Medilodge Of Westwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalamazoo, Michigan.
- Location
- 2575 N Drake Road, Kalamazoo, Michigan 49006
- CMS Provider Number
- 235542
- Inspections on file
- 28
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Medilodge Of Westwood during CMS and state inspections, most recent first.
A resident with multiple serious comorbidities and intact cognition was discharged home despite repeatedly stating she could not safely enter her house or care for herself, and despite her family’s clear objections and inability to prepare the home environment. Staff, including RNs and therapy, documented and reported that the resident was distraught, crying, and fearful about going home, and one RN refused to sign the discharge paperwork due to safety concerns. The facility proceeded with discharge after managed care coverage ended, requiring advance private payment and refusing a personal check, while a second-level insurance appeal was still in process. On arrival home, the transport driver could not get the resident’s wheelchair through the doorway and noted additional obstacles inside, leading the family to call an ambulance and the resident to be sent to the hospital, demonstrating that the discharge planning process did not ensure a safe and appropriate transition.
Two residents with significant mobility and cognitive impairments did not receive adequate supervision or consistent implementation of care planned fall prevention interventions. One resident suffered a fall resulting in a fracture after being found unsupervised in a hallway, with required safety equipment not in place. Another resident was transferred by a CNA without the use of a gait belt or prescribed walker, contrary to care plan and facility policy.
The facility did not adequately follow up or resolve grievances related to missing personal items for several residents, with incomplete documentation and lack of communication regarding investigation outcomes. Residents, including those with cognitive and visual impairments, reported missing money, clothing, and unauthorized debit card charges, and staff interviews confirmed that investigations and resolutions were not consistently completed or communicated.
Multiple failures in infection prevention and control were observed, including lack of proper PPE use and signage for residents requiring enhanced barrier precautions, inadequate hand hygiene and glove use during insulin injections, and unclean shared equipment. These lapses involved residents with wounds or surgical sites and staff who were unaware or did not follow required protocols, increasing the risk of infection transmission.
Surveyors identified multiple deficiencies in environmental safety and sanitation, including moisture accumulation and insect presence in the kitchen, unsanitary conditions and missing supplies in shower and utility rooms, and unclean, poorly maintained resident rooms. Staff interviews confirmed lapses in cleaning routines and maintenance reporting.
Two residents experienced a lack of dignified dining when they were not served their meals in a timely manner while others at their table were already eating. One resident waited so long that he ate leftover bread from another's place, and another left the table with her meal untouched after finally being served. The Regional Registered Dietitian confirmed that such delays were not normal and that residents seated together should receive meals at the same time.
Two residents with complex medical needs were discharged without being provided the required SNF-ABN and NOMNC forms. Due to a transition in social services leadership, the forms were not completed or documented, and staff were unable to produce them during the survey.
The facility did not provide required discharge notifications to the State LTC Ombudsman for two residents who were transferred to the hospital. Documentation confirmed the transfers, but the ombudsman's office had not received notifications for several months. Interviews indicated a lack of clarity regarding staff responsibilities for this process.
A resident was inaccurately coded as having schizophrenia on the MDS assessment, despite no evidence of psychosis-related behaviors or treatment for schizophrenia. Staff interviews confirmed the resident was not being treated for this condition, and the diagnosis was based on outdated documentation rather than current clinical findings.
Two residents did not receive physician-ordered medications and wound care treatments as documented, with staff admitting to false documentation and failure to notify providers of missed doses or treatments. One resident with psychiatric diagnoses missed an antidepressant dose without provider notification, while another with a surgical wound did not receive required dressing changes despite records indicating completion. Nursing staff confirmed lapses in documentation and communication, contrary to facility policy and professional standards.
A resident with hemiplegia and reduced mobility was repeatedly observed with greasy, unkempt hair and wearing the same clothing, despite scheduled showers and bed baths. Staff interviews revealed that hair washing was expected as part of ADL care but was not consistently performed or documented, and the resident reported her hair was not washed as often as she preferred. Documentation gaps and lack of clarity among staff contributed to the resident's unmet hygiene needs.
