Medilodge Of Campus Area
Inspection history, citations, penalties and survey trends for this long-term care facility in East Lansing, Michigan.
- Location
- 2815 Northwind Drive, East Lansing, Michigan 48823
- CMS Provider Number
- 235517
- Inspections on file
- 29
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Medilodge Of Campus Area during CMS and state inspections, most recent first.
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.
A resident with a history of hypotension, COPD, and acute respiratory failure experienced a significant decline after staff failed to consistently monitor vital signs and follow physician orders for PRN Midodrine and Albuterol. Despite clear signs of deterioration and new orders for medication and monitoring, staff did not document required assessments or administer all prescribed treatments, resulting in the resident becoming unresponsive, requiring CPR, and ultimately being transferred to the hospital for comfort care.
The facility failed to maintain an effective QAPI program, as the LNHA could not provide specifics on projects or address concerns like medication storage and food temperatures. The LNHA was unaware of several issues until the State Survey Process, indicating a lack of comprehensive understanding and documentation of the program's activities.
The facility failed to maintain a safe and homelike environment, with issues such as torn laminate, loose sink counters, and persistent urine odors in resident rooms. A resident reported frequent noise and inappropriate staff behavior, while resident council minutes highlighted ongoing concerns about staff phone use and noise levels. Maintenance and housekeeping efforts were inadequate, as confirmed by staff.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. CNAs were often assigned up to 20 residents, making it impossible to complete all care tasks. Residents reported waiting over an hour for call light responses, and staff confirmed that management did not assist during shortages. Essential care tasks were frequently left incomplete, leaving residents in soiled conditions.
The facility failed to maintain preferred food temperature and acceptable palatability for three residents, leading to a deficiency citation. A resident with multiple health conditions reported that the food was always cold, and observations confirmed that the scrambled eggs were below the preferred temperature. Another resident, who is cognitively intact, also reported cold food and was told to eat in the dining room for warm meals. Observations showed that his lunch items were not at the correct temperatures. A third resident expressed dissatisfaction with the food, describing it as unappetizing and often cold, with observations confirming the poor quality of her meal.
The facility failed to maintain resident dignity by allowing staff to engage in disrespectful behavior, such as using personal cell phones and being noisy, which disturbed residents' peace and sleep. A resident reported staff complaints about workload and other residents, while another experienced rude communication from staff. Additionally, a resident felt his concerns about therapy services were not taken seriously. The facility's Quality Assistance Forms did not show resolution of these issues to the residents' satisfaction.
The facility failed to address resident grievances effectively, as evidenced by repeated concerns raised in Resident Council meetings about staff behavior, noise levels, and call light response times. Despite some staff education efforts, issues persisted, and the Social Services Director was reported as unresponsive. A resident confirmed these ongoing problems, and the new NHA could not explain the lack of resolution.
The facility did not provide necessary beneficiary notifications to two residents, resulting in potential uninformed private pay charges and inability to appeal. One resident was missing a SNF-ABN, and another had an incomplete NOMNC. The SSD could not explain the omissions or locate the missing documents.
A resident with multiple medical conditions expressed concerns about medication administration, food temperature, room cleanliness, and noise levels. Despite these grievances being documented, the facility failed to accurately record and resolve them, with incomplete documentation and unresolved issues. Interviews with the DON and LNHA revealed a lack of understanding and resolution of the resident's concerns.
A facility failed to accurately complete an MDS assessment for a resident by incorrectly documenting that the resident did not use corrective lenses. Despite the resident's admission of wearing glasses and a progress note confirming an eye exam and glasses order, the MDS Coordinator marked the section as 'no' in error. This discrepancy was identified during a review of the resident's medical record, which included a picture showing the resident wearing glasses.
A facility failed to timely notify the local state mental health authority of PASARR changes for a resident with mental health and developmental disorders. The resident's significant change in condition was not reported until over three months after a legal guardian was appointed, due to delays in obtaining a level II assessment and communication issues between the Social Service Director and the Community Mental Health Authority.
A facility failed to document and communicate a resident's dental needs, specifically the use of upper dentures, in the care plan and Kardex. The resident, who was cognitively intact and had multiple medical conditions, reported missing his dentures, which were not documented in his care plan. The Social Services Director and MDS Coordinator were unaware of the issue, indicating a deficiency in the facility's documentation and communication processes.
A resident with mild cognitive impairment, schizophrenia, and a seizure disorder was not included in the care plan development after readmission to the facility. Despite expressing a desire to be discharged back to the community, the resident was not involved in a care conference, and there was no documentation of attempts to include her or her guardian. The Social Service Director acknowledged the lack of documentation and involvement.
