contained various stored items, such as laundry bin frames and used foam wedges, and were not maintained in a clean state. Toilets in these areas had brown water stains, dead flies, and missing cabinet parts. The maintenance logs indicated unresolved issues, such as non-working lights and heating problems, which were reported but not promptly addressed. Interviews with residents and staff highlighted further issues, such as the delayed provision of necessary items like toilet seats and televisions upon admission. The facility's policies on maintaining a safe and homelike environment were not effectively implemented, as evidenced by the numerous maintenance and cleanliness issues observed. The administrator acknowledged that room readiness checks should be conducted by admissions, maintenance, and housekeeping staff before resident placement, but these checks were evidently insufficient or not performed.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement effective actions to prevent repeated falls for a resident, resulting in nine falls without appropriate goals and interventions to prevent further incidents. The resident, who was admitted after sustaining a fractured left wrist and left femur, had a history of dementia, heart disease, difficulty walking, cognitive communication deficit, and muscle weakness, with a BIMS score indicating moderate cognitive impairment. Despite experiencing multiple falls on various dates, the care plan was not adequately updated to address the resident's needs. A fall pad was only added to the care plan after a fall on 6/12/2024, and the care plan was revised again on 7/16/2024, 15 days after another fall, without interventions being put in place after the other falls. The facility's policy on fall prevention required reviewing and updating the care plan after any fall, which was not consistently followed.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for three residents, resulting in dissatisfaction during meals. A complaint was submitted to the state agency, stating that the food was terrible, and residents had to spend their own money on food, which they could not afford. During a surveyor's taste test of a random lunch meal, it was found that the cheeseburger and fries were only warm, the slaw lacked flavor, and the pickle spear was soggy, negatively impacting the meal's palatability. Interviews with the Dietary Manager and residents confirmed the issues with food temperature and palatability. The Dietary Manager acknowledged that hot food should be hot and cold food should be cold but could not explain why the last tray served was not warmer. Residents expressed dissatisfaction with the food, describing it as terrible. The facility's policy on food palatability, revised in 2017, stated that food should be palatable and served at an appetizing temperature, which was not adhered to in this instance.
Inadequate Lighting in Dining Room
Penalty
Summary
The facility failed to maintain adequate lighting in the East Dining Room, one of two dining rooms reviewed for a homelike environment. During an interview, a resident mentioned that the lights in the East Dining Room had been out for some time, and staff were aware but frustrated with the maintenance issues. An observation confirmed that five lights were not illuminated, and attempts to operate the switches with the Activities Director were unsuccessful. The Nursing Home Administrator was unaware of the issue until notified by the Activities Director and indicated that maintenance requests should be submitted through the electronic maintenance request system. The facility's Preventative Maintenance Program policy requires documentation of all tasks in the electronic maintenance request system to ensure a safe and comfortable environment.
Unsanitary Steam Table Conditions
Penalty
Summary
The facility failed to maintain a sanitary condition of the steam tables in the East Dining Room, specifically the third steam table with a small hood. During an observation, loose crusted material and mold were noted on this steam table. When the material was touched, it fell onto the area where food would be placed during use. This observation was made in the presence of the Nursing Home Administrator, who acknowledged that the steam table hoods should be clean and free of mold and materials that could contaminate food. The facility's cleaning policy, provided by a cleaning company, emphasizes the importance of cleaning and sanitizing to maintain a safe operation for residents, stating that cleaning removes visible debris and sanitizing removes most harmful bacteria.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for two residents, resulting in feelings of anger and frustration. A complaint was submitted to the state agency regarding bugs and a black substance leaking from the air conditioner in the residents' rooms. During an interview, one resident expressed their upset and anger over the situation, which had been ongoing for two to three months without resolution. The surveyor observed a dried blackish substance on the rug under the air conditioner and a small black bug on the resident's bedding. Housekeeping aides confirmed the presence of bugs and the unsuccessful attempt to remove the black substance from the carpet, which was reported to maintenance. The Maintenance Director was unaware of the environmental issues and indicated that bug spray had been used, but a pest control contractor had not inspected or treated the room. The account manager for environmental services, who was filling in for the facility manager, stated that if a stain could not be removed, they would consult with the Administrator and Maintenance Director about further actions. The Nursing Home Administrator indicated that rooms should be deep cleaned on a schedule and that pest control was expected soon. The facility's policies on maintaining a safe and homelike environment and pest control were reviewed, highlighting the failure to adhere to these guidelines.
Failure to Notify Guardian of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the guardian of a resident's transfer to the hospital. The resident, who was admitted with diagnoses of Vascular Dementia, Acute Kidney Failure, and Hypertension, had a severe cognitive impairment as indicated by a BIMS score of 0. On the date of the incident, the resident was found to be tachypneic and required immediate oxygen administration. Despite the medical intervention and the decision to transfer the resident to the hospital via EMS, the responsible party was not notified of the change in the resident's condition as required by the facility's policy. Interviews with the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA) confirmed that it was the facility's expectation to notify the responsible party or family members as soon as possible about any change in condition. A review of the facility's policy on Notification of Changes, revised on 1/01/22, also supported this requirement. However, the failure to inform the guardian of the resident's transfer to the hospital resulted in a deficiency in adhering to the policy and ensuring the guardian was aware of the resident's condition.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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