Medilodge Of Munising
Inspection history, citations, penalties and survey trends for this long-term care facility in Munising, Michigan.
- Location
- 300 West City Park Drive, Munising, Michigan 49862
- CMS Provider Number
- 235410
- Inspections on file
- 32
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Medilodge Of Munising during CMS and state inspections, most recent first.
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 who was fully dependent on staff for transfers suffered bruising and a toe injury when staff used an incorrectly sized sling and mechanical lift, contrary to the care plan. Staff were unable to identify the correct sling size, and the storage area lacked clear instructions, resulting in the use of a sling that was too small and caused significant discomfort and injury.
Two residents were admitted without timely transcription and receipt of physician orders for essential medications and treatments. One resident with severe cognitive impairment and glaucoma did not receive prescribed ophthalmic medications for nearly two weeks, while another with respiratory failure and COPD did not have a physician order for supplemental oxygen despite low oxygen saturation and documented need. Facility leadership confirmed the absence of required orders at admission.
A resident dependent on staff for personal care did not receive required assistance with denture use and timely incontinence care. The resident's dentures were found improperly stored and covered in mold, and the resident was left in a urine-soaked brief and clothing for several hours without regular checks, contrary to care plan and facility policy. Staff were unable to account for the dentures' whereabouts and did not document incontinence checks unless a change was made.
A resident with severe visual and hearing loss, cognitive impairment, and dependence on staff was left without meaningful engagement or appropriate activities, despite care plan interventions. Observations showed the resident was left alone for long periods, positioned away from sources of stimulation, and staff did not interact with her during care. Documentation of activities was unclear, and the resident's preferences were not addressed, resulting in social isolation.
Two residents with complex wounds did not receive physician-ordered wound care on multiple occasions, as documented in the TAR. Nursing staff and the DON confirmed that wound treatments were missed, despite facility policy requiring adherence to physician orders for wound management.
Several residents with conditions such as diabetes and peripheral vascular disease were found to have thick, long, and curled toenails that had not been trimmed for an extended period, resulting in pain and difficulty wearing shoes. CNAs confirmed the lack of recent nail care, and staff interviews revealed that only residents with certain insurance received podiatry services, leaving others without necessary foot care. The facility's policy for regular nail assessment and trimming was not followed, and nail care was not consistently provided on shower days as required.
A facility failed to securely store medications, as an insulin pen was left on a cognitively impaired resident's bedside table, and a treatment cart was found unlocked with prescription items accessible. An LPN admitted the oversight, and the facility's policy requires medications to be stored in locked compartments.
The facility failed to maintain and sanitize resident equipment, leading to an increased risk of infection spread. Observations showed multiple wheelchairs and hoyer lifts were heavily soiled, with damaged components and inadequate cleaning. Staff interviews revealed a lack of adherence to cleaning protocols, despite the facility's policy requiring regular cleaning and disinfection to prevent pathogen transmission.
A resident was involuntarily discharged from an LTC facility without proper preparation or documentation, leading to homelessness. The resident, who was on a pre-approved vacation, was informed he could not return due to unpaid bills. The facility failed to follow its discharge policy, resulting in the resident being unable to re-enter the facility and eventually becoming homeless.
A resident with severe cognitive impairment and type 2 diabetes had numerous expired food items in their personal mini-fridge, including yogurt, cheese, and sausage with mold. Interviews with staff revealed confusion over who was responsible for monitoring the food, and the facility's policy on refrigerator maintenance was not followed, as no temperature log was present. This oversight posed a risk of foodborne illness.
A resident admitted for osteomyelitis treatment did not receive prescribed IV antibiotics for several days due to transcription errors at the LTC facility. The resident's condition worsened, leading to hospitalization. Staff interviews revealed missed orders due to unfamiliar discharge paperwork.
The facility failed to prevent and manage pressure ulcers for three residents, leading to severe outcomes. A resident with cognitive impairment developed a heel ulcer that deteriorated due to inadequate documentation and intervention, resulting in amputation. Another resident's wound vac was frequently turned off, worsening a stage four ulcer. A third resident developed a stage three ulcer due to improper repositioning and support.
A resident with cognitive impairment and a history of falls suffered a major injury due to inadequate supervision, as staff were spread thin and left the resident unattended. Another resident with a history of smoking and falls was observed smoking unsupervised, contrary to the care plan and facility policy requiring supervision. Staff confirmed ongoing issues with low staffing levels and inadequate supervision.
The facility failed to provide adequate staffing, resulting in unmet care needs and safety concerns for all 65 residents. A resident reported long wait times for toileting assistance, leading to incontinence, and often receiving bed baths instead of showers. Another resident expressed difficulty in receiving showers, while a third resident reported not being repositioned as required, leading to discomfort. Additionally, a resident with moderate cognitive impairment experienced an unwitnessed fall due to insufficient supervision. Staff confirmed the ongoing issue of low staffing levels.
The facility failed to adhere to food safety standards, with cold foods like potato salad and cottage cheese held at improper temperatures, and a lack of proper labeling and monitoring in nourishment rooms. Additionally, roast beef was not reheated to the required temperature, and a cross-connection issue with the ice machine's drain line was identified, posing potential contamination risks.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with an indwelling catheter, despite multiple observations noting the absence of EBP outside the resident's room. The resident, admitted with several medical conditions including cellulitis and lymphedema, did not have EBP included in her care plan, putting her at risk for MDRO infection over a six-day period.
The facility failed to ensure resident privacy and dignity by not knocking or waiting for permission before entering rooms. Multiple residents reported staff entering without proper acknowledgment, causing embarrassment and lack of privacy. Observations confirmed staff entering rooms without knocking, violating the facility's policy on resident dignity.
The facility failed to provide written notifications for hospital transfers for four residents, as required by policy. Residents were transferred due to various medical conditions, including unresponsiveness, sepsis, a deteriorating wound, and a fall with injury. Interviews revealed that the interim social worker was not sending the required notifications, and the Nursing Home Administrator was unaware of this oversight.
The facility failed to provide written bed-hold notifications to residents or their representatives before hospital transfers, affecting five residents. Interviews and record reviews revealed missing documentation in clinical records, and the Nursing Home Administrator confirmed the oversight. The facility's policy requires written information on bed-hold duration and conditions for readmission to be given prior to transfers.