The facility failed to adhere to physician orders for three residents, resulting in deficiencies in care. A resident awaiting prosthetics did not have a fitting appointment scheduled, another received medication after meals instead of before, and a third was not wearing a required cervical spine collar. Staff were unable to provide explanations for these oversights.
A resident with Type 2 Diabetes Mellitus experienced discomfort due to long toenails, as the facility failed to provide timely podiatry services. Despite an order for podiatry as needed, no services were documented, and the resident's toenails were observed to be long and causing discomfort. The Social Services Director, responsible for ancillary services, was unaware of the need for podiatry, and the Director of Nursing had not yet addressed the issue. The facility's nail care policy, which includes special considerations for diabetic residents, was not followed.
A resident admitted with multiple health conditions experienced a delay in receiving prescribed medications, Pregabalin and Diazepam, due to the facility's failure to provide controlled prescriptions to the pharmacy in a timely manner. The Director of Nursing confirmed the delay, which was not in accordance with the facility's expectation for medication delivery within 24 hours of admission.
A facility failed to ensure a physician documented the rationale for disagreeing with a medication review recommendation for a resident on hospice care. The resident was prescribed Atorvastatin, and the review suggested discontinuation. The physician disagreed but did not provide a documented rationale, only a handwritten note to continue the medication. The DON stated that providers should document their rationale, but this was not done.
The facility failed to ensure that two residents were free from unnecessary medications. A resident was prescribed a nicotine patch for smoking cessation but continued to smoke, and the order was not discontinued timely. Another resident had orders for Tylenol and Norco that, if given as prescribed, would exceed the maximum dose of acetaminophen. The DON confirmed the doses exceeded the safe limit.
A facility's medication error rate exceeded 5% when an RN failed to provide necessary instructions during the administration of Spiriva and Advair inhalers to a resident. The RN did not instruct the resident to wait 2 minutes between inhalers or to rinse their mouth after using the Advair inhaler, leading to a medication error rate of 7.41%. The DON confirmed that these instructions are expected during administration.
The facility failed to ensure proper medication storage and administration for two residents and one medication cart. A resident with multiple medical conditions was found with a cup of pills without an order for self-administration. Another resident had medications left at the bedside, and an LPN stored pre-pulled medications in the cart. The DON confirmed these practices were not acceptable.
A resident with multiple health conditions and dental issues was not assisted by the facility in obtaining a second opinion or arranging for necessary dental procedures. The resident expressed a desire for a second opinion from a personal dentist, but the Social Services Director did not facilitate this request, nor did they assist in arranging an appointment with an oral surgeon as recommended. The lack of documentation and assistance resulted in a deficiency in addressing the resident's dental needs.
The facility failed to honor the dietary preferences of three residents, leading to a deficiency in nutritional care. A resident with intact cognition reported not receiving requested double portions and specific items like whole milk. Another resident expressed dissatisfaction with food quality and lack of menu choices, receiving items he disliked. A third resident with mild cognitive impairment reported frequently not receiving ordered items, leading her to order food out-of-pocket. The dietary manager acknowledged the issues but could not explain the discrepancies.
The facility failed to track employee illnesses effectively, delayed implementing TBP for a COVID-19 positive resident, and improperly cleaned and stored a resident's CPAP mask. A resident's COVID-19 status was not acted upon promptly, and another resident's CPAP mask was mishandled, leading to potential infection risks.
The facility failed to obtain consent or declination for flu and pneumonia vaccinations for a resident with heart failure, COPD, and end-stage renal disease. Despite attempts to contact the resident's Guardian and Responsible Party, no consents were documented, and no immunizations were administered. The ADON noted that immunizations are offered yearly, with consent efforts beginning in August.
The facility failed to offer COVID-19 booster immunizations to three residents, resulting in a deficiency. A resident with a guardian last received a COVID-19 immunization in late 2023, with no further booster offers documented. Another resident, dependent on a medical Power of Attorney, last received an immunization in 2021, with no consents or declinations recorded despite attempts to contact the guardian. A third resident, responsible for their own decisions, also lacked documentation of booster offers after their last immunization in 2023. The ADON noted that boosters were offered when available, but documentation gaps persisted.
A resident with severe cognitive impairment and multiple diagnoses was physically restrained by a CNA after striking the CNA. The CNA held the resident's arms down while the resident was on the floor, which was deemed inappropriate and a violation of the facility's abuse policy. Witnesses confirmed the CNA's actions, leading to the substantiation of the abuse allegation.
