Medilodge Of Zeeland
Inspection history, citations, penalties and survey trends for this long-term care facility in Zeeland, Michigan.
- Location
- 285 North State St, Zeeland, Michigan 49464
- CMS Provider Number
- 235347
- Inspections on file
- 29
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Medilodge Of Zeeland during CMS and state inspections, most recent first.
A resident with quadriplegia, TBI, and hydronephrosis, who was moderately cognitively impaired and incontinent of stool, reported that staff refused to transfer him from his power chair to bed overnight and did not clean him despite his repeated requests before a scheduled hospital procedure. He arrived at the hospital upset, with multiple buttock pressure injuries, dressings saturated with old and new stool, a strong stool odor, and extensive redness, and hospital staff had to clean him and change three soiled dressings. Facility staff acknowledged responsibility for preparing residents for transport and the resident’s need for a mechanical lift for incontinence care, but the EMR lacked documentation of the off-site appointment, any refusals of bed or care, behavior symptoms, or bowel movements around the time of transfer.
A resident with dementia, communication barriers, and a history of stroke experienced several days of UTI symptoms, behavioral changes, and decreased intake that were identified by hospice, which obtained orders for Levaquin and PRN ondansetron. Facility staff had reported abnormal urine and increased behaviors but did not document timely practitioner or guardian notification, did not track UTI symptoms, and never transcribed or administered the ordered medications, nor documented any rationale or provider notification about the missed treatment. Nursing notes after the hospice visit relied on hospice findings, lacked a comprehensive assessment or updated vitals, and showed no administration of ordered PRN acetaminophen despite documented pain, while PRN Ativan was given without clear behavioral description or pain follow‑up. Later, when the resident refused assessment, only a temperature was recorded, with no further assessment, no documented re‑approach, and no guardian notification, and CNA charting showed no documented care for many hours despite reports the resident was declining. The resident was ultimately found unresponsive and cold with marked lividity and large amounts of dark fluid from his mouth, and the RN did not initiate CPR, while the record showed no licensed nurse assessment or CNA observation for nearly seven hours before he was found.
The facility failed to timely report and document multiple allegations of abuse and resident-to-resident incidents involving several cognitively impaired residents. In one case, a CNA found two residents partially undressed in the same bed and notified a nurse and the NHA, but no incident report, assessment, or physician/guardian notification was documented. In another case, a resident reported that another resident climbed into her bed, pushed against her, and verbally abused her; the NHA was notified by phone but kept the event in a private file and did not report or investigate it as required. Additional allegations included a resident stating she was grabbed by the neck and pushed against a wall, with no corresponding documentation found, and a separate scratching incident that an RN initially documented as resident-to-resident but was later reclassified by management as an injury of unknown origin. These actions and omissions conflicted with the facility’s own abuse/neglect policy requiring prompt reporting of all alleged violations to appropriate authorities within specified timeframes.
The facility failed to timely and thoroughly investigate and document multiple abuse allegations involving several cognitively impaired residents. In one case, a CNA found two residents in a sexually inappropriate situation and reported it, but no incident report, EMR documentation, or physician/guardian notification occurred. In another event, a resident reported that a male resident climbed into her bed, verbally abused her, and had to be forcefully removed; this was kept in a "soft file," not reported to the State Agency, and staff were told not to document it. Additional allegations included a resident reporting that another resident grabbed her by the neck, and a separate incident where one resident was scratched after another walked past; in both situations, required incident documentation, investigation, and accurate classification as resident-to-resident incidents were missing or altered, despite a written abuse policy mandating immediate investigation, interviews, and thorough documentation.
The facility failed to individualize dementia care, revise care plans, and provide adequate supervision for several residents with Alzheimer’s disease and other dementias who exhibited wandering, aggression, and sexually inappropriate behaviors. One resident with alcohol-induced dementia and psychotic disorder repeatedly wandered into others’ rooms, climbed into a female resident’s bed while verbally abusing her, barricaded himself in a room with two female residents, and was found partially undressed in bed with another resident, yet these events were not documented in the EMR and did not result in person-centered care plan changes. Staff reported being told not to document certain resident-to-resident incidents, and key episodes were kept only in risk management or soft files outside the medical record. Other residents with dementia and behavioral disturbances had documented angry outbursts, physical altercations, and alleged neck grabbing, but these behaviors and incidents were not reflected in updated care plans or consistent behavior documentation, leaving staff unaware of the reasons for increased monitoring or 1:1 supervision.
