Medilodge Of West Bloomfield

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to consistently implement infection control standards during medication administration and to maintain an effective infection control surveillance program. During a medication pass, an LPN was observed administering medications to four residents, including residents 9 and 65, without performing hand hygiene before each medication administration for each resident. This practice was inconsistent with the facility’s Medication Administration policy, which requires staff to wash hands prior to administering medications and to follow facility hand hygiene protocols. In an interview, the DON confirmed that nurses are expected to perform hand hygiene before and after each medication administration for each resident. The facility also failed to maintain complete and accurate infection surveillance documentation during a COVID outbreak in October 2025 that affected 13 residents and six staff members. The Infection Control RN produced a Respiratory Surveillance Line List for that period and verbally confirmed that the listed individuals had tested positive for COVID, but the document itself did not specify COVID as the pathogen. The line list contained multiple blank or incomplete fields, including missing dates of specimen collection, unspecified test types marked only as “Other,” missing or “N/A” symptom onset dates, blank symptom documentation columns, and pathogen fields marked as “Other” without specifying the organism. The outbreak symptom resolution dates were blank for all names, and the October 2025 facility infection map did not indicate which residents had COVID. These practices did not align with the facility’s Infection Prevention and Control Program policy, which states that the Infection Preventionist leads surveillance activities and maintains documentation of incidents and findings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect, particularly regarding toileting, incontinence care, and staff interactions. One resident with diagnoses including difficulty in walking, polyneuropathy, and primary insomnia, and a BIMs score of 15 indicating no cognitive impairment, reported that night shift staff were not responsive to toileting needs. This resident stated they were only changed once during the night around 11:00 PM–12:00 AM and not again until approximately 6:30 AM, and that when they used the call light at night, a CNA would enter, ask what was needed, turn off the call light, and leave without providing toileting assistance until morning, resulting in the resident using the restroom in their brief. Another resident, also cognitively intact with a BIMs score of 15 and admitted with diagnoses including urinary tract infection and muscle disorder, reported that when they used the call light, it took staff so long to respond that they forgot what they had requested, and that it was difficult to get their brief changed on the night shift. A family member of one resident reported to the state agency that CNAs did not help the resident when the call light was used at night and that nurses did not administer nighttime medications until after 11:00 PM. The same family member stated they believed grievance forms were only available for missing items and not for nursing concerns, and also reported that the social worker did not follow up on requests. Resident council minutes over several months documented repeated concerns about staff attitudes and professionalism, including cleaning staff being rude, nurses and aides not being professional, ongoing issues with name tags, a Foley catheter not being emptied, and a CNA demanding a resident wear a brief and lecturing the resident about incontinence. In a confidential resident council interview with eight residents, multiple residents reported that some aides and nurses did not treat them with dignity, stating that staff did not “have a heart for the people” and did not actually care. The DON later reported being unaware of these dignity concerns. These findings occurred despite a facility policy on promoting and maintaining resident dignity that requires respectful communication and acting upon resident preferences.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean, safe, comfortable, and homelike environment in multiple common-use areas, including the upper-level pantry and shower rooms. Surveyors observed an ice machine in the upper-level pantry leaking water onto the floor, with a black, mold-like substance present on the floor tiles. The cupboard under the pantry sink showed visible water damage and a black, mold-like substance on the bottom shelf. The Maintenance Supervisor stated they planned to get a new ice machine but did not explain why the mold-like substance on the floor had not been cleaned, and further reported he had repaired a leak under the sink about a year earlier but was not aware of any new leak or current water damage. In the upper-level shower room near the nurse's station, a bariatric shower chair was observed with torn vinyl on the seat, exposing foam and creating a surface that was no longer smooth and easily cleanable. In the C/D unit shower room, surveyors and the DON observed two shower stalls with significantly pitched tiled flooring, a torn and heavily stained white vinyl shower curtain, and a heavy buildup of dark, blackish debris along the wall and floor tiles inside the shower area. The tiled shower room walls had several chipped tiles, and plastic corner coverings were missing caps at the top, exposing sharp metal and plastic edges. The DON reported being unaware of these conditions prior to the observation. These conditions occurred despite a facility policy stating that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment and that unresolved environmental concerns should be reported to the Administrator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to monitor and evaluate antibiotic use for a resident in accordance with its antibiotic stewardship program. The Infection Control RN reported that the resident was sent to the hospital after vomiting yellow-green emesis and returned the same day with antibiotic orders for a urinary tract infection (UTI). The facility’s Infection Report Form listed an onset date of 10/13/25, a suspected