Medilodge Of Marshall
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshall, Michigan.
- Location
- 879 East Michigan Ave, Marshall, Michigan 49068
- CMS Provider Number
- 235495
- Inspections on file
- 32
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Medilodge Of Marshall during CMS and state inspections, most recent first.
A resident with necrotizing fasciitis, depression with anxiety, and type 2 DM, who was cognitively intact, reported concerns about late pain medication. The resident had a physician order for oxycodone 10 mg every 4 hours, scheduled six times daily, but controlled substance records showed multiple instances of administration intervals that were shorter or longer than 4 hours. An RN reported that nurses often covered two halls, leading to late medication administration, and the DON confirmed that the oxycodone was not consistently signed out according to the every-4-hour order.
A resident with multiple comorbidities and intact cognition developed several facility-acquired pressure ulcers on the right heel and medial malleolus, including an unstageable heel wound attributed to a brace and another heel wound that progressed to a stage 3 ulcer. The record showed multiple overlapping and conflicting wound care orders for the same wound sites and repeated missed treatments on several ordered days. During observation, dressings that had not been changed for several days were removed, revealing unstageable and stage 3 pressure ulcers with increased size, drainage, foul odor, and slough, while the resident reported significant pain despite the wound nurse using appropriate infection control during the dressing changes.
A resident with severe cognitive impairment and dementia, known to have a history of physical aggression toward others, was left in a dining room without documented, active interventions to prevent altercations. While another cognitively impaired resident with significant neurological and psychiatric conditions was shouting, the aggressive resident grabbed the resident’s clothing and struck the resident multiple times in the face, causing a scratch, before a CNA intervened. Facility records showed multiple prior aggressive incidents by the same resident, particularly in the dining room, yet the care plan lacked ongoing, specific strategies to prevent such behaviors in that setting, and leadership could not provide evidence of appropriate behavioral interventions despite a policy requiring assessment and care planning for residents with behaviors that might lead to conflict.
Nursing staff failed to follow professional standards for medication administration when an RN preceptor pulled a full set of morning medications, including insulin and antihypertensives, for one resident and handed them to an LPN on orientation who lacked access to the electronic MAR. The LPN did not verify the five rights of medication administration and gave the medications to a different resident with multiple comorbidities, while that resident’s own scheduled morning medications were held. Interviews confirmed that the person who removed the medications from the cart did not administer them and that standard medication verification practices were not followed.
A resident with multiple chronic conditions was given another resident’s full morning medication regimen, including insulin and cardiovascular medications, after an RN preceptor removed and documented the medications in the EHR for a different resident and then handed them to an orienting LPN who lacked MAR access. The LPN did not verify the five rights of medication administration and administered the medications to the wrong resident, while the resident’s own scheduled morning medications were held. A regional clinical consultant later identified that the person who pulled the medications was not the one who administered them and that standard professional practices and the five rights were not followed.
A resident with severe cognitive impairment was the subject of a suspected abuse allegation involving possible non-consensual sexual activity, as reported by a roommate. The allegation was initially communicated by a CNA to an LPN, but there was no immediate follow-up or investigation. Subsequent staff, including an RN, delayed reporting while waiting for clarification from the LPN, resulting in a late notification to the State Agency.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident receiving hospice care, who was cognitively intact, reported being verbally and physically abused by a CNA during an argument about a room change. The resident stated the CNA yelled, called him names, and struck him on the head with a roll of an object. Multiple staff members confirmed witnessing the CNA being verbally and physically aggressive with other residents and reported these behaviors to management, but the CNA continued to work in the facility.
A resident who was bed bound, non-verbal, and dependent on staff for all ADLs did not receive scheduled showers or bed baths, and had excessively long fingernails and toenails with no documentation of nail care or podiatry consult. The resident was observed with matted hair and an unpleasant odor, indicating a failure to provide necessary grooming and hygiene services as required by facility policy.
A resident with multiple complex medical conditions who was totally dependent on staff for toileting did not have required two-hourly toileting and shift-based bowel elimination documented for several periods. The DON confirmed that documentation was missing and could not provide evidence that the resident received necessary assistance, following a complaint that the resident was left in a wet brief for an extended time.
A resident with multiple chronic conditions did not receive prescribed Hydrocodone-Acetaminophen for pain management as ordered by the physician. Documentation showed missed doses due to issues with medication supply and delays in reordering, and the DON confirmed that staff did not reorder the medication before it ran out.
A resident with severe cognitive impairment and multiple comorbidities was not accurately assessed or monitored for pressure ulcers. Wound documentation was inconsistent, with measurements for separate wounds sometimes combined and assessments not matching photographic evidence. The wound nurse could not explain these discrepancies, and the plan of care did not accurately reflect the resident's wound status. The DON confirmed the inaccuracies in both wound assessments and care planning.
The facility failed to maintain a clean and functional environment, affecting 91 residents. Observations revealed leaking sinks, soiled light covers, and non-cleanable surfaces in the laundry rooms. Common areas and resident rooms had accumulated dust, non-functional lights, and damaged fixtures. The facility's cleaning and maintenance protocols were not followed, increasing the risk of cross-contamination and bacterial harborage.
A resident with cognitive intactness and multiple diagnoses experienced ongoing frustration due to constant yelling from nearby residents. Despite informing staff, grievances were not documented or resolved, leading to increased frustration and uncharacteristic behavior from the resident. CNAs confirmed the issue was reported to the Unit Manager, but no changes were made.
A facility failed to accurately complete MDS assessments for a resident, resulting in incorrect documentation of insulin injections. The resident's MDS indicated insulin administration, but physician orders showed no record of such treatment. The MDS Coordinator confirmed the inaccuracies but could not explain the discrepancies.
A resident with multiple health issues was not provided with the 1:1 activities outlined in her care plan, leading to unmet care needs and increased frustration among other residents. Despite being cognitively intact, she was observed repeatedly yelling for help without staff intervention. Interviews with CNAs confirmed the lack of engagement, and documentation was insufficient to show that activities were offered as planned.
A resident with cognitive intactness and multiple health conditions was not provided with meaningful, individualized activities as per her care plan. Despite being at risk for altered activity patterns, the resident was often found in bed yelling for help, with no staff engaging in 1:1 activities. CNAs reported that the resident did not get out of bed and was not observed participating in activities, causing frustration among other residents. The facility's documentation showed limited 1:1 activity offerings, and the administrator acknowledged the lack of adherence to the care plan.
A resident developed a stage 3 pressure ulcer due to the facility's failure to adhere to care plans and policies. The resident, admitted with multiple health issues, did not initially have pressure ulcers. However, inconsistent documentation and failure to implement interventions like regular turning and use of pressure redistribution mattresses led to the ulcer's development. The Wound Nurse missed the initial assessment and incorrectly staged the wound, while documentation showed the resident was not turned every two hours as required.
The facility failed to document the size of tracheostomy cannulas in physician orders for two residents, leading to a deficiency in professional standards for respiratory care. One resident's tracheostomy care was inconsistent, and the size of the cannula was known by staff familiarity rather than documented orders. The issue was confirmed by facility staff, who acknowledged the need for clearer documentation.
A resident with a history of depression and anxiety experienced increased distress due to constant yelling from other residents. Despite reporting frustrations, the facility failed to address the issue, leading to the resident's decreased social interaction and increased withdrawn and angry behaviors. Incomplete mood assessments and ineffective interventions contributed to the deficiency.