The facility failed to maintain complete and accurate medical records for several residents involved in behavioral and resident-to-resident incidents. Multiple episodes of sexually inappropriate behavior, aggression, and wandering documented by CNAs or reported by residents and families were not reflected in nursing notes or incident reports, and staff providing 1:1 supervision were unaware of the reasons due to missing EMR entries. One resident’s skin tear was minimally documented without follow-up assessment, another resident’s behavior monitoring record showed no behaviors despite reported conflict, and an incident where a resident was found in another resident’s bed with a partially dressed male nearby was not documented in the EMR.
A resident with Alzheimer's and a history of elopement exited through an unsecured window into the courtyard without staff awareness. The CNA noticed the window was open and the screen damaged but only reported the screen issue, not the unsecured window, to maintenance. The lack of thorough communication and prompt repair allowed the resident to leave unsupervised, and staff were only alerted after a neighbor saw the resident outside.
The facility failed to maintain a sanitary and safe environment, as observed in shared bathrooms with dirty exhaust fans, improperly stored oxygen concentrators, and mixed, unlabeled toiletries. Additionally, sewer gas odor and improper storage of supplies under wastewater lines were noted in the pantry and dining areas. A resident reported that his room was not cleaned, with food crumbs and dried substances observed on the floor over several days. These deficiencies indicate a lack of regular cleaning and proper storage practices.
A resident with cognitive intactness and a chronic skin condition was left in a soiled state after a CNA instructed her to wait for assistance, causing emotional distress and physical discomfort. The facility's policy requires immediate attention to residents reporting being soiled, which was not followed, compromising the resident's dignity.
A resident with psoriasis and hemiparesis reported untreated rash and itching under her breast. Dermatology recommended zinc oxide and nystatin, but orders were not placed due to a zinc allergy. The facility failed to follow up for alternative recommendations, and the DON found no documentation of addressing the recommendations.
A facility failed to maintain proper tube feeding precautions for a resident with a feeding tube. During a dressing change, the resident's bed was elevated only ten degrees, contrary to the policy requiring a 30-45 degree elevation to prevent aspiration. The LPN involved was unaware of the policy, and the resident's bed was not adjusted after the procedure.
A resident with a wound vac dressing experienced a breach in infection control during a dressing change. The LPN and Unit Clerk involved did not use proper barriers, failed to sanitize scissors, and did not change gloves or sanitize hands appropriately. The LPN acknowledged the oversight but did not fully recognize the extent of the infection control breach.
A resident with a history of orthopedic issues and recent surgery experienced severe pain that was not adequately managed by the facility. Despite reporting high pain levels, the resident did not receive timely pain medication, leading to a 911 call. The LPN's documentation was inconsistent, and the facility's investigation was incomplete, failing to address the resident's pain management needs effectively.
A resident with multiple diagnoses, including hypertension, did not receive several critical medications upon re-admission to the facility. The LPN responsible for the admission assessment failed to activate necessary medications, and the facility's admission process, which requires verification by a second nurse and a unit manager, was not followed. The Nursing Home Administrator was unaware of the omissions until later informed, highlighting a breakdown in the medication reconciliation process.
A facility failed to ensure nursing staff were competent in reconciling medications during the admission process, leading to a resident not receiving all prescribed medications. The resident, with conditions including seizures and hypertension, was found to be missing critical medications upon discharge from the hospital. Interviews revealed that an LPN missed orders and another nurse did not complete a required second check, with no documentation of training for the latter.
A facility failed to ensure timely physician response to Medication Regimen Review recommendations for a resident with seizures, fibromyalgia, and hypertension. The pharmacist's recommendations to add 'do not crush' instructions and address duplicate therapy were not documented as addressed. Interviews revealed a lack of immediate action on urgent issues, contrary to facility policy.