Two residents did not receive care in accordance with physician orders and professional standards. One resident with a mental health disorder missed doses of prescribed Wellbutrin due to staff not locating available medication and failing to notify the provider, with inaccurate documentation of administration. Another resident with a recent foot amputation and diabetic wound did not receive ordered wound care, as dressing changes were omitted for several days without documentation of refusal. Nursing staff confirmed treatments were not provided as ordered, and required documentation and provider notifications were not completed.
A resident with right-sided contracture following a stroke did not consistently receive prescribed hand splinting and positioning devices as outlined in the care plan and Kardex. Observations showed the resident without any splint, and interviews with a CNA and LPN revealed they were unaware of the need for such devices. No documentation was found to indicate the devices were applied, despite care plan directives.
Two residents did not receive safe respiratory care as required: one received supplemental oxygen at a rate higher than the physician-ordered range, with the nasal cannula sometimes improperly applied, while another used a CPAP machine without an active physician order and with inadequate cleaning of the mask and straps. Staff interviews and documentation revealed inconsistent practices and lack of adherence to facility policy regarding respiratory care.
A resident with end stage renal disease who required dialysis did not have post-dialysis assessments and monitoring completed or documented as required. Nursing staff confirmed that vital signs, weight, and access site checks were expected after dialysis, but records showed these were not performed or recorded for several months after related orders were discontinued. The DON acknowledged the lack of documentation and missing orders for post-dialysis monitoring.
Two residents with significant trauma histories did not have their trauma triggers identified or addressed in their care plans. One resident with a history of psychiatric illness, substance use, and recent amputations, and another who lost her home and pets in a fire, both lacked trauma-informed interventions. Staff were not informed of their trauma histories, and social services did not conduct adequate trauma assessments or referrals, resulting in unmet emotional needs and the potential for re-traumatization.
A resident with anxiety and depression, admitted for rehabilitation after a traumatic event, did not receive ordered psychological support services. Despite a physician's order and care plan interventions for behavioral health, the resident was not referred to counseling or psychological services, and the DSS was unaware of the order.
Two residents experienced medication errors when a nurse administered insulin from a pen past the recommended discard date and failed to provide a scheduled antidepressant dose due to not checking all storage areas. Additionally, a resident received the wrong opioid medication, with inaccurate documentation. These actions led to a medication error rate above 5%.
Staff failed to store and manage medications according to manufacturer and facility guidelines, including using insulin pens beyond recommended discard dates, leaving an inhaler unsecured in a resident's room, and maintaining a disorganized medication cart. These actions resulted in medications being administered past their safe usage period and improper storage of drugs and biologicals.
Surveyors found that food items brought in by family and visitors for a resident were not consistently labeled with opened or discard dates, and some items were stored past their safe consumption period. The facility's policy required labeling and timely consumption of such foods, but this was not followed, as confirmed by the RRD during an interview.
Two residents in a LTC facility experienced preventable falls due to inadequate supervision and improperly secured equipment. One resident, with Alzheimer's and a history of falls, was left unattended despite requiring 1:1 supervision, resulting in a head injury. Another resident fell out of bed when an enabler bar was not properly engaged, causing a skin tear. Both incidents highlight lapses in safety protocols.
The facility did not adequately address resident concerns about long call light wait times, as documented in Resident Council Minutes and confirmed by resident and staff interviews. Residents reported waiting up to an hour for responses, particularly during understaffed shifts, leading to dissatisfaction and potential care issues.
The facility failed to serve food at a palatable temperature, leading to dissatisfaction among two residents with type 2 diabetes. Both residents, who were cognitively intact, reported that meals were often not hot enough, especially breakfast. Staff interviews confirmed these complaints, and temperature logs lacked documentation for certain days, indicating a failure to ensure food was served at a safe and appetizing temperature.
The facility failed to provide two residents with the food items they requested, leading to dissatisfaction and potential nutritional decline. A resident with diabetes did not receive the correct breakfast items or substitutions for items she did not eat. Another resident did not receive the cottage cheese she ordered. Staff reported frequent complaints about incorrect meal deliveries and communication issues with the kitchen.