A resident identified as a high fall risk was found injured on the floor due to the absence of a fall protection mat, as required by their care plan. Despite being able to move independently, the resident was unsteady and unsafe without assistance. The lack of the mat, confirmed by the DON and admitted by an LPN, led to the resident sustaining head and leg injuries.
A resident with dementia and major depressive disorder experienced discrepancies in the controlled medication count for ABHR Cream. The facility's records showed inconsistent remaining amounts of the medication, with no documentation explaining the discrepancies. The DON suggested air in the container as a cause, but a pharmacy technician confirmed that air would not affect the count. The facility lacked ABHR gel/cream at the time of the investigation.
The facility failed to respect resident dignity and privacy, as staff entered rooms without knocking and referred to a resident disrespectfully. A resident was observed without a meal, and a CNA referred to them as 'whatever, whatever,' which the resident found disrespectful. The resident was new to the facility and expressed feeling disrespected by the comment.
A resident with hemiplegia experienced a delay in receiving a necessary x-ray for left hand pain, ordered on October 1, 2024, but not completed until October 12, 2024. The delay was attributed to an imaging company issue and miscommunication among staff. The resident reported severe pain, and staff interviews confirmed the expectation for quicker x-ray completion.
A resident with a full code status was found unresponsive in a facility, but CPR was not initiated by staff until EMS arrived. Despite the facility's policy requiring immediate CPR, staff delayed action, checking the code status and calling 911 instead. The resident had a history of Obstructive Sleep Apnea and Morbid Obesity, and the delay in CPR initiation resulted in Immediate Jeopardy.
A facility failed to create a comprehensive care plan for a resident with severe cognitive impairment and a history of swallowing non-food items. The care plan lacked specific interventions to prevent the resident from ingesting non-food items, despite previous hospitalizations for such behavior. The deficiency was identified during a survey, and the issue was acknowledged by facility administrators.
A resident with cerebral atherosclerosis, legal blindness, and dementia experienced a fall, resulting in a lack of documented neurological assessments in the facility's records. Despite the fall, the facility did not have a specific neurological assessment policy, and the Director of Nursing believed the standard of care was followed with daily neuro checks. However, the documentation showed outdated vital signs and no detailed neurological assessments, raising concerns about the thoroughness of the assessments.
A resident with Obstructive Sleep Apnea and Morbid Obesity was not reassessed for respiratory status after a hypoxic episode, despite having used a CPAP machine in the hospital. An LPN administered oxygen, but no further assessments were documented. The resident was later found unresponsive and pronounced dead after CPR efforts. The DON acknowledged the need for follow-up assessments, and the facility did not provide additional information on CPAP use.
The facility failed to provide written notice before room changes for four residents, violating their rights. Room changes were related to payor source transitions from Medicare to Medicaid, but no written notices were documented, affecting residents with conditions such as dementia, anxiety disorder, cerebral infarction, anemia, COPD, diabetes, bipolar disorder, and major depressive disorder.
The facility failed to maintain cleanliness and repair in resident bathrooms, with observations of dried feces on toilet surfaces and structural issues like peeling wall molding and worn door frames. The Maintenance Manager was unaware of these issues due to reliance on the TELS system for maintenance communication, indicating a lapse in the facility's preventive maintenance program.
The facility failed to maintain accurate medical records for two residents. One resident had a DNR order, but CPR was performed without documentation of the event. Another resident's transfer to the hospital was inadequately documented, lacking details about their condition and necessary forms. These deficiencies highlight lapses in record-keeping and communication.
Failure to Administer Oxycodone as Ordered Every 4 Hours
Penalty
Summary
The deficiency involves the facility’s failure to administer pain medication as ordered for a cognitively intact resident with necrotizing fasciitis, major depressive disorder with anxiety, and type 2 diabetes. The resident was admitted with these diagnoses and had an MDS BIMS score of 13/15, indicating intact cognition. During an observation, the resident reported concerns that their pain medications were occasionally administered late. The physician’s order dated 12/30/25 directed that oxycodone 10 mg be given every four hours, and the MAR showed scheduled administration times at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM daily. Review of the controlled substance records for the resident’s oxycodone 10 mg showed multiple instances where the medication was signed out at intervals shorter or longer than the ordered four hours. Examples included doses given approximately 2 hours and 18 minutes apart, 4 hours and 45 minutes apart, 4 hours and 50 minutes apart, over 5 hours apart, and as close as 1 hour and 45 minutes apart on various dates. In an interview, an RN stated that nurses often worked two halls, resulting in late medication administration. The DON stated that the controlled substance records should reflect the time the medication was pulled for administration and that, for an every-4-hour order, staff were expected to sign it out every four hours unless refused. The DON reviewed the records and agreed that the oxycodone had been signed out outside of the ordered every-4-hour schedule.
Failure to Prevent and Properly Treat Pressure Ulcers on Resident’s Right Foot
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development and progression of pressure ulcers and to consistently provide ordered wound care for one resident with multiple right foot pressure injuries. The resident was admitted with multiple medical conditions including COPD, obesity, anxiety, mild neurocognitive disorder, neuromuscular bladder dysfunction, depression, anemia, hypothyroidism, insomnia, hypertension, sleep apnea, GERD, and osteoarthritis, and was cognitively intact per a recent MDS. The MDS documented one stage 3 pressure ulcer present on admission and one unstageable pressure ulcer that was not present on admission. Facility records identified three facility-acquired wounds on the right foot: an unstageable right heel wound attributed to a brace, an initially unstageable right superior heel wound that progressed to a stage 3 pressure ulcer, and an unstageable right medial malleolus wound, all with documented increases in size over time. The medical record showed multiple overlapping and conflicting treatment orders for the right heel and right medial malleolus, including different instructions for cleansing, use of betadine, iodine, calcium alginate, Medihoney, and various dressings, with several orders remaining active simultaneously. During interview, the wound nurse responsible for pressure wound oversight acknowledged that some of these orders should have been deleted and was unable to identify which orders were correct for either the right heel or the right medial malleolus. Review of the treatment records revealed that ordered wound care was not completed on multiple specified dates for both the right heel and right medial malleolus wounds, despite the orders being in effect. On observation, the resident was found in bed on an alternating air mattress with the right foot elevated, and reported having several pressure wounds on the right foot caused by a boot previously worn at the facility. During a wound care observation, dressings dated three days prior were removed from the right heel, right superior heel, and right medial malleolus. The right heel wound was observed as unstageable with eschar; the right superior heel wound had a large amount of yellowish/greenish drainage with foul odor and was measured and classified as a stage 3 pressure ulcer with a pink granulating wound bed; and the right medial malleolus wound appeared unstageable with slough tissue and increased dimensions. The wound nurse performed cleansing and dressing changes using wound wash, betadine, calcium alginate, Medihoney, and bordered gauze, and used appropriate infection control technique. The resident reported pain rated between 7 and 9 out of 10 at the conclusion of the dressing changes.