Failure to Provide Dignified Incontinence Care Before Off-Site Appointment
Penalty
Summary
Facility staff failed to provide dignified care to a quadriplegic resident with a traumatic brain injury and hydronephrosis who was moderately cognitively impaired and dependent on staff and a mechanical lift for incontinence care and transfers to bed. The resident routinely went to the hospital every two weeks for a urinary procedure. On the night before one such scheduled procedure, the resident reported that staff refused to transfer him from his power chair to bed, resulting in him sleeping in his chair. The next morning, prior to transport for the appointment, the resident stated he repeatedly requested to be cleaned after soiling himself while sitting in the hallway, but staff did not provide the requested care before he left for the hospital. Hospital records for that appointment documented that the resident arrived very upset, reported that facility staff had made him sit in his wheelchair all night, and was found with multiple pressure injuries on his buttocks with dressings saturated with old and new stool and extensive redness of the buttocks. A hospital RN confirmed the resident had a strong stool odor, that staff there had to clean old and new stool and change three stool-soiled dressings, and that the smell permeated the unit while the resident expressed embarrassment and frustration. Facility staff interviews indicated that floor staff were responsible for preparing residents for transport and that the resident was known to be incontinent of stool and required a mechanical lift for changing, but there was no documentation in the EMR of the resident leaving for the appointment, of any refusal to go to bed or refusal of care on the dates in question, or of behavior symptoms related to rejection of care. Bowel movement documentation did not reflect a bowel movement around the time of transfer, and there was no record that staff checked or cleaned the resident before transport.
Failure to Recognize Change in Condition, Implement Hospice Orders, and Monitor Resident Prior to Death
Penalty
Summary
The deficiency involves the facility’s failure to promptly identify and act upon a resident’s change in condition, including not implementing ordered treatments and not adequately assessing or monitoring the resident prior to death. The resident was an older male with a history of stroke and on palliative care, with a guardian and advance directives specifying full code status and a desire for all available medical treatments, including transfer to the hospital when necessary. His care plans identified communication barriers (Cambodian language, dementia), risk for impaired communication, and the need to use simple, direct communication and translation support as needed. His urinary care plan directed staff to observe and report signs and symptoms of UTI, and his pain care plan documented a pain threshold of zero, with instructions to administer medications per orders and notify the practitioner if pain was present. Hospice documentation on one evening showed a clear change in condition: strong‑smelling, dark urine for several days, abnormal UA strip with protein, elevated pH, and small amount of blood, low‑grade fever (99.4°F), tachycardia (pulse 102), abdominal tenderness with guarding over the bladder, increased agitation and behaviors, and decreased oral intake with spitting out food. Hospice contacted the physician, who prescribed Levaquin 500 mg daily for seven days for UTI symptoms, and also ordered PRN ondansetron for nausea. The hospice note indicated facility staff had reported the abnormal urine and behaviors had been present for a few days, but review of the EMR showed no documentation that the practitioner or guardian had been notified of these changes before the hospice assessment, and no symptom tracking or UTI monitoring by licensed nurses was provided. The DON acknowledged the EMR did not prompt UTI/symptom charting and that nurses were expected to perform assessments per professional standards. After hospice obtained orders for Levaquin and ondansetron, the facility failed to transcribe these medications into the EMR or administer them at any time before the resident’s death, and there was no documentation explaining the delay or notifying a provider that treatment had not been initiated. The NHA later stated the orders were not found on the fax until two days after they were written. A nurse’s note early the next morning documented that hospice had been in the night before and that the resident had a temperature of 99.4 and pain with palpation, but there was no evidence that the nurse performed an independent physical assessment or obtained updated vital signs at that time. Despite the resident’s documented pain and an order for PRN acetaminophen 650 mg, there was no record that any pain medication was administered following the hospice assessment. Later that day, the resident received PRN Ativan for anxiety, which was documented as effective, but there was no description of the behaviors prompting its use, no linkage to possible pain, and no follow‑up pain assessment. That evening, a nurse note recorded that the resident refused assessments and a temperature of 98.3°F was obtained, but no further assessment findings were documented, and there was no evidence of re‑approach as directed in the behavior care plan or use of observational assessment for non‑verbal pain or decline. There was also no documentation that the guardian was notified of the resident’s change in condition, refusal of assessment, or involved to assist with translation and decision‑making, despite the facility’s Notification of Changes policy and the resident’s inability to make his own decisions. CNA documentation showed no recorded care from 6:00 PM through 6:00 AM, and the NHA stated best practice was rounding every two hours. A CNA on the night shift reported being told at shift change that the resident was declining, with more pain behaviors and refusal to eat, and stated she last checked him around 1:00 AM by quickly checking his brief without disturbing him because of his behavioral history. In the early morning hours, CNAs found the resident unresponsive and cold at approximately 4:20 AM. The RN’s note described no pulse, cold skin, fixed and dilated eyes, mottling, and large amounts of dark, rust‑colored fluid draining from the resident’s mouth and onto the bed and wall when repositioned. The RN documented “blood pooling” and lividity on the resident’s back, and both the RN and CNAs described his back as dark red to deep dark purple. The DON and NHA later reported that CPR was not initiated because RN A determined there were signs of irreversible death, although the State Operations Manual lists specific criteria for obvious clinical signs of irreversible death that differ from those described. Review of the EMR showed no documented licensed nurse assessment or CNA observation for approximately 6 hours and 45 minutes before the resident was found unresponsive. The facility’s Notification of Changes policy required prompt notification of the physician and representative for significant changes in condition and new treatments, but the record lacked evidence that these notifications occurred when the resident’s condition deteriorated and when new orders were obtained.