healthcare-associated UTI, and documented orders for Keflex 500 mg every six hours from 10/14/25 to 10/18/25, followed by Macrobid 100 mg twice daily from 10/17/25 to 10/22/25. A McGeer Criteria for Infection Surveillance Checklist was started for this resident, but the criteria section was not completed. The Infection Control RN provided a spreadsheet indicating that the resident did not meet McGeer’s criteria for UTI, yet the antibiotics were continued. When asked why antibiotics were continued if criteria were not met, the RN stated they followed the hospital’s UTI diagnosis and that the attending physician wanted the antibiotics continued, but there was no documentation of this discussion. The Infection Control RN also stated they did not personally reassess residents after antibiotics were ordered and was unsure whether facility physicians assessed the relevance of the antibiotic therapy. These actions and omissions conflicted with the facility’s written Antibiotic Stewardship Program policy, which required monitoring response to antibiotics to determine ongoing need or adjustments, and review of antibiotic orders from consulting, specialty, or emergency providers for appropriateness.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to honor a resident’s full code advance directive by not initiating CPR or other life-saving measures when the resident was found unresponsive. The resident had diagnoses including Parkinson’s disease with dyskinesia and encephalopathy and had a BIMS score of 0/15, indicating severe cognitive impairment. When an LPN went to care for the resident at approximately 4:45 PM, the resident was observed unresponsive, with eyes open and fixed, mouth open, and no vital signs detected. The LPN then approached another LPN and reported that the resident had passed, inquired about the code status, and was told the resident was a DNR. Based on this information, no immediate resuscitative efforts were initiated. A supervising RN was called to pronounce death and, upon arrival, found the resident cool to the touch and not breathing, and pronounced the resident deceased. Shortly afterward, another LPN discovered in the resident’s profile that the resident was actually a full code. The RN then initiated the facility’s code protocol and started CPR only after learning of the correct code status. Interviews revealed that the LPN who first found the resident unresponsive did not know the resident’s code status, did not know where code status was documented, and did not know the code status of any assigned residents. The facility’s policy stated that decisions regarding treatment and advance directives were to be documented in the medical record and communicated to staff responsible for the resident’s care. The Administrator confirmed that, due to the unexpected death, the facility’s response to provide CPR and other life-saving measures was delayed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a safe and timely discharge process for a resident whose Medicaid coverage needed to be transitioned from nursing home level to community level upon discharge. A complaint submitted to the State Agency alleged that the facility delayed notifying the Michigan Department of Health and Human Services that the resident had been discharged, which affected the resident’s ability to access community level Medicaid services. Record review showed the resident was admitted on an unspecified date and discharged back to the community on 8/1/25, with Medicaid-MI as the payor source at the time of discharge. During an interview, the Regional Business Office Manager explained that the facility business office is responsible for switching a resident’s Medicaid from nursing home level to community level, typically on the day of discharge, the next day, or by the end of that week. However, for this resident, the request to switch to community Medicaid was not submitted until 8/28/25, nearly four weeks after discharge. The Regional Business Office Manager attributed the delay to the prior business office manager leaving around that time. Review of the facility’s Social Services policy showed that the facility is responsible for providing medically related social services, including assisting residents with financial matters, to help them attain or maintain their highest practicable well-being.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves failures in controlled substance administration and documentation, as well as incorrect transcription and implementation of a physician’s order. During a morning medication pass, an LPN prepared and administered Ativan 0.5 mg for a resident by removing one tablet from the locked controlled medication drawer and adding it to the resident’s other morning medications. The LPN did not verify the current Ativan count, did not document the dose removed on the controlled count sheet at the time of removal, and proceeded to prepare and administer medications for three additional residents without signing out the Ativan dose. When interviewed, the LPN stated they sign for controlled medications after completing all morning medication administrations and indicated that some nurses sign when removing the pill and others after finishing the medication pass. Facility policy on controlled substance administration and accountability requires that each dose administered be recorded, subtracted from the previous count, and the remaining amount documented. The deficiency also includes a failure to correctly transcribe and carry out a physician’s order for IV hydration for another resident with chronic diastolic heart failure, stage 3 chronic kidney disease, and severe cognitive impairment. A progress note documented that this resident was lethargic, difficult to arouse, with low blood pressure, but responsive to verbal stimuli and sternal rub, and with stable vital signs otherwise. The physician was notified and gave STAT orders for labs (CBC with diff, CMP, UA/urine culture), IV hydration with 0.9% normal saline at 70 cc/hr for one liter, and vital signs every six hours for 24 hours. However, the IV fluid order was transcribed in the medical record with an incorrect start date, setting the infusion to begin the following day instead of the same day, which created a delay in medical treatment. Attempts by surveyors to contact the nurse who transcribed the order were unsuccessful, and the regional nurse consultant could not explain why the order was not transcribed correctly.