Medilodge Of Capital Area
Inspection history, citations, penalties and survey trends for this long-term care facility in Lansing, Michigan.
- Location
- 2100 E Provincial House Drive, Lansing, Michigan 48910
- CMS Provider Number
- 235653
- Inspections on file
- 31
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Medilodge Of Capital Area during CMS and state inspections, most recent first.
A resident with multiple psychiatric and medical diagnoses, who was cognitively intact, was issued immediate involuntary discharge paperwork for alleged repeated threats toward staff and other residents. Police were involved after the resident called 911, and the resident was later transported to the ED under a court-appointed petition. When the hospital attempted to return the resident, facility staff stated the resident would not be readmitted and could instead go to a local motel, and the hospital ultimately discharged the resident to the community. Although facility forms cited danger to the safety and health of others as the reason for transfer/discharge, the medical record lacked physician documentation that the transfer/discharge was necessary for these safety concerns.
A resident with a history of major depressive disorder and traumatic brain injury, who was cognitively intact, underwent an x‑ray performed by a contracted technician. During the procedure, the interaction escalated into a heated verbal altercation in which the technician used profanity, spoke aggressively, and, according to multiple staff, antagonized and challenged the resident while continuing the x‑ray. Staff responded after hearing the resident call for help and observed the technician yelling, cursing, and making disrespectful and threatening remarks, leading the resident to request that the technician be removed from the room. The facility’s investigation confirmed the incident and the heated verbal exchange between the technician and the resident.
The facility did not report multiple allegations of abuse and misappropriation involving several residents, including an incident where a resident's debit card was allegedly misused by staff and physical altercations between residents with severe cognitive impairment. Despite initial notifications and documentation, required reports to the State Agency were not made, and investigations were not initiated as per facility policy.
The facility did not investigate or report multiple incidents of physical altercations between residents with severe cognitive impairment, despite documented injuries and pain. Incident reports were signed by the NHA after the events, but no investigations or required notifications to state agencies were initiated, contrary to facility policy.
The facility did not follow its abuse and neglect policies when multiple residents with severe cognitive impairment were involved in physical altercations, resulting in pain and minor injury. Incident reports were completed, but the NHA was not notified, did not investigate, and did not report the incidents to the state agency as required by facility policy.
A resident with moderate cognitive impairment and a legal guardian had a signed and witnessed DNR advanced directive, including a physician signature, but the facility did not have a physician order in place to implement the DNR. Staff interviews indicated a breakdown in communication regarding updating orders after the advanced directive was signed.
Two residents did not receive accurate or timely MDS assessments related to pressure ulcers. One resident was incorrectly coded as requiring tracheostomy care, while another developed a new pressure ulcer without a required change in condition assessment being completed. Staff interviews and record reviews confirmed these assessment failures.
A resident with severe cognitive impairment and multiple diagnoses was transferred from a secure dementia unit to another hall, but the care plan was not updated to reflect this change. The LPN confirmed the oversight, which was identified during a survey through observation, interview, and record review, resulting in the potential for unmet care needs.
A resident who required one-person assistance for hygiene was repeatedly observed with greasy, uncombed hair, an excessively long mustache, and wearing the same soiled clothing over multiple days. Staff interviews confirmed the resident was cooperative and had not refused care, but the facility had not provided needed grooming or clothing changes, and had been without a beautician for several months. The ADON was unaware of the resident's condition and acknowledged the facility's responsibility to meet care needs.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
Two residents, one cognitively intact and one with severe cognitive impairment, consistently received meals that were not at safe or appetizing temperatures. Food items, including hot entrees and beverages, were served below recommended temperatures, and cold items were not sufficiently chilled. Despite residents expressing dissatisfaction, staff did not take steps to address the temperature concerns during meal service.
A resident with multiple medical conditions and a regular diet order repeatedly did not receive requested or preferred food items, instead receiving items on their dislike list, despite submitting multiple complaints and meal tickets showing the discrepancies. Facility staff confirmed the resident's food preferences were not consistently honored and could not explain the ongoing errors.
A facility failed to administer medications as ordered for a resident with diabetes and liver cirrhosis. The resident's medications, including Lactulose, Glimepiride, and Isosorbide Dinitrate, were not consistently given due to unavailability. The issue was discovered after a family member raised concerns, and the DON confirmed the medications were not pulled from backup supply or delivered timely.
A facility failed to follow professional guidelines by using PDI Sani-Cloth Germicidal Disposable Wipes for a resident's incontinent bowel care. The resident, with a history of multiple medical conditions, was cleaned with bleach wipes by a Staff Development Coordinator, despite the wipes being unsuitable for skin contact. The incident was reported by a CNA, and the SDC admitted to the inappropriate use of the wipes, initially intended for cleaning the mattress.
A cognitively impaired resident was sexually assaulted by another resident with a known history of sexual offenses. The facility failed to monitor the offender adequately and did not activate the missing resident policy when the victim was unaccounted for over an hour. The incident was captured on surveillance, but the footage was not saved, and the facility's abuse prevention policies were not effectively followed.
The facility failed to maintain plumbing and refrigeration equipment, risking foodborne illness for residents. A leak was observed from the coffee maker's water filter, and the Arctic Air cooler was holding food at 52°F, above the safe threshold. The CDM discarded the food as the temperature did not decrease. Additionally, the atmospheric vacuum breaker for the mop sink was under constant pressure, violating FDA standards.