A facility failed to timely identify, investigate, and report a staff-to-resident allegation of abuse involving a resident with severe cognitive impairment. The incident involved a resident attacking a CNA, who then improperly restrained the resident. Witnesses did not report the incident immediately, assuming the DON would handle it. The NHA was informed over a week later, delaying the investigation and reporting to the State Agency.
A facility failed to provide necessary assistance with ADLs for a resident with multiple medical conditions, resulting in unmet care needs. Despite the resident's clear preferences and cognitive ability to communicate, staff did not routinely offer or document scheduled showers or bed baths, leading to a lack of proper hygiene care.
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.
Failure to Monitor and Follow Physician Orders Leads to Resident Decline
Penalty
Summary
The facility failed to assess, monitor, and follow physician orders for a resident with multiple diagnoses, including hypotension, COPD, and acute respiratory failure with hypoxia. The resident was cognitively intact and had recently been seen by a nurse practitioner for acute hypoxia and shortness of breath, resulting in new orders for PRN Midodrine for hypotension and Albuterol for shortness of breath. Despite these orders, documentation showed that vital signs were not consistently monitored or recorded as required, and the resident did not receive the ordered Albuterol when experiencing shortness of breath. On the day of the incident, the resident's blood pressure was critically low, and a dose of Midodrine was administered. However, after this administration, there was a lack of ongoing monitoring, as no additional vital signs were documented after a certain point, and no further doses of Midodrine were considered despite continued hypotension. Staff interviews confirmed that the resident was observed to be declining, lethargic, and nonverbal, deviating from his baseline condition, but these changes were not adequately addressed through timely assessment or intervention. The resident ultimately became unresponsive and went into cardiac arrest, requiring CPR and emergency transfer to the hospital. Hospital records indicated the resident suffered from septic shock, lactic acidosis, and was placed on comfort care. The failure to follow physician orders for monitoring and medication administration, as well as the lack of timely assessment and response to a significant change in condition, directly contributed to the poor outcome.
Deficiency in QAPI Program Implementation
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. The facility's policy, implemented on 10/24/22, outlined key components for the QAPI program, including tracking and measuring performance, establishing goals, identifying quality deficiencies, analyzing underlying causes, and developing corrective actions. However, during an interview, the Licensed Nursing Home Administrator (LNHA) was unable to provide specific details about the QAPI projects implemented since the last survey, indicating a lack of comprehensive understanding and documentation of the program's activities. The LNHA mentioned projects related to staff retention, food tray pass, water pass, tray removal, and noise level but could not provide specifics without consulting the team. When asked about concerns such as medication storage, cell phone usage, food temperature, grievances, smoking, Activities of Daily Living, and vaccinations, the LNHA was unaware of these issues until the State Survey Process. The LNHA only provided temperature logs from the dietary department and had no additional information or performance improvement plans for food temperatures, highlighting a deficiency in the facility's QAPI program.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In multiple resident rooms, issues such as torn laminate on countertops, loose sink counters, and torn gripper strips on the floor were noted. Additionally, a resident's wheelchair had visibly torn armrests, and a closet door had a hole. The Maintenance Supervisor confirmed that no work orders had been received to address these issues, indicating a lack of effective communication and maintenance procedures. Furthermore, the facility did not provide a peaceful environment for its residents, as reported by a resident who frequently heard staff yelling and using inappropriate language in the hallways. Resident council minutes from previous months also highlighted ongoing concerns about staff using phones in common areas and excessive noise levels during night shifts. Additionally, persistent urine odors were detected in certain rooms, which housekeeping staff were unable to eliminate despite multiple attempts. These findings demonstrate a failure to uphold residents' rights to a comfortable and dignified living environment.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing levels to ensure adequate and timely resident care, affecting four residents out of a total census of 65. Interviews with staff and residents revealed that staffing levels were primarily based on facility census, leading to situations where certified nursing assistants (CNAs) were assigned an unmanageable number of residents. CNAs reported being assigned up to 20 residents at times, making it impossible to complete all necessary care tasks. This staffing shortage was exacerbated by frequent call-ins, with no replacements being brought in, leaving the facility understaffed. Residents reported significant delays in call light response times, often waiting over an hour for assistance. One resident described waiting three hours for a call light to be answered, while another resident, who is bedridden, frequently waited over an hour for help with basic needs such as getting a drink of water. These delays in response times were consistent across multiple residents, indicating a systemic issue with staffing and care delivery. Interviews with staff further highlighted the severity of the staffing issues. CNAs and nurses reported that management did not assist on the floor when staffing was short, and some staff members were observed ignoring call lights. The workload was described as extremely heavy, with essential care tasks such as showers, oral care, and brief changes not being completed. The facility's inability to maintain adequate staffing levels resulted in residents being left in soiled conditions and experiencing extended wait times for care.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to maintain preferred food temperature and acceptable palatability for three residents, leading to a deficiency citation. Resident #41, who has multiple health conditions including COPD, PVD, and dementia, reported that the food was always cold. During an observation, the scrambled eggs served to Resident #41 were found to be at 105.2°F, which the resident described as cold. The Dietary Manager explained that the temperature should be to the resident's palatability, but the resident expressed dissatisfaction with the temperature. Resident #318, who is cognitively intact and has conditions such as atherosclerotic heart disease and Barrett's esophagus, also reported that his food was always cold. He was told by the facility that he needed to come to the dining room for warm food. During an observation, the temperatures of his lunch items were found to be below the acceptable range, with pizza at 112°F and salad and peaches above the required cold temperature. Resident #11 expressed dissatisfaction with the food, describing it as unappetizing and often cold. An observation of her lunch tray revealed overcooked and tasteless steamed broccoli and lemon baked tilapia lacking flavor.