Failure to Timely Report and Document Multiple Allegations of Abuse and Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to timely report and investigate multiple allegations of abuse and neglect involving several residents with dementia and related psychiatric diagnoses. One incident involved a CNA finding a resident with alcohol-induced dementia and Alzheimer’s disease standing by the head of another resident with Alzheimer’s disease and mood disturbance, with both residents’ pants lowered or partially down while the second resident was lying in the first resident’s bed. The CNA reported the situation to the nurse, who then notified the Nursing Home Administrator (NHA). The NHA acknowledged awareness of this incident but stated she did not report it to authorities because she arrived at the facility within 30 minutes and believed she could immediately rule out concerns. There were no incident reports, statements, assessments, or EMR documentation showing that the incident occurred or that any notifications were made to the physician or guardians. Another unreported incident involved a resident with alcohol-induced dementia and Alzheimer’s disease entering the room of a resident with Alzheimer’s disease and dementia, climbing into bed between the wall and the resident, and pushing his back against her, moving her toward the edge of the bed. The resident expressed concern about her baby doll being suffocated and about being pushed out of bed, and she got up to get the nurse. Staff statements documented that the resident reported being called a derogatory name before the other resident climbed into her bed. The NHA received calls from the facility during the night and was informed of the incident in the early morning hours. The NHA kept a “soft file” on the event, did not conduct an investigation at the time, and did not report the allegation to the State Agency. The NHA later stated she had been looking for willful intent, believed the resident was fine and not upset, and acknowledged that the verbal abuse should have been reported. Additional concerns involved a resident with dementia and behavioral disturbances who reportedly told her guardian and several family members that another resident grabbed her by the neck, held her head against the wall, and caused neck pain on Christmas Eve. An RN, after being questioned by the guardian about this event, could not find any incident report or documentation in the EMR and stated that the resident was in the hallway talking to staff with tears in her eyes and reported that an LPN had applied cream to her neck. The RN reported this to the NHA and was told the incident was already known and had been dealt with, while the NHA later denied awareness of any such incident. In a separate event, the same RN completed a Risk Management document for a scratch on a resident’s forearm after another resident walked past her, initially documenting it as a resident-to-resident incident. Management later changed it to an injury of unknown origin, with the narrative altered to state that the other resident lost balance and accidentally scratched her. The NHA reported not being aware of any contact between these two residents, despite the room change that followed. These events occurred in the context of a written facility policy requiring immediate or timely reporting of all alleged violations of abuse, neglect, or exploitation to the Administrator, state agency, and other required agencies within specified timeframes, which was not followed in these cases.
Failure to Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The facility failed to timely and thoroughly investigate multiple allegations of abuse involving several residents with dementia and related psychiatric diagnoses. One resident with alcohol-induced dementia, Alzheimer's disease, psychotic disorder with delusions, and major depressive disorder was documented by a CNA as sexually inappropriate on a specific date. The CNA later described entering the resident's room and finding another resident with Alzheimer's disease and dementia with mood disturbances lying in his bed with her pants slightly down to her hips, while his pants were lowered with his buttocks exposed. The CNA reported this to a nurse, who then notified the Nursing Home Administrator (NHA). The Unit Manager/RN initially denied knowledge of any sexually inappropriate incidents or the documented behavior task, and there were no incident reports, statements, assessments, EMR documentation, or notifications to the physician or guardians regarding this event. The NHA acknowledged awareness of the incident and stated she did not report it because she arrived within 30 minutes and believed she could rule out concerns, later admitting there was no documentation of the incident or interventions. Another incident involved the same male resident entering the room of a female resident with Alzheimer's disease and dementia in lack of coordination, climbing into bed with her, and refusing to leave. The female resident left the bed to seek help, reporting that the male resident called her derogatory names and climbed into her bed, pushing his back against her and moving her toward the edge of the bed while she worried about her baby doll and being pushed out. Staff statements documented that the male resident verbally abused her with profane language and had to be forcefully removed from the room. The NHA kept this incident in a "soft file," did not report it to the State Agency, and admitted she did not conduct an investigation at the time. A CNA reported being instructed by the nurse, per the NHA, not to document anything about the incident. Later, staff providing 1:1 supervision to the male resident did not know why he required such supervision, and there was no EMR documentation explaining the reason. Additional allegations involved the same male resident and another female resident with dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. An RN reported that this resident's guardian called about a skin tear and relayed that the resident had told multiple family members that the male resident grabbed her by the neck, held her head against the wall, and hurt her neck on Christmas Eve. The RN could not find any incident reports or EMR documentation of this event, although the resident was observed in the hallway tearfully recounting the incident and stating that an LPN had applied cream to her neck. The RN stated she informed the NHA, who said the incident was already known and addressed, but the NHA later reported she was not aware of any incident between these two residents. In a separate event, an RN completed