Medilodge At The Shore
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Haven, Michigan.
- Location
- 900 South Beacon Boulevard, Grand Haven, Michigan 49417
- CMS Provider Number
- 235356
- Inspections on file
- 27
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Medilodge At The Shore during CMS and state inspections, most recent first.
The facility did not follow its pressure injury prevention and wound management policies, resulting in missed skin assessments, delayed provider notifications, incomplete wound documentation, and failure to update care plans for residents with pressure injuries. Several residents did not receive wound treatments as ordered, and staff interviews revealed issues with communication, care plan adherence, and timely response to resident needs.
Two cognitively intact residents were involved in a physical altercation, with one resident observed by a CNA to be hitting the other. Although staff intervened and separated the residents, the incident was not reported to the state survey agency within the required timeframe, as the NHA was initially informed it was only a verbal argument. The delay in reporting and lack of clear documentation led to a deficiency for not timely reporting suspected abuse.
A resident with multiple complex diagnoses did not have her care plan updated to reflect new physician orders, changes in condition such as new onset seizures, or deterioration of a pressure injury. The care plan also failed to include specific dietary orders, individualized food preferences, and effective pain management interventions. Staff were observed using inappropriate feeding utensils and not consistently following the care plan, resulting in incomplete and inaccurate care.
Staff failed to follow Enhanced Barrier Precautions and infection control protocols during care for two residents with complex medical needs, including not wearing required PPE, improper glove use, inadequate hand hygiene, and mixing clean and soiled linens. Additionally, the facility did not properly track or document staff illnesses, omitting key information needed for infection surveillance.
The facility did not establish or follow required policies and procedures for administering flu and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
Three residents experienced medication administration errors, including controlled pain medications given at incorrect intervals without documented rationale and a cardiac medication administered without required pre-dose vital sign assessments. Facility records lacked appropriate documentation to justify these deviations from physician orders and facility policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
A resident with hemiplegia and cognitive impairment did not receive prescribed splint therapy for the left upper extremity as ordered, with multiple missed applications and lack of follow-up documentation or re-approach by licensed staff. The splint was found unused in the resident's drawer, and staff interviews confirmed the care plan was not consistently followed.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided according to regulatory standards.
A resident with severe cognitive impairment and multiple medical conditions did not receive a required face-to-face visit from a physician or non-physician practitioner within the mandated 60-day interval after the initial 90 days post-admission. Review of records and staff interviews confirmed a gap of over 90 days without a documented visit, despite the resident receiving care from an outside provider and experiencing a hospitalization during this period.
A pharmacist made a medication regimen review recommendation for a resident with severe cognitive impairment and multiple diagnoses, but the facility failed to document the recommendation or show that a physician reviewed or acted on it. Required documentation was missing from the EMR, and attempts to retrieve it from an outside provider were unsuccessful, resulting in noncompliance with facility policy.
Surveyors found that individual medication containers, such as a nasal spray and a diskus, were not labeled with resident names inside the medication cart, even though the outer boxes were labeled. Nursing staff confirmed that the usual practice is to label each container to prevent mix-ups, but this was not done in these cases.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with multiple complex medical conditions was started on a new Clonidine transdermal patch, but the facility failed to remove the old patch when applying a new one and did not initiate monitoring for side effects after starting the medication. The resident was later found unresponsive with two patches still in place and was sent to the ER, where staff confirmed the medication administration error.
Two residents receiving tube feeding did not have their feeding equipment properly labeled or maintained according to standards of practice. Feeding solution bottles lacked required information such as initiation date, time, and ordered rate, and syringes were not separated, rinsed, or dried between uses. The DON confirmed these lapses and noted the absence of a facility policy addressing these practices.
The facility failed to meet the needs of two residents by not ensuring timely response to call lights. A resident with Alzheimer's had her call light out of reach, while another with multiple sclerosis experienced delays in response, especially during the third shift. Staff interviews confirmed similar complaints from other residents.
The facility failed to provide quality care to two residents. A resident with a feeding tube had incorrect wound care orders followed, leading to pus and a foul smell at the site. Another resident with Alzheimer's had outdated nursing notes, and a low blood pressure reading was not promptly addressed. These deficiencies highlight lapses in following care orders and timely documentation.
An unattended medication cart was found unlocked with resident information visible and contained loose unidentified pills and an unsecured metal box with controlled substances. An LPN acknowledged the oversight, and another LPN confirmed that medication carts and narcotic boxes should always be locked when unattended. The facility's policy requires all medications to be stored securely.