The facility failed to control a gnat infestation in the kitchen, affecting all 99 residents. Gnats were observed in various areas, including the dry storage room, grease trap, dish machine area, and dining room. The Certified Dietary Manager noted that the pest control operator provided floor and drain cleaner, but service reports did not mention treatment for gnats. This failure violates the 2017 FDA Food Code, which requires premises to be free of pests.
The facility's Activities Director on the memory care unit lacked the necessary qualifications and experience, resulting in residents being left unengaged and inactive. Observations showed that scheduled activities were either not conducted or inadequately executed, with many residents observed sleeping or passively watching television. The director admitted to not being certified and was still completing her training.
A facility failed to serve meals at the preferred temperature and provide necessary condiments and utensils, causing dissatisfaction among residents. One resident experienced delays due to cold food and missing items, while a group of residents reported ongoing issues with meal accuracy and preferences. A test tray revealed inadequate food temperatures, highlighting the facility's deficiencies in food service.
A resident at the facility was found with a bruise on her forehead, which was not immediately reported as an injury of unknown origin. Staff provided conflicting accounts of the resident's behavior and the bruise's appearance, leading to inconsistencies in documentation. The facility's internal determination that the bruise was self-inflicted resulted in the incident not being reported to the state agency, highlighting a deficiency in the reporting and investigation process.
A resident at the facility was found with a bruise on her forehead, and the facility failed to conduct a thorough investigation. Staff provided inconsistent accounts of the resident's behavior and the bruise's appearance, with some suggesting it resulted from the resident leaning her head against a bathroom wall. The facility's DON and Administrator were informed, but the investigation was incomplete, lacking comprehensive documentation and follow-up. This raises concerns about the facility's ability to protect residents from potential abuse.
A resident admitted with multiple health conditions, including a stage 3 pressure ulcer, was not accurately assessed in the MDS. Despite the ulcer being documented in the medical record, it was omitted from the MDS assessment, as confirmed by the MDS Coordinator and Nurse, leading to potential unmet care needs.
The facility failed to implement adequate care plans for two residents, leading to potential health risks. One resident with severe cognitive impairment and a Stage 3 pressure ulcer was not consistently provided with required interventions, such as the correct sling size for transfers. Another resident with moderate cognitive impairment experienced delays in dental care due to a lack of a comprehensive care plan addressing oral issues. These deficiencies highlight the facility's failure to ensure comprehensive and effective care plans.
A resident with severe cognitive impairment was not engaged in meaningful activities as per their care plan. Despite enjoying music, walking, and pet visits, the resident was observed wandering alone without staff intervention to participate in scheduled activities. The activity director noted the resident's interest in sensory activities, yet records did not reflect pet visits, highlighting a disconnect between the resident's interests and provided activities.
A resident with severe cognitive impairment and multiple health issues was improperly transferred using a mechanical lift, resulting in a hematoma and bruises. The staff involved were not adequately trained or assessed for competency, and the sling used was inappropriate for the resident's weight. The incident was linked to a failure to follow the facility's mechanical lift transfer policy.
A resident in an LTC facility experienced three medication errors, resulting in an 11.11% error rate. An LPN administered a full tablet of Metoprolol instead of a half tablet, gave Senna Plus without an order, and incorrectly measured ClearLax using a pill cup instead of the bottle's measuring cap. The DON confirmed the errors and was unaware of the improper measurement method.
A resident with moderate cognitive impairment experienced continued pain due to the facility's failure to promptly schedule a dental referral. Despite a dental visit recommending an oral surgeon referral for nodules removal, the appointment was not scheduled in a timely manner. The resident's care plans did not initially address dental issues, and even after the dental visit, the care plan was not updated to include the nodules or the goal of receiving dentures.
A resident with multiple health conditions, including a history of stroke, was not provided with a necessary built-up knife for meal preparation, despite it being part of their care plan. Observations showed the resident had to use inappropriate utensils to prepare food, and the Dietary Manager confirmed the oversight, acknowledging the expectation for the knife to be included with meals.
A facility failed to communicate and document hospice services for a resident with severe cognitive impairment, leading to uncoordinated care. The resident's DPOA was not informed about the hospice disciplines or visit schedules, and hospice calendars were inconsistently updated in the medical record. Staff interviews confirmed the absence of a hospice admission meeting with the DPOA, violating the facility's policy for coordinated care planning.
A facility failed to administer the PCV20 vaccine to a resident as recommended by CDC guidelines, despite the resident's age and medical history indicating the need for it. The resident had previously received PCV13 and PCV23 vaccines, but the Infection Preventionist was unaware of the requirement for PCV20, leading to a deficiency in care.
A resident with multiple medical conditions and a history of PTSD and anxiety reported that the facility's policy of requiring two caregivers for all care violated her rights and privacy. Despite being cognitively intact and expressing her wishes, the facility enforced the policy, leading to increased anxiety and distress for the resident. The ombudsman confirmed that the resident's rights were not being honored.