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide medically-related social services to address psychosocial well-being, behavioral needs, and follow-up after resident-to-resident incidents for two residents with dementia and mood disorders. One resident (R35) had vascular dementia with severe cognitive impairment, verbal behavioral symptoms toward others, and documented episodes of swearing, resisting care, and verbal and physical aggression toward a roommate. Another resident (R49) had major depressive disorder, generalized anxiety disorder, unspecified dementia with behavioral disturbance, and adjustment disorder, with documented episodes of yelling, verbal aggression, threatening behavior, and refusing care. The facility became aware of an allegation that R49 had been physically and verbally assaulted by R35, and later documentation described R35 becoming verbally aggressive and physically violent with a roommate, including an observation of attempting to hit the roommate through the curtain. Despite these incidents and the residents’ known behavioral and psychosocial conditions, the social services documentation was incomplete and lacked evidence of assessment and follow-up. For R35, social service progress notes since December consisted of only two entries related to family consent for continued medication, without details of the medication. An annual social service progress review for R35 was left incomplete in multiple sections, including cognitive/mental status comments, mood/behavior/emotional status, current mood and behavior status, triggers for anxiety/agitation, calming strategies, comfort foods/drinks, and psychoactive medication review. There was no documented social services follow-up after the resident-to-resident incident in December or after the February incident where R35 became physically violent with the roommate. For R49, only one social service assessment was completed shortly after admission, and no quarterly assessment was available. That assessment was also incomplete, omitting documentation of behavior, medical and psychiatric history impact, admitting and historical behaviors or mood disorders, triggers for anxiety/agitation, calming strategies, comfort foods/drinks, daily foods/drinks, and conflict-handling style, despite the resident being on a psychoactive medication and having a very low BIMS score. Clinical notes documented that R49’s family reported verbal aggression from the roommate and requested room changes, and psych services documented ongoing depression, anxiety, agitation, verbal aggression, and threatening behavior. However, there was no social services follow-up documented after the alleged abuse incident in December, the later roommate conflict, or the psych note describing significant psychosocial distress. Interviews with the Social Service Director revealed uncertainty about how psychosocial needs and behavioral monitoring were assessed and communicated, and the Administrator acknowledged expectations for follow-up that were not met, in contrast to the facility’s policy requiring initial and quarterly assessments, documentation of medically-related social service needs, and monitoring of residents’ mental and psychosocial functioning. The facility’s own policy on social services required the social worker or designee to complete initial and quarterly assessments for each resident, identify and document medically-related social service needs, and ensure that the care plan reflected ongoing psychosocial needs and how they were being addressed. The policy also specified services such as identifying individualized non-pharmacological approaches to meet mental and psychosocial needs and meeting the needs of residents coping with stressful events. In the cases of R35 and R49, the documented omissions in assessments, lack of detailed psychosocial and behavioral information, and absence of follow-up after resident-to-resident incidents and documented behavioral concerns demonstrate that these policy requirements were not followed, leading to the cited deficiency in providing medically-related social services to help each resident achieve the highest practicable quality of life.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate and timely administration of a prescribed seizure medication for one resident. The resident had diagnoses including other seizures, neuromuscular bladder dysfunction, and multiple muscle contractures, and had a BIMS score indicating severe cognitive impairment. The resident had a physician’s order for Valproic Acid oral solution, 15 ml via PEG tube twice daily, scheduled for 7:30 AM and 9:00 PM. Review of the MAR showed that on 9/15 the morning dose was documented as given by a nurse, and the evening dose was documented as given by another nurse. However, the facility’s Medication Admin Audit Report revealed that the 7:30 AM dose was actually administered and documented at 12:44 PM, well outside the one-hour before/after window described by the DON, and there was no record on the audit report that the 9:00 PM dose was administered at all. A complaint to the State Agency alleged that on that date the nurse falsified having given the resident their needed seizure medication, resulting in the resident sustaining two seizures during the night, and further alleged that this nurse often provided medications late or not at all. Nursing notes from the early morning of the following day documented that the resident experienced an active seizure at 4:23 AM and a second seizure at 4:23 AM lasting until 4:25 AM, with the resident positioned on the left side and suction available and the physician contacted. During interview, the DON confirmed that the Valproic Acid dose scheduled for 7:30 AM but administered at 12:44 PM was significantly delayed and that, after reviewing the audit, the 9:00 PM dose had not been administered. The facility’s Medication Errors policy stated that medications are to be administered according to physician orders and that time of administration and medication omission are factors indicating errors in medication administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A