Failure to Prevent Resident-on-Resident Physical Abuse in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by another resident, despite a known history of aggressive behaviors. One resident (R2) had multiple neurological and psychiatric diagnoses, including pseudobulbar affect, severe intellectual disabilities, cognitive impairment, bipolar disorder, and conversion disorder with seizures, and was documented as rarely or never understood on the most recent MDS. Another resident (R6) had severe cognitive impairment with a BIMS score of 3, along with Alzheimer’s disease, dementia, depression, morbid obesity, and other medical conditions. Both residents were present in the dining room at the time of the incident. On the date of the incident, an incident report documented that R6 approached R2 in the dining room while R2 was shouting, became upset, yelled at R2, and then hit R2 in the face multiple times, leaving a scratch on R2’s nose. A CNA witness stated that she entered the dining room to report off to another CNA, observed R6 standing beside R2, heard R2 begin to yell, and then saw R6 grab R2 by the sweatshirt and hit R2 three to four times on the forehead before the CNA separated them. The CNA reported that she was aware R6 had a history of altercations with other residents and believed R6 was not to be left unattended in the dining room or placed next to other residents there, and she did not see any other staff member observing R6 in the dining room at the time. Record review showed that R6 had multiple prior documented incidents of physical aggression toward other residents, including accusations of physical aggression, altercations and hitting in the dining room, slapping another resident in the dining room, throwing a plastic bottle at another resident in the dining room, and hitting a roommate. R6’s care plan identified behavioral issues such as physical aggression toward staff and other residents, yelling, hitting, wandering into other residents’ rooms, and resistance to care, but the interventions listed were time-limited (such as 1:1 care until infection ruled out and frequent checks) and had been resolved before the incident. The care plan did not include interventions specifically aimed at preventing altercations in the dining room. The Nursing Home Administrator confirmed R6’s prior altercations in the dining room and could not provide evidence of care plan interventions implemented after each altercation or in place prior to the incident to prevent R6’s behaviors and potential physical altercations, despite a facility policy requiring identification, ongoing assessment, care planning, and monitoring of residents with behaviors that might lead to conflict or neglect.
Medication Error During LPN Orientation Leads to Wrong-Resident Administration
Penalty
Summary
The deficiency involves nursing staff failing to follow professional standards for medication administration, resulting in one resident receiving another resident’s medications. Resident #1 was admitted with multiple diagnoses including depression, thyroiditis, GERD, osteoporosis, dementia, sleep apnea, insomnia, chronic pain, dysphagia, and hypercholesterolemia. On the date of the incident, Resident #1 received a full set of morning medications that had been ordered for Resident #7, including Farxiga 10 mg, hydrochlorothiazide 25 mg, furosemide 20 mg, loratadine 10 mg, a multivitamin, potassium chloride 10 mEq, Tylenol 650 mg, Lantus 22 units subcutaneous, and metoprolol tartrate 25 mg. Resident #1 later recalled receiving the wrong medication but could not recall the specific drugs or the date, and reported no negative outcome. Resident #7 had been admitted with chronic respiratory failure, type 2 diabetes, depression, PTSD, hypercholesterolemia, anxiety, adjustment disorder, mild cognitive impairment, dementia, dysphagia, hypertension, and a cognitive communication deficit, and had a BIMS score of 12, indicating moderate cognitive impairment. The medications administered to Resident #1 were those ordered for Resident #7. Review of Resident #1’s medical record showed that blood sugars were monitored following the event, with readings of 126 mg/dL, 150 mg/dL, 218 mg/dL, and 123 mg/dL over the subsequent hours. Resident #1’s October MAR showed that all of her own 0800 medications, including alendronate, cholecalciferol, duloxetine, fenofibrate, hydrochlorothiazide, losartan, clonidine, and famotidine, were held that morning. Interviews revealed that the error occurred during orientation of a new LPN. The Nursing Home Administrator and Regional Clinical Consultant stated that an RN preceptor pulled the medications for Resident #7 from the medication cart and then handed them to the LPN, who was on orientation and did not have access to the electronic MAR in PointClickCare. The LPN then administered these medications to Resident #1 instead of Resident #7 and acknowledged not following the five rights of medication administration (right patient, right medication, right dose, right time, right route). The Regional Clinical Consultant stated that professional practice dictates that the person who pulls the medication should be the one to administer it, and that this standard, as well as the five rights, were not followed in this incident.
Medication Error When Precepting Nurse Prepares Medications for Another Nurse
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when one resident received another resident’s medications, including insulin and antihypertensive medication. The affected resident had multiple diagnoses, including depression, thyroiditis, GERD, osteoporosis, dementia, hypercholesterolemia, sleep apnea, insomnia, chronic pain, and dysphagia. The resident and a family member both reported that the resident had been given the wrong medications, with the family member specifically noting insulin and a blood pressure medication. The resident recalled receiving the wrong medication but could not identify which medications or when the incident occurred. Record review showed that on the morning in question, the resident was administered a full set of medications that were ordered for another resident with chronic respiratory failure, type 2 diabetes, depression, PTSD, hypercholesterolemia, anxiety, mild cognitive impairment, dementia, dysphagia, hypertension, and cognitive communication deficit. The medications given in error included Farxiga 10 mg, hydrochlorothiazide 25 mg, furosemide 20 mg, loratadine 10 mg, a multivitamin, potassium chloride 10 mEq, acetaminophen 650 mg, Lantus 22 units subcutaneously, and metoprolol tartrate 25 mg. The resident’s blood sugars were monitored and documented following the error, and the medication administration record showed that the resident’s own scheduled 0800 medications were held that day. Interviews with facility staff revealed that the error occurred during orientation of a new LPN. The precepting RN pulled and documented the medications for the other resident in the electronic system because the orienting LPN did not yet have access to the electronic MAR. The RN then handed those medications to the LPN to administer. The LPN reported that she did not follow the five rights of medication administration and mistakenly gave the medications to the wrong resident. The regional clinical consultant identified that the root cause was the LPN not pulling the medications herself and not following the five rights, and that professional practice standards requiring the same person to both pull and administer medications were not followed.
Failure to Timely Report Suspected Abuse Allegation
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the State Agency involving a resident with severe cognitive impairment. A resident with a low BIMS score, indicating severe cognitive impairment and inability to consent, was alleged by their roommate to be involved in sexual activity with another person. The initial allegation was reported by a CNA to an LPN, but the LPN did not follow up to gather more information. The CNA reported the allegation again to the charge nurse and an RN during a subsequent shift, but the RN delayed action, waiting for the LPN to arrive before proceeding. The Nursing Home Administrator was not notified until the following morning. The incident was ultimately reported to the State Agency, but not until several hours after the initial allegation was made. The delay in reporting was due to a lack of immediate follow-up and communication among staff, including the LPN not investigating further and the RN waiting for confirmation from the LPN before taking action. The facility's failure to promptly report the suspected abuse as required resulted in a deficiency.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Resident from Verbal and Physical Abuse by CNA
Penalty
Summary
A resident under hospice care, who was cognitively intact, reported being verbally and physically abused by a Certified Nursing Assistant (CNA) approximately a year prior to the survey. The resident described an incident where the CNA argued with him about a room change, yelled at him, called him names, and struck him on the head with a roll of an object, possibly a paper towel. The resident stated he reported the incident at the time, and the CNA continued to work at the facility, though was not assigned to his care. The facility's incident report corroborated the resident's account, and staff interviews revealed that multiple staff members were aware of the CNA's aggressive behavior toward residents, including both verbal and physical abuse, which had been reported to management. Several staff members, including CNAs and LPNs, confirmed witnessing the CNA being verbally and physically aggressive with other residents and reported these incidents to management. One LPN specifically recalled witnessing the CNA being verbally abusive toward the resident in question and other residents, and stated that management responded by moving the CNA to another hall. The Director of Nursing and Nursing Home Administrator indicated that the abuse prevention coordinator at the time handled the investigation. The facility's policy on abuse, neglect, and exploitation lists resident or staff reports of abuse and observed verbal or physical abuse as possible indicators, all of which were present in this case.