The facility failed to destroy discontinued schedule two medications in a timely manner and improperly used another resident's medication. A resident had another's acetic acid solution used for wound care, and expired lorazepam orders were not removed from medication carts, violating facility policies.
The facility failed to ensure dementia training was completed by four CNAs as required by annual training requirements. A review of training logs showed that the course 'Dementia Care: Normal Aging vs. Alzheimer's/Dementia' was incomplete for three CNAs and not listed for one. The ADON was unaware of the course and assumed dementia training was included in 'Challenging Behaviors,' which did not cover dementia care. This deficiency could potentially affect all residents with dementia in the facility.
A resident with multiple medical conditions reported verbal abuse by a nurse, who suggested the resident should end his life. The nurse had a history of inappropriate communication, and despite previous warnings, continued to work at the facility. This resulted in mental distress for the resident.
The facility failed to report alleged abuse timely for two residents, leading to potential ongoing abuse. A cognitively intact resident reported an inappropriate comment by a nurse, which was acknowledged as abuse by an LPN but not reported immediately. Another resident experienced alleged abuse when a nurse spoke harshly after multiple falls, which was not reported until later. Both incidents were reported to the State Agency days after occurring, violating the facility's policy on timely reporting.
The facility failed to assess the clinical need for urinary catheterization for two residents, leading to potentially unnecessary catheter usage. One resident had a catheter placed post-surgery without a documented diagnosis of urinary retention, and a requested urology referral was not made. Another resident was admitted with a catheter, but their care plan did not reflect its presence or care instructions. The facility lacked a policy for evaluating catheter necessity, contributing to the deficiency.
The facility failed to monitor weight fluctuations for two residents, one with multiple diagnoses including diabetes and heart failure, and another with protein-calorie malnutrition and dysphagia. Significant weight changes were not documented, and weights were not obtained upon readmission after hospitalizations, contrary to the facility's policy requiring weekly monitoring for new admissions and weight loss cases.
The facility failed to obtain informed consent and physician orders for psychotropic medication, leading to unauthorized administration of lorazepam to two residents. Additionally, a resident did not receive timely gradual dose reduction (GDR) for psychotropic medications despite recommendations, due to a breakdown in communication between the behavioral health provider and facility physician.
The facility failed to effectively implement its QAPI program, as the NHA could not explain the process for identifying, analyzing, correcting, or monitoring medical errors or adverse events. Despite monthly QAPI meetings and a policy requiring systematic data collection and investigation, the NHA relied on emails from the regional clinical nurse and DON for information, indicating a lack of understanding and execution of the QAPI process.
A resident was given a laxative without proper assessment, despite having regular bowel movements, leading to diarrhea and incontinence. The nurse responsible did not document the administration on the MAR, and the facility's PRN medication policy was not followed.
A resident with multiple health issues, including hemiplegia and dementia, received only one shower during a 17-day stay, despite requiring moderate assistance and the facility's policy of twice-weekly showers. The care plan lacked interventions for showering, and the DON could not explain the deficiency.
A resident with a stage 4 pressure injury did not receive proper care due to the facility's failure to transcribe hospital discharge orders and follow wound clinic recommendations. The resident's wound, which developed at the facility and led to hospitalization for sepsis, was not treated as instructed upon their return. The wound clinic's recommendation to reapply a wound VAC was not followed, and the attending physician was not informed, resulting in a lack of appropriate wound care.
The facility failed to provide adequate staffing, resulting in unmet care needs for residents. A resident with intact cognition reported urinating in bed due to delayed assistance, while another experienced long wait times for help. A resident with severe cognitive impairment was found soaked in urine. CNAs reported being overwhelmed and unable to provide necessary care. Staffing records showed insufficient CNA numbers, and the facility's policies lacked clarity on required staffing levels.
The facility failed to post daily nurse staffing information, as required, impacting transparency about staff availability for resident care. The NHA could not locate the staffing posting, and missing information was noted for several dates. The DON confirmed that the information should be posted daily near the entrance.
The facility failed to provide adequate PPE and ensure its proper use in rooms under Transmission-Based Precautions for COVID-19. Staff, including an LPN and SSD, were observed entering these rooms without the required PPE. Interviews revealed a shortage of PPE supplies, with staff having to search for masks and other protective gear. Observations confirmed that PPE carts were inadequately stocked, lacking essential items such as gowns, N95 masks, and face shields.
The facility failed to investigate the root cause of falls for three residents with severe cognitive impairments, resulting in injuries such as fractures and lacerations. The DON did not complete root cause analyses or update care plans with necessary interventions, despite the facility's policy requiring such actions.
A resident with multiple health conditions, including legal blindness, experienced an incident where another resident yelled and cursed at him. Although initially addressed, there was no follow-up or care plan update by the Social Services Designee to address the incident's impact on the resident's well-being. This failure to provide adequate social services led to a deficiency citation.
A resident with multiple diagnoses experienced uncontrollable shaking and sought help from an LPN, who refused assistance, dismissing it as attention-seeking behavior. A CNA witnessed the event and comforted the resident. The DON confirmed the LPN did not assess the resident, and no documentation was made regarding the incident.
The facility failed to prevent and manage pressure ulcers for two residents, leading to severe deterioration and medical complications. The facility did not consistently follow wound care orders, document dressing changes, or implement timely interventions, resulting in worsened conditions and additional medical treatments.
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 Use Correct Sling and Lift During Transfer Causes Resident Injury
Penalty
Summary
The facility failed to ensure the use of an appropriately sized sling and mechanical lift during resident transfers, resulting in injury to a resident who was totally dependent on staff for all transfers. During an observed transfer, staff used a blue sling with green binding, presumed to be a large size, with a [Name Brand] 450 mechanical lift, despite the resident's care plan specifying the use of an XXL blue or black sling with a [Name Brand] 600 lift. The sling used was too small, causing the resident's abdominal area to extend out the sides and exerting significant pressure on her back, arms, and legs. Staff were unable to confirm the correct sling size, and the sling's labels were missing or illegible. The resident expressed discomfort and reported that the incorrect equipment pinched her during transfers. The resident had a complex medical history, including debility, cardiorespiratory conditions, heart failure, peripheral vascular disease, anxiety, PTSD, COPD, and morbid obesity. She was also at risk for abnormal bleeding due to anticoagulant and aspirin therapy. Multiple progress notes and incident reports documented deep purple bruises on her arms and legs, which matched the shape of the sling, as well as a skin tear on her right second toe sustained when a CNA bumped her toe on a door frame during a shower transfer. The care plan had been updated previously to specify the correct sling and lift, but staff failed to follow these interventions, and there was no clear system in place for identifying or selecting the correct sling size in the storage area. Interviews with staff and review of facility policies revealed a lack of knowledge and adherence to the resident's care plan and safe lifting procedures. Staff were unsure of the correct sling size, and the storage area lacked instructions for assessing sling size. The facility's policy required ongoing assessment of residents' transfer needs and availability of appropriately sized slings, but these requirements were not met. The deficiency resulted in harm to the resident, including bruising, an injured toe, and discomfort during transfers.