Failure to Obtain Physician Documentation for Involuntary Transfer/Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician documented the necessity of a resident’s transfer/discharge based on safety concerns. The resident was admitted with multiple diagnoses including a left leg fracture, epilepsy, anxiety disorder, depression, schizophrenia, and PTSD, and was documented as cognitively intact on the MDS BIMS assessment. On one day, social services and the nursing home administrator attempted to issue immediate involuntary discharge paperwork citing repeated threats toward staff and other residents, and the resident requested appeal paperwork but refused to physically accept the documents. Nursing notes indicated that police came to the facility after the resident called 911, and the DON gave the police the involuntary discharge letter. The resident was documented as being aware he needed to leave the next day, based on what the police told him. The following day, nursing documentation showed the resident was unexpectedly discharged via police car to the ED under a court-appointed petition. Multiple staff interviews confirmed that the facility was in the process of an involuntary discharge and had not yet received State Agency approval. The NHA, DON, ADON, SSD, and an RN all reported that when the hospital called seeking to return the resident, facility staff stated the resident would not be readmitted and instead could go to a local motel, and the hospital ultimately discharged him to the community when he refused the motel. The involuntary discharge forms and notice cited endangerment to the safety and health of others due to the resident’s clinical/behavioral status, but review of the medical record revealed there was no physician documentation that the transfer/discharge was necessary for these safety reasons.
Failure to Protect Resident From Verbal Abuse by X‑Ray Vendor
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by an outside x‑ray technician. The resident had a history of major depressive disorder and traumatic brain injury and was cognitively intact per a recent MDS assessment. The resident had an order for an x‑ray, and the contracted x‑ray technician entered the resident’s room to perform the procedure. During the encounter, the technician and the resident engaged in a heated verbal exchange that escalated beyond a simple disagreement. According to the facility’s own incident investigation and multiple staff interviews, the technician used profanity toward the resident, stood over the resident, and engaged in an aggressive, confrontational manner. The resident reported that the technician got in his face, threatened him with a closed fist, and used profanity. Nursing staff documented hearing the resident yell for help and, upon entering the room, observed a verbal altercation in progress. Staff reported that the technician told the resident he did not care who the resident told, that he was going to finish his “f*cking job,” and that he antagonized the resident by challenging him to get out of bed and try to hit him, while continuing to yell and curse. Additional staff corroborated that the technician spoke aggressively and disrespectfully, made statements such as “this is why you’re in here” and “I wish you could get up and hit me,” and that the resident asked staff to remove the technician from his room because he felt threatened and disrespected. The technician himself acknowledged that the interaction became extremely heated, that cursing went back and forth, and that he warned the resident to watch his mouth or he would leave, while continuing to perform the x‑ray. The facility’s investigation substantiated that the incident occurred and that there was yelling and words exchanged between the resident and the technician, but the facility concluded it could not substantiate that verbal abuse occurred, despite the consistent staff accounts of aggressive, profane, and threatening behavior toward the resident by the vendor.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or misappropriation of property to the State Agency for four residents, as required by regulation and facility policy. In one case, a resident with a history of alcohol dependence and anxiety disorder was alleged by a family member to have had her debit card taken and used by a staff member. The resident initially confirmed the allegation to the Nursing Home Administrator (NHA) and Director of Nursing (DON), resulting in the suspension of the accused staff member. However, after the family member left, the resident retracted her statement, claiming she felt pressured to make the accusation. Despite the retraction, both the DON and NHA acknowledged that the initial allegation constituted a reportable event, but it was not reported to the State Agency. Additional incidents involved residents with severe cognitive impairment. Two separate altercations occurred between residents, resulting in physical contact and complaints of pain. Incident reports documented these events, including one where a resident's arm was grabbed and another where residents swung at each other, making contact. The NHA, who was responsible for abuse investigations, was not initially notified of these incidents. Upon later review of the incident reports, the NHA agreed that these events met the criteria for abuse allegations and should have been reported and investigated, but no such actions were taken at the time. Facility policy clearly defined abuse to include staff-to-resident and resident-to-resident altercations, and required immediate investigation and reporting of all allegations to the appropriate authorities. Despite this, the NHA signed off on incident reports without ensuring that the required notifications and investigations were completed. The failure to report these incidents as required resulted in a deficiency related to the timely reporting and investigation of suspected abuse, neglect, or misappropriation.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate allegations of abuse involving three residents with severe cognitive impairment. Incident reports documented physical altercations between residents, including one event where a resident removed another's hat, leading to both residents swinging at each other and one making contact with the other's back. Another incident involved a resident becoming agitated, grabbing another resident's arm, and a physical struggle ensued, resulting in pain and minor injury to both residents and a CNA who intervened. Despite these documented events, there was no evidence that the facility initiated investigations or reported the incidents to the appropriate state agency as required by policy. Interviews with the Nursing Home Administrator (NHA), who also served as the facility abuse coordinator, revealed that she was not notified of the incidents at the time they occurred. Upon review of the incident reports during the survey, the NHA acknowledged that the events constituted allegations of abuse and should have been investigated and reported. The NHA also confirmed that she had signed the incident reports after the fact but had not initiated any investigation or reporting process prior to the surveyor's inquiry. Facility policy required immediate investigation and reporting of any suspicion or report of abuse, including resident-to-resident altercations. The policy defined physical abuse to include actions such as hitting, slapping, and grabbing. Despite this, the facility did not follow its own procedures, as the incidents were neither investigated nor reported in accordance with state and federal regulations. The failure to act was confirmed through record review, staff interviews, and the absence of investigation documentation.