Failure to Provide Scheduled Bathing and Nail Care
Penalty
Summary
A resident with diagnoses including aphasia and cerebral infarction was admitted and readmitted to the facility, and was described as rarely or never understood, bed bound, incontinent, and unable to make her needs known. The resident required staff assistance for all activities of daily living, including bathing and personal hygiene, and was scheduled to receive showers on Sundays and Wednesdays. Observations revealed that the resident's fingernails and toenails were excessively long, her hair was matted, and she had an unpleasant odor. Review of facility records showed that the resident did not receive a shower or bed bath on her scheduled days, and there was no documentation of completed nail care. Additionally, there was no evidence that a podiatry consult had been requested to address the long toenails. Facility policy required that residents unable to perform activities of daily living receive necessary services to maintain grooming and hygiene, but these services were not provided as scheduled for this resident.
Failure to Provide and Document Required Toileting and Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically toileting and incontinence care, for a resident who was totally dependent on staff for these needs. The resident, who had multiple complex medical conditions including COPD, morbid obesity, pulmonary fibrosis, and congestive heart failure, was admitted and required one-person assistance for toileting. Documentation revealed that required two-hourly toileting and shift-based bowel elimination records were missing for several time periods during the resident's stay. This lack of documentation indicated that the resident may not have been offered or provided toileting assistance as required by facility policy. The Director of Nursing confirmed during an interview that it was the facility's expectation and practice to offer and document toileting every two hours for newly admitted residents, and to document bowel movements once per shift. Upon review, the DON acknowledged the absence of documentation for the specified periods and could not provide any alternative records to demonstrate that the resident received the necessary assistance. The deficiency was identified following a complaint that the resident had been left in a wet brief for an extended period.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to implement physician orders for the administration of pain medication for one resident. The resident was admitted with multiple chronic conditions, including rheumatoid arthritis, and had a series of physician orders for Hydrocodone-Acetaminophen to be administered at specific intervals for pain management. Review of the medical administration record (MAR) showed that the pain medication was not documented as given according to the physician's orders. Progress notes indicated ongoing issues with obtaining the medication from the pharmacy and the facility's emergency drug kit (EDK), resulting in missed doses. Interviews with the Director of Nursing (DON) confirmed awareness of the issue and revealed that the resident's pain medication supply had run out, necessitating a new order for the pharmacy to provide additional medication or approve use from the facility's backup supply. The DON stated that it was expected for staff to reorder the medication before it ran out, but could not explain why this was not done. As a result, the resident did not receive pain medication as ordered by the physician.
Failure to Accurately Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess and monitor pressure ulcers for a resident with multiple medical conditions, including severe cognitive impairment, COPD, dementia, and a history of falls. The resident was admitted with significant risk factors for skin breakdown and was documented to have pressure injuries on the left gluteus and coccyx. Multiple Skin and Wound Evaluation forms were completed over several weeks, but the documentation was inconsistent and inaccurate. Wound measurements were sometimes combined for separate wounds, and at times, the assessments did not match the photographic evidence, with some wounds not being individually measured or properly classified. Interviews with the wound nurse revealed a lack of clarity and understanding regarding the documentation and assessment process. The wound nurse was unable to explain why wounds were recorded as a single injury when photographs showed two distinct wounds, or why some wounds were not measured separately. Additionally, the wound nurse could not account for discrepancies between the documented wound locations and the actual wounds observed in photographs. The plan of care for the resident was also found to be inaccurate, as it did not reflect the presence of both pressure ulcers or indicate when a wound had healed. The Director of Nursing confirmed that the wound assessments and the resident's plan of care were not completed accurately. Observations of wound care revealed that only the coccyx wound was present and treated, while the left gluteal area was intact. The documentation, however, did not consistently reflect these findings, and the plan of care was not updated to accurately represent the resident's current wound status.
Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to effectively clean and maintain its physical plant, affecting 91 residents. During an environmental tour of the facility's laundry service, it was observed that the clean laundry room had a leaking hand wash sink cold water supply valve and soiled overhead light assembly lens covers. In the soiled laundry room, transport carts were found to be etched and scored, creating non-cleanable surfaces. Additionally, the common areas, including the nurses' station and staff restrooms, were noted to have accumulated dust and dirt deposits, and several light assemblies were non-functional. In various units, multiple deficiencies were observed, including stained ceiling tiles, loose commode supports, and non-functional resident call systems. The nursing supply closets had bare and unsealed shelving units, and the emergency water supply closet was in disarray with soiled containers. Resident rooms across different units had non-functional light assemblies, missing pull string extensions, and damaged drywall surfaces. The commode base caulking in many restrooms was etched and scored, and several hand sink basins were draining slowly. The facility's policies and procedures for cleaning schedules and preventative maintenance were reviewed, revealing that routine cleaning and maintenance were not performed according to the predetermined schedule. The Direct Supply TELS work orders for the last 60 days showed no specific entries related to the maintenance concerns identified during the survey. This lack of adherence to cleaning and maintenance protocols increased the likelihood of cross-contamination and bacterial harborage, posing a risk to the safety and comfort of residents, staff, and the public.