A resident with severe cognitive impairment and multiple health issues was not administered oxygen as per physician orders. Observations showed the oxygen concentrator was off and tubing improperly stored. Staff interviews revealed confusion about the resident's oxygen orders, with a CNA adjusting the concentrator to the correct flow rate after noticing it was set incorrectly.
The facility failed to maintain sanitary conditions in the kitchen, risking foodborne illness for 87 residents. Observations revealed a reach-in refrigerator with temperatures above the recommended 41°F, packed with food. The Maintenance Director's attempts to fix the issue increased temperatures further. The Dietary Director discarded perishable items, and a follow-up found improper storage and unidentified solutions in the kitchen, violating FDA Food Code standards.
The facility failed to control hot water temperatures in the B hall, with measurements showing 127°F in the shower room and 128°F in the utility room, exceeding the safe limit of 120°F. The Maintenance Director confirmed that each hall has its own hot water system, and there were no mixing valves to temper the water. Maintenance staff typically checks temperatures in the morning but does not track fluctuations throughout the day.
The facility failed to implement proper infection control protocols, including Enhanced Barrier Precautions, for residents with indwelling devices. Staff did not consistently use PPE, and medical equipment was inadequately cleaned, posing risks of infection. Observations revealed improper wound care practices and poorly maintained resident equipment, indicating systemic issues with infection control.
The facility failed to protect residents from abuse, involving two cognitively impaired residents who engaged in verbal and physical altercations. One resident, with a history of aggression, admitted to slapping another and continued to exhibit inappropriate behavior without adequate supervision. Staff were unable to prevent a physical altercation despite attempts to intervene, and ongoing concerns about the residents' interactions were noted.
The facility failed to prevent further abuse during an ongoing investigation involving two cognitively impaired residents. One resident, with a history of aggressive behavior, was not adequately monitored, leading to a physical altercation with another resident. Despite interventions in place, the facility did not effectively supervise or separate the residents, resulting in repeated conflicts.
The facility failed to provide required transfer/discharge notices to two residents when they were transferred to the hospital. Both residents, who were cognitively intact, did not receive the necessary documentation, and staff interviews revealed a lack of adherence to the facility's policy on transfer notices.
The facility failed to provide two residents with a written bed hold policy notice upon their transfer to a hospital, as required by the facility's policy. Both residents, who were cognitively intact, did not receive the necessary documentation, and staff interviews confirmed the absence of such notices in their records.
A resident with severe sepsis and cellulitis received IV antibiotics inconsistently, with all doses administered outside the prescribed timeframe. Nursing staff interviews revealed confusion about administration times, and the Medication Administration Record showed significant deviations from the recommended schedule.
A resident with pyogenic arthritis experienced worsening knee pain and was unable to walk safely, yet the facility failed to provide a wheelchair despite the resident's requests. Staff interviews revealed a lack of awareness and communication regarding the resident's increased needs, resulting in struggles with mobility, incontinence, and personal hygiene.
A resident with cognitive impairment and a history of heart and respiratory failure did not receive necessary care for pressure ulcers, resulting in infrequent dressing changes and potential infection. The care plan required daily dressing changes, but observations showed dressings were not changed as ordered. Interviews with the resident and family member expressed dissatisfaction with care, and documentation was inconsistent, indicating a lapse in care.
A facility failed to maintain communication and documentation for a resident with end-stage renal disease who required dialysis. The resident's dialysis communication binder was missing, and no communication forms had been received or documented in the medical record for three months. Staff interviews confirmed the lack of communication and documentation, and the facility could not provide any records of communication with the dialysis center during this period.
Two residents experienced medication administration errors, leading to a 16% error rate. One resident did not receive prescribed medications due to unavailability, while another received an incorrect dose of Fexofenadine. These incidents reflect the facility's failure to maintain a medication error rate below five percent.