Failure to Investigate and Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to implement its own written policies and procedures for abuse and neglect for multiple residents. Specifically, the facility did not initiate investigations or report incidents of resident-to-resident altercations as required by its policy. For example, one incident involved a resident with severe cognitive impairment who was involved in a physical altercation with another resident over a personal item, resulting in physical contact. The incident report documented the altercation, but the Nursing Home Administrator (NHA), who is also the facility abuse coordinator, was not notified and did not investigate or report the event to the appropriate state agency. Another incident involved a resident with severe cognitive impairment and multiple comorbidities who was physically grabbed by another resident, leading to pain and minor injury. The incident report documented the event, including the resident's complaints of pain and the involvement of a certified nursing aide (CNA) who intervened. Despite the documentation and the facility's policy requiring immediate investigation and reporting of suspected abuse, the NHA was not aware of the details and did not initiate an investigation or report the incident to the state agency. Record review confirmed that the NHA signed the incident reports days after the events occurred, but there was no evidence of timely investigation or reporting as required by the facility's abuse, neglect, and exploitation policy. Interviews with the NHA revealed a lack of awareness of the incidents and a failure to follow the facility's procedures for investigating and reporting allegations of abuse, particularly in cases involving resident-to-resident altercations resulting in physical contact and injury.
Failure to Obtain Physician Order for DNR Status
Penalty
Summary
The facility failed to obtain a physician order to implement an advanced directive/Do Not Resuscitate (DNR) for one resident. The resident, who had moderate cognitive impairment and a full legal guardian authorized to make health and medical care decisions, had an advanced directive form signed by the guardian and witnessed, with a physician signature present on the form. However, upon review of the clinical record, it was found that there was no corresponding physician order in place to enact the DNR status. Interviews with facility staff revealed that the process for updating orders relies on notification from the social worker, but the Assistant Director of Nursing was not notified that the advanced directive had been signed, and the responsible social worker was unavailable for interview during the survey.
Failure to Complete Accurate and Timely MDS Assessments for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to complete accurate and timely Minimum Data Set (MDS) assessments for two residents with pressure ulcers. For one resident, the MDS inaccurately indicated the presence of a tracheostomy and the need for tracheostomy care, despite direct observation, resident interview, and staff confirmation that the resident did not have a tracheostomy or require related care. The error was acknowledged by the MDS nurse, who confirmed the assessment was incorrect. For another resident, staff interviews and record review revealed that a new pressure ulcer developed on the resident's left heel, but a required change in condition MDS assessment was not completed within the mandated timeframe. The MDS nurse confirmed that the development of a new pressure ulcer should have triggered a change in condition assessment, but this was not done. The failure to complete accurate and timely assessments was confirmed through interviews with nursing and MDS staff, as well as review of the residents' medical records.
Failure to Update Care Plan After Resident Transfer
Penalty
Summary
The facility failed to update and revise the individualized, person-centered care plan for one resident following a significant change in the resident's care environment. The resident, who had severe cognitive impairment with a BIMs score of 1 out of 15 and diagnoses including dementia, anxiety, and depression, was observed resting in bed on the 300-unit hall with a perimeter mattress and bilateral fall mats. Despite being moved from the secure dementia unit (100-unit hall) to the 300-unit hall on July 17th, the resident's care plan continued to state that the resident resided on the secure care unit for a therapeutic environment related to dementia. This discrepancy was identified during a survey through observation, interview, and record review. The LPN managing the 300-hall unit confirmed that the care plan had not been updated to reflect the resident's new location and care needs, despite the facility's policy requiring comprehensive, person-centered care plans to be developed, implemented, and revised as needed. The failure to update the care plan resulted in the potential for unmet care needs for the resident.
Failure to Provide Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to ensure that a resident who required assistance with activities of daily living (ADLs) received appropriate care to maintain personal hygiene and grooming. The resident, who was cognitively intact and required one-person assistance for hygiene according to the care plan, was repeatedly observed over several days with greasy, uncombed hair, an excessively long mustache that extended into his mouth, and wearing the same soiled clothing with food and debris. There was no documentation indicating that the resident refused or was resistant to care. Interviews with staff confirmed that the resident was cooperative with care and had not refused showers, clothing changes, or grooming. Staff also reported that the resident had been requesting a haircut, but the facility had been without a beautician for approximately six months. The Assistant Director of Nursing was unaware of the resident's unkempt appearance and soiled clothing, and acknowledged that, despite the family's wishes for the resident to be independent, it was ultimately the facility's responsibility to ensure care needs were met.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food at the preferred temperature for two residents, resulting in dissatisfaction during meals. One resident, who was cognitively intact and had multiple medical diagnoses including kidney failure and heart disease, reported never receiving a hot meal since admission, with meals described as only warm at best. This resident also noted that hot tea was rarely hot, iced tea was rarely cold, and meats were inconsistently cooked, sometimes overcooked or undercooked. Another resident, with severe cognitive impairment and a history of stroke, diabetes, and dysphagia, frequently received meals in his room and stated that the food was never really warm. Direct temperature checks of this resident's food trays revealed that hot items such as quiche, peas, and coffee were served well below the expected temperature of 165°F, and ice cream was above the recommended cold temperature. On another occasion, breakfast items like hash browns, biscuits, and coffee were also served below appropriate temperatures, and the resident expressed dissatisfaction with the temperature of the food. Staff did not offer to provide warmer food when concerns were raised.