a Risk Management document when a resident with Alzheimer's disease, dementia with psychotic disturbances, and generalized anxiety disorder was found with a scratch on her forearm after another resident with dementia walked past her. The RN initially documented it as a resident-to-resident incident, but management later changed it to an injury of unknown origin, with the narrative altered to state that the other resident lost her balance and accidentally scratched her. The RN was told she could not document it as a resident-to-resident incident because she did not directly witness the scratch, and she did not complete a witness statement. The NHA reported not being aware of any contact between these two residents, despite the room change that followed. These actions and omissions occurred despite a facility policy requiring immediate investigation of suspected abuse, identification and interviewing of all involved persons, and complete and thorough documentation of investigations. The facility’s abuse, neglect, and exploitation policy required immediate investigation upon suspicion or reports of abuse, including identifying responsible staff, preserving evidence, investigating different types of alleged violations, interviewing alleged victims, alleged perpetrators, and witnesses, and providing complete and thorough documentation. Across the described incidents, the facility did not follow these procedures. There were repeated failures to initiate formal investigations, complete incident or risk management reports, document findings and interventions in the EMR, notify physicians and guardians, and accurately classify and record resident-to-resident altercations. In some cases, staff were explicitly instructed not to document incidents, and in others, documentation that initially identified resident-to-resident contact was later changed by management. The NHA acknowledged responsibility for the lack of documentation and agreed that at least one verbal abuse incident should have been reported, but contemporaneous investigative steps and required reporting were not carried out as outlined in the facility’s own policy.
Failure to Individualize Dementia Care, Document Behaviors, and Supervise Residents With Repeated Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to develop individualized, person-centered interventions, to review and revise care plans, and to provide adequate supervision for multiple residents with dementia, resulting in repeated resident-to-resident incidents and undocumented behaviors. Several residents had diagnoses including Alzheimer’s disease, dementia with behavioral or psychotic disturbances, and anxiety or depressive disorders. For one resident with alcohol-induced dementia, Alzheimer’s disease, psychotic disorder with delusions, and major depressive disorder, CNA behavior documentation over a 30‑day period showed wandering, abusive language, threatening behavior, grabbing, pushing, yelling, screaming, and a sexually inappropriate episode. Despite this, there were no corresponding nursing progress notes or care plan changes addressing these behaviors, and staff were unclear why the resident was placed on 15‑minute checks or 1:1 supervision, with no explanation documented in the EMR. The facility also failed to document and care plan multiple serious resident-to-resident incidents involving this same resident and others with dementia. One incident involved a resident with dementia and anxiety found in another resident’s bed, both with pants partially down, which was reported verbally by a CNA and known to the NHA, but not documented in the EMR, and no care plan updates were made for either resident. Another incident involved the same male resident entering a female resident’s room, climbing into her bed, calling her derogatory names, and having to be forcefully removed; staff statements describing this event were kept in a soft file outside the medical record, and no EMR documentation or care plan interventions were created. Staff reported being told by the NHA not to document this incident. In a separate event, the same resident barricaded himself in a room shared by two female residents by placing a chair against the door, requiring multiple staff and police assistance to gain entry; again, there was no EMR documentation of the incident. Additional deficiencies in documentation and care planning occurred with other residents with dementia and behavioral symptoms. One resident with dementia and behavioral disturbances reported that the same male resident grabbed her by the neck and pushed her head against the wall; her guardian relayed this allegation to an RN, who could not find any incident report or EMR documentation, although another LPN acknowledged being informed and texting the NHA about it. Another resident with Alzheimer’s disease, dementia with psychotic disturbances, and generalized anxiety disorder had documented angry outbursts, refusal of medications, and conflicts with roommates, including striking another resident, but her care plan contained no person-centered revisions reflecting these behaviors or a scratching incident that had been initially documented as a resident-to-resident event and later reclassified by management as an injury of unknown origin. Overall, care plans for the residents reviewed, particularly the male resident with alcohol-induced dementia and multiple behavioral issues, lacked meaningful, person-centered interventions or revisions to address wandering, aggression, and resident-to-resident incidents, and key events were either omitted from the EMR or recorded only in non-medical risk management files. The NHA acknowledged awareness of at least some of the incidents, including the sexual incident between two residents and the bed incident involving the male resident and a female resident, and admitted that staff did not document these events in the EMR or reflect physician and guardian notifications. The NHA also stated she was not fully informed of all incidents involving the male resident and another female resident and could not provide documentation of frequent monitoring after those events. Staff interviews revealed confusion about behavior documentation tasks, lack of awareness of documented behaviors, and reports that management directed them not to document certain resident-to-resident incidents as such. The care plan for the male resident with alcohol dependence and alcohol-induced persisting dementia listed wandering and exit-seeking but contained no meaningful, person-centered interventions or revisions to address his documented behaviors and repeated interactions with other residents.