The facility failed to ensure proper medication storage and administration for two residents. A nurse left medications, including controlled substances, unattended at the bedside without observing the residents taking them. Neither resident had orders or assessments for self-administration, and their care plans lacked focus on self-administration. The DON confirmed no residents were authorized to self-administer medications.
A resident's pressure ulcer care was inadequately documented and not performed as scheduled, leading to potential issues in follow-up care. Family concerns and staff interviews revealed that wound dressings were not changed daily as required, with discrepancies in the Treatment Administration Record and observed dressing dates.
Two residents in the facility experienced unclean living conditions, with rooms and bathrooms having odors of urine, sticky floors, and flying insects. One resident, with dementia and anxiety disorder, had a room with persistent cleanliness issues, while another resident, with bladder-neck obstruction, struggled with managing a urinary drainage bag, leading to leaks and further uncleanliness. The facility's housekeeping efforts were insufficient, as noted by the District Housekeeping Manager and Interim Nursing Home Administrator.
Unsafe Discharge Home Despite Resident and Family Objections
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge for a cognitively intact female resident with multiple serious medical conditions, including left lower limb cellulitis, diabetes, morbid obesity, peripheral atherosclerosis with gangrene, heart disease, hypertension, anemia, anxiety, and severe chronic kidney disease. Her care plan documented that she planned to discharge home, with interventions to involve her and her family in discharge planning, coordinate home care agencies and community supports, and provide written instructions for a safe return to the community. Despite this, the discharge planning process did not adequately address her and her family’s expressed concerns about the safety and feasibility of returning home, particularly regarding access to the home and the availability of care. In the days leading up to discharge, the resident, her family member, and multiple staff members reported significant distress and concern about the planned discharge home. The resident’s MDS showed she was cognitively intact, and she repeatedly stated she could not go home and could not get into the house, which was corroborated by a physical therapy note documenting that she was very emotional and requesting to stay longer. The family member told staff, including the DON, that the resident was in no condition to be discharged and that there was no way to get the resident into the home due to an electric wheelchair blocking the door and the resident’s own wheelchair being too wide. Nursing staff, including RNs, reported that the resident was distraught, crying, and verbalizing that she could not care for herself and would have to call 911 after discharge. Staff nurses expressed that they did not feel safe discharging her and one RN refused to sign the discharge paperwork because she felt it was inappropriate. Financial and insurance issues were central to the decision to proceed with discharge despite these concerns. The business office manager reported that the resident’s managed insurance coverage ended with a last covered day and that a Notice of Medicare Non-Coverage was issued and appealed, with the first appeal rejected. The facility informed the resident and family that, without a secondary payer source, continued stay would require private payment in advance, and the DON and regional director stated that facility policy did not allow acceptance of personal checks for room and board, requiring cash, debit/credit card, or certified check. The family member attempted to pay the requested amount with a personal check but was told it would not be accepted and was unable to obtain a certified check before the scheduled discharge. Despite ongoing appeals and later confirmation that a second-level appeal had been approved, the facility proceeded with the planned discharge when transportation arrived. On the day of discharge, multiple staff and the transport driver observed that the resident was upset, crying, and apprehensive, and upon arrival at home, the wheelchair would not fit through the door and the path inside was blocked, leading the family member to call an ambulance and the resident to be rehospitalized. These events demonstrate that the facility did not ensure the discharge plan met the resident’s needs and preferences or that she was prepared for a safe transfer home, as required by its discharge planning policy.