Failure to Honor Resident Food Preferences Results in Repeated Meal Errors
Penalty
Summary
The facility failed to provide food in accordance with a resident's documented preferences, resulting in repeated instances where the resident did not receive requested or preferred food items. The resident, who was cognitively intact and had multiple medical diagnoses including kidney failure, heart disease, and mood disorders, reported ongoing issues with meal accuracy. Specific examples included not receiving items such as tossed salad, hot tea, yogurt, cold cereal, 2% milk, potato chips, ketchup, and homestyle turkey and gravy, and instead receiving items on his dislike list, such as coffee and beef products. The resident had documented these issues through multiple Quality Assistance Forms, noting frequent discrepancies between meal tickets and actual meals received. Despite the resident's ongoing communication with the dietary manager and submission of concerns, the problems persisted over several weeks, as evidenced by saved meal tickets and repeated complaints. Interviews with facility staff, including the Nursing Home Administrator and Dietary Account Manager, confirmed that the resident's food preferences were not consistently honored and that staff could not explain the repeated errors. The facility's own review of the situation acknowledged noncompliance with meeting the resident's food preferences as documented.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to follow physician's orders for medications for a resident who was admitted with diagnoses including type two diabetes and cirrhosis of the liver. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Physician orders included Lactulose, Glimepiride, and Isosorbide Dinitrate, which were not consistently administered on specific dates. A family member raised concerns about the unavailability of these medications, which were confirmed by a review of the medication administration record. The Director of Nursing discovered the issue when the family filled out a Quality Assurance form. Despite attempts to contact the staff responsible for the medication administration, no responses were received by the time of the survey exit. The facility's failure to ensure the timely delivery and administration of the prescribed medications led to the deficiency, as the medications were not available from the pharmacy and were not pulled from the backup supply as expected.
Improper Use of Disinfectant Wipes for Resident Care
Penalty
Summary
The facility failed to adhere to professional guidelines by using PDI Sani-Cloth Germicidal Disposable Wipes for incontinent bowel care on a resident. The resident, who had a history of traumatic brain injury, schizoaffective disorder, dementia, and other medical conditions, was admitted to the facility in 2020. During an incident in early 2025, a Certified Nurse Aide (CNA) reported that a Staff Development Coordinator (SDC) used bleach wipes to clean the resident after a bowel movement, despite knowing it was inappropriate for skin contact. The incident was observed and reported by the CNA, who witnessed the SDC using the wipes on the resident's buttocks, groin, legs, and penis. The resident later confirmed that bleach wipes were used on him, although he could not recall specific details about the incident. The SDC admitted to using the wipes, initially intended for cleaning the mattress, on the resident's skin, acknowledging it was a mistake. The facility's incident report corroborated the CNA's account, detailing the use of disinfectant wipes during the resident's care. The SDC's witness statement explained the decision to use the wipes due to the resident's condition and the difficulty in cleaning him. The Safety Data Sheet for the wipes clearly stated they were not intended for skin use, highlighting the deviation from proper care protocols.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, R505, from sexual abuse by another resident, R501, resulting in a sexual assault. R505, who was cognitively impaired, was ushered into R501's room, where she remained for over an hour. The incident was captured on surveillance video, but the facility did not save the footage. Staff later found R505 with soiled underwear, leading to her being sent to the emergency room for examination. The Director of Nursing confirmed the incident after reviewing the video, which showed R501 barricading his room to prevent entry. R505 was diagnosed with Alzheimer's disease and dementia, with a BIMS score indicating severe cognitive impairment. She was unable to make decisions for herself and had a legal guardian. The facility's staff did not report her missing for over an hour, and the missing resident policy was not activated. R501, who had a history of sexual offenses, was not under any special monitoring or supervision, and his care plan did not reflect any precautions related to his past behavior. The facility's failure to implement adequate monitoring and supervision for R501, despite his known history, and the lack of timely reporting and intervention by staff, contributed to the incident. The facility's policies on abuse prevention and missing residents were not effectively followed, leading to the sexual assault of R505 and the subsequent investigation by law enforcement.
Removal Plan
- Resident was transferred to hospital and was provided a SANE examination.
- Resident was placed on 1:1 supervision until discharged from the facility.
- Female residents with a BIMS 10 or less had skin assessments completed with no concerns identified.
- Female residents with a BIMS 10 or higher were interviewed regarding any concerns with other residents in the facility and if they feel safe.
- Social Services Director completed an audit of sex offender registry for residents in facility.
- Three additional residents identified as sex offenders were placed on one to one supervision and assessed regarding risk factors.
- Resident's interventions/supervision updated as deemed appropriate based on risk factors.
- Care plans updated for residents identified as sex offenders.
- Facility staff were re-educated on the facility Abuse, Neglect and Exploitation Policy to include Criminal Sexual Abuse.
- Administrator, Director of Nursing and Social Services Director educated on ensuring that active sex offenders within the facility have appropriate supervision and interventions initiated and have ongoing monitoring.
- Facility staff were educated on signs of potential sexual abuse and actions to take if sexual abuse is suspected or has occurred.
- Facility staff were educated on following the kardex / care plan regarding interventions placed for residents who are active registered sex offenders.
- Sexual Abuse education will be completed during ongoing facility orientation.
- Residents who are on the sex offender list will be care planned with discussion and agreement, to allow entry when staff has a need to verify the whereabouts of another resident.
- Should a suspected or confirmed sexual abuse occur, the facility staff will immediately intervene and stop contact between residents.
- Perpetrator will be placed on one to one supervision in the interim.
- Notify the Administrator and Police as appropriate.
- Nurse will complete a physical assessment.
- Ad hoc QAPI initiated.
- Current residents in facility with a sex offender history will be reviewed by the Social Services Director or designee and IDT weekly for any new behaviors and to ensure current interventions remain in place and are appropriate.
- The Medical Director/designee was notified of the event.