Failure to Obtain and Transcribe Physician Orders for Immediate Care on Admission
Penalty
Summary
The facility failed to ensure the timely receipt and transcription of physician orders for immediate care upon admission for two residents. For one resident with Alzheimer's disease and visual loss, there was a 12-day delay in obtaining and administering prescribed ophthalmic medications, including Timolol-Dorzolamide-Latanoprost and Latanoprost, which were documented as necessary for the resident's glaucoma and visual loss. Despite the medications being listed in the pre-admission physician note and the family inquiring about them, the orders were not transcribed or administered until nearly two weeks after admission. Progress notes indicate that staff were aware of the need for these medications and communicated with the resident's ophthalmologist, but the actual orders and administration were delayed. Another resident with acute and chronic respiratory failure, pneumonia, and COPD was admitted without a physician order for supplemental oxygen, despite having a care plan intervention for oxygen and being observed with low oxygen saturation levels. The resident was seen in the dining room without oxygen, and staff later provided an oxygen tank holder and tubing after observing low oxygen saturation readings. However, review of the medical record confirmed that no physician order for oxygen was present from admission through the time of the survey, even though oxygen was administered when low saturation was detected. Interviews with facility leadership confirmed that the required physician orders for both medications and oxygen were not present or transcribed at the time of admission for these residents. The facility's own policy requires documentation and verification of physician orders for care and treatment, but this process was not followed, resulting in a lack of necessary medications and treatments for the affected residents.
Failure to Provide Timely Denture and Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Alzheimer's disease, non-Alzheimer's dementia, depression, visual and hearing loss, and dependence on staff for personal care did not receive proper denture and incontinence care. The resident's care plan required staff to encourage and assist with denture use and to provide regular incontinence checks and changes. However, the resident's dentures were found by a complainant in a cup on a discolored paper towel, covered in what appeared to be white mold, and not in the resident's mouth as required. Staff were unable to locate the dentures in the resident's room and later found them in the Staff Development Coordinator's office, with no explanation for their placement there. Observations revealed that the resident was left sitting in a wheelchair and later in a recliner for extended periods without incontinence checks or changes. Staff did not interact with the resident during these periods, and no incontinence care was provided between 10:15 a.m. and 4:15 p.m., despite the facility's policy of checks every two hours. When finally checked, the resident was found to be wet with urine, and both the resident's clothing and recliner were soiled. Staff admitted that documentation only occurred when a resident was changed, not when checked and found dry, leading to uncertainty about the timing of care provided. The facility's own policies and the resident's care plan required regular assistance with oral hygiene and incontinence care, but these were not followed. The Director of Nursing confirmed that the observed lapse in incontinence care was unacceptable and acknowledged the poor condition of the dentures as shown in photographs. The deficiency was substantiated by direct observation, staff interviews, and review of care plans and facility policies.
Failure to Provide Meaningful Activities for Resident with Sensory Impairments
Penalty
Summary
The facility failed to provide meaningful activities to promote psychosocial well-being for a resident with severe visual and bilateral hearing loss, as well as cognitive impairment and dependence on staff for daily care. Despite care plan interventions that included escorting the resident to activity programs, providing friendly visits, and offering an activity calendar, observations revealed the resident was left alone for extended periods without engagement. The resident was seen sitting slumped in a wheelchair or recliner, with no staff interaction, and was positioned with her back to a television, which was not an appropriate activity given her blindness. Staff were observed performing care tasks without speaking to the resident, and the resident was left in silent environments without stimulation. Interviews and documentation review further indicated a lack of individualized activity provision. The activity director was unable to explain what activities had been provided, as documentation was unclear and included ambiguous entries such as "other" without specifics. The resident's preferences for music and conversation were not addressed, and there was no evidence of staff actively engaging the resident in meaningful activities tailored to her sensory impairments. This resulted in social isolation for the resident, contrary to the facility's policy to support residents' psychosocial well-being through individualized activities.
Failure to Complete Physician-Ordered Wound Care for Two Residents
Penalty
Summary
The facility failed to follow physician orders for wound care for two residents with complex medical conditions. One resident, admitted with peripheral vascular disease and heart failure, had a venous/arterial ulcer and was prescribed a specific wound care regimen, including dressing changes every other day and the application of various topical treatments. Review of the Treatment Administration Record (TAR) showed that the ordered wound care was not completed on multiple specified dates across several months. Interviews with nursing staff confirmed that the treatments were missed as documented in the TAR. Another resident, admitted with diagnoses including cancer, cirrhosis, and neurogenic bladder, had multiple pressure ulcers, including a stage 3 ulcer and unstageable wounds. This resident had physician orders for daily application of Santyl ointment and specific wound care procedures. The TAR indicated that the prescribed treatments were not completed on two documented dates. Both the wound care nurse and the Director of Nursing acknowledged that the physician-ordered wound care was not completed as required. Facility policy requires wound treatments to be provided in accordance with physician orders, but this was not followed for these residents.