facility failed to develop and consistently implement an adequate safety plan and provide sufficient supervision for a resident with a significant history of falls and severe cognitive impairment. The resident was admitted with multiple serious injuries from a prior fall, including intracerebral and subdural hemorrhages, spinal and rib fractures, and a right orbital fracture. Upon admission, the resident was noted to be restless, impulsive, and required staff assistance for all activities of daily living, with a care plan that included a one-on-one sitter due to high fall risk. Despite these interventions being documented, the facility did not consistently provide the required one-on-one supervision. Throughout the resident's stay, there were at least ten documented falls, several resulting in injuries such as hematomas, lacerations, and bruising, and requiring emergency department evaluation. Progress notes and interviews revealed that the resident was frequently agitated, difficult to redirect, and continued to attempt to stand or move unassisted. Staff and medical providers repeatedly documented the resident's need for close supervision, yet the one-on-one sitter was removed at some point prior to a significant fall, contrary to the established care plan. Staff interviews confirmed that the removal of the sitter was a management decision, and that the resident's supervision was insufficient during this period. The facility's administration acknowledged to the resident's legal guardian and to surveyors that they could no longer provide the one-on-one supervision as outlined in the care plan, and even requested the guardian to provide or pay for additional supervision. There was no documentation of a revised strategy or adequate alternative supervision plan, and the facility failed to ensure the care plan interventions were followed. The facility's own policy required individualized supervision based on assessed risk, but this was not adhered to, resulting in repeated falls and injuries for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of physical abuse involving a resident with severe cognitive impairment and multiple diagnoses, including dementia and a recent clavicle fracture. The resident, who was dependent on staff for most aspects of care, was admitted, readmitted, and later discharged to the hospital following an incident where she claimed to have been pushed from her wheelchair by staff. The allegation was communicated to facility leadership via an email from the Transitional Care Liaison, which included a hospital case manager's note stating that the resident's son found her story inconsistent but agreed to a report being made to Adult Protective Services (APS). Despite being notified of the abuse allegation, the facility did not report the incident to the State Agency as required by both federal regulations and the facility's own policy, which mandates immediate reporting of all abuse allegations. During an interview, the Administrator acknowledged the decision not to report, stating that the team felt the incident did not occur. Facility documentation confirmed that the abuse allegation was not reported to the State Agency, constituting a failure to follow established procedures for reporting alleged violations.

Plan Of Correction

Element 1 - The facility identified resident #803 and they no longer reside at the facility. The administrator during this survey is no longer employed at the center effective 6/19/2025. Element II - The facility identified that all residents residing at the center could be affected by the deficient practice. The facility interviewed all patients who can be interviewed (BIMS>11), to ensure that any potential abuse allegations have been reported. There were no findings to report. Element III - The new facility administrator reviewed and understands the reporting requirements of the abuse policy. The facility educated the transitional care staff on proper abuse reporting methods to promote timely abuse reporting. Element IV - The facility administrator/designee will conduct 3 random interviews, weekly, times four weeks to ensure that all abuse allegations have been identified and reported. The results from those interviews will be submitted to the QAPI committee for review and recommendation. Element V - The administrator is responsible for achieving and maintaining compliance. The compliance date is 7/15/25.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to consistently assess, monitor, and review the nutritional needs of a resident with severe protein-calorie malnutrition, dysphagia, and recent surgical amputation. Upon admission, the resident had a documented history of inadequate energy intake, significant weight loss, and was identified as needing a regular diet with specific supplements and feeding assistance. Despite physician orders for weekly weights, the facility missed obtaining a required weight during the first week, and subsequent weights showed a rapid and significant decline in body weight. Throughout the resident's stay, food intake records indicated that the resident was consuming only 0% to 25% of meals, and multiple notes documented ongoing poor intake, difficulty swallowing, and a preference for fluids over solid foods. Although interventions such as supplements and a modified diet were ordered, the facility did not consistently implement or adjust these interventions in response to the resident's continued weight loss and declining intake. The care plan noted the need for feeding assistance and monitoring for signs of dysphagia, but documentation showed that these needs were not adequately addressed or modified as the resident's condition worsened. The facility's Registered Dietician did not identify or address the resident's significant weight loss until after the resident was transferred to the hospital for extreme weakness, lethargy, and refusal of food and fluids. Additionally, a dietary evaluation following the weight loss was incomplete and lacked documentation of interventions to prevent further decline. The facility's own policy required ongoing evaluation and modification of interventions for significant weight loss, but this was not followed, resulting in a severe weight loss of over 15 pounds within four weeks of admission.