Failure to Maintain Plumbing and Refrigeration Equipment
Penalty
Summary
The facility failed to maintain its plumbing and refrigeration equipment, which could potentially increase the risk of foodborne illness for all residents consuming food from the kitchen. During an observation, a leak was noted from the in-line water filter for the coffee maker, resulting in water accumulation on the floor. This is a violation of the 2017 FDA Food Code Section 5-205.15, which requires plumbing systems to be repaired according to law and maintained in good repair. Additionally, the Arctic Air reach-in cooler was observed to be holding a temperature of around 52 degrees Fahrenheit, which is above the safe temperature threshold for cold holding as per the 2017 FDA Food Code Section 3-501.16. This section mandates that time/temperature control for safety food should be maintained at 41 degrees Fahrenheit or less. The Certified Dietary Manager (CDM) acknowledged the issue and discarded the food from the cooler as the temperature was not decreasing. Furthermore, the atmospheric vacuum breaker for the mop sink was under constant pressure, which is against the 2017 FDA Food Code Section 5-202.14, requiring backflow prevention devices to meet specific standards.
Facility Fails to Control Gnat Infestation in Kitchen
Penalty
Summary
The facility failed to control pests in the kitchen, resulting in a swarm of gnats affecting the entire facility with a census of 99 residents. Observations on multiple occasions revealed gnats in various areas of the kitchen, including the dry storage room, the grease trap by the three-compartment sink, the dish machine area, and the dining room. The presence of gnats was particularly noted around food storage and preparation areas, such as the bread rack next to a drainage pipe and breakfast trays in the dining room, which were attracting gnats. The Certified Dietary Manager (CDM) acknowledged the issue, stating that the pest control operator had provided floor and drain cleaner to address the gnats. However, the pest control service reports from previous months did not mention any treatment for gnats, drain flies, or fruit flies. The facility's failure to eliminate harborage conditions and effectively control pests is in violation of the 2017 FDA Food Code, which mandates that premises be maintained free of insects and other pests through routine inspections and appropriate pest control methods.
Unqualified Activities Director Leads to Resident Disengagement
Penalty
Summary
The facility failed to ensure that the Activities Director on the memory care unit was qualified to perform the duties effectively. Observations over several days revealed that residents were often left unengaged, with many observed sleeping or passively watching television. Scheduled activities, such as 'Coffee and Cocoa' and 'Dance to Dine,' were either not conducted as planned or were inadequately executed. For instance, during a scheduled activity, the Activities Director engaged residents in a brief two-minute balloon toss before leaving them with an aide who did not attempt further engagement. The Activities Director admitted to not being a recreational or occupational therapist and was still in the process of completing the MEPAP class to become certified in Activities. She had no prior experience as an Activity Director, having only three months of experience as an Activity Aide at a sister facility. The director's lack of qualifications and experience contributed to the deficiency, as she was unable to provide meaningful and individualized activities for the residents, many of whom were observed to be disengaged and inactive.
Deficiencies in Food Service and Temperature Control
Penalty
Summary
The facility failed to serve food at the preferred temperature and provide necessary condiments and utensils, leading to dissatisfaction among residents. One resident, identified as R57, consistently received cold meals and was informed by staff that reheating was not allowed. Instead, a new tray had to be requested from the kitchen, which took additional time. On one occasion, R57's breakfast tray was replaced, but it lacked hash browns and included a plastic spoon instead of metal silverware, further delaying her meal consumption by 27 minutes. A confidential group of six residents reported ongoing issues with food service, including cold food, soggy bread, and inaccuracies in meal trays. They noted that their preferences were often not followed, such as missing condiments or utensils. During a test tray observation, a resident's lunch was found to be served at inadequate temperatures, with meatloaf at 113 degrees F, mashed potatoes at 133 degrees F, and corn at 125 degrees F. The Dietary Manager acknowledged awareness of these issues and mentioned ongoing audits to address them.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to immediately report an injury of unknown origin for one resident, resulting in the potential for further injuries of unknown origin to not be reported and facility corrective action to not be taken. The resident, who had been at the facility since November 2023 with a recent readmission in January 2024, was noted to have a small bruise on her forehead. The incident report indicated that the resident often leaned her head on the wall while being changed in the bathroom, but the report lacked details on the color or stage of healing of the bruise. Interviews with staff provided conflicting accounts of the resident's behavior and the timeline of the bruise's appearance. Some staff members reported that the resident would rest her head on the wall, while others stated they had not observed this behavior. The bruise was described by different staff members as being yellow, purple, or blue at various times, indicating inconsistencies in observations and documentation. The facility's Administrator and DON were notified of the bruise, but the report was not made to the state agency as it was determined internally that the bruise was caused by the resident's behavior. However, the investigation and reporting process was unclear, with discrepancies in who reported the incident and when. The lack of immediate reporting and thorough investigation of the injury of unknown origin highlights a deficiency in the facility's handling of such incidents.
Inadequate Investigation of Resident's Bruise
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged abuse incident involving a resident, identified as R25, who was found with a bruise on her forehead. The incident report dated 6/20/2024 noted a small bruise on R25's forehead, but lacked details such as the color or stage of healing. Statements from staff, including a CNA and an LPN, suggested that R25 had a habit of leaning her head against the bathroom wall, which was believed to be the cause of the bruise. However, there was inconsistency in the staff's accounts regarding the timing and nature of the bruise, with some staff reporting it as a newer bruise and others as an older one. The facility's Director of Nursing (DON) and Administrator were notified of the bruise, but the investigation was incomplete. The Administrator could not recall who reported the incident to her, and there was no documentation of further investigation or assessment of other residents for similar injuries. Interviews with various staff members revealed discrepancies in their observations and recollections about R25's behavior and the bruise's appearance. Some staff members reported that R25 did not tap her head on the wall, while others stated she did. The lack of a comprehensive investigation and documentation raises concerns about the facility's ability to protect residents from potential abuse. The incident report was the only document available regarding the bruise, and it contained only two staff witness statements. There was no follow-up documentation or assessment of the bruise after 6/20/2024, indicating a failure to ensure resident safety and compliance with reporting requirements for injuries of unknown origin.