Failure to Provide Routine and Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot and nail care, including toenail trimming, for four residents who were reviewed for nail care. Observations revealed that multiple residents had thick, long, yellowed, and curled toenails, with some residents reporting pain and difficulty wearing shoes due to the condition of their nails. Certified Nursing Assistants (CNAs) acknowledged that the toenails had not been cut for a significant amount of time and that they were unable to trim certain residents' toenails due to their condition. The facility's nail care policy requires regular assessment and trimming of nails, with specific provisions for residents with diabetes or circulation problems, but these procedures were not followed for the affected residents. Interviews with residents and staff indicated that nail care was not consistently provided, with some residents stating they could not recall the last time their toenails were trimmed or that it had been almost a year since their last nail care. Staff interviews further revealed that access to podiatry services was limited to residents with certain insurance coverage, and the affected residents were not on the list to receive mobile medical podiatry. The DON stated that nail care was supposed to be provided on shower days, but this was not consistently implemented, resulting in untrimmed toenails and unnecessary pain for the residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to securely store medications and treatment supplies, leading to potential misuse. An insulin pen belonging to a resident with type 2 diabetes was found on the resident's bedside table, with approximately 150 units of insulin remaining. The resident was severely cognitively impaired, as indicated by a BIMS score of 00/15. A Licensed Practical Nurse (LPN) acknowledged that the insulin pen was likely left there from an earlier medication pass and admitted that medications should not be left on residents' bedside tables. Additionally, a treatment cart near the nurse's station was observed unlocked, containing various prescription powders, creams, and medical supplies. The cart was accessible to unauthorized individuals, and the LPN interviewed was unsure who last used the cart. The facility's policy mandates that all medications be stored in locked compartments and that medication carts be locked when unattended, which was not adhered to in these instances.
Failure to Maintain and Sanitize Resident Equipment
Penalty
Summary
The facility failed to maintain equipment in good working order and to clean and sanitize resident equipment, which increased the potential for the spread of infections among residents. Observations revealed that multiple wheelchairs were heavily soiled with food crumbs, dried spillage, and had damaged components such as seat cushions with holes. Additionally, a motorized wheelchair was noted to be in a similar state of disrepair and uncleanliness. Hoyer lifts were also observed to be soiled with dust, debris, and dried crusted substances, and the bags holding sanitizing wipes were heavily soiled. A vital sign machine and its components, including a pulse oximetry probe and a thermometer, were found to be soiled and sticky. Interviews with staff, including a CNA and an LPN, indicated that CNAs and nursing staff were responsible for cleaning and sanitizing resident equipment before and after use, with a specific emphasis on the 3rd shift for thorough cleaning. However, the observations contradicted these statements, as the equipment was not maintained according to the facility's policy on cleaning and disinfection of resident-care equipment. The policy outlined the importance of cleaning and disinfecting reusable equipment to prevent the transmission of pathogens, yet the facility failed to adhere to these guidelines, as evidenced by the condition of the equipment observed during the survey.
Inadequate Discharge Planning Leads to Resident's Homelessness
Penalty
Summary
The facility failed to implement and follow their policy to ensure a safe and orderly discharge for a resident, resulting in an involuntary discharge into the community without sufficient preparation and orientation. The resident, who was cognitively intact and had pertinent diagnoses including type 2 diabetes, was originally admitted to the facility and had a history of cellulitis requiring antibiotics and wound care. The resident left the facility for a pre-approved vacation to Texas, with the understanding that there would be no issue with returning as he was self-pay. However, during his absence, the acting Nursing Home Administrator informed him that he would not be able to return due to an unpaid bill, and he was officially discharged without any discharge paperwork or medications. The facility's electronic medical record indicated that a Notice of Involuntary Discharge was served to the resident, citing non-payment of services. Despite this, the facility's legal department advised that the involuntary discharge process was not properly followed, and the appeal was lost. The resident was not provided with appropriate follow-up and discharge instructions, and upon returning from vacation, he was unable to re-enter the facility and had to stay at a hotel. Eventually, a local hospital social worker reported that the resident was homeless, highlighting the lack of proper discharge planning and communication. Interviews with staff revealed that there was confusion and miscommunication regarding the resident's status, with the facility failing to document the discharge process adequately. The acting Nursing Home Administrator acknowledged that the previous management had not properly documented the involuntary discharge process and that the resident's discharge was not planned or executed according to policy. The facility's policy on involuntary transfer and discharge was not adhered to, resulting in the resident's unplanned discharge and subsequent homelessness.
Expired Food Items Found in Resident's Mini-Fridge
Penalty
Summary
The facility failed to remove expired foods from the mini-fridge of a resident who was severely cognitively impaired and had type 2 diabetes. During an observation, numerous expired food items were found in the resident's personal mini refrigerator, including expired yogurt, cheese, mustard, butter, and sausage with visible mold. Additionally, there were expired snacks and drinks on a shelf and in a nightstand drawer, along with soiled and open protein shakes on the bedside table. Interviews with various staff members, including an LPN, housekeeping staff, and a CNA, revealed a lack of clarity regarding who was responsible for monitoring and maintaining the cleanliness and safety of the resident's food items. The LPN and other staff members were unsure if it was the responsibility of the kitchen, housekeeping, or floor staff to track the food items. The resident herself was unaware of the expired items and reported receiving snacks from her daughter through the mail. The facility's policy on resident refrigerators stated that housekeeping staff should record refrigerator temperatures daily and clean the refrigerators, discarding any non-compliant foods. However, there was no temperature log present, and the housekeeping manager confirmed that the department was not responsible for the mini-fridges. This lack of adherence to the facility's policy resulted in the potential for expired food to be consumed, increasing the risk of foodborne illness.
Failure to Administer IV Antibiotics and Transcribe Orders
Penalty
Summary
The facility failed to properly transcribe and administer medications according to physician orders for a resident who was admitted with osteomyelitis in the left ankle and foot. Upon admission, the resident was supposed to receive intravenous antibiotics and wound care, but the facility did not administer the prescribed IV antibiotics for approximately five days. This oversight resulted in the resident's condition worsening, leading to hospitalization. The resident, who was severely cognitively impaired, reported that the facility's nursing staff did not administer the IV antibiotics or properly clean the wound. The resident's guardian noticed the resident's foot and leg were swollen and red, prompting a visit to the hospital where the resident was treated for the worsened infection. The hospital discharge paperwork included specific orders for antibiotic administration and PICC line flushes, which were not followed by the facility. Interviews with facility staff, including a registered nurse and the Director of Nursing, revealed that the transcription of the physician's orders was missed due to differences in the hospital's discharge paperwork. The staff did not notice the orders for the IV antibiotics and PICC line flushes, resulting in a delay in treatment. The facility's incident report confirmed that the staff failed to initiate the IV antibiotic treatment until several days after the resident's admission.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three residents. Resident #29, who had severe cognitive impairment and multiple health conditions, developed a pressure injury on the left heel that was not properly documented or treated in a timely manner. Despite orders to offload pressure from the heel, the care plan was not updated, and staff were not informed of the correct interventions. This led to the deterioration of the wound, resulting in gangrene, sepsis, and ultimately, a below-knee amputation. Resident #22 developed a stage four pressure ulcer, and the facility failed to ensure the proper functioning of a wound vac device. The wound vac was frequently turned off due to alarms, and staff did not consistently perform dressing changes as ordered. The lack of timely intervention and proper wound care management contributed to the worsening of the resident's condition. Resident #36 developed a stage three pressure ulcer on the spine, which was not present upon admission. The resident was often observed in a slouched position in bed without proper support or repositioning. Despite the presence of a care plan that included repositioning interventions, these were not consistently implemented, leading to the development and deterioration of the pressure ulcer.