Failure to Preserve Resident Dignity and Address Complaints
Penalty
Summary
The facility failed to preserve the dignity of several residents by allowing staff behavior that was disrespectful and disruptive. Resident #2 reported that staff frequently complained about their workload and other residents, particularly Resident #32, while also being observed using personal cell phones instead of attending to call lights. This behavior was described as common knowledge and treated as acceptable within the facility. During a confidential group meeting, multiple residents expressed frustration over staff using personal cell phones and being noisy, especially at night and early in the morning, which disturbed their sleep and peace. Resident #32 experienced rude communication from staff, particularly when using the call light, and there was no evidence that the nurse involved received the promised re-education. Resident #318 also reported feeling that the facility did not honor his dignity due to staff yelling and using inappropriate language in the hallways. Additionally, he felt that his concerns about therapy services were not taken seriously by the Director of Therapy. The facility's Quality Assistance Forms did not demonstrate that these issues were resolved to the satisfaction of the residents involved.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances from residents were promptly documented, investigated, tracked, and resolved. This deficiency was evident in the Resident Council (RC) meetings where multiple concerns were repeatedly raised without resolution. Issues such as staff not wearing name tags, delayed call light response times, high noise levels at night, and staff using personal phones in common areas were consistently reported in RC minutes from September 2024 to March 2025. Despite the Nursing Home Administrator (NHA) attending some meetings and reporting that inservices were conducted, residents continued to express dissatisfaction with the lack of resolution to their concerns. Additionally, the Social Services Director was reported to be unresponsive and rude, further exacerbating the residents' grievances. Resident #2, who was cognitively intact, voiced similar concerns about food, call light response times, noise, and staff behavior, indicating that these issues were longstanding and unresolved. The resident mentioned that these concerns were regularly brought up in RC meetings but were not addressed effectively. The new NHA, who had been employed for only a week, was unable to provide explanations for the ongoing issues. The involvement of the Ombudsman was sought due to the high volume of unresolved concerns, lack of accurate documentation, and inadequate follow-through on resident grievances.
Failure to Provide Beneficiary Notifications
Penalty
Summary
The facility failed to provide the necessary beneficiary notifications, specifically the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), to two residents, R323 and R325, out of three reviewed. This resulted in the potential for these residents or their representatives to be uninformed about potential private pay charges for continued services and their inability to file an appeal. During the review, it was found that R323 was missing a SNF-ABN, and the NOMNC for R325 was incomplete, lacking the second page where the resident or their representative would sign to acknowledge receipt and understanding. The Social Services Director (SSD) reported that she typically provides a SNF-ABN with every NOMNC but could not explain why R323 did not receive one. Additionally, the SSD was unable to locate the missing second page of the NOMNC for R325 or any 2024 beneficiary documents.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to accurately record and promptly resolve grievances for a resident who was admitted with multiple medical conditions, including atherosclerotic heart disease and hypertension. The resident, who was cognitively intact, expressed concerns about not receiving medications as ordered, receiving cold food, room cleanliness, and noise levels. Despite these grievances being documented on Quality Assistance Forms, the forms lacked completion dates and resolutions, and the resident refused to sign them due to incorrect information. Interviews with the Director of Nursing and the Licensed Nursing Home Administrator revealed a lack of detailed understanding and resolution of the resident's concerns. The facility's grievance process was not followed as expected, with incomplete documentation and unresolved issues. The administrator could not explain why the forms did not include more detail or demonstrate a satisfactory conclusion to the resident's grievances.