Plan Of Correction
Element #1 Clean Laundry Room: Hand wash sink leak was fixed. Overhead light assembly clear plastic protective lens covers cleaned. Soiled Laundry: 6 new laundry transport carts were ordered. Nurses station: 6 new chairs were ordered. Staff Restroom: return-air-exhaust cleaned Shower Room (A): wand assembly corrected light assemblies functioning, hand sink basin re-secured. Call light system corrected. Nursing Supply Closets ALL now have painted, sealed shelves. Stained ceiling tiles replaced. Womens Locker Room: sink drain repaired, cove base reinstalled, Emergency Water Supply area cleaned with new shelving purchased. Staff Breakroom was cleaned including the toaster and refrigerator freezer unit. A11 - The restroom overhead light assembly was fixed. The restroom commode base perimeter was also cleaned and caulked. B1 - The restroom over sink light assembly was fixed. The restroom commode base perimeter caulking was redone. The interior and exterior commode base surfaces were cleaned. The window ledge drywall surface was repaired. The floor mounted heating grill assembly was replaced. B7 - The commode base caulking was redone. B9 - The floor mounted heating grill plate was replaced. C2 - Commode base caulking was repaired. The restroom sink was unclogged and is draining normally. C3 - The Bed 1 over bed light assembly pull string was replaced. The Bed 2 floor mounted anti-skid strips were replaced. The restroom over sink light assembly corrected and is functioning. The restroom commode base caulking was replaced. The restroom bathtub interior surface and perimeter surround was cleaned. The Bed 1 over bed light assembly pull string was added. C6 - The Bed 2 over bed light assembly pull string extension was replaced. The restroom overhead light assembly was also fixed. The restroom commode base caulking was redone. The restroom commode base seat was replaced. C-7 - The restroom commode base caulking was repaired. The restroom over sink light assembly was also corrected. The restroom overhead light assembly protective lens cover was cleaned and replaced. The Bed 2 drywall surface was further observed (etched, scored, particulate), adjacent to the footboard. The damaged drywall surface measured approximately 4-feet-wide by 4-feet-long. C9 - The restroom commode base caulking was redone. The restroom overhead light assembly was also corrected. C-10 - The restroom commode base caulking redone. The restroom hand sink basin was unclogged and is draining normally. The restroom perimeter wall/flooring coving strip was reinstalled and is no longer loose. D2 - The restroom commode base caulking was redone. The restroom over sink light assembly was also corrected. The restroom commode support was additionally tightened. D-3 - The restroom commode base caulking was replaced. The restroom overhead light assembly was also corrected. The Bed 2 drywall surface was repaired. D7 - The commode base caulking was replaced. The restroom and sink basin caulking was also replaced. The drywall surface was repaired. D-9 - The restroom commode base caulking was replaced. The restroom commode base was also tightened. The restroom commode support was additionally tightened. The restroom over sink light assembly was repaired. The restroom overhead light assembly lens cover was also cleaned. The Bed 1 over bed light assembly pull string extension was replaced. D-11 - The restroom commode base caulking was repaired. The restroom commode base was also tightened. The restroom commode support was additionally tightened. The restroom over sink light assembly was fixed. The restroom overhead light assembly lens cover cleaned. The Bed 1 over bed light assembly pull string extension was added. D-13 - The Bed 1 over bed light assembly pull string extension was added. The restroom commode base caulking was also replaced. D-17 - The restroom commode base caulking was redone. The restroom overhead light assembly lens cover was cleaned. Element 2 Residents who reside in facility are considered at risk. Facility-wide audit was completed to ensure a safe and sanitary environment is possible for all residents. Findings were entered into TELS and corrected by facility maintenance. Element 3 The Administrator has reviewed the Preventative maintenance policy and cleaning schedules policy and deemed them appropriate. Staff have been educated on the use of the TELS work order system. Staff will utilize TELS daily to submit needed work orders. Element 4 NHA or designee will audit 10 areas each week x4 weeks, then monthly to ensure proper maintenance needs have been met, and surfaces are cleanable. Results will be reviewed monthly by QAPI until substantial compliance achieved. Administrator is responsible for overall compliance.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances were promptly documented, investigated, tracked, and resolved for a resident, resulting in ongoing frustration and unresolved grievances. The resident, a cognitively intact female with diagnoses including hypertension, Guillain-Barre Syndrome with paraplegia, major depression, and anxiety disorder, expressed repeated frustration over the constant yelling of nearby residents. Despite informing staff of her grievances, no changes were made, and the resident was not familiar with the facility's grievance process. Observations and interviews revealed that the resident and her roommate preferred to keep their door closed due to the noise, and the resident resorted to using ear buds to cope with the situation. Certified Nurse Aides (CNAs) working on the hall confirmed that complaints about the yelling were common and reported to the Unit Manager. However, the grievances were not documented or resolved, leading to increased frustration for the resident, who even began yelling back, which was uncharacteristic for her.
Plan Of Correction
Element 1: Resident #52 no longer resides in the facility. Resident #52 concerns were addressed with the Assistant Administrator. A white noise machine was purchased to assist with the noise level in the hall. Follow-up visit was completed, and the resident states the machine has helped. Concern form signed and completed by the Administrator. Element 2: The Administrator/Designee will complete an audit of residents to ensure concerns have been documented on grievance forms. Any new concerns will be documented per the QA policy and addressed. Element 3: The QAPI Committee will review the Quality Assistance Procedure policy and deem it appropriate. The Administrator and Director of Nursing have been educated by Regional Director of Operations on the QA Policy. Staff will be educated on the QA policy/grievance policy to ensure concerns are addressed appropriately. Staff to turn concern forms to the administrator daily. Administrator will follow up with appropriate departments to ensure concerns are addressed. Element 4: Administrator/Designee will complete random weekly audits for 4 weeks and then monthly until substantial compliance is achieved, ensuring concern forms and follow-up are completed. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. The Administrator is responsible for achieving and maintaining compliance.
Inaccurate MDS Assessments for Insulin Administration
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for a resident, resulting in inaccurate documentation. The resident, who was admitted with multiple diagnoses including type 2 diabetes, hypertension, and vascular dementia, had discrepancies in the MDS assessments regarding insulin injections. The MDS with an Assessment Reference Date (ARD) of 02/28/2025 indicated that the resident received one insulin injection during the seven-day look-back period, while the MDS with an ARD of 12/24/2024 indicated seven injections. However, a review of the resident's physician orders showed no record of insulin injections during the entire stay at the facility. The MDS Coordinator, responsible for completing the MDS, confirmed the inaccuracies in the assessments. Despite reviewing the physician orders, the coordinator could not explain why the MDS assessments contained incorrect information about insulin administration. This discrepancy highlights a failure in accurately documenting the resident's medical treatment, which is crucial for ensuring appropriate care and treatment plans.
Plan Of Correction
Element 1: Resident #8 MDS assessment was modified to ensure correct coding of section N of the MDS. Element 2: All current residents with insulin coded on the most recent MDS were reviewed to verify accurate drug class coded, and modifications were made as necessary. Element 3: Regional MDS Coordinator to provide facility MDS coordinator and MDS nurse education on RAI manual Chapter 3, pages N1-N28, for accurate coding of Section N. Facility MDS staff provided with pharmacy reference material to identify proper drug classes of medications. MDS will verify MDS coding of section N to ensure appropriate coding of insulin medication class prior to completion. Element 4: MDS coordinator or designee will audit Section N for accurate insulin coding for 5 residents weekly x4 weeks, and then 5 residents monthly x 3 months. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Administrator is responsible for overall compliance.
Failure to Implement Resident-Centered Care Plan
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered care plan for a resident, resulting in unmet care needs and increased frustration among other residents. The resident, a cognitively intact female with multiple diagnoses including hypertension, heart failure, kidney failure, lung cancer, depression, and anxiety disorder, was observed repeatedly yelling for help from her room without receiving attention from staff. Despite having a care plan that included 1:1 visits and activities to engage her, there was no evidence of these activities being carried out, as the resident was observed in bed without interaction or engagement from staff over several days. Interviews with Certified Nurse Aides (CNAs) revealed that the resident did not get out of bed and that they had never observed staff conducting 1:1 activities with her. The resident's yelling was noted in nurse progress notes as a daily occurrence, causing frustration and sleep disruption for other residents. The Nursing Home Administrator (NHA) acknowledged the lack of documentation in the resident's medical record regarding offered activities, which were only noted on five occasions over a 60-day period. There was also no evidence that the resident had been invited to participate in group activities or taken outside.