Inadequate Supervision Leads to Resident Injuries and Safety Risks
Penalty
Summary
The facility failed to provide adequate supervision, resulting in a fall with major injury for a resident with a history of osteoporosis, repeated falls, stroke, and toxic encephalopathy. The resident, who had moderate cognitive impairment, experienced an unwitnessed fall from a wheelchair, leading to a head laceration and a cervical fracture. Staff interviews revealed that the resident was placed at the nurse's station for better supervision due to low staffing levels, but was left unattended when staff were occupied elsewhere, contributing to the fall. Another deficiency was identified regarding a resident with a history of tobacco use, falls, COPD, and vascular dementia, who was observed smoking unsupervised outside the facility. Despite the resident's care plan requiring supervision during smoking, the resident was allowed to smoke alone, and facility management was unaware of the specific interventions outlined in the care plan. The facility's smoking policy mandates direct supervision for residents with smoking privileges, which was not adhered to in this case. Interviews with facility staff, including the Nursing Home Administrator and Director of Nursing, confirmed that low staffing levels and inadequate supervision were ongoing issues. The facility's policies on accidents, supervision, and smoking were not effectively implemented, leading to these deficiencies in resident care and safety.
Staffing Shortages Lead to Unmet Care Needs and Safety Concerns
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care needs and ensure the safety of all 65 residents, as evidenced by multiple instances of unmet care needs and potential safety issues. A staff member reported that residents were being neglected, left in wet and soiled beds, and not receiving showers due to inadequate staffing. Resident #42, who requires assistance with personal care and has intact cognition, reported long wait times for toileting assistance, resulting in incontinence, and often receiving bed baths instead of preferred showers due to staffing shortages. Resident #15, also with intact cognition, expressed difficulty in receiving showers and suspected that the facility marked his shower opportunities as refused instead of offering alternative times. His care plan indicated a preference for showers twice a week, but records showed refusals or non-applicable statuses for several opportunities. Resident #61, with pressure ulcers and intact cognition, reported not being repositioned every two hours as required, leading to discomfort and potential worsening of his condition. The facility's records confirmed inconsistent repositioning, further highlighting the staffing inadequacies. Additionally, Resident #64, with moderate cognitive impairment, experienced an unwitnessed fall resulting in injuries, attributed to insufficient supervision due to staffing shortages. Staff interviews corroborated the challenges faced due to low staffing levels, with CNAs and RNs acknowledging the impact on resident care and supervision. The Nursing Home Administrator and Director of Nursing confirmed that low staffing levels have been an ongoing issue at the facility.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among the 65 residents. During a noon meal service, small bowl servings of potato salad and cottage cheese were observed at room temperature, with temperatures ranging from 46 F to 49 F, which is above the recommended 41 F or less for cold foods. The Kitchen Manager acknowledged the improper holding and disposed of the products. Additionally, a refrigerator in the nourishment room contained a package of rotisserie chicken without identifying information and a bottle of maple syrup past its expiration date, indicating a lack of proper monitoring and labeling. Further deficiencies were noted in the reheating process of roast beef, where the dietary staff failed to reheat the product to the required 165 F for 15 seconds. The staff member was unaware of the proper reheating temperature, and subsequent measurements showed the temperature ranged between 126 F and 146 F, below the required standard. This indicates a lack of knowledge and adherence to the FDA Food Code 2017 standards for reheating food for hot holding. Additionally, a cross-connection issue was identified with the ice machine's drain line, which was submerged into a floor drain and covered with a mold-like substance. The Kitchen Manager was aware of the issue but had not yet addressed it, and the Maintenance Director was only informed after the surveyor's observation. This situation presents a potential risk of contamination due to the improper configuration of the drain line, violating the FDA Food Code 2017 standards prohibiting cross-connections.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for one of the three residents reviewed for EBP, specifically for Resident 274 (R274). On multiple occasions, it was observed that there was no EBP outside of the room assigned to R274, who had an indwelling catheter. R274 was admitted with several diagnoses, including cellulitis, lymphedema, chronic diastolic heart failure, paroxysmal atrial fibrillation, morbid obesity, obstructive sleep apnea, essential hypertension, osteoarthritis, and a history of falls. Despite these conditions, R274's care plan did not include EBP for her catheter as per standards of care. The lack of EBP was noted over a period of six days, putting R274 at risk for a Multidrug Resistant Organism (MDRO) infection during her catheter care.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the residents' right to a dignified existence by not ensuring privacy during care. This deficiency was identified through observations, interviews, and record reviews, where it was found that staff members frequently entered residents' rooms without knocking or waiting for permission. During a group meeting with the President of the Resident Council and seven other residents, several residents expressed their concerns about staff entering their rooms without proper acknowledgment, leading to feelings of embarrassment and a lack of privacy. Residents reported that staff would often knock quietly and enter immediately, not allowing residents time to prepare or cover themselves, which was particularly distressing during personal care activities. Further observations confirmed these reports, as staff members were seen entering rooms without knocking. For instance, housekeeping staff was observed entering a resident's room without knocking, and the resident confirmed that this was a frequent occurrence. Similarly, a CNA was also observed entering a room without knocking. The facility's policy on promoting and maintaining resident dignity, which emphasizes treating residents with respect and ensuring their privacy, was not adhered to, resulting in the identified deficiency.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notifications to residents and their representatives regarding transfers to hospitals, as required by policy. This deficiency was identified for four residents who were transferred out of the facility without receiving the necessary written notices. Resident 124 was sent to the hospital twice in October 2024 due to unresponsiveness and after a discussion with the on-call physician, but no written transfer notices were found in their electronic medical record. Similarly, Resident 22, who had a primary diagnosis of sepsis, was transferred multiple times to the emergency department for a deteriorating wound, yet did not recall receiving any transfer paperwork. Resident 29 was transferred to an acute care hospital due to a worsening left heel wound with necrotic tissue, but no written transfer notice was documented. Resident 64 was sent to the hospital following a fall with injury, and again, no written transfer notice was found in their records. Interviews with the Nursing Home Administrator and Regional Clinical Nurse revealed that the interim social worker was not sending the required notifications, and the Nursing Home Administrator was unaware that this task was not being completed. The facility's policy mandates that transfer or discharge notices be provided to the resident, their representative, the long-term care ombudsman, the state survey agency, and the physician, with a copy placed in the resident's file.