Inaccurate MDS Assessment for Resident's Use of Corrective Lenses
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #6, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, and other significant health conditions. The MDS assessment, with an Assessment Reference Date of November 14, 2024, incorrectly documented that the resident did not use corrective lenses, despite evidence to the contrary. During an observation and interview, the resident mentioned that she usually wears glasses and was in the process of having them replaced. A progress note from February 13, 2025, confirmed that the resident had been seen by an eye physician and had glasses ordered. The MDS Coordinator, responsible for completing the assessment, stated that she had never personally seen the resident wearing glasses and had marked the section regarding corrective lenses as 'no' in error. This discrepancy was identified during a review of the resident's medical record, which included a picture showing the resident wearing glasses. The error in the MDS assessment highlights a failure in accurately documenting the resident's use of corrective lenses, which is a critical component of ensuring each resident receives an accurate assessment.
Delayed PASARR Notification for Resident with Mental Health Needs
Penalty
Summary
The facility failed to notify the local state mental health authority of Pre-Admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) changes for a resident with mental health and developmental disorders. The resident was admitted with diagnoses including end-stage renal disease, developmental disorder of scholastic skills, and bipolar disorder. The resident's level one screening indicated a mental illness and learning disability, with a level II screen showing a 30-day exemption for expected discharge. However, a significant change in the resident's condition was not reported in a timely manner, as the next screening was delayed until several months after a legal guardian was appointed. The Social Service Director (SSD) reported that the delay in obtaining a level II assessment was due to the Omnibus Budget Reconciliation Act (OBRA) refusing to conduct the assessment until a significant change in status was established. The SSD also mentioned that the corporate Social Worker, responsible for completing the necessary documentation, was unavailable. Despite communication with a Licensed Master Social Worker (LMSW) from the Community Mental Health Authority, who advised holding off on submitting the screening until the resident's capacity and guardianship were established, the significant change PASARR was not completed until over three months after guardianship was granted. This delay was acknowledged as untimely by the LMSW, and the SSD could not provide an explanation for the extended delay.
Failure to Document and Communicate Resident's Dental Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted with multiple complex medical conditions, including multiple sclerosis, paraplegia, and type 2 diabetes. The resident, who was cognitively intact, reported missing his upper dentures, which he had received in the fall of 2024. However, the resident's care plan and Kardex did not include any information about his upper dentures, indicating a lack of documentation and communication regarding his dental needs. During interviews, the Social Services Director and the MDS Coordinator were unaware of the missing dentures, despite the resident having received them recently. The MDS Coordinator, responsible for updating care plans, confirmed that the resident's partial upper dentures were not included in his care plan or Kardex. This oversight highlights a deficiency in the facility's process for ensuring that all aspects of a resident's care, including dental needs, are documented and communicated effectively among staff members.
Resident Excluded from Care Plan Development
Penalty
Summary
The facility failed to include a resident in the care plan development process, which is a requirement for ensuring that residents' needs and preferences are considered. The resident, who has mild cognitive impairment, schizophrenia, and a seizure disorder, expressed dissatisfaction with her current living situation and a desire to be discharged back to the community. She reported that during her initial stay, she was involved in her care planning, but since her readmission, she has not been included in any care conferences. The resident attempted to discuss her concerns with the Social Service Director (SSD) but felt dismissed and unheard. The SSD confirmed that the resident was discharged to an adult foster care facility and later readmitted to the facility. Despite this being a new admission, the SSD did not hold a care conference upon the resident's return, citing that the resident was not gone long enough to warrant one. A care conference was eventually held months later, but neither the resident nor her guardian attended, and there was no documentation of attempts to involve them. The SSD claimed that the guardian attended, but this was not documented, and there was no record of the resident being invited. The SSD acknowledged that documentation could have been better.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in their care. One resident, who had undergone bilateral leg amputations, was eager to receive prosthetics. Despite a referral for a prosthetic fitting being entered into the medical record, the appointment had not been scheduled. The Assistant Director of Nursing confirmed the oversight and could not explain why the appointment had not been requested earlier. Another resident was supposed to receive Protonix before meals for GERD management. However, the medication was consistently administered after meals, contrary to the physician's order. The Director of Nursing was unable to provide an explanation for this discrepancy, despite the resident's repeated complaints about the timing of the medication administration. A third resident, who was supposed to wear a cervical spine collar at all times, was observed without it on multiple occasions. The collar was out of the resident's reach, and there were no documented refusals for its use. A Certified Nursing Assistant acknowledged the resident's need for the collar but was unaware of its purpose, indicating a lack of communication and adherence to the care plan.