Failure to Implement Fall Prevention and Supervision Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent accidents for two residents. One resident with a history of dementia, multiple fractures, unsteadiness, and cognitive deficits was care planned for fall prevention measures, including keeping the bed in a low position, using a fall mat, ensuring the call light was within reach, and maintaining a hazard-free environment. Despite these interventions, the resident experienced an unwitnessed fall in the hallway, was found sitting on the floor, and later was diagnosed with a closed fracture of multiple pubic rami. Observations after the fall revealed that the fall mat was not consistently placed next to the bed as required, and the wheelchair was not within reach. The resident was also observed unsupervised in the dining room, attempting to pick up items from the floor without staff present, despite her impulsiveness and cognitive impairment. Another resident with a history of stroke, right-sided paralysis, muscle weakness, and reduced mobility was care planned for two-person assistance with transfers and ambulation, and the use of a gait belt for safety. During an observed transfer, a CNA assisted the resident from the wheelchair to the bed without using a gait belt and did not utilize the prescribed walker. The resident was prompted to hug the CNA for support during the transfer, and the wheelchair was placed out of reach afterward. The facility's policy and staff interviews confirmed that a gait belt should be used for all transfers involving residents who are weak or unsteady. The facility's fall prevention program required that residents at risk for falls receive care and services according to their assessed risk, and that interventions be monitored for effectiveness and revised as needed. However, direct observations and interviews indicated that care planned interventions were not consistently implemented for both residents, resulting in a fall with injury for one and the potential for harm for the other.
Failure to Resolve and Communicate Outcomes of Resident Grievances
Penalty
Summary
The facility failed to follow up and resolve grievances for multiple residents regarding missing personal items, including money, clothing, and other belongings. Documentation for grievances submitted by residents was incomplete, with forms lacking information on whether concerns were resolved, if results were communicated to residents, and whether residents were satisfied with the outcomes. In several cases, there was no evidence that investigations were completed or that residents were informed of the findings, despite facility policy requiring such actions. Residents reported missing items such as cash, clothing, and personal care items, and in one case, a resident with visual impairment reported unauthorized charges on his debit card after staff assisted him with purchases. Interviews with staff revealed that some were not involved in investigations or were unaware of the outcomes, and that the previous administrator was responsible for handling certain incidents but did not complete the required documentation. Resident Council minutes and group interviews further confirmed that concerns about missing items and unresolved grievances were ongoing and not addressed in a timely or effective manner. The facility's Quality Assistance Policy required that grievances be investigated, findings reported to the administrator, and results communicated to the resident or their representative. However, review of records and interviews indicated that these steps were not consistently followed. The lack of a specific policy regarding missing items and the absence of thorough documentation and communication contributed to the deficiency, resulting in unresolved grievances and dissatisfaction among residents.
Failure to Implement Infection Control Protocols and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control protocols for multiple residents, specifically regarding enhanced barrier precautions (EBP), injection practices, and the handling of soiled shared equipment. For three residents requiring EBP due to wounds or surgical sites, there were lapses in the use of personal protective equipment (PPE), signage, and care plan documentation. One resident with a deep tissue injury to the left heel had a care plan indicating the need for EBP, but no interventions were listed, and the EBP signage was inconsistently posted. Another resident with a right foot surgical incision had orders and care plans specifying EBP, but staff were observed providing high-contact care without donning the required PPE, and the EBP sign was missing until after surveyor intervention. A third resident with a coccyx wound had no EBP signage or care plan documentation, and an LPN provided direct care without PPE, stating she was unaware of the EBP requirement. Additionally, infection control practices during medication administration were not followed. A nurse was observed preparing and administering an insulin injection without performing hand hygiene or wearing gloves, and later reported that she did not typically use gloves for injections, nor was she trained to do so. This practice deviates from standard infection control protocols and increases the risk of cross-contamination. The facility also failed to ensure that shared equipment was properly cleaned between uses. A hoyer lift was observed in the hallway with a resident grasp cover that had dried, soiled material, indicating it had not been cleaned after use. These deficiencies collectively increased the potential for the spread of infection, bacterial harborage, cross-contamination, and disease transmission among residents.