Failure to Provide Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents or their representatives prior to hospital transfers for five residents. This deficiency was identified through interviews and record reviews, revealing that the necessary documentation was missing from the clinical records of the affected residents. For instance, Resident #18 was transferred to the emergency department on two occasions without any bed-hold document in their clinical documentation. During an interview, the resident stated they were not informed about the bed-hold policy and assumed their bed would be available upon return. Similarly, Resident #124 was transferred to the hospital twice without receiving a written bed-hold notice, as confirmed by a review of their electronic medical record. Further investigation showed that Resident #22, who had been transferred multiple times due to medical conditions, did not recall receiving any bed-hold paperwork. Resident #29 and Resident #64 also experienced hospital transfers without documented bed-hold notifications. The Nursing Home Administrator acknowledged that bed-hold notifications were not being completed, indicating a lapse in adherence to the facility's policy. The facility's policy, revised in February 2022, mandates that written information about the bed-hold policy, including its duration and conditions for readmission, be provided to residents or their representatives before any transfer to a hospital or therapeutic leave.
Failure to Timely Destroy Discontinued Medications and Improper Use of Resident Medications
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not destroying discontinued schedule two medications in a timely manner and using another resident's medication on a different resident. During an observation, it was found that a resident had another resident's acetic acid solution in their room, which was being used on them for wound care. The resident confirmed that the solution was used on their lower legs. The Licensed Practical Nurse (LPN) acknowledged that the supplies should not have been in the room and should have been stored in the wound care cart, indicating a lapse in following proper procedures for medication storage and use. Additionally, the facility did not remove expired medications from the medication carts, as evidenced by the presence of expired lorazepam orders for multiple residents. The narcotic sign-out sheets for these medications were still present on the medication carts, despite the physician orders having expired and not being reordered. The facility's policy on discontinued medications requires that medications be removed from the active supply immediately upon receipt of a discontinuation order to prevent inadvertent administration. However, this policy was not followed, leading to the deficiency.
Deficiency in Dementia Training for CNAs
Penalty
Summary
The facility failed to ensure that dementia training was completed by four Certified Nursing Assistants (CNAs) as required by annual training requirements. This deficiency was identified through a review of CNA in-service training logs for CNAs F, V, U, and E. The training transcripts for CNAs F, V, and U indicated that the course titled 'Dementia Care: Normal Aging vs. Alzheimer's/Dementia' was incomplete and overdue, with a due date of 9/30/24. CNA E's transcript did not list any dementia training at all. An interview with the Assistant Director of Nursing (ADON) revealed that there was no specific dementia training provided to nurse aides, as it was assumed to be included in a course called 'Challenging Behaviors.' However, a review of the 'Challenging Behaviors' training transcript did not show any education regarding dementia care. The facility's most recent Facility Assessment Tool, covering the period from 7/2023 to 6/2024, stated that required in-service training for nurse aides must include dementia management training and resident abuse prevention training. The lack of specific dementia training for the CNAs resulted in the potential for unmet care needs and could potentially affect all residents with dementia in the facility, which had a current census of 65 residents.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse, resulting in mental distress and anguish. A resident, who was cognitively intact and had multiple medical conditions including spinal stenosis, diabetes, heart failure, and kidney disease, reported an incident where a nurse made an inappropriate comment suggesting that the resident should end his life due to his health problems. The resident described the nurse and the circumstances of the incident, which he had reported to several staff members. The incident was documented by the facility and reported to the State Agency. Interviews with other staff members, including a CNA and an LPN, revealed that the nurse in question had a history of speaking inappropriately to residents and had been previously educated and nearly terminated for similar issues. Despite this, the facility allowed the nurse to continue working, which contributed to the deficiency in protecting residents from verbal abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report alleged abuse in a timely manner for two residents, resulting in a potential for ongoing abuse. Resident 61, who was cognitively intact with a BIMS score of 15, reported an inappropriate comment made by a nurse, suggesting that if she were in his position, she would end her life. This incident was reported to several staff members, including LPN M, who acknowledged the comment as abusive but failed to report it immediately to the Nursing Home Administrator (NHA) due to being preoccupied with other tasks. Additionally, Resident 124 experienced alleged abuse when a nurse, frustrated during her medication pass, spoke harshly after the resident fell out of bed multiple times. This incident was not reported to the administration until much later, when CNA F was questioned about another incident. Both events were not reported to the State Agency until several days after they occurred, violating the facility's policy that requires immediate reporting of abuse allegations within specified timeframes.
Inadequate Assessment of Catheter Necessity
Penalty
Summary
The facility failed to properly assess the clinical need for urinary catheterization for two residents, leading to inappropriate or potentially unnecessary catheter usage. Resident #18 had an indwelling catheter placed after shoulder surgery, reportedly due to urinary urgency and the inability to get out of bed quickly without assistance. However, there was no documented diagnosis of urinary retention in the resident's chart, and a referral to a urologist, as requested by the resident, was not made. The resident's care plan indicated the catheter was for urinary retention, but this was not supported by the medical record. Resident #274 was admitted with an indwelling catheter from the hospital, reportedly due to the inability to reach the bathroom in time. However, the resident's care plan did not reflect the presence of a catheter or provide guidance on its care. The Assistant Director of Nursing was unaware of the resident having a catheter, and the facility lacked a policy for evaluating the medical necessity of catheter usage, relying only on catheter care procedures. This lack of standardized assessment and documentation contributed to the deficiency.