Failure to Provide Diabetic Foot Care
Penalty
Summary
The facility failed to provide appropriate diabetic foot care to a resident, resulting in long toenails and discomfort. The resident, who was admitted with Type 2 Diabetes Mellitus and required assistance with personal care and had reduced mobility, had an order for podiatry services as needed. However, there were no progress notes indicating that podiatry services had been provided. Observations revealed that the resident's toenails were long, extending past the toes, causing discomfort and scraping the resident's legs. The resident and a family member reported waiting a long time for toenail trimming, and the family member had trimmed all but the big toenails. The Social Services Director, responsible for ancillary services, reported that they had taken over the role three weeks prior and had not been alerted to any need for podiatry services for the resident. The Director of Nursing was aware of the concern but had not yet seen the resident's toenails. The facility's policy on nail care requires assessments on admission and regular trimming and filing, with special considerations for diabetic residents. Despite these policies, the resident's toenails remained untrimmed, indicating a failure to adhere to the facility's nail care policy.
Delay in Medication Administration for Resident
Penalty
Summary
The facility failed to provide timely pharmaceutical services to a resident, resulting in a delay in medication administration. The resident, who was admitted with multiple diagnoses including atherosclerotic heart disease, vertigo, hyperlipidemia, hypertension, anemia, and Barrett's esophagus, did not receive prescribed medications, Pregabalin and Diazepam, in a timely manner. The resident reported not receiving these medications until several days after admission, despite having physician orders dated shortly after admission. The Medication Administration Record (MAR) and progress notes indicated that Pregabalin was not available for several days due to awaiting drug delivery, and Diazepam was not administered until four days after the order was placed. The Director of Nursing confirmed the delay and attributed it to the lack of controlled prescriptions being provided to the pharmacy in a timely manner, which was not in line with the facility's expectation of medication delivery within 24 hours of admission.
Failure to Document Rationale for Medication Review Disagreement
Penalty
Summary
The facility failed to ensure that the attending physician documented the rationale for not implementing a medication review recommendation for a resident. The resident, who was admitted with a diagnosis of vascular dementia and was on hospice care, had a current order for Atorvastatin Calcium 20 mg. A medication regimen review conducted on 5/7/2024 recommended discontinuing the atorvastatin due to the resident's hospice status. However, the physician disagreed with this recommendation on 5/21/2024, marking the response as disagree without providing a documented rationale in the medical record. Instead, a handwritten note stating 'keep on statin' was found at the bottom of the document. During an interview, the Director of Nursing stated that providers are expected to complete a rationale if they disagree with pharmacy recommendations, but this was not fulfilled by the survey exit.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident #6 was prescribed a transdermal nicotine patch for smoking cessation, which was never used as the resident continued to smoke cigarettes. Despite the resident's refusal to use the patch, the order was not discontinued in a timely manner, leading to a discrepancy in the resident's medication record. The Licensed Practical Nurse and Director of Nursing acknowledged that the order should have been discontinued earlier, as the resident was not using the patch and continued to smoke. Resident #50 had physician orders for both Tylenol and Norco, which, if administered as prescribed, would exceed the maximum allowable dose of acetaminophen. The orders lacked parameters for the maximum dose, creating a risk of overdose. The Director of Nursing confirmed that the ordered doses exceeded the prescribed parameter of 3000 mg of acetaminophen, indicating a failure to ensure safe medication administration practices for the resident.