Plan Of Correction

Element I- Resident #305 was identified and no longer resides at the center. All residents who reside at the center have the potential to be affected by the deficient practice. Element II- The facility completed an initial audit that consisted of pulling a PCC report for all residents who triggered for significant weight loss in the past 90 days. The facility reviewed the residents on report to ensure adequate interventions are in place to further weight loss. Element III- During morning clinical meetings, the facility IDT will review the EMR clinical dashboard for any resident who triggers for less than 50% of meal consumption and/or significant weight loss. The IDT will immediately assess the nutritional needs of those residents to ensure adequate interventions are consistently implemented and/or modified to prevent further weight loss. The facility will conduct weekly risk management meetings to complete follow-up on all residents who are identified as having weight loss and/or poor appetite. The facility will educate the RD/Designee, and members of the IDT which includes the DON, MDS, Unit Managers, and the Certified Dietary Manager on the Nutrition Monitoring and Management policy to promptly identify risk and address any concerns regarding weight loss or poor appetite. Element IV- The Registered Dietician/Designee will audit the medical records of 5 residents with triggered weight loss, four times over four weeks, then monthly for three months to ensure the facility is assessing, monitoring, and reviewing nutritional needs and intervention to prevent further weight loss of its residents. The audit results will be given to the administrator who will provide them to the QAPI committee for review and recommendations. Element V- The Administrator is responsible for achieving and maintaining compliance, the compliance date is 6/2/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate an allegation of sexual abuse involving one resident. The resident was admitted to the facility, later went to the emergency room, and upon return, a review of their clinical record showed a progress note indicating the resident woke up confused and believed there was a man in their room. The facility's investigation file revealed that the only interviews conducted were with the resident's responsible party and two male staff members from the unit. No interviews were conducted with other staff, such as the assigned nurse, nurse aide, other staff present at the time of the allegation, the nurse who documented the resident's report, or any other residents. The Administrator/Abuse Coordinator confirmed that no additional staff or residents were interviewed and was unaware of the earlier report made by the resident about a man in their room. The facility's policy required a careful and deliberate investigation, including gathering statements from the alleged victim and witnesses, and ensuring all relevant information was reported and recorded. The investigation did not meet these requirements, as key staff and potential witnesses were not interviewed, and relevant information was not fully gathered.

Plan Of Correction

Element I: Resident #304 continues to reside in the facility and states that she feels safe. She was physically assessed by the charge nurse and provider. Resident #304 is followed by the facility social worker with no effect to mood or routine noted. The allegation of abuse was investigated and not verified. All residents have the potential to be affected by this citation. Element II: An initial “care concern” audit was completed to ensure that there were not any existing or new allegations of abuse. There was nothing remarkable to report. Element III: The Senior Administrator educated the facility administrator on the facility policy titled, “Nursing Administration...Subject: Abuse and Neglect.” The Senior Administrator also provided education on the contents of a proper investigation, including, but not limited to, reviewing PCC documentation. The facility educated its staff on abuse reporting. Element IV: The Senior Administrator will perform weekly audits on any investigative files should the need arise, to ensure that necessary contents are provided. The findings from those audits will be reviewed by the administrator and submitted to the QAPI committee for review and recommendation. Element V: The Administrator is responsible for achieving and maintaining compliance with

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with hemiplegia, hemiparesis, and severely impaired cognition required partial to moderate assistance for shower transfers. During a shower, a CNA attempted to transfer the resident alone, despite the resident indicating she needed help. The resident subsequently fell to the floor on her knees and toes. The incident was not documented by the day shift staff at the time of the fall, and there was no immediate assessment or documentation of the event. The fall was only reported later during the midnight shift when the resident self-reported the incident and complained of pain in both lower extremities. An LPN documented the resident's account and provided pain medication, and a STAT x-ray was ordered. However, there was no documentation of a timely assessment or notification of management, the physician, or the resident's responsible party at the time of the fall, as required by facility policy. Further review revealed that the incident report was completed after the fact, and there was no documented investigation to determine the root cause of the fall. The post-fall assessment was initiated but left incomplete and not locked. The DON confirmed that there was no additional documented investigation and could not recall which staff were involved in the transfer or in assisting the resident after the fall. Facility policy required immediate assessment, documentation, and investigation, none of which were completed in a timely manner for this incident.