Failure to Monitor Resident Weight Fluctuations
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for weight fluctuations for two residents, resulting in the potential for inaccurate assessments and physical decline. Resident 61, who had multiple diagnoses including diabetes, heart failure, and a pressure ulcer, reported not being weighed as frequently as in the hospital. The medical record showed a significant weight drop from 175 pounds to 149 pounds, but no initial weights were recorded in the facility. The Registered Dietitian noted the absence of an admission weight and requested a current weight, but no further weights were documented. Resident 124, diagnosed with protein-calorie malnutrition and dysphagia following a stroke, was not weighed upon readmission after two hospitalizations. The only recorded weight was from before these hospitalizations, which was used to calculate nutritional needs. Despite the care plan's directive to periodically obtain and evaluate weights, no updated weights were recorded. The facility's policy required weekly weight monitoring for newly admitted residents and those with weight loss, but this was not adhered to, as confirmed by interviews with the Nursing Home Administrator and the Registered Dietitian.
Failure to Obtain Consent and Conduct Timely GDR for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent and physician orders for psychotropic medication for two residents, leading to the administration of lorazepam without proper authorization. One resident received nine doses of lorazepam without a physician order, and the consent for psychotropic medication was outdated and lacked specific dosage information. Another resident received five doses of lorazepam without a physician order, and the facility's policy on medication administration was not followed, as medications were given without a physician's order. Additionally, the facility did not conduct a timely gradual dose reduction (GDR) for psychotropic and anti-anxiety medications for a resident, despite recommendations from behavioral health providers. The resident, who had severe cognitive impairment and multiple psychiatric diagnoses, was on Paxil and Abilify for an extended period without adjustments. Recommendations for GDR were made but not acted upon in a timely manner, with significant delays in the facility physician's response to these recommendations. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed a breakdown in the process of reviewing and relaying GDR recommendations to the facility physician. The facility's policy on gradual dose reduction of psychotropic drugs was not adhered to, as there was a delay in evaluating and acting on the resident's medication needs, potentially leading to adverse side effects and excessive duration of medication use.
Ineffective QAPI Program Implementation
Penalty
Summary
The facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program, which is essential for the development, monitoring, and evaluation of adverse events to correct quality deficiencies. This deficiency was identified during an interview with the Nursing Home Administrator (NHA), who confirmed that QAPI meetings were held monthly but was unable to explain how medical errors or adverse resident events were identified, analyzed, corrected, or monitored through the QAPI process. The NHA relied on emails from the regional clinical nurse and the Director of Nursing for information on adverse events but lacked a clear understanding of the QAPI process. The facility's policy on QAPI, reviewed and revised in October 2022, mandates systematic data collection and investigation of medical errors and adverse events, yet these procedures were not effectively implemented.
Failure to Ensure Accurate Indication for Laxative Administration
Penalty
Summary
The facility failed to ensure an accurate indication for administering a laxative to a resident, leading to unnecessary medication use. The resident, who was always continent of bowel and bladder and required assistance for toileting, was given a laxative despite having regular bowel movements documented prior to the administration. The resident experienced diarrhea and bowel incontinence as a result of the laxative administration. The Medication Administration Record (MAR) showed that the laxative was not initialed as administered by a nurse, indicating a lack of proper documentation. Registered Nurse (RN) C, who was responsible for the resident's care on the day of the incident, admitted to administering the laxative without performing an assessment. RN C relied on a report that the resident had not had a bowel movement, which was later found to be inaccurate. The bowel elimination tracking record was updated after the laxative was given, showing bowel movements on previous days. The facility's policy on PRN medications requires an assessment for need and effectiveness, which was not followed in this case.
Failure to Provide Adequate Showering Services
Penalty
Summary
The facility failed to provide adequate showering services for a resident, identified as R5, who was admitted with multiple diagnoses including hemiplegia, urinary tract infection, dementia, cognitive communication deficit, and weakness. R5 required moderate assistance for showering and was occasionally incontinent of bladder. During the 17-day stay at the facility, R5 received only one shower, despite the facility's policy that residents should receive showers twice per week unless otherwise documented in the care plan. The care plan for R5 was revised after discharge and did not include interventions for showering or bathing. The Director of Nursing (DON) confirmed that showers are documented by CNAs and could not provide an explanation for the lack of showers provided to R5. The facility's policy on Activities of Daily Living (ADLs) states that residents unable to carry out ADLs should receive necessary services to maintain personal hygiene. However, the documentation showed that R5's showering needs were not adequately met, as evidenced by the CNA documentation and the lack of additional records in R5's health record.
Failure to Transcribe Treatment Orders and Follow Wound Clinic Recommendations
Penalty
Summary
The facility failed to transcribe treatment orders and follow up on wound clinic recommendations for a resident with a stage 4 pressure injury. The resident developed a severe pressure injury on the sacrum while at the facility, which later became infected, leading to hospitalization for sepsis. Upon returning to the facility, the hospital discharge instructions included specific treatment orders for the wound, which were not transcribed into the resident's electronic medical record (EMR). Consequently, the sacral wound was not documented as being treated until several days after the resident's return. Additionally, the facility did not follow up on the wound clinic's recommendation to reapply a wound VAC, which was noted in the resident's health record. The attending physician was not notified of these recommendations, and there was no documentation of an order to restart the wound VAC. Interviews with nursing staff revealed a lack of awareness regarding the wound clinic's recommendations, and the Director of Nursing acknowledged that the expected procedures for transcribing orders and following up on recommendations were not followed.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by the experiences of four residents who reported significant delays in receiving care. Resident #11, who has intact cognition, reported waiting excessively for assistance, resulting in an incident where they urinated in bed due to the lack of timely help. This resident also experienced delays in receiving medications and was unable to participate in activities due to insufficient staff. Similarly, Resident #7, also with intact cognition, expressed frustration over long wait times for assistance. Resident #1, with intact cognition, highlighted the issue of understaffing, particularly during night shifts, which affected their ability to receive timely care. Resident #3, who has severe cognitive impairment, was found soaked in urine due to inadequate staffing, as reported by their Durable Power of Attorney. Interviews with Certified Nursing Assistants (CNAs) revealed that they were overwhelmed with the number of residents they had to care for, often working alone and unable to provide necessary care such as transfers and showers. The facility's staffing records showed that the number of CNAs on duty was consistently below the required levels to adequately care for the residents, as per the facility's own staffing ratios. The facility's Emergency Staffing policy did not specify the number of staff needed to meet daily resident needs, and the Facility Assessment Tool did not indicate the required staffing levels. This lack of adequate staffing led to unmet care needs and compromised the quality of life and care for the residents.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to complete and post the daily nurse staffing information, which is a requirement for transparency regarding the number of staff available to provide resident care. This deficiency was identified during an interview with the Nursing Home Administrator (NHA), who was unable to locate the daily staffing posting. An observation revealed that the Regional Director of Clinical Services was filling out the staffing sheet for the current day and instructed staff to post it near the entrance of the facility. A review of the nursing staffing sheets showed missing information for several dates, including 7/13/24, 7/11/24, 6/23/24, 6/15/24, and 6/10/24. The NHA acknowledged that the staffing sheet was not posted at the beginning of the shift, and the Director of Nursing (DON) confirmed that the information should be posted daily by the nurses' station near the entrance.