Plan Of Correction
Element 1: Resident 7 no longer resides in facility. Element 2: Residents in facility were reviewed to ensure their care plans were implemented appropriately to reflect activities, interests, and preferences. If missing, interests and preferences were added to care plans. Element 3: Education was provided to Activity Director and staff to ensure care plans are implemented timely to include interests. Activities staff will ensure comprehensive care plans are updated upon completing the activities assessment. Element 4: Act dir/designee will audit 10 random residents weekly to ensure activity comprehensive care plan is completed and individualized. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide meaningful, individualized, and engaging activities to a resident, identified as R7, who was cognitively intact and had a history of hypertension, heart failure, kidney failure, depression, and anxiety disorder. Despite having a care plan that included 1:1 visits from staff and volunteers, and a preference for activities such as keeping up with the news, watching TV, coloring, word searches, and reading, there was no evidence of 1:1 activity visits being conducted. Observations revealed that R7 was often found in bed, yelling for help, and no staff were observed entering the room to engage with the resident. The resident's care plan also indicated a risk for altered activity patterns due to anxiety and disinterest, yet the facility did not adhere to the plan. Interviews with Certified Nurse Aides (CNAs) revealed that R7 did not get out of bed and staff were not observed conducting activities with the resident. The CNAs reported that residents on the same hall often complained about yelling, which caused frustration and sleep disruption. The facility's documentation showed that R7 was only offered 1:1 activities on five occasions over a 60-day period, and there was no documentation of R7 being invited to or refusing group activities or outdoor programs. The facility's administrator acknowledged the lack of documentation in the medical record and the failure to follow the resident's care plan.
Plan Of Correction
Element 1: Resident 7 no longer resides in facility. Element 2: Residents in facility were reviewed to ensure their care plans were updated appropriately to reflect interests and preferences. If missing, interests and preferences were added to care plans. Element 3: Education was provided to Activity Director and staff to ensure likes/dislikes are followed, care plans are updated, and a meaningful and diverse calendar was offered. Activities staff will ensure residents get equal opportunity to participate in activities each week. Element 4: Act dir/designee will audit 10 random residents weekly to ensure activity likes and dislikes are in place and care planned. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer for a resident, identified as R81, who was admitted with multiple health issues including a fracture of the left femur, dementia, and nutritional deficiencies. Upon admission, R81 did not have any pressure ulcers, but later developed a stage 3 pressure ulcer on the left gluteal fold. The facility's documentation was inconsistent, as the initial skin assessment did not record the pressure ulcer, and subsequent assessments failed to accurately stage the wound, which was covered with slough tissue and should have been classified as unstageable. The facility's policy required weekly skin assessments and documentation of pressure ulcers, but these were not consistently followed. The Wound Nurse admitted to missing the pressure ulcer in the initial assessment and incorrectly staging the wound. Additionally, the facility's plan of care for R81 included interventions such as the use of pressure redistribution mattresses and regular turning and repositioning, but these were not effectively implemented. Observations revealed that the alternating air mattress was not plugged in, rendering it ineffective, and documentation showed that R81 was not turned every two hours as required, but rather only once per shift or less on several occasions. Interviews with Certified Nursing Aides confirmed the expectation of turning residents every two hours, yet the documentation did not support this practice. The failure to adhere to the care plan and facility policies contributed to the development and progression of R81's pressure ulcer. The lack of consistent and accurate documentation, along with the failure to implement prescribed interventions, highlights significant deficiencies in the facility's care practices for preventing pressure ulcers.
Plan Of Correction
Element 1 Resident #81 was assessed by a licensed nurse to ensure wound assessment was completed to include measurements and correct staging. The APM was assessed to ensure proper function. And resident has been turned and repositioned per care plan. Element 2 Residents in facility with impaired skin integrity are considered at risk. Residents in facility have had a full skin assessment completed. If any new skin areas found, they were measured, and assessed, with appropriate interventions in place. Braden assessments were completed to identify the residents at risk for skin breakdown. The DON/designee to ensure accurate staging of the wound was documented and measurements completed. Any identified concerns were addressed. Care plans were reviewed by IDT for Residents with pressure ulcer or at risk for developing to ensure interventions were in place including turning and repositioning to promote healing. Element 3 The Administrator and DON have reviewed using the NPUAP Guidelines for Pressure Injury Staging, Pressure injury prevention and Management and Pressure Injury Prevention Guidelines Policies and deemed them appropriate. Wound Nurse will receive education from the DON/Designee on staging and the documentation required for a pressure ulcer using the NPUAP Guidelines for Pressure Injury Staging. This education also includes who to contact if assistance is needed. Licensed nurses will receive education on Pressure Ulcer/Skin Breakdown Clinical Protocol including who to notify if a new area is observed or a change in injury is noted, also educated on documenting nutritional supplement intake. Clinical staff including Nurses Aides will be educated on Pressure Ulcer Prevention and Management including where to find the turn and reposition schedule in the kardex for each resident, as well as ensuring interventions are in place. Daily (Monday-Friday) during the morning clinical meeting, all new admissions and clinical alerts will be reviewed to identify any new skin conditions. New admissions and residents with pressure ulcers will be observed weekly during wound rounds to ensure that the staging of the wound remains accurate. Changes in the pressure ulcer will be reported to the provider for further recommendations as needed. Element 4 DON/Designee will audit 10 residents with pressure ulcers or with a decreased Braden score per week ensuring care plan is appropriate and being implemented, wound notes, and provider notes accurately reflect the status of the pressure injury weekly for 4 weeks and then monthly to ensure that interventions are in place and appropriate for resident. Results will be reviewed monthly by the QAPI Committee. The Administrator is responsible to maintain compliance.
Deficiency in Tracheostomy Care Documentation
Penalty
Summary
The facility failed to adhere to professional standards for tracheostomy care by not ensuring physician orders included the size of the tracheostomy cannulas for two residents. Resident #87, who had a tracheostomy due to respiratory failure and other medical conditions, did not have physician orders specifying the size of the inner and outer cannula. During an observation, it was noted that the resident's tracheostomy was clean, but the absence of specific orders was confirmed by the Unit Manager, who could not explain the oversight. The Regional Respiratory Therapist emphasized that it is a professional standard to have such orders, including the manufacturer's details, as sizes may vary. Similarly, Resident #38, who also had a tracheostomy, did not have the size of the tracheostomy specified in the physician orders. The resident reported inconsistent tracheostomy care, and during an observation, an LPN replaced the inner cannula with a size 6 Shiley, knowing the size from familiarity rather than documented orders. The Clinical Regional Consultant confirmed that the size should be part of the physician orders and acknowledged that changes were being made to clarify the orders for this resident.
Plan Of Correction
Element 1: Resident #38 and 87 physician orders reviewed and updated to reflect correct trach orders, including sizing. Element 2: Residents with trachs are like residents. No other residents in the facility have a trach. Element 3: The Trach Policy has been reviewed by the NHA and DON and deemed appropriate. The facility-licensed nursing staff have been re-educated on the Trach care policy, and appropriate orders are required. During daily clinical stand-up, nurse managers will ensure orders are in place for Trach. Element 4: Residents who have a Trach will have their orders reviewed weekly for 4 weeks to ensure the orders are correct and match the trach currently being used for each resident. Audits will then be completed monthly for 3 months, or until substantial compliance is obtained or discontinued by the QAPI team. Results will be reviewed monthly by the QAPI Committee. The Administrator is responsible for maintaining compliance.