The facility failed to provide adequate supervision and timely root cause analysis for fall incidents involving three residents, leading to significant injuries. Despite having care plans identifying them as at risk for falls, interventions were not effectively implemented, and residents were often left unsupervised. This resulted in multiple falls, with one resident sustaining a wrist fracture and another requiring emergency treatment for a laceration.
The facility failed to properly assess and implement advanced directives for two residents. One resident, not her own responsible party, had an advanced directive signed by herself instead of her Durable Power of Attorney. Another resident, who was her own responsible party, had an advanced directive incorrectly signed by her husband.
A facility failed to complete timely PASARR Level I and II evaluations for a resident with multiple diagnoses, including dementia and schizophrenia. The social worker did not follow up with the OBRA Coordinator to ensure the Level II Evaluation was scheduled, assuming the coordinator would see the need in the system. The Director of Nursing acknowledged the delay and lack of a tracking system, noting the social worker's failure to act promptly.
A resident with multiple health issues, including dysphagia and cognitive deficits, was observed eating alone without staff assistance, contrary to his care plan requiring one-person assistance. Despite being on a puree diet and receiving speech therapy, the resident was left unattended during meals, highlighting a failure in following the prescribed care plan.
A resident with multiple health issues, including dysphagia, was not adequately assessed for hydration and food intake. The resident repeatedly requested cold water but was not provided with appropriate thickened liquids due to a shortage. Discrepancies in fluid intake documentation were noted, with staff recording incorrect amounts. Observations showed the resident consumed minimal food and fluids, and staff assistance was inconsistent.
A facility failed to follow up on dialysis concerns for a resident with end-stage renal disease. The resident experienced issues such as cramping and hypotension during dialysis, but the facility did not complete necessary documentation or address these concerns. Interviews revealed a lack of clarity on responsibility and policy regarding dialysis communication.
A facility failed to ensure a pharmacist reported drug regimen irregularities to a physician for a resident with multiple diagnoses, including chronic kidney disease and bipolar disease. Despite medication reviews noting irregularities, the reports were not documented in the resident's medical record, and the DON could not obtain the necessary documentation from the pharmacist, leading to a potential lack of physician awareness.
A resident with chronic respiratory issues received Oxycodone five hours earlier than prescribed, contrary to the physician's order for 12-hour intervals. The facility failed to document the medication error or notify the physician, and no monitoring occurred post-administration. The DON confirmed the deviation from the policy, which allows a one-hour window for scheduled medications.
The facility failed to maintain complete medical records for three residents, missing hospice visit notes and a medication irregularity report. The DON struggled to locate hospice notes for two residents, eventually obtaining them from the hospice company. For another resident, a medication irregularity report was not documented in the electronic health record, contrary to facility policy.
A resident with an IV line was not provided with proper Enhanced Barrier Precautions (EBP) as required. Two CNAs were observed providing care without gowns, despite instructions to wear them for high-contact activities. The Infection Control Preventionist confirmed the oversight and noted the absence of PPE supplies in the resident's room.
A facility failed to offer a pneumococcal vaccine to a resident with diabetes, heart failure, and COPD, as required by their policy. The resident, who was cognitively intact, had previously received a PCV23 vaccine but was not offered the PCV20 vaccine upon admission. The oversight was identified during an immunization audit by the Infection Control Preventionist.
A resident with a history of stroke was admitted with existing wounds, but the facility failed to assess, monitor, and document these wounds accurately. The facility did not notify the physician or DPOA of new and worsening pressure injuries, and treatments were not completed as ordered. The resident was later hospitalized with severe sepsis due to an infected ulcer, highlighting the facility's inadequate wound management and communication.
The facility failed to ensure routine monitoring of patient care equipment, potentially affecting the safety of all residents. The DON reported no log for monitoring equipment, and while mechanical lifts are checked by an external company, other equipment like wheelchairs and bed rails are not routinely monitored. An electronic communication program exists for repairs, but no formal preventative maintenance system is in place.
The facility failed to ensure proper hand hygiene during meal tray delivery and incontinence care, leading to potential cross-contamination. Staff were observed not washing hands before or after entering resident rooms, and a CNA did not change gloves or perform hand hygiene during incontinence care for a resident with colitis.