Inadequate PPE Availability and Usage in COVID-19 Precaution Rooms
Penalty
Summary
The facility failed to provide adequate Personal Protective Equipment (PPE) for staff and ensure its proper use when entering rooms under Transmission-Based Precautions (TBP) for COVID-19. Observations revealed that several resident rooms had signage indicating TBP due to active COVID-19 infections. However, staff members, including a Licensed Practical Nurse (LPN) and a Social Services Designee (SSD), were seen entering these rooms without donning the required PPE. Additionally, a Durable Power of Attorney (DPOA) reported that staff were not consistently wearing masks or gowns, and there was a lack of encouragement for visitors to wear masks. Interviews with staff, including Certified Nurses Assistants (CNAs) and a Registered Nurse (RN), highlighted a shortage of PPE supplies, particularly on weekends, with reports of having to search for masks and other protective gear. Observations confirmed that PPE carts on various wings were inadequately stocked, lacking essential items such as gowns, N95 masks, and face shields. The facility's policy mandates the use of specific PPE for residents with suspected or confirmed COVID-19, but the central supply clerk was not maintaining adequate supplies, leading to non-compliance with the policy.
Failure to Investigate Falls and Update Care Plans
Penalty
Summary
The facility failed to investigate the root cause of injuries for three residents who experienced falls, leading to deficiencies in resident safety and care planning. Resident #5, with severe cognitive impairment and multiple health conditions, was found on the bathroom floor with a hip fracture. The Director of Nursing (DON) did not provide answers regarding the root cause analysis or care plan interventions for this incident. The care plan lacked assessments for pain and interventions to minimize fall risks. Resident #3, also with severe cognitive impairment, experienced two falls. The first incident involved a CNA assisting the resident to the floor, and the second resulted in a nasal bone fracture. The DON acknowledged that no root cause analysis or care plan updates were completed for these falls. Similarly, Resident #4, with severe cognitive impairment and a history of traumatic brain injury, experienced two falls, one resulting in a laceration. The DON confirmed the absence of root cause analyses and care plan updates for these incidents. The facility's policy on falls required interventions based on assessed needs, which were not implemented.
Failure to Provide Adequate Social Services
Penalty
Summary
The facility failed to provide adequate medically-related social services to a resident, identified as R2, who was involved in an incident where another resident yelled and cursed at him. R2, who has multiple sclerosis, depression, legal blindness, and a neurogenic bladder, was admitted to the facility and is capable of understanding and being understood. Following the incident, R2 expressed feeling upset and worried about his safety. Although initially addressed by the staff, R2 reported that there had been no follow-up discussions or interventions added to his care plan to address the incident or its impact on his well-being. The Social Services Designee (SSD) admitted to not having conducted any trauma assessment or added any interventions to R2's care plan following the incident. The facility's policy on social services, which aims to provide medically-related social services to maintain residents' highest practicable physical, mental, and psychosocial well-being, was not adhered to in this case. The lack of follow-up and failure to update the care plan with necessary interventions for R2's psychosocial needs contributed to the deficiency identified by the surveyors.
Failure to Assess Change in Condition for Resident
Penalty
Summary
The facility failed to assess a change in condition for a resident, identified as R2, who was admitted with multiple active diagnoses including hereditary and idiopathic neuropathy, anxiety disorder, major depressive disorder, chronic pain, repeated falls, muscle weakness, and a compression fracture of the lumbar vertebra. R2, who had intact cognition, reported experiencing an uncontrollable shaking episode upon returning to the facility, which was a new and frightening experience for him. Despite seeking help from a Licensed Practical Nurse (LPN), the resident was denied assistance, as the LPN dismissed the situation as attention-seeking behavior and prioritized medication administration over assessing the resident's condition. A Certified Nursing Assistant (CNA) witnessed the resident's distress and attempted to seek help from the LPN, who refused to provide care. The CNA then comforted the resident until the episode subsided. The Director of Nursing (DON) confirmed that the LPN did not assess the resident for a change in condition, and there were no progress notes or assessments documented in the medical record regarding this incident. The resident had filed a grievance with the DON about the lack of assessment and care provided by the LPN.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer and provide appropriate care for two residents, R4 and R8. R4 developed an unstageable pressure ulcer on 2/18/24, which worsened to a stage IV ulcer by 3/11/24. The facility did not consistently measure wound care assessments, follow physician wound care orders, or ensure timely wound care interventions. R4's condition deteriorated, leading to a wound infection, hospitalization, and multiple medical interventions, including wound debridement and colostomy placement. The facility also failed to turn and reposition R4 consistently, as documented in the medical records, contributing to the worsening of the pressure ulcer. R4's medical history included muscle weakness, pneumonia, spinal stenosis, and rheumatoid arthritis, among other conditions. Despite these vulnerabilities, the facility did not provide timely and adequate wound care. The wound care consult was delayed, and there were multiple instances where dressing changes were not documented or performed as ordered. The facility's failure to implement a turning and repositioning schedule further exacerbated R4's condition, leading to severe pain and infection. Similarly, R8 developed an unstageable pressure ulcer to the coccyx area, which deteriorated over time. The facility did not document wound dressing changes consistently and failed to follow physician orders for wound care. R8's wound measurements showed significant deterioration, and the facility's care plan interventions were not effectively implemented. The facility's policies on wound treatment management and pressure injury prevention were not adhered to, resulting in the worsening of R8's condition and the need for additional medical interventions, including the placement of a urinary catheter to promote healing.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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