Failure to Maintain Complete and Accurate Medical Records for Behavioral and Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation of resident incidents and behaviors for multiple residents. For one resident, a risk management document dated 12/28/25 referenced an incident in which he was observed in another resident’s room lying on her bed and exposing himself, yet there was no corresponding documentation in the EMR describing the incident, no record of physician or guardian notification, and no documentation of interventions. Another resident’s EMR lacked daily behavior documentation and contained no entries regarding several resident-to-resident incidents on 10/22/25, 12/24/25, and 12/28/25, despite a behavioral health note describing a history of significant behavioral disturbances including yelling, kicking, hitting, pushing, grabbing, wandering, abusive language, threatening behavior, and sexually inappropriate behavior. Certified Nursing Assistant behavior task documentation showed that this same resident was recorded as sexually inappropriate on 12/28/25, with additional behaviors such as wandering, abusive language, threatening behavior, grabbing, pushing, and yelling/screaming documented on 6 days within a 30‑day look‑back period. However, there was no nursing documentation or follow-up in the EMR to address or evaluate these behaviors. Nursing staff, including an LPN and a unit manager RN, reported being unaware of the sexually inappropriate behaviors and incidents, and a CNA and LPN assigned to provide 1:1 supervision to this resident did not know the reason for the supervision and could not find any explanation in the EMR. Another RN reported that when a resident’s guardian asked about an alleged incident in which this behaviorally disturbed resident reportedly grabbed the guardian’s family member by the neck on Christmas Eve, there was no incident report or EMR documentation of the event, even though the resident was later observed in the hallway tearful and talking to staff about it. Additional documentation gaps were identified for other residents. One RN stated she completed a risk management document for a resident-to-resident incident in which one resident ended up with a scratch on her forearm after another resident walked past her, but the event was later reclassified by management as an injury of unknown origin, and the RN did not complete a witness statement. The nursing progress note for the scratched resident only documented that she was observed standing in her doorway with a skin tear to her right forearm, that the area was cleaned and a bandage applied, and that the resident stated it was from a scratch, with no further assessment or follow-up. Behavior monitoring documentation for another resident showed no behaviors recorded during the 30‑day look‑back period, including on the date of the above incident, and nursing progress notes contained no behavior or concern entries for that date. For yet another resident, there was no EMR documentation on 12/28/25 regarding an incident in which she was found sleeping in another resident’s bed while a male resident, inappropriately dressed, was standing in front of her, leaving that event entirely undocumented in the medical record.
Elopement Due to Unsecured Window and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and a psychotic disorder, who had a documented history of elopement and was admitted specifically due to increased elopement risk, was able to exit the facility unsupervised. The resident's baseline care plan indicated a risk for wandering or attempting to leave the facility unattended. On the day of the incident, the resident exited through her bedroom window into the facility's enclosed courtyard without staff awareness, as there was no alarm to notify staff of her exit. Prior to the incident, a Certified Nursing Assistant (CNA) observed that the resident's window was open and the screen was damaged. The CNA reported the hole in the window screen to the Maintenance Assistant but did not communicate that the window itself was unsecured or fully open. The Maintenance Assistant did not assess the reported damage before the incident occurred. As a result, the window remained unsecured, providing an opportunity for the resident to exit the building. The resident was last seen inside the facility around 6:00 pm and was found in the courtyard at 6:15 pm after a neighbor notified staff. A Code Yellow was initiated, and the resident was located and returned inside without injury or distress. The lack of timely and thorough reporting, assessment, and repair of the window and screen, as well as insufficient supervision, directly contributed to the resident's ability to elope from the secured unit.