Failure to Implement Pressure Ulcer Prevention and Treatment Protocols
Penalty
Summary
The facility failed to implement its policy for pressure injury and wound management and did not ensure that treatments were completed as ordered for multiple residents with skin integrity issues. One resident, a female with dementia, Alzheimer's disease, dysphagia, peripheral vascular disease, and urinary incontinence, was identified as high risk for pressure injuries but did not receive consistent skin assessments or timely notification to the provider or responsible party when a pressure injury developed. Documentation showed missed skin assessments, delayed notification of a new pressure injury, and incomplete wound assessments. The care plan for this resident did not include specific interventions such as a turning/repositioning schedule, and interventions were not updated in response to wound deterioration. Staff interviews revealed that the resident was often left wet and not repositioned as required, with communication gaps and staffing issues contributing to missed care. Other residents with wounds or pressure injuries also did not receive wound treatments as ordered, with documentation showing missed treatments on several occasions. Staff interviews indicated that some CNAs did not follow care plans, and there were reports of staff not assisting with care, leaving residents waiting for extended periods, and not responding promptly to call lights. Cognitively intact residents reported waiting so long for assistance that they became incontinent, and observed staff ignoring call lights or engaging in personal conversations instead of providing care. Review of facility policy and nursing standards highlighted the requirement for individualized care plans, timely provider notification of wound changes, and consistent implementation of interventions based on risk assessments. The facility did not consistently document or communicate interventions, modify care plans in response to wound deterioration, or ensure that all staff were aware of and followed the required interventions. These failures resulted in residents not receiving appropriate pressure ulcer care and prevention as required by facility policy and professional standards.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving two cognitively intact residents who were involved in a physical altercation. According to the records, one resident was observed by a Certified Nursing Assistant (CNA) to be hitting another resident in the upper chest and collarbone area while the other resident was lying in bed in a defensive posture. The CNA immediately intervened and separated the residents. Statements from multiple staff members, including the CNA and a Registered Nurse (RN), confirmed that the incident involved physical contact, with the CNA consistently stating she witnessed one resident hitting the other. Despite these observations, the Nursing Home Administrator (NHA) was initially informed that the incident was only a verbal argument. The NHA did not receive or document clear information about the physical nature of the altercation until after further investigation the following day. The facility's own policy requires that allegations of abuse be reported to the Administrator, state agency, and other required authorities immediately, but no later than two hours after the allegation is made. However, the incident was reported to the state survey agency approximately 17 hours after it occurred. The delay in reporting was compounded by inconsistent communication and documentation. The NHA did not document a follow-up conversation with the CNA, who maintained her original statement about witnessing physical abuse. Additionally, the NHA did not have the CNA revise her statement to reflect any uncertainty, as claimed during the investigation. The facility's failure to promptly and accurately report the abuse allegation as required by policy resulted in a deficiency.
Failure to Update and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed, revised, and implemented according to the resident's changing needs and physician orders. The resident, an elderly female with diagnoses including dementia, Alzheimer's disease, dysphagia, peripheral vascular disease, and urinary incontinence, had multiple care needs that were not accurately reflected or updated in her care plan. For example, her care plan did not address the need for a geri chair with direct supervision as ordered, nor did it reflect the restriction against using a broda chair. Additionally, the care plan failed to include the administration of pain medication one hour prior to wound dressing changes, despite a physician's order for this intervention. The resident experienced new onset seizures, but her care plan did not include this diagnosis or interventions for seizure precautions and injury prevention. There was also a lack of updated interventions following the deterioration of her unstageable pressure injury, such as specific positioning or offloading measures. The care plan did not reflect the need for frequent repositioning as documented in provider notes, nor did it address the significant weight loss the resident experienced over a three-month period. Dietary orders for pureed food and nectar thick liquids by teaspoon were not fully incorporated into the care plan, and the use of inappropriate feeding utensils, such as straws, was observed during meal assistance. Furthermore, the care plan lacked individualized details regarding the resident's food preferences, dislikes, and effective non-pharmacological pain interventions. Staff interviews and observations confirmed that the care plan was not consistently referenced or followed, leading to discrepancies between the resident's documented needs and the care provided. These omissions and failures to update the care plan resulted in incomplete and potentially inappropriate care measures for the resident.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by multiple observations of staff not adhering to Enhanced Barrier Precautions (EBP) and proper infection control practices. In one instance, two certified nurse aides provided a bed bath to a resident with a feeding tube and severe cognitive impairment without wearing the required gowns, despite clear signage indicating EBP was necessary. The aides also failed to change gloves between soiled and clean activities, left the room with soiled gloves without performing hand hygiene, and continued care after inadequate handwashing. Both aides acknowledged awareness of the EBP requirements but admitted to not following them during care. Another resident, who was cognitively intact but nonverbal and dependent on staff for care, was observed receiving morning care from a certified nursing assistant who did not use any PPE, despite signage indicating EBP was required. The assistant used the same gloves and washcloths for both clean and soiled areas, mixed clean and dirty linens, and failed to perform hand hygiene when leaving and re-entering the room. A registered nurse assisted in transferring the resident but did not ensure the assistant donned appropriate PPE, even though the nurse was aware of the requirements and the assistant's noncompliance. Additionally, the facility's infection surveillance system was found lacking in tracking and documenting staff illnesses. The call-in log for staff absences due to illness did not consistently record essential information such as the unit worked, specific symptoms, onset dates, or return-to-work dates. The infection control preventionist confirmed these gaps, and there was no documentation of follow-up or analysis to identify potential clusters or prevent the spread of infection, contrary to facility policy and procedures.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards for medication administration for three residents. For one resident, a controlled pain medication (Norco) was administered at intervals shorter than the physician-ordered four hours, with doses given three hours apart and no documentation providing a rationale for this deviation. Another resident received Percocet doses at intervals of 2 to 2.5 hours instead of the ordered four hours, with no documentation explaining the early administration. In both cases, the medication administration records and electronic medical records lacked required documentation to justify the timing discrepancies. A third resident, prescribed Metoprolol with specific parameters to hold the medication if blood pressure or heart rate were below set thresholds, did not have vital signs assessed prior to several evening doses. Instead, morning vital sign results were inappropriately documented as if they were taken before the evening doses. The facility's own medication administration policy requires obtaining and recording vital signs when applicable or as ordered by the physician, and to hold medication for vital signs outside prescribed parameters. The Nursing Home Administrator confirmed these errors and reported no additional documentation to refute the findings.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently provided to affected residents.