Plan Of Correction

Resident # 303 is currently not in the facility (unrelated to this citation). Resident 303's root cause for the incident was identified post-incident. The resident was assessed with orders for x-rays of her knee, ankle, hips, and back related to pain. No abnormal findings were identified. The resident's care plan was updated to have 2-person assistance with transfers. CNA no longer employed at the facility. Nurse Tyonna Hayes-King was provided 1:1 education on the Fall Management policy, with emphasis on what is considered an incident, timely assessment of a resident post-fall with investigation to determine root cause analysis, and reporting/documentation of all incident/accidents to the Director of Nursing. All residents have the potential to be affected by the deficient practice. An audit was conducted of all resident incident/accidents from the past 90 days to ensure all residents with incident/accidents were assessed, investigation completed to determine root cause analysis, and documentation, and care plans updated in the resident medical record. The DON/designee spoke with all residents who were able to be interviewed for any incident/accident/falls that have not been reported. None were identified. The DON/designee will review all incident/accidents from the previous day/weekend during daily clinical meetings to ensure residents with incident/accidents have been assessed timely after a fall, and investigation is completed to determine root cause analysis. The DON/unit managers will provide focused oversight during daily rounds on the units and provide educational opportunities and reminders to staff who provide care to residents to ensure any incidents that occur while providing care are immediately reported for investigation. This will include random interviews with residents while rounding daily. By 5/21/2025, licensed nurses and certified nursing assistants will be educated on the Best Practice Fall Management policy with emphasis on what is considered a fall (examples of residents being lowered to the floor), head-to-toe assessments of residents in a timely manner, investigations to determine root cause analysis, and reporting of incident/accidents. The DON/designee will audit all risk management reports weekly for 4 weeks and then monthly for 3 months or until substantial compliance has been maintained to ensure that nurses are following the policy for risk management and falls, with emphasis on assessing residents in a timely manner and investigation to determine root cause analysis for falls. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain STAT laboratory tests as ordered by a physician for a resident who experienced a change in condition. The resident, admitted with multiple serious diagnoses including orthopedic aftercare following amputation, severe protein-calorie malnutrition, peripheral vascular disease, and acute kidney failure, was noted by nursing staff to have decreased oral intake, weight loss, and increased weakness. On the day of concern, the physician ordered STAT comprehensive metabolic panel (CMP) and complete blood count with differential (CBCD), along with other interventions, due to the resident's declining condition. However, there was no documentation that the STAT labs were completed, and no results were found in the medical record. During the survey, facility staff confirmed that the contracted laboratory did not provide STAT lab services on the day the order was placed, and that such labs would not be performed until the following week unless the resident was transferred to a hospital. The facility's laboratory contract did include provisions for STAT services, but staff stated these were not available in practice. The resident's condition continued to deteriorate, leading to further physician notification and eventual transfer out of the facility. No further explanation or documentation regarding the missing STAT labs was provided by the facility during the survey.

Plan Of Correction

Resident #305 no longer resides in the facility. All residents have the potential to be affected by this citation. Nurse Mary Bryant was given 1:1 education related to timely execution and ordering of labs by the provider and follow-up. On 5/21/2025, an audit was completed on all residents from the past 90 days for any labs ordered by the physician/provider that were not obtained/documented. Any lab noted to be ordered that was not obtained, the physician was notified, and labs were re-ordered per the physician. Any labs verified as being drawn, with no evidence of documentation in the resident's medical record, was followed up with the provider for review and input into the resident's medical record. The DON/unit managers/designee will review the EMR orders portal daily for labs pending confirmation to ensure that labs ordered by the provider are confirmed and ordered by the charge nurse prior to them being cleared. The DON/unit managers/designee will check the lab portal daily for timely results of ordered labs. Lab results will be communicated to the physician for follow-up and documentation. By 5/21/2025, licensed nurses will be educated on the policy of laboratory services, specifically ensuring that resident labs ordered by the provider are carried out when ordered and stat labs ordered and follow-up as ordered. Education will include the notification of the provider upon receipt of lab results and documentation in the resident's medical record. The DON/designee will conduct random audits on 5 residents' medical records weekly for 4 weeks, then monthly thereafter for 3 months or until substantial compliance has been maintained. These audits aim to ensure that residents' labs are carried out when ordered, with follow-up by the physician and documentation in the resident's medical record. The results of the audits will be presented to the QAA committee for review and consideration of further corrective actions. The DON will be responsible for assuring substantial compliance is attained through this plan of correction by 6/2/2025 and for sustained compliance thereafter.