Failure to Address Resident's Psychosocial Distress Due to Environmental Noise
Penalty
Summary
The facility failed to adequately assess and address a resident's expressions of distress, leading to decreased social interaction and increased withdrawn, angry, and depressive behaviors. The resident, a cognitively intact female with a history of major depression and anxiety disorder, expressed frustration due to the constant yelling of other residents in her hall. Despite reporting these frustrations to staff, no effective measures were taken to alleviate the situation, resulting in the resident's increased distress and uncharacteristic behavior. Observations revealed that the resident preferred to keep her door closed and use ear buds to block out the noise, yet she continued to experience frustration and anxiety. The facility's psychiatric consults noted the resident's sleep disturbances and recommended non-pharmaceutical interventions, but these were not effectively implemented. The resident's mood assessments were incomplete, further indicating a lack of comprehensive evaluation and intervention by the facility. Interviews with staff confirmed that the issue of residents yelling was well-known, yet no grievance forms were completed, and the problem persisted. The facility's decision to place several residents who frequently yelled in the same area exacerbated the situation, affecting the resident's mental well-being. The Social Service Director acknowledged the resident's recent behavioral changes, which were uncharacteristic and linked to the ongoing disturbances.
Plan Of Correction
Element 1: Resident 52 no longer resides in facility. Element 2: Residents on C hall with a Brief Interview of Mental Status of 9 or greater had a Patient Health Questionnaire-9 completed to ensure residents have had no expressions of distress, developed decreased social interaction, increased withdrawal, anger, and depressive behaviors. Any changes in Patient Health Questionnaire-9 have had referrals made to psychology services. Element 3: CNAs and Nurses were re-educated on proper documentation of behaviors including depression, agitation, withdrawal, distress, anger, etc. Interdisciplinary Team will review clinical documentation M-F to ensure any changes in behaviors are followed up on. Element 4: The Administrator will complete an audit reviewing 6 residents per week to evaluate Patient Health Questionnaire-9 scores and ensure appropriate interventions are in place if eligible. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. Any instances of noncompliance that are identified will be addressed per company policy concerning education and disciplinary action when necessary. The Administrator is responsible for achieving and sustaining compliance.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a fall protection mat was placed at the bedside of a resident, as specified in the care plan, to prevent injury from falls. The resident, who was admitted with diagnoses including pneumonia, emphysema, paroxysmal atrial fibrillation, and arthropathy, was identified as a high fall risk upon admission. The care plan, updated shortly after admission, included interventions such as educating the resident on safety, encouraging the use of a call light, and ensuring a fall protection mat was placed on the floor next to the bed. However, on the morning of February 7, the resident was found on the floor with injuries, and it was noted that the fall protection mat was not in place. Interviews with staff revealed that the resident had the ability to move independently but was unsteady and unsafe without assistance. The Director of Nursing confirmed the care plan's requirement for a fall protection mat, and a Licensed Practical Nurse admitted that the mat was not present at the time of the fall. The incident resulted in the resident sustaining bleeding from the head and leg, as well as several skin tears. The absence of the fall protection mat, as required by the care plan, directly contributed to the resident's fall and subsequent injuries.
Controlled Medication Discrepancy for Resident
Penalty
Summary
The facility failed to ensure an accurate account of controlled medications for a resident diagnosed with dementia and major depressive disorder. The resident was prescribed ABHR Cream, a controlled drug, to be applied topically every 12 hours as needed. A review of the Control Substance Record revealed discrepancies in the medication count. Initially, 30 grams of ABH gel were received, and the first dose was signed out on 1/23/25, with a remaining count of 28 mL instead of the expected 29 mL. Subsequent records showed further discrepancies, with the count on 2/1/25 being 24 mL when it should have been 27 mL. There was no documentation explaining these discrepancies. Interviews conducted during the investigation revealed that the Director of Nursing (DON) could not account for the discrepancies and suggested that air in the medication container might have contributed to the issue. However, a pharmacy technician confirmed that the facility received 30 mL of ABH cream and that each click of the dispenser equaled 0.25 mL, requiring four clicks for a 1 mL dose. The pharmacy technician also stated that air in the bottle would not cause a discrepancy in the medication count. The facility did not have any ABHR gel/cream available at the time of the investigation.
Plan Of Correction
Element 1: Resident 17 controlled substance sheets were reviewed by the Director of Nursing. There are no inaccurate counts on current controlled medications. Element 2: A one-time audit was completed by the clinical team of active controlled substance orders to ensure accurate counts. No inaccurate counts were found during this audit. Element 3: The Director of Nursing was re-educated on medication administration and accurate counts for controlled substances by the Regional Director of Clinical Services. Licensed nurses have been re-educated on ensuring accurate counts when administering and documenting controlled substances. At shift change, nurses will review counts, and if any inaccuracy is noted, the DON or designee will be notified. A daily review, Monday through Friday, will be completed by nurse managers to ensure controlled substance use sheets are accurate. The QAPI Committee reviewed the policy, "Medication Administration," and deemed it appropriate. Element 4: An audit will be completed weekly for four weeks, then monthly, of nine residents with controlled substance orders to ensure accurate counts. Audit findings will be presented to the facility QAPI Committee and will only be discontinued with substantial compliance and with approval of the facility QAPI Committee. The Administrator is responsible for achieving and sustaining compliance.
Failure to Respect Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor residents' rights to be treated with respect and dignity, as evidenced by staff members entering resident rooms without knocking on multiple occasions. This was observed on three separate instances on January 8, 2025, where staff entered rooms without knocking. Additionally, a resident, identified as Resident 13, was observed in the dining room without a lunch meal, and a CNA referred to the resident as 'whatever, whatever' when requesting a meal tray, which the resident found disrespectful. The resident, who was new to the facility, expressed feeling disrespected by the comment but chose to ignore it. Another instance of a staff member entering a resident's room without knocking was observed on January 9, 2025.
Delay in X-ray Completion for Resident
Penalty
Summary
The facility failed to obtain a timely x-ray for a resident, leading to a delay in care. The resident, who was admitted with hemiplegia and hemiparalysis following a stroke, reported pain and swelling in the left hand. Despite a physician's order for an x-ray on October 1, 2024, the x-ray was not completed until October 12, 2024. The resident expressed that the pain was severe, initially rated as 10 out of 10, and later as 6 out of 10, with no improvement over time. Interviews with facility staff revealed that the delay was due to an issue with the imaging company and a miscommunication regarding the order. The Licensed Practical Nurse acknowledged the delay, stating that x-rays should typically be completed within a day or two. The Director of Nursing indicated that the order was incorrectly entered by the physician, contributing to the delay. This deficiency highlights a lapse in the facility's process for ensuring timely diagnostic testing for residents.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) for a resident who was a full code, resulting in Immediate Jeopardy. The resident, identified as R200, was found unresponsive with no pulse or respirations. Despite being a full code, CPR efforts were not initiated by the facility staff at the time the resident was discovered. Instead, the staff checked the code status and called 911, but did not begin CPR until Emergency Medical Services (EMS) arrived. The incident involved Licensed Practical Nurse (LPN) M, who was notified by a Certified Nurse Assistant (CNA) that the resident was not breathing. LPN M documented that upon finding the resident unresponsive, she checked the code status and called 911, but did not start CPR. LPN D, another nurse, confirmed that CPR was not in progress before EMS arrived and noted that LPN M was not actively participating in the resuscitation efforts. The delay in initiating CPR was estimated to be about 5 to 10 minutes from the time the resident was found unresponsive to the arrival of EMS. The resident, R200, had a history of Obstructive Sleep Apnea and Morbid Obesity, and was cognitively intact according to the Minimum Data Set (MDS). The facility's policy required staff to provide basic life support, including CPR, prior to the arrival of emergency medical services, but this was not followed. The failure to initiate CPR immediately upon finding the resident unresponsive was a significant deviation from the facility's policy and contributed to the adverse outcome.