Failure to Follow Physician Orders and Care Plan for Splint Application
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders and the care plan for a resident with hemiplegia, hemiparesis, vascular dementia, and pseudobulbar affect, who required a splint for the left upper extremity. The physician's order specified that the splint should be applied upon rising, removed for lunch, reapplied after lunch, and removed at bedtime, as tolerated by the resident. Multiple observations revealed that the resident was not wearing the splint at the required times, and the resident reported that the splint was never applied and was unaware of its location. The splint was later found in the resident's drawer, and the resident allowed it to be applied without resistance. Documentation showed that there were 21 instances where the splint application did not occur, with no follow-up documentation by licensed staff to address refusals or investigate the root cause. The care plan indicated that if the resident refused, staff should encourage compliance and document refusals, but there was no evidence that this was consistently done. Interviews with staff confirmed that the care plan was not followed, and communication regarding refusals was lacking.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Ensure Timely Face-to-Face Physician Visits
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician or non-physician practitioner conducted a face-to-face visit with a resident at least once every 60 days after the initial 90 days post-admission, as required. The resident in question was admitted with multiple diagnoses, including dementia, diabetes, bipolar disorder, depression, and hepatic encephalopathy, and was assessed as being severely cognitively impaired. Review of the resident's electronic medical record showed no documentation of a physician or non-physician practitioner visit between late February and early June, a period of 93 days, which exceeded the required interval for such visits. The Director of Nursing confirmed that there was no evidence in the facility's records of a face-to-face visit during this time frame. Although the resident received physician services from an outside company and had been hospitalized for part of the period in question, there was still a significant gap where no documented visit occurred. The deficiency was identified through both record review and staff interview, with the DON agreeing that a visit should have taken place within the required timeframe.
Failure to Document and Communicate Pharmacy Medication Review Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacist's medication regimen review recommendation was properly documented and communicated for one resident. The resident in question was admitted with multiple diagnoses, including dementia, bipolar disorder, and depression, and was assessed as being severely cognitively impaired. On a specific date, the pharmacist indicated that a comment or recommendation had been made regarding the resident's medication regimen, as noted in the progress note. However, a review of the resident's electronic medical record did not reveal any documentation of what the pharmacist's recommendation or comment was, nor any evidence that the physician had reviewed or acted upon it. Interviews with the DON confirmed that the expected documentation, which should have been scanned into the resident's EMR, could not be located. Further attempts to obtain the report from an outside company providing physician services were unsuccessful, as they also did not have a copy of the relevant pharmacy report. The facility's policy requires that any irregularities identified by the pharmacist be reported to the attending physician, medical director, and DON, and that the physician document their review and any actions taken in the resident's medical record. In this case, there was no documentation to confirm that these steps were followed.
Failure to Properly Label Individual Medication Containers
Penalty
Summary
During an inspection of the Southwest Medication Cart, surveyors observed that medications were not appropriately labeled in accordance with professional standards. Specifically, a box of Desmopressin Nasal Spray and a box of fluticasone and salmeterol were found with the respective residents' names on the outer boxes, but the individual nasal spray container and diskus inside the boxes were not labeled with any identifying information. This created a situation where, if the medication containers became separated from their boxes, it would not be possible to identify which resident they belonged to. Interviews with nursing staff confirmed that the standard practice is to label individual medication containers with the resident's name, either using pharmacy-provided labels or by writing the name directly on the item. Staff members acknowledged the importance of this practice, especially when multiple residents are prescribed the same medication, to prevent mix-ups. However, in these instances, the labeling procedure was not followed, resulting in a failure to ensure that all drugs and biologicals were properly labeled as required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential resident information or proper record-keeping were not followed as expected. No additional details regarding specific residents, staff actions, or the circumstances leading to the deficiency are provided in the report.