Medication Error Rate Exceeds 5% Due to Inadequate Instructions
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% due to two observed medication errors out of 27 opportunities for a resident. During a medication administration, a registered nurse (RN) prepared and administered Spiriva and Advair inhalers to a resident without providing the necessary instructions. The RN did not instruct the resident to wait 2 minutes between inhalers, which is the standard protocol. Additionally, the RN failed to instruct the resident to rinse their mouth after using the Advair inhaler, a steroid, to prevent potential throat irritation and infection. The Director of Nursing confirmed that the expectation was for nursing staff to provide these specific instructions during administration.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and administration of medications for two residents and one medication cart. Resident #41, who has multiple medical conditions including COPD, dementia, and anxiety, was observed with a cup containing nine pills that he had not taken immediately. The resident explained that nurses usually watch him take his medication, but sometimes they leave the medication with him. There was no order or assessment in the medical record indicating that Resident #41 was capable of self-administering medication. The Director of Nursing confirmed that Resident #41 was not allowed to self-administer medication, and no explanation was provided for why this occurred. Resident #55 was found with a medication cup containing five pills on the nightstand, and the resident reported that medications were sometimes left at the bedside. The Assistant Director of Nursing confirmed that no residents were approved for self-administration of medication and that nurses were expected to ensure medications were consumed in their presence. Additionally, an LPN was observed storing pre-pulled medications in the medication cart, which included Tylenol and other medications for a resident who was sleeping. The Director of Nursing stated that storing medications in this manner was not acceptable.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to address the dental needs of a resident who was admitted with conditions including congestive heart failure, chronic obstructive pulmonary disease, and morbid obesity. The resident, who was cognitively intact, was observed to have multiple missing and discolored teeth and reported experiencing mouth pain. A dental consult at the facility recommended extractions and dentures to improve the resident's nutrition and general health, with the extractions to be performed by an oral surgeon. However, the resident expressed a desire to seek a second opinion from a personal dentist in a neighboring town. The Social Services Director (SSD) was aware of the resident's request for a second opinion but did not assist in making arrangements, stating that the resident needed an oral surgeon rather than a second opinion. The SSD also did not assist in making an appointment with an oral surgeon, claiming the resident refused to see one. There was no documentation provided to support the claim that the resident refused treatment, and the SSD did not respond when asked if it was her decision to deny the resident's request for a second opinion. This lack of assistance and documentation led to the deficiency in addressing the resident's dental needs.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to meet the dietary needs and preferences of three residents, leading to a deficiency in nutritional care. Resident 60, who has intact cognition, reported that his requests for double portions and specific dietary preferences, such as whole milk and additional brown sugar, were often not honored. Despite his meal ticket indicating these preferences, they were not consistently followed. Similarly, Resident 319, with a history of fractures and other health issues, expressed dissatisfaction with the food quality and the lack of menu choices. He reported receiving items he disliked, such as a banana, and not receiving requested beverages like coffee or hot tea, despite assurances from the dietary manager that his preferences would be considered. Resident 29, who has mild cognitive impairment and other health conditions, also experienced issues with meal service. She reported that her food preferences were frequently not honored, leading her to order food out-of-pocket. During an observation, her meal tray lacked items listed on her meal ticket, such as fruit cups and a dinner roll with margarine. The dietary manager acknowledged the availability of these items but could not explain why they were not provided. The facility's dietary manager stated that staff were trained to follow meal tickets, but discrepancies in meal service were evident, and no audits were conducted to ensure accuracy.
Infection Control and Equipment Handling Deficiencies
Penalty
Summary
The facility failed to effectively track and trend employee illnesses, as there was no formatted document for this purpose. The Assistant Director of Nursing (ADON) reported that call-ins were discussed in morning meetings and with the Scheduler, but the data was only entered into the infection watch system when trends were noticed. This lack of a structured tracking system led to a delay in identifying and responding to potential outbreaks among staff. A resident, who was admitted with severe cognitive impairment and other medical conditions, tested positive for COVID-19 during a hospital visit. However, Transmission-Based Precautions (TBP) were not implemented until two days after the resident returned to the facility, despite the hospital's After Visit Summary indicating a positive COVID-19 test result. The delay in implementing TBP was attributed to the facility not being aware of the resident's COVID-19 status until informed by a Cardiology office. Another resident's CPAP mask was not appropriately cleaned or stored. The resident reported that the mask had fallen on the floor multiple times without being cleaned, and it was not consistently stored in a plastic bag as required by the facility's policy. Observations confirmed that the mask was often left on the floor or nightstand without proper storage, and staff used inappropriate cleaning methods, such as Super Sani-Cloth Germicidal Wipes, which are not recommended for respiratory equipment.
Failure to Obtain Immunization Consents for a Resident
Penalty
Summary
The facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for Resident #18, who was admitted with diagnoses including heart failure, COPD, and end-stage renal disease requiring dialysis. The medical record showed no immunizations were administered, and there were no consents or declinations documented. The Assistant Director of Nursing reported that immunizations were offered yearly, with attempts to obtain consents starting in August. A progress note from December indicated multiple messages were left for the resident's Guardian regarding the need for consents, but no calls were returned. Another note from February documented a call to the resident's Responsible Party, requesting a return call regarding immunization consents.