Removal Plan
- Documentation of the amount of residents at risk.
- The facility identified CPR was not initiated immediately.
- The Director of Nursing and/or designee began education of facility staff on initiating CPR immediately to include: checking of code status utilizing the electronic medical record on the laptop or kiosk or utilizing the paper chart; the timeline and steps for assessing pulse and respirations when a resident is found unresponsive and initiating CPR immediately to include placing on floor if needed. Initiating CPR includes checking airway, breathing, circulation and beginning compressions while someone verifies the code status and 911 is called. Identify a team leader to assign duties and scribe. Ensure crash cart is with patient and AED is applied. Compressions will continue until EMS arrives and verbalizes they will take over.
- The facility has 26 Licensed Nurses. The facility has educated 25 of the 26 Licensed Nurses.
- Any staff not educated will not be permitted to work a shift until education has been completed.
- The facility Medical Director was notified.
- The Director of Nursing and/or designee completed a chart audit on 85 charts and verified the advanced directives to the physician order for accuracy.
- An audit was completed of Licensed Nurses to ensure CPR certifications were up to date. The identified nurse was recertified.
- The QAPI committee has reviewed the Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) policy and has deemed them appropriate.
- The facility had an Adhoc QAPI meeting including the Medical Director and deemed this removal plan appropriate.
- The Director of Nursing is responsible for continued compliance.
Failure to Develop Comprehensive Care Plan for Resident with Pica Behavior
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R201, who had a history of swallowing non-food items. This deficiency was identified during a survey where it was noted that the care plan did not include specific interventions to prevent the resident from picking up and swallowing non-food items. The resident, who had severe cognitive impairment and diagnoses including unspecified intellectual disabilities, generalized anxiety disorder, and schizophrenia, had previously been hospitalized twice for ingesting non-food items, including quarters and AAA batteries. The care plan for R201, dated 10/17/24 and updated on 10/30/24, addressed the behavior of swallowing non-food items but only included interventions such as approaching the resident in a calm manner, communicating with him, and observing his mental status and situational stressors. However, it lacked specific safeguards against the behavior of picking up and swallowing non-food items. This omission was discussed with the Nursing Home Administrator, Director of Nursing, and Regional Nurse Consultant, who acknowledged the lack of specific interventions in the care plan.
Failure to Conduct Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to provide ongoing clinical assessments, specifically neurological assessments, for a resident who was reviewed for such assessments. The resident, who had diagnoses of cerebral atherosclerosis, legal blindness, and dementia, experienced a fall that resulted in redness and a red mark on the forehead. Despite this incident, there was a lack of documented neurological assessments in the progress notes following the fall. The facility's Director of Nursing (DON) acknowledged that the neurological assessment portion of the fall follow-up forms required manual entry each time, yet the forms contained outdated vital signs from previous days, indicating a lack of current assessments. The facility did not have a specific neurological assessment policy, relying instead on a general fall policy. This policy stated that residents who have fallen and were suspected to have hit their head should have neuro checks per medical order or protocol. However, the facility's documentation did not reflect adherence to this protocol, as there were no detailed neurological assessments recorded after the fall. The DON believed that the standard of care was followed, stating that neuro checks were done daily, but the lack of documentation and the reliance on outdated vital signs raised concerns about the thoroughness of the assessments conducted.
Failure to Reassess Respiratory Status Leads to Resident's Death
Penalty
Summary
The facility failed to reassess the respiratory status of a resident, identified as R200, who had a history of Obstructive Sleep Apnea and Morbid Obesity. Upon admission, it was noted that the resident had been using a CPAP machine during sleep in the hospital, but there was no documentation of CPAP use during the facility stay. An incident occurred where the resident was found in a supine position, appearing hypoxic and cyanotic, prompting an LPN to administer oxygen and elevate the head of the bed, which improved the resident's oxygenation. However, there was a lack of follow-up documentation or reassessment of the resident's respiratory status after this episode. Later, the resident was found unresponsive and was pronounced dead after CPR efforts. Interviews with facility staff revealed uncertainty about the timeline of events and a lack of documentation regarding the resident's respiratory assessments. The Director of Nursing acknowledged that follow-up assessments should have been conducted after the initial hypoxic episode, and the absence of documentation suggested that assessments may not have been performed. The facility did not provide additional information regarding the CPAP use prior to the end of the survey.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice prior to room changes for four residents, which is a violation of the residents' rights. Resident #2, who was admitted with dementia and anxiety disorder, experienced a room change due to a payor source change from Medicare to Medicaid on 8/21/24, without any written notice provided to the responsible party. Similarly, Resident #5, admitted with a cerebral infarction, had a room change on 10/14/24 for the same reason, again without written notice. Resident #6, with acute posthemorrhagic anemia and COPD, underwent room changes on 9/12/24 and 10/8/24. Although discussions were held with the family regarding room rates and Medicaid coverage, no written notice was documented. Resident #11, with diabetes, bipolar disorder, and major depressive disorder, had room changes on 6/28/24 and 8/12/24, and reported not being informed in advance. The Nursing Home Administrator confirmed that these changes were related to transitions from Medicare to Medicaid rooms, yet no written notices were provided.
Facility Fails to Maintain Cleanliness and Repair in Resident Bathrooms
Penalty
Summary
The facility failed to maintain cleanliness and repair in resident bathrooms, as observed during a survey. On multiple occasions, the bathroom shared by three residents was found with dried feces on the toilet seat riser and in the toilet bowl. This unsanitary condition persisted over two days, indicating a lack of timely cleaning and maintenance. Additionally, another bathroom was observed with a bent and rusted metal vent/register on the floor, further highlighting the facility's failure to maintain a clean and safe environment. Structural issues were also noted in several bathrooms. One bathroom had a section of wall molding peeled away, exposing a cracked and crumbling wall. Another bathroom had metal door frames with sections worn away, revealing a black interior. Additionally, molding was seen hanging off the wall behind the toilet in another bathroom. The Maintenance Manager was unaware of these issues, as they were not included in the work orders submitted through the TELS system, which the facility relies on for communication of maintenance needs. The facility's preventive maintenance program, as outlined in their policy, was not effectively implemented to ensure a safe and sanitary environment.
Deficiencies in Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical record documentation for two residents, leading to deficiencies in care and services provided. For Resident #1, the electronic medical record indicated a signed Do Not Resuscitate (DNR) order and an Advanced Directive. Despite this, when the resident was found not breathing, a code was called, and CPR was initiated. The Registered Nurse involved did not document the code event or the subsequent discovery of the DNR status, resulting in a lack of documentation regarding the resident's change in condition and the actions taken. For Resident #3, the facility failed to document the resident's transfer to the hospital adequately. The progress notes lacked details about the resident's condition at the time of transfer, vital signs, and the time of departure. The nurse responsible for the resident's care did not document the transfer or complete the necessary forms, such as the SBAR change in condition form and the Transfer V2 form. This omission resulted in incomplete records regarding the resident's transfer and condition.
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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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