Failure to Remove Old Clonidine Patch and Monitor After New Medication Initiation
Penalty
Summary
The facility failed to follow professional standards for medication administration for one resident. A male resident with a history of recent brain bleed, left-sided weakness and paralysis, chronic kidney disease stage 4, morbid obesity, insulin-dependent diabetes mellitus, and a feeding tube was admitted and started on a new order for a Clonidine transdermal patch. The electronic medication administration record showed that the patch was to be applied weekly, but there was a delay in administration due to the patch not being available, resulting in it being placed two days late. Additionally, there was no new monitoring ordered to assess for side effects after starting this new medication. On a later date, the resident was found unresponsive with labored breathing and was sent to the emergency room. Upon arrival, two unidentified Clonidine patches were found on each of his upper arms, one from the initial application and one from the later application, indicating that the old patch had not been removed as required. Nursing home staff confirmed that the patches were old and should have been removed. The presence of multiple patches was noted as concerning by the ER staff, and the resident exhibited symptoms including extreme drowsiness, difficulty arousing, and periods of apnea.
Failure to Follow Standards of Practice for Tube Feeding
Penalty
Summary
The facility failed to follow standards of practice for tube feeding for two residents. For one male resident with paraplegia and protein-calorie malnutrition, observations revealed that the irrigation container and syringe used for tube feed flushes were left on the bedside table with the plunger inside the syringe, and the syringe was sitting in a graduated container containing clear liquid dated from the previous day. Additionally, the bottle of tube feed did not have the time it was initiated as required. The resident's electronic medication administration record indicated an order to change and label the feeding syringe and/or container every night shift, but this was not followed. For a female resident with spastic quadriplegic cerebral palsy who is dependent on tube feeding, the tube feed solution bottle did not have the ordered rate or the date the feed was initiated written on it. The syringe and plunger were not separated and were left together in a cylinder with clear liquid on the bedside table. During an interview, the DON confirmed that the tube feed bottles should be labeled with the date, time, and ordered rate, and that syringes and plungers should be separated, rinsed, and allowed to dry between uses. The DON also reported that the facility did not have a policy addressing these standards of practice.
Failure to Ensure Timely Response to Call Lights
Penalty
Summary
The facility failed to ensure that residents' needs were met in a timely manner and that call lights were within reach for two residents. Resident #6, a female with Alzheimer's and rheumatoid arthritis, was observed multiple times with her call light out of reach and covered by a hat, making it inaccessible. Despite being in bed and needing assistance, she was unable to notify staff due to the call light's placement. The facility's policy requires staff to ensure resident access to call lights, but this was not adhered to in the case of Resident #6. Resident #9, a male with multiple sclerosis and difficulty speaking, reported delays in staff responding to his call light, particularly during the third shift. His roommate corroborated these delays, noting that staff would sometimes dismiss the urgency of the call. Confidential staff interviews revealed similar complaints from other residents about the third shift staff being rough, rushed, and slow to respond to call lights. The facility's policy states that any staff member who sees or hears an activated call light is responsible for responding, yet this was not consistently practiced, leading to unmet needs for Resident #9.
Failure to Provide Quality Care for Residents
Penalty
Summary
The facility failed to provide quality care to two residents, leading to deficiencies in their treatment. Resident #1, a female with a history of cerebral aneurysm, stroke, and other medical conditions, was admitted with a feeding tube. The hospital discharge orders specified that the tube feed site should be cleaned with a dermal wound cleanser. However, the facility's electronic medication administration record indicated that normal saline was used instead. This discrepancy in care led to the resident's daughter observing pus and a foul smell from the tube site, which was confirmed by an observation showing pus-like drainage and a saturated drain sponge. Resident #6, a female with Alzheimer's and rheumatoid arthritis, exhibited severely impaired cognition. The facility's nursing progress notes for this resident were outdated, with the last entries made over a month apart. A low blood pressure reading was recorded on 11/17/24, but there was no documentation of physician notification or a timely re-check of the blood pressure until four days later. This lack of timely documentation and follow-up on the resident's condition indicates a failure to provide appropriate care according to the resident's needs.