Failure to Document Pressure Ulcer in MDS Assessment
Penalty
Summary
The facility failed to accurately complete a comprehensive assessment for a resident, resulting in the potential for unmet care needs. The resident was admitted with multiple diagnoses, including Parkinson's Disease, type 2 diabetes, COPD, epilepsy, schizoaffective disorder, atrial fibrillation, anxiety, insomnia, dementia, hypertension, depression, anemia, orthostatic hypotension, and stroke. Upon admission, a Skin & Wound Evaluation identified a stage 3 pressure ulcer on the resident's right ischial tuberosity. However, the Minimum Data Set (MDS) assessment, completed shortly after admission, did not document this pressure ulcer. During interviews, both the MDS Coordinator and the MDS Nurse confirmed the presence of the pressure ulcer in the resident's medical record but could not explain why it was omitted from the MDS assessment. The omission of the pressure ulcer from the MDS assessment indicates a failure in accurately completing the comprehensive assessment, which is crucial for addressing the resident's care needs effectively.
Deficiencies in Resident Care Plans and Implementation
Penalty
Summary
The facility failed to develop and implement adequate care plans for two residents, leading to potential health risks. Resident #34, who had severe cognitive impairment and was dependent on assistance for activities of daily living, was observed with a Stage 3 pressure ulcer. The care plan for this resident included specific interventions such as using a mechanical lift with a shower sling, orthotic boots, and a pillow between the knees. However, observations revealed that these interventions were not consistently implemented. The resident was transferred using an incorrect sling size, and staff failed to use the required shower sling, leading to a bruise on the resident's forehead. Additionally, there was no documented assessment of the correct sling size, and staff competency in using the mechanical lift was not validated. Resident #36, who had moderate cognitive impairment, complained of mouth sores and was supposed to see a dentist. However, there was no care plan addressing dental issues or oral care. The resident's dental visit notes indicated a need for a referral to an oral surgeon for the removal of nodules, but this referral was delayed. The Unit Manager confirmed that the referral was sent to the scheduler, but the appointment was not scheduled in a timely manner. The care plan developed after the surveyor's interview did not include the nodules noted by the dentist, and the resident's goal to receive dentures was not addressed. These deficiencies highlight the facility's failure to ensure that care plans were comprehensive and effectively implemented, resulting in potential harm to the residents. The lack of proper documentation, assessment, and follow-up on care plans contributed to the inadequate care provided to these residents.
Failure to Engage Resident in Meaningful Activities
Penalty
Summary
The facility failed to provide a meaningful, diverse, and engaging activity program for a resident with severe cognitive impairment residing in the secured memory care unit. The resident, who enjoys music, talk radio, walking, and pet visits, was observed wandering alone in the hallways on multiple occasions without staff intervention to engage them in scheduled activities. Despite having an activity care plan that included encouraging participation in group activities and providing sensory materials, the resident was not encouraged to join activities such as 'Coffee and [NAME]' or music sessions on the patio. The activity director, who has been with the facility for 10 months, acknowledged the resident's interest in sensory activities and pet visits, yet the activity participation record for June 2024 did not reflect any pet visits in the last 30 days. Additionally, the resident's activity care plan and the most recent activity assessment did not include pet therapy, indicating a disconnect between the resident's interests and the activities provided. This lack of engagement and failure to adhere to the resident's care plan contributed to the deficiency identified by the surveyors.
Improper Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to safely transfer a resident using a mechanical lift, resulting in a hematoma and bruises. During an observation, a resident was lifted from her bed with a transfer sling that did not support her head or lower trunk adequately. The staff involved, including a Resident Aide and a Certified Nurse Aide, were not properly trained or assessed for competency in using the mechanical lift. The Staff Development Registered Nurse expressed concerns about the incorrect donning of the sling and the lack of proper assessments for sling size. The resident's care plan required a shower sling for transfers, but no specific size was recommended, and the sling used was inappropriate for the resident's weight. The resident, who had severe cognitive impairment and was dependent on assistance for activities of daily living, had a history of non-traumatic brain dysfunction, dementia, anxiety, depression, arthritis, and a hip fracture. An incident report noted a bump on the resident's forehead and bruising on her ear, which were not previously observed. The Nursing Home Administrator and Director of Nursing acknowledged that the injury could have been caused by a staff member not following the mechanical lift transfer policy, as the transfer was performed without the required two-person assistance. The staff member involved was suspended, but there was no confirmation that the resident's transfer was evaluated after the injuries were noted and before the surveyor's observation.
Medication Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed for one resident, resulting in an error rate of 11.11%. The errors were identified during the administration of medications to a resident with thoracic spine injuries and hypertension. The Licensed Practical Nurse (LPN) administered a full tablet of Metoprolol 25 mg instead of the prescribed half tablet (12.5 mg), two Senna Plus capsules without a corresponding physician's order, and an incorrect dosage of ClearLax, which was not measured using the appropriate measuring cap. The LPN admitted to administering a full tablet of Metoprolol due to the pharmacy providing full tablets and confirmed the resident's preference for Senna Plus, despite the lack of an order. Additionally, the LPN used a plastic pill cup to measure ClearLax instead of the bottle's measuring cap, which is marked for the correct dosage. The Director of Nursing (DON) acknowledged the errors related to Metoprolol and Senna Plus and was unaware of the improper measurement method for ClearLax.