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident was admitted to the facility and later reported to have been sexually abused. The clinical record showed that the resident expressed confusion and reported to a nurse that she believed a man had been in her room. Subsequently, while at the hospital, the resident alleged to police that she had been raped by a male caregiver, but later denied the allegation. The facility's investigation file indicated that only the resident's responsible party and two male staff members from the unit were interviewed. No interviews were conducted with other staff, such as the assigned nurse, nurse aide, other staff present at the time, the nurse who documented the initial report, or other residents. The facility's abuse and neglect policy required a thorough investigation, including gathering statements from the alleged victim and witnesses, and ensuring all relevant information was reported and recorded. However, the investigation did not include interviews with all potentially relevant staff or residents, and the Abuse Coordinator was unaware of the initial report made by the resident to the nurse. The documentation and investigation process did not meet the facility's stated policy requirements for a careful and deliberate investigation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program for all 82 residents, as evidenced by the mishandling of a MRSA infection case. A resident was informed by their dermatologist that a culture from a cyst on their head tested positive for MRSA, a contagious infection. Despite being placed on contact precautions and started on an antibiotic, the facility did not adequately clean the resident's room or ensure staff wore appropriate protective equipment. The resident reported that staff were not wearing gowns during care and that the facility did not notify external providers about the infection when the resident was transported for physical therapy and other appointments. The facility's infection control surveillance program was found lacking, with no infection control data, including surveillance, line listing, mapping, and analysis reports, available for November 2024, December 2024, and January 2025. The Director of Nursing was unaware of the MRSA case and any potential trends in the facility, and the Infection Control Preventionist was absent during the survey. The Administrator confirmed that the last Quality Assurance meeting did not review November's infection control report, and no additional data was provided before the survey concluded. The facility's policy on infection prevention and control mandates ongoing monitoring and documentation of infections, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper functioning of the hot water supply, affecting all 82 residents. The deficiency was identified when it was reported that the facility had no hot water from January 11 to January 16, 2025, due to both hot water boilers failing. During an interview, the Maintenance Director (MD C) confirmed the lack of hot water and revealed that the boilers had not undergone the required CSD-1 inspection in 2024. The inspection was delayed because the boilers needed maintenance and cleaning, and although a quote was sent to the corporate office, no further action was taken. The facility's preventive maintenance policy requires regular inspections and maintenance of equipment, including boilers, to ensure compliance with applicable codes. However, the facility did not have documentation of the annual CSD-1 inspection for 2024 or 2023, only a receipt of service. The CSD-1 code mandates that controls and safety devices of boilers be tested annually, and the facility failed to comply with this requirement, leading to the prolonged hot water outage.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the physician evaluated the total program of care for a resident, specifically regarding a newly developed skin impairment. The resident, who had a history of type 2 diabetes mellitus and lymphedema, reported a pus-filled blister on his scalp to the attending physician. The physician initially dismissed it as a common condition for diabetics and prescribed an antibiotic, Keflex, without documenting the condition properly in the medical records. The resident, concerned about the unusual nature of the blister, sought a second opinion from a dermatologist, who diagnosed the condition as MRSA, a contagious infection. Despite the dermatologist's diagnosis and the resident's notification to the facility, the attending physician failed to document the MRSA diagnosis or the treatment plan in the medical records. Progress notes from the physician repeatedly indicated no new concerns and did not mention the skin impairment or the MRSA diagnosis. The resident's medical records showed orders for antibiotics and contact precautions for MRSA, but these were not reflected in the physician's documentation. Interviews with the physician and the Director of Nursing revealed a lack of thorough documentation and follow-up on the resident's condition. The physician admitted to a documentation error and could not provide evidence of proper assessment or follow-up for the skin impairment. The Director of Nursing confirmed that the facility's expectations for physician evaluations were not met, as the documentation lacked accuracy and thoroughness regarding the resident's change in condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate assistance with activities of daily living (ADLs) for a resident, specifically in the areas of regular bathing and transfers. The resident, identified as R803, was observed waiting for assistance to transfer from their bed to a wheelchair for approximately two hours. The resident reported that the CNA was aware of their need but did not return to assist after helping another resident with eating. The resident also indicated that they rarely received showers due to the staff's reluctance to help them, despite needing maximal assistance for such tasks. The medical record review revealed that R803 had only received two showers since their admission, with no documented refusals of showers, except for two instances where the resident chose not to have their hair washed. The Director of Nursing confirmed that residents should be offered showers at least twice a week and that staff should document when a shower is provided or refused. However, there was no additional documentation to support that R803 had been offered or provided scheduled bathing as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly identify, monitor, and assess a skin impairment for a resident, R802, who had consulted with a physician about bumps on his scalp. Despite being informed by the resident that the bumps were spreading and having a dermatologist appointment, the facility did not document any skin impairments on the resident's head or