Failure to Offer COVID-19 Boosters to Residents
Penalty
Summary
The facility failed to offer COVID-19 booster immunizations to three residents, leading to a deficiency in their immunization protocol. Resident #6, who had a guardian, last received a COVID-19 immunization on December 2, 2023, but there was no documentation indicating that any further booster immunizations had been offered. Similarly, Resident #18, who had a medical Power of Attorney, last received a COVID-19 immunization on November 9, 2021, and there were no records of immunization consents or declinations. Despite multiple attempts to contact Resident #18's guardian for consent, no response was received. Resident #32, who was their own responsible party, last received a COVID-19 immunization on November 30, 2023, with no documentation of further booster offers. During an interview, the Assistant Director of Nursing (ADON) reported that COVID-19 booster immunizations were offered to residents when they became available, specifically mentioning a booster that became available in 2024. However, the lack of documentation for these three residents indicates a failure in the facility's process to ensure that all eligible residents were offered the booster immunizations. This deficiency highlights a gap in the facility's immunization offering and documentation practices, particularly in maintaining up-to-date records and ensuring communication with responsible parties for consent.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. Resident #3, who had severe cognitive impairment and multiple diagnoses including Huntington's Disease and dementia, was involved in an incident where a Certified Nurse Aide (CNA) allegedly threw the resident against a wall during an altercation. The incident was reported by another resident who had heard about it from a third resident. The facility's investigation revealed that the CNA had improperly restrained the resident by holding her arms down while she was on the floor, which was deemed as abuse by the facility's standards. On the day of the incident, Resident #3 approached the CNA from behind and struck her in the head. The CNA responded by grabbing the resident's arms and lowering her to the floor, where she continued to hold the resident's arms down until help arrived. Witnesses, including another CNA and a Registered Nurse (RN), confirmed that the CNA had restrained the resident in a manner that was considered inappropriate. The Director of Nursing (DON) arrived at the scene and assisted the resident off the floor, noting that the resident did not suffer any physical or psychological harm but that the CNA's actions were improper. Interviews with staff and residents corroborated the sequence of events. The CNA admitted to holding the resident down to prevent further strikes, and witnesses confirmed this account. The facility's abuse policy, which prohibits such actions, was reviewed, and it was determined that the CNA had violated this policy by not walking away from the situation and instead restraining the resident. The facility substantiated the allegation of abuse based on these findings.
Failure to Timely Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to timely identify, investigate, and report a staff-to-resident allegation of abuse involving a resident with severe cognitive impairment. The incident occurred when a resident with Huntington's Disease and dementia allegedly attacked a CNA, who then improperly restrained the resident by holding her arms down while she was on the floor. Witnesses, including another CNA and an RN, observed the incident but did not report it immediately, assuming that the Director of Nursing (DON) would handle the situation. The Nursing Home Administrator (NHA) was not informed of the incident until over a week later, delaying the investigation and reporting to the State Agency. The resident involved in the incident was admitted to the facility with diagnoses including Huntington's Disease and dementia with behavioral disturbance. The resident had a severe cognitive impairment, as indicated by a BIMS score of 7. During the incident, the resident reportedly attacked the CNA from behind, prompting the CNA to restrain her by holding her arms down while she was on the floor. Witnesses confirmed that the CNA's actions were inappropriate and could be considered abuse, but they did not report the incident immediately, believing that the DON, who was present, would take the necessary steps. The delay in reporting the incident was further compounded by the fact that the DON did not take immediate action to report the abuse. The DON assumed that the situation was under control and did not realize the severity of the incident until it was reported by another resident over a week later. This delay in reporting and investigating the incident resulted in a failure to protect the resident and potentially allowed further allegations of abuse to go unreported.
Failure to Provide Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident, resulting in unmet care needs. The resident, who had multiple medical conditions including the absence of both legs above the knee, congestive heart failure, and mild cognitive impairment, was not routinely receiving scheduled showers or bed baths. Despite being cognitively intact and able to communicate her needs, the resident reported that staff had not been approaching her to discuss or provide the scheduled showers or bed baths, leading her to stop reminding them as they were aware of her preferences. The resident's care plan indicated a preference for showers or bed baths on Wednesday and Sunday evenings, with assistance from one person. However, documentation revealed that the resident had not been offered or provided a shower or bath on five out of nine scheduled days within a 30-day period. There were no entries or documentation for several scheduled shower dates, and no episodes of care refusal were recorded, contradicting the resident's care plan and progress notes. Interviews with staff, including a Certified Nurse Aide (CNA) and the Director of Nursing (DON), confirmed that the resident was scheduled for twice-weekly showers and that refusals should be documented. However, the DON could not explain why documentation reflected
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A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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