Failure to Schedule Dental Referral Timely
Penalty
Summary
The facility failed to promptly schedule a dental referral for a resident, resulting in continued pain and a delay in meeting the resident's goals. The resident, who had a moderate cognitive impairment, was observed complaining of mouth sores and pain. Despite a dental visit on 3/28/24 recommending a referral to an oral surgeon for the removal of nodules on the maxillary anterior frenum, the referral was not scheduled in a timely manner. The unit manager confirmed that the referral was sent to the scheduler on 5/28/24, but the appointment had not been scheduled by 6/26/24. The resident's care plans did not initially address the dental issues or oral care, and even after the dental visit, the care plan was not updated to include the nodules or the goal of receiving dentures. The resident's goal to have reduced complications related to dental issues and to receive upper and lower dentures was not incorporated into the care plan. This oversight contributed to the delay in addressing the resident's dental needs and alleviating their pain.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment for a resident, identified as R30, who required built-up eating utensils due to multiple health conditions, including osteomyelitis, type 2 diabetes, arthritis, and a history of stroke. R30 was admitted to the facility with a care plan that included the provision of built-up handles for utensils at meals. Despite this, observations on two separate occasions revealed that while R30 was provided with a built-up spoon and fork, a built-up knife was consistently missing from his meal tray. This omission required R30 to use inappropriate utensils to prepare his food, such as buttering toast and applying jam. Interviews with the Dietary Manager (DM) G confirmed that the facility had adaptive knives available and that the meal ticket for R30 indicated the need for built-up utensils. However, DM G was unable to explain why the built-up knife was not provided, despite acknowledging that it was expected to be included with every meal. This oversight in providing the necessary adaptive equipment as per the resident's care plan highlights a deficiency in the facility's adherence to ensuring residents' needs are met for meal preparation and eating.
Failure in Hospice Service Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation of hospice services for a resident, resulting in a lack of coordination of comprehensive care. The resident, who was admitted with multiple diagnoses including dementia and Alzheimer's Disease, was receiving hospice care as indicated in their medical record. However, the Durable Power of Attorney (DPOA) for the resident was not informed about the specific hospice services being provided or the schedule of these services. Despite a physician's order for hospice services to begin, there was no evidence that the DPOA was notified about the hospice disciplines involved or the frequency of visits. Interviews with facility staff revealed that there was no documentation of a hospice admission meeting with the DPOA, and the hospice visit calendar was not consistently updated in the resident's medical record. The hospice calendar for certain weeks was not scanned into the medical record until after the visits had occurred, and there was no calendar for some weeks. The facility's policy required coordination of a care plan with the hospice provider, but this was not effectively implemented, as evidenced by the lack of communication with the resident's representative.
Failure to Administer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to administer pneumococcal immunizations in accordance with CDC recommendations for a resident, resulting in a potential risk for severe illness and complications from pneumococcal disease. The resident, identified as R25, was admitted to the facility with multiple diagnoses including dementia, chronic kidney disease, and severe protein-calorie malnutrition. The resident's medical record indicated that she had received the PCV13 vaccine in 2017 and the PCV23 vaccine in 2018, but there was no documentation of the PCV20 vaccine being administered, which is recommended by the CDC for individuals over the age of 65 at least five years after their last pneumococcal vaccination. During an interview, the Infection Preventionist (IP) confirmed that the resident had not been offered or received the PCV20 vaccine as per CDC guidelines. The IP admitted to being unaware of the specific CDC recommendation that the resident should receive the PCV20 vaccine. The facility's policy on pneumococcal vaccines, last revised in October 2023, stated that the type of vaccine offered should depend on the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines. However, this policy was not followed in the case of the resident, leading to the deficiency.
Violation of Resident's Rights and Privacy
Penalty
Summary
The facility failed to honor a resident's rights, resulting in increased anxiety, PTSD symptoms, decreased self-worth, and psychosocial wellbeing. The resident, who has a history of chronic obstructive pulmonary disease, acute kidney failure, pressure ulcers, malignant neoplasm, major depression, anxiety, PTSD, and other conditions, was cognitively intact and required assistance for personal care. Despite the resident's care plan emphasizing the need to offer choices and promote self-worth, the facility imposed a two-person assist for all care, including answering call lights, against the resident's wishes. The resident reported that the facility did not always staff two female caregivers on her hall, leading to delays in care. The resident also stated that the facility's decision to require two caregivers was a response to her allegation that an occupational therapist had left bruises on her arm. The facility investigated the allegation and found no wrongdoing, but continued to enforce the two-person assist policy, which the resident felt violated her rights and privacy. The resident expressed her concerns to the ombudsman, who confirmed that the resident's rights were not being honored. The facility's staff, including the Social Services Director, Unit Manager, and Nursing Home Administrator, maintained that the two-person assist was necessary for the resident's safety and to protect staff. However, the resident repeatedly expressed that this policy exacerbated her anxiety and PTSD, and she felt her autonomy and privacy were being compromised. The resident's refusal of care and verbal aggression were documented multiple times, highlighting her distress and the ongoing conflict between her wishes and the facility's policies.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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