Facility Fails to Maintain Sanitary and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by several observations and interviews. In rooms 409/411, a shared bathroom was found with a dirty exhaust fan and an oxygen concentrator with a nasal cannula stored under the sink, next to a grossly soiled toilet and a bedside commode pan with a used brief. Certified Nursing Assistant (CNA) B confirmed the inappropriate storage of the oxygen concentrator and the unsanitary condition of the bathroom. Similarly, rooms 404/406 had a shared bathroom with mixed, unlabeled toiletries scattered on the sink and shelf, including opened ointment packets. CNAs B and C acknowledged that the toiletries should have been stored properly and the bathroom should not appear as it did. Additional deficiencies were noted in the Gilead Pantry and dining areas, where sewer gas odor was detected due to an evaporated pee-trap, and supplies were stored under wastewater lines, posing contamination risks. In room 45410, a resident reported that staff never cleaned his room, which was observed to have food crumbs and dried red substances on the floor over several days. Housekeeping Aide K confirmed the presence of these substances, which were easily removed with a wet mop, indicating a lack of regular cleaning. These findings highlight the facility's failure to ensure a clean and safe environment, increasing the potential for contamination and decreasing resident satisfaction.
Failure to Promote Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity of a resident, identified as R21, who was cognitively intact and required assistance with toileting. On the morning of the incident, R21 had a bowel movement and activated the call light for assistance. A CNA responded but informed R21 that she would have to wait to be changed because it had not been two hours since her last change. This left R21 in a soiled state, causing her emotional distress and physical discomfort due to her chronic skin condition. The CNA later discussed the incident with a unit manager and was instructed that residents should be changed immediately if they report being soiled. Interviews with the LPN and the DON confirmed that the facility's policy requires residents to be checked and changed promptly when they report being soiled, contradicting the CNA's initial response. The facility's policy emphasizes treating residents with kindness, dignity, and respect, which was not adhered to in this instance.
Failure to Implement Dermatology Recommendations for Resident's Skin Condition
Penalty
Summary
The facility failed to implement dermatology recommendations in a timely manner for a resident with a skin condition. The resident, who was cognitively intact, reported having a rash, itching, and burning under her right breast that was not being treated by the staff. The resident had been evaluated by a dermatologist, who recommended the application of zinc oxide diaper cream and nystatin topical powder to affected areas. However, upon review of the resident's physician orders, no medicated creams, powders, or lotions were ordered to treat the rash. The dermatology recommendations were reviewed by a nurse practitioner, who noted the resident's allergy to zinc and indicated that the facility would follow up with dermatology for alternative recommendations. Despite this, the nystatin order was not placed, and the facility staff did not contact the dermatology office for alternative recommendations for zinc. The Director of Nursing confirmed that there was no documentation showing that the dermatology recommendations had been addressed prior to the surveyor's conversation with the nurse practitioner.
Failure to Maintain Proper Tube Feeding Precautions
Penalty
Summary
The facility failed to ensure proper tube feeding precautions for a resident receiving enteral nutrition. The resident, who had a history of stroke and dementia, was observed during a dressing change with the head of the bed elevated only ten degrees, contrary to the facility's policy requiring a 30-45 degree elevation during feeding and for at least one hour afterward to prevent gastric reflux and possible aspiration. The enteral feeding pump continued to infuse at the prescribed rate during the procedure, and the head of the bed was not adjusted after the dressing change. An interview with the LPN involved revealed a lack of awareness regarding the policy on bed elevation during tube feeding. The LPN mentioned that the resident had bed controls and could adjust the bed angle independently. The facility's job description for charge nurses includes responsibilities such as administering tube feedings and supporting facility policies, indicating a failure to adhere to established procedures for enteral nutrition management.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control measures during a dressing change for a resident with a wound vac dressing. The resident, who had a history of stroke and dementia, was admitted with a wound vac dressing after being hospitalized for a lump at the hairline of the neck. The dressing change was observed to be conducted by an LPN and a Unit Clerk, where several infection control breaches occurred. The supplies were placed directly on an unprotected over-the-bed table, and unsanitized scissors were used to cut adhesive film for the dressing. Additionally, the LPN did not change gloves or sanitize hands after cleaning the wound, and the scissors were not sanitized before being used again. During an interview, the LPN acknowledged that the Unit Clerk prompted a glove change due to a ripped glove but did not recognize the need to deglove after cleaning the wound. The LPN also admitted that the scissors should have been sanitized and placed in a different location during the procedure. The facility's job description for the charge nurse included understanding and following infection control guidelines, which were not adhered to during this dressing change.