scalp. The resident was later diagnosed with MRSA by the dermatologist, but this information was not adequately followed up by the facility. Interviews and record reviews revealed that the resident had informed the facility of his dermatologist appointment and provided the paperwork to a registered nurse. However, there was no documentation of the skin impairment in the resident's clinical record, and the facility's staff, including the attending physician and the Director of Nursing, were unaware of the MRSA diagnosis. The facility's protocols for documenting and following up on new skin impairments were not adhered to, as evidenced by the lack of documentation and assessment of the resident's condition. The facility's failure to document and follow up on the resident's skin condition and MRSA diagnosis was further compounded by the lack of communication and coordination among the care team. The attending physician and registered nurse provided conflicting accounts of the resident's treatment, and the Director of Nursing was unaware of the MRSA diagnosis despite existing physician orders for treatment and contact precautions. This lack of documentation and follow-up highlights a significant deficiency in the facility's care and monitoring processes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that personal clothing items sent to the laundry were returned to residents in a timely manner. During a Resident Council meeting, several cognitively intact residents reported missing clothing items, including green shirts, pants, and other personal garments. Despite reporting these issues, the residents did not receive their clothing back nor compensation to replace them. Past Resident Council Minutes also documented similar grievances, indicating a pattern of missing clothing items and delayed returns. Interviews with facility staff revealed awareness of the issue. The Activity Director acknowledged the complaints and stated that grievance forms were completed and forwarded to the Administrator. Laundry staff, employed by an outside company, noted that the problem often arose from facility staff failing to label clothing bags with residents' names and room numbers, making it difficult to return items correctly. The Housekeeping Director confirmed the issue, showing the surveyor bins of unlabeled laundry, which complicated the return process. The Administrator recognized the problem and mentioned that some residents or their families were reluctant to label clothing, although alternative solutions were acknowledged.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the safe and secure storage of medications, as observed during a medication administration session with an LPN. Loose, unidentifiable medications were found in the medication cart labeled as Cart C Hall. Specifically, the cart contained several loose pills, including a round white pill with no identifier, two round white pills stamped 337, a half peach-colored pill, a round pink pill stamped R50, a quarter white pill, a round pink pill stamped IG/207, and a half white round pill. The LPN acknowledged that these medications were not properly stored and should not be loose without patient identifiers. Additionally, the medication room identified as Traverse had two stacked refrigerators, with the top refrigerator storing insulin lacking a thermometer and temperature logs. The LPN confirmed that the refrigerator's temperature should be monitored and recorded, but was unsure why the thermometer was missing. The Director of Nursing was informed of these observations and acknowledged the need for temperature monitoring in the refrigerator and proper storage of medications in the cart. The facility's policy on medication access and storage, dated July 2018, requires medications needing refrigeration to be kept in a refrigerator with a thermometer for temperature monitoring.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain clean storage of linens and resident clothing in the laundry room, leading to contamination with dust and dryer lint. During a tour of the laundry room, two linen carts containing clean folded linens, comforters, and clothing were observed to be covered with large amounts of thick white fuzzy debris. The right cart's green protective sheet panel was lifted to reveal a cardboard box and wheelchair adaptive equipment also covered with the debris. The left cart had folded cardboard boxes used as a top shelf, which were covered with dusty material, and a half-consumed water bottle was found on it. Housekeeping Manager B and Assistant Housekeeping Manager C acknowledged the presence of clean laundry on the carts and confirmed the contamination with dust and dirt, deeming the conditions unhygienic. The facility was unable to provide a clean laundry storage policy by the end of the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's right to be free from verbal abuse by staff. The incident involved a resident with Chronic Obstructive Pulmonary Disease and Adjustment Disorder, who was independent in most activities of daily living and had intact cognition. The resident alleged that a Certified Nursing Assistant (CNA) verbally threatened him with physical harm during an altercation at the nurse's station. The resident reported that the CNA told him she would 'beat his ass' after he refused to leave the nurse's station and began swearing at her. Witnesses, including another CNA and a receptionist, confirmed hearing the CNA use threatening and abusive language towards the resident. The facility's investigation included interviews with the involved parties and a review of the resident's medical record and the CNA's personnel file. The CNA admitted to using inappropriate language but denied making any threats. However, both the receptionist and another CNA corroborated the resident's account, stating they heard the CNA use threatening language. The facility determined that the CNA violated multiple work rules, including using profane language and failing to show respect to the resident. The Director of Nursing acknowledged that the CNA's behavior was unprofessional and confirmed that the CNA was terminated for multiple violations of work rules. The facility also conducted a house-wide re-education of staff on abuse and neglect policies to prevent future incidents. The facility's policy on resident rights and abuse was reviewed, emphasizing the importance of providing care in an environment free from any type of abuse, including verbal abuse.