Unsecured Medication Cart with Controlled Substances
Penalty
Summary
The facility failed to secure an unattended medication cart, which was observed on 01/08/25 at 7:20 AM. The cart, designated for rooms 1-15, was found with resident information displayed on the computer screen and was unlocked. Inside the cart, 14 different loose unidentified pills were found in the second drawer on the left side, and an unsecured metal box containing controlled substances was found in the second drawer on the right side. During an interview shortly after the observation, an LPN acknowledged the oversight, expressing regret. Another LPN confirmed that medication carts and narcotic boxes are required to be locked at all times when not attended by a nurse. The facility's policy on medication storage, last reviewed on 01/30/24, mandates that all medications be stored in locked compartments, with controlled substances requiring double lock and key.
Inadequate Supervision and Fall Risk Management
Penalty
Summary
The facility failed to provide adequate supervision and timely root cause analysis for fall incidents involving three residents, leading to significant injuries. Resident R48, a female with a history of bipolar disorder, epilepsy, and muscle weakness, experienced multiple falls resulting in a wrist fracture. Despite having a care plan that identified her as at risk for falls, interventions such as bed height adjustments and non-skid footwear were not effectively implemented. Observations revealed that R48's bed was often at an unsafe height, and she was left unsupervised, contributing to her falls. Resident R102, diagnosed with congestive heart failure, Alzheimer's disease, and muscle weakness, also suffered from multiple falls, one of which resulted in a laceration requiring emergency treatment. Her care plan included interventions like wheelchair anti-rollback and non-skid footwear, but these did not address her cognitive deficits or history of unsafe transfers. The facility failed to conduct thorough investigations or root cause analyses for her falls, and there was no evidence of increased supervision despite her known safety issues. Resident R465, a male with dementia and visual problems, was found sitting on the floor after an unwitnessed fall. His care plan included interventions for fall risk, but there were no specific measures for supervision. Observations showed that R465 was often left alone and did not know how to use his call light, indicating a lack of adequate supervision. The facility did not conduct a root cause analysis or implement new interventions following his fall.
Failure to Implement Advanced Directives
Penalty
Summary
The facility failed to accurately assess and implement advanced directives for two residents upon admission. Resident R102, a female with multiple diagnoses including congestive heart failure and Alzheimer's disease, was not her own responsible party. The facility did not have a signed advanced directive from R102's son, who was her Durable Power of Attorney. Instead, an advanced directive form was signed by R102 herself, despite her not being her own responsible party. The Director of Nursing confirmed the absence of contact with R102's son regarding the advanced directive. Resident R110, who was her own responsible party, also had issues with her advanced directive. Although R110 was listed as her own clinical responsible party, the facility had an advanced directive signed by her husband. The Director of Nursing acknowledged that R110 should have signed her own advanced directive. The advanced directive on record incorrectly had the husband's signature, indicating a failure in the process of obtaining and verifying the correct responsible party's signature.
Failure to Complete Timely PASARR Evaluations
Penalty
Summary
The facility failed to ensure timely completion of the Pre-Admission Screening and Resident Review (PASARR) Level I and Level II evaluations for a resident. The resident, who was admitted with multiple diagnoses including dementia, depression, anxiety, and schizophrenia, was identified as needing a PASARR Level II Evaluation by a specific date. However, the PASARR Level I Screening was completed late, and the Level II Evaluation was not completed at all. The social worker responsible for coordinating these evaluations did not follow up with the OBRA Coordinator to ensure the Level II Evaluation was scheduled, assuming instead that the coordinator would automatically see the need for it in the system. Interviews revealed that the social worker did not have a system in place for tracking and following up on PASARR evaluations, relying instead on the OBRA Coordinator to notify her of necessary actions. The Director of Nursing acknowledged the delay and the lack of a tracking system, noting that the social worker had not heard from the OBRA Coordinator for over 30 days after the Level I Screening was completed. Despite receiving an email from the OBRA Coordinator about the need for the Level I Screening, the social worker delayed its completion by 35 days, contributing to the overall deficiency in the resident's care assessment process.
Failure to Assist Resident with Eating as per Care Plan
Penalty
Summary
The facility failed to follow the care plan for a resident, identified as R465, who required assistance with eating. R465, a male resident with diagnoses including kidney failure, dementia, macular degeneration, dysphagia, and cognitive communication deficit, was observed eating independently on multiple occasions without staff assistance, despite his care plan indicating he needed one-person assistance for eating. On one occasion, R465 was observed eating lunch alone and requesting cold water, but he was unable to use the call light to request help. A CNA briefly entered the room to get thickened cold water but left R465 alone with his meal tray. Further observations revealed R465 eating breakfast alone in his room on two separate occasions. During an interview, the Registered Dietitian confirmed that R465 was on a puree diet with thickened fluids and was receiving speech therapy for swallowing problems. The Speech Therapy Progress note indicated that R465 had impaired cognitive-communication and swallowing functioning, which affected his ability to safely complete activities of daily living and meet his nutrition and hydration needs independently.