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and adequate pain management for a resident, leading to a deficiency in care. The resident, who had a history of orthopedic issues, polyneuropathy, and recent Achilles tendon surgery, reported severe pain levels that were not adequately addressed by the nursing staff. On one occasion, the resident's pain was rated at 10 out of 10, yet there was no timely reassessment or notification to the physician. The resident's pain continued to be severe, and despite being eligible for additional pain medication, it was not administered until after the resident called 911. The incident involved a Licensed Practical Nurse (LPN) who failed to administer pain medication at the scheduled time and did not reassess the resident's pain levels appropriately. The LPN's documentation was inconsistent with the statements provided during the facility's investigation, indicating a lack of awareness of the resident's pain levels and the medication schedule. The resident's family member also expressed concerns about the timeliness of pain management and the overall quality of care, which led to the resident considering hospice care due to the lack of quality of life. The facility's investigation into the incident was incomplete, as key staff members were not interviewed, and there was a lack of documentation regarding the resident's pain tolerance levels. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the deficiencies in pain assessment and management, acknowledging that the resident's pain was not adequately addressed. The resident's care plan did not specify a tolerable pain level, and there were discrepancies in the pain assessments recorded by the staff.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to prevent significant medication errors for a resident who was admitted with diagnoses including seizures, fibromyalgia, and hypertension. Upon discharge from the hospital, it was discovered that the resident had not been taking all prescribed medications according to discharge orders. The hospital discharge summary indicated that several medications, including antihypertensives and bowel routine medications, were discontinued by the facility's RN. The LPN responsible for the resident's admission assessment and medication order review failed to activate several critical medications, including Amlodipine, Baclofen, Senna, Miralax, Metoprolol Succinate, and Lisinopril. The Nursing Home Administrator was unaware of the medication omissions until informed by a regional consultant. The facility's admission process, which requires a second nurse and a unit manager to verify admission orders, was not followed. The paper admission checklist was incomplete, and the medical provider also failed to check the admission orders. The facility's policy requires the admission nurse to confirm orders with a physician and ensure the pharmacy has the medication orders, but these steps were not adequately executed, leading to the medication errors.
Failure in Medication Reconciliation During Admission
Penalty
Summary
The facility failed to ensure that nursing staff were competent and adequately trained to reconcile physician's orders and medications during the admission process, which could potentially compromise resident safety and well-being. Resident #101 was admitted to the facility with diagnoses including seizures, fibromyalgia, and hypertension. However, it was discovered that the resident had not been taking all prescribed medications according to discharge orders from a previous hospital stay. A hospital case manager reported that upon preparing the resident for discharge back to the facility, it was noted that the resident was not on antihypertensives or a bowel routine, which were part of her medication list during previous admissions. Interviews with facility staff revealed lapses in the medication reconciliation process. LPN G, who was responsible for the initial review of medication orders upon the resident's return, admitted to missing orders and received written counseling for errors in transcription and placement of orders. Additionally, Prior Nurse E, who was supposed to perform a second check of the admission orders, could not recall if she completed this task and was not documented as having been trained in the admission process and medication reconciliation. The Nursing Home Administrator confirmed the lack of documentation for Prior Nurse E's training and noted that an admission process checklist should have been completed.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that Medication Regimen Reviews, which noted irregularities or recommendations, were addressed by the physician in a timely manner for one resident. Resident #101, who was admitted with diagnoses including seizures, fibromyalgia, and hypertension, had Medication Regimen Reviews performed by a pharmacist following re-admissions from the hospital. The reviews, dated 6/18/2024 and 6/30/2024, included recommendations to add 'do not crush' instructions for certain medications and to address duplicate therapy. However, there was no documentation that these recommendations were addressed by a medical provider. Interviews revealed that the Nursing Home Administrator could not find evidence that the recommendations had been acted upon. The Regional Consultant reported discussing the reports with a Nurse Practitioner on 7/16/2024. The Nurse Practitioner indicated that she was absent in June and expected urgent issues to be brought to her attention immediately. The facility's policy stated that urgent irregularities should be addressed as soon as possible, but this was not followed, leading to the potential for unnecessary medications and negative side effects.
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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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