Failure to Provide Adequate Hydration and Nutrition Assessment
Penalty
Summary
The facility failed to adequately assess and provide for the hydration and food intake needs of a resident, identified as R465, who was reviewed for nutrition. R465, a male resident with kidney failure, dementia, macular degeneration, dysphagia, and cognitive communication deficit, required assistance with eating. On multiple occasions, R465 was observed requesting cold water but was unable to use the call light to alert staff. The Certified Nurse Aide (CNA) L was unable to provide cold thickened water due to a shortage in the kitchen and instead offered thickened milk, which R465 refused. The Registered Dietitian (RD) K later provided thickened Pepsi, which R465 accepted in small sips, but he continued to request thin liquids, which were not provided due to his swallowing problems. There were discrepancies in the documentation of R465's fluid intake. CNA L and CNA J provided conflicting accounts of the amount of fluid R465 consumed, with CNA J initially recording an incorrect amount due to a misunderstanding of the cup size. The Director of Nursing (DON) confirmed the error in the recorded fluid intake. Additionally, observations showed that R465 consumed minimal food and fluids during meals, and staff were not consistently present to assist or accurately document his intake. These issues highlight a failure in the facility's processes to ensure accurate assessment and documentation of R465's nutritional and hydration needs.
Failure to Follow Up on Dialysis Concerns
Penalty
Summary
The facility failed to provide appropriate follow-up care for a resident requiring dialysis services. The resident, who had multiple diagnoses including end-stage renal disease and diabetes, experienced issues during dialysis sessions, such as intradialytic cramping and symptomatic hypotension. Despite these concerns being documented by the dialysis center, the facility did not complete the necessary sections of the hemodialysis communication records upon the resident's return. This included missing vital signs, site observations, and documentation of the resident's response to pain. Interviews with the Unit Manager and the Director of Nursing revealed a lack of clarity regarding who was responsible for addressing the dialysis communication and what the facility's policy was. The Director of Nursing confirmed the absence of documentation addressing the resident's concerns and acknowledged that education for staff on completing dialysis forms had just begun. Additionally, there was no evidence that the facility was applying lidocaine cream as directed by the dialysis center.
Failure to Report Drug Regimen Irregularities
Penalty
Summary
The facility failed to ensure that a licensed pharmacist reported identified drug regimen irregularities to the physician for a resident reviewed for monthly pharmacist Medication Regimen Reviews. The resident, who was admitted to the facility with multiple diagnoses including chronic kidney disease, diabetes, visual hallucinations, and bipolar disease, had medication reviews conducted by the pharmacist on two occasions. However, the reports and recommendations from these reviews were not documented in the resident's electronic medical record, as required by the facility's policy. During the survey, the Director of Nursing (DON) was unable to locate the pharmacist's reports or notes detailing the irregularities found on the specified dates. Despite attempts to contact the pharmacist for copies of the recommendations, the facility did not provide any documentation related to the pharmacist's findings by the completion of the survey. This lack of documentation and communication resulted in the potential for the physician to be unaware of drug irregularities, which is a violation of the facility's policy on addressing medication regimen review irregularities.
Early Administration of Oxycodone
Penalty
Summary
The facility failed to adhere to the physician's ordered time frame for administering a controlled substance, Oxycodone, to a resident. The resident, who was admitted with chronic respiratory failure with hypoxia, asthma, and dementia, had a physician's order for Oxycontin to be administered every 12 hours. However, the medication was administered five hours early, at 7:00 AM, instead of the scheduled time. This deviation from the prescribed schedule was not documented as a medication error, and there was no evidence that the physician was contacted or that any incident or monitoring occurred following the early administration. The Director of Nursing (DON) acknowledged that medications with a scheduled time frame should be administered within one hour before or after the scheduled time unless otherwise ordered by a physician. Despite this policy, the facility's documentation did not reflect any identification or explanation of the medication error. The facility's policy on medication administration, which emphasizes adherence to professional standards and verification of medication details, was not followed in this instance. As of the survey exit, no additional information or explanation was provided regarding the incident.
Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete medical records for three residents, which could potentially hinder providers from having an accurate and complete picture of the residents' stay. For one resident, the electronic medical record lacked hospice aide visit notes from a specified period. Despite the Director of Nursing's (DON) efforts to locate these notes, they were initially unavailable in the facility's system and had to be obtained from the hospice company. Another resident's electronic medical record also lacked hospice visit notes, including those from hospice aides and nurses, for a specific timeframe. The DON acknowledged the absence of these notes and indicated that the facility's medical records person was unable to locate them. Eventually, the hospice visit notes were retrieved from the hospice company and added to the resident's electronic medical record. For a third resident, the facility failed to document a medication irregularity report in the electronic health record. The surveyor could not find evidence of the irregularity report or the physician's response to it. The DON provided a document with recommendations but admitted that the final report, which should include the physician's signature, was not available. The facility's policy requires the attending physician to document any irregularities and actions taken, but this was not done in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident, identified as R5, who was under infection control practices due to an IV line. R5 was admitted with diagnoses including sepsis, diabetes, and a right femur fracture, and was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance with activities of daily living. During an observation, it was noted that a stop sign on R5's door instructed staff to wear gloves and gowns for high-contact care activities. However, two Certified Nurse Assistants (CNAs) were observed providing personal care to R5 while wearing gloves but not gowns, contrary to the posted instructions. When questioned, one of the CNAs stated that they believed gowns were not necessary for R5, as the precaution was only for her IV. Additionally, there was no personal protective equipment (PPE) stand or supplies found in R5's room. The Infection Control Preventionist (ICP) confirmed that the CNAs should have been wearing gowns and acknowledged the absence of PPE supplies in the room. The ICP indicated that re-education of the CNAs and placement of a PPE stand in R5's room would be necessary.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to ensure that immunizations were offered and provided to a resident, identified as R29, who was reviewed for immunizations. R29 was admitted to the facility with diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, and was cognitively intact with a BIMS score of 15 out of 15. According to the facility's Pneumococcal Vaccine policy, adults aged 19-64 with such diagnoses should be offered the pneumococcal vaccine upon admission. However, a review of R29's immunization record revealed that although R29 had received a PCV23 vaccine in 2011, they were not offered the PCV20 vaccine upon admission in 2023, as required by the policy. The Infection Control Preventionist acknowledged the oversight during an interview and record review, noting that an immunization audit had revealed several residents, including R29, were missed for the PCV20 vaccine offer.
Failure to Assess and Treat Pressure Injuries
Penalty
Summary
The facility failed to adequately assess, monitor, and document pressure injuries and wounds for a resident, leading to incomplete and inaccurate wound assessments and a delay in treatment. The resident, a male with a history of stroke and other medical conditions, was admitted with existing wounds documented by the hospital. However, the facility did not identify or document these wounds accurately during the admission assessment, and there was a lack of treatment orders for certain areas, such as the reddened area on the right outer ankle and bilateral heels. The facility also failed to notify the physician and the Durable Power of Attorney (DPOA) of new and deteriorating pressure injuries. There were multiple instances where wound treatments were not completed as ordered, and there was no documentation of a rationale for the lack of wound care. The resident's care plans were not updated to reflect the multiple pressure injuries following skin assessments, wound assessments, or hospitalization. Additionally, the facility's wound management program was found to be lacking, with late and incomplete assessments and inconsistent documentation. The resident was eventually admitted to the hospital with severe sepsis due to an infected sacral decubitus ulcer, and multiple pressure ulcers were identified. The facility's failure to provide timely and appropriate wound care, along with inadequate communication and documentation, contributed to the deterioration of the resident's condition. Interviews with staff and family members confirmed the lack of notification and communication regarding the resident's worsening condition and new wounds.
Lack of Routine Monitoring of Patient Care Equipment
Penalty
Summary
The facility failed to have a system in place to ensure routine monitoring of patient care equipment for safe and functional condition, potentially affecting the safety of all residents. During an interview, the Director of Nursing (DON) reported that there is no log of resident care equipment being monitored. Mechanical lifts are checked once or twice a year by an external company, but the maintenance department does not maintain a log for routine monitoring of other patient care equipment such as wheelchairs, shower chairs, mechanical lifts, and bed rails. Although an electronic communication program exists to report equipment needing repairs, there is no formal system for preventative maintenance and monitoring. A review of the facility's Preventative Maintenance Program policy, last revised in March 2022, revealed that a program should be developed and implemented to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Failure to Follow Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during meal tray delivery and incontinence care, leading to potential cross-contamination and the spread of illness. During observations on the Northwest Hallway, staff members, including a Registered Dietitian, Certified Nursing Aides, and a Social Worker, were seen delivering meal trays without performing hand hygiene before or after entering resident rooms. This was confirmed by the Director of Nursing, who stated that staff are expected to wash their hands after resident contact and before handling another resident's tray. Additionally, a Certified Nursing Assistant was observed providing incontinence care to a resident with generalized weakness and colitis without changing gloves or performing hand hygiene between handling soiled items and clean surfaces. The CNA admitted in an interview that she should have changed her gloves and performed hand hygiene when transitioning from dirty to clean tasks.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