Failure to Maintain Sanitary and Safe Environment in Multiple Facility Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas, as evidenced by direct observations and staff interviews. In the kitchen, worn and missing grout, as well as raised tiles under the dish machine and garbage disposal, allowed moisture to accumulate, creating conditions conducive to insect and bacterial growth. Multiple gnats were observed in these areas, particularly around an unused floor drain and sections with low grout. The lack of a functioning exhaust for the high-temperature dish machine further exacerbated moisture accumulation and humidity in the area. During a tour of resident care and utility areas, additional deficiencies were noted. In the B hall shower room, crusted white powder debris was found on the commode seat, and there was no paper towel holder or paper towels available. The shower bed had accumulated trash, debris, and staining under the mat, with care staff reportedly responsible for cleaning between residents. In the central supply room, boxes of briefs were stored directly on the floor, and shelving units were made of press-board that was not smooth or easily cleanable. The C Hall Soiled Utility room had vinyl coving that had fallen and lacked proper structural support, while the D Hall Soiled Utility room had a non-functioning exhaust fan, affecting the entire hall. Resident rooms were also found to be unsanitary and in disrepair. Observations included dried liquid spills and brown stains on floors and walls, cobwebs and dust on window sills and blinds, and dirty thresholds. One room had a wall bead strip detached and leaning against the wall, chipped paint on the heater, cracks on the wall, and exposed nails or screws. Housekeeping staff described a multi-step cleaning process but noted that rooms could be skipped if residents were present, and maintenance issues were reported through an electronic work order system.
Failure to Provide Dignified Dining Experience Due to Delayed Meal Service
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents by not serving their meals in a timely manner while others at their table were already eating. During a dining observation, one resident was served and began eating, while another at the same table waited without a meal. Two more residents joined, and one of them received his meal and finished eating before the two waiting residents were served. One of the waiting residents eventually took uneaten bread left by another and began to eat it, while the other left the table with her meal untouched after finally being served. The last resident was served his meal after being left alone at the table. The Regional Registered Dietitian confirmed that residents seated together should receive their meals at the same time or as soon as possible, and that waiting 20 minutes or more was longer than normal.
Failure to Provide Required Medicare Coverage Notices to Discharged Residents
Penalty
Summary
The facility failed to provide required Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) and Notice of Medicare Non-coverage (NOMNC) forms to two residents prior to their discharge. Both residents had significant medical conditions, including metastatic lung cancer, COPD, malnutrition, and cognitive deficits. Review of records and interviews confirmed that these forms were not issued as required, and no documentation of the forms could be located for either resident. The Social Services Director, who became responsible for issuing these forms in mid-February, reported that she did not provide the SNF-ABN or NOMNC forms to the affected residents prior to their discharge. The Regional Director of Operations also confirmed that, due to a transition in social services leadership during the residents' stays, the required forms were not completed and could not be found. No copies of the SNF-ABN or NOMNC forms were provided to surveyors for either resident by the time of the survey exit.
Failure to Notify State LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that proper discharge notifications were completed for two residents who were transferred to the hospital. In both cases, documentation showed that the residents were sent to the emergency department or hospital, and all physician orders were discontinued for one of the residents. The State LTC Ombudsman reported not receiving any discharge notifications from the facility for several months. Interviews revealed that the social worker was not involved in notifying the ombudsman's office and had only recently received official training, while the nursing home administrator stated that the social worker was responsible for these notifications and that reports should be sent monthly. As a result, the required notifications to the State LTC Ombudsman regarding resident discharges were not completed.
Inaccurate Schizophrenia Diagnosis Documented on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident received an accurate clinical assessment reflective of their current status, resulting in an inaccurate diagnosis of schizophrenia being documented on the Minimum Data Set (MDS) assessment. The MDS for the resident indicated an active diagnosis of schizophrenia, despite no evidence of psychosis-related behaviors during the assessment period and no treatment or prescription of antipsychotic medication for schizophrenia while at the facility. The resident's medical diagnosis list included schizophrenia, but this was based on a historical entry and not on current clinical findings. Interviews with facility staff confirmed that the resident was not being treated for schizophrenia and had no related behaviors observed. The social worker stated that the resident's depression medication was managed by a psychiatrist, but there was no treatment for schizophrenia. The MDS nurse acknowledged that the resident was coded as having schizophrenia on the MDS, despite the absence of supporting clinical evidence or treatment. Review of the MDS 3.0 RAI manual emphasized the requirement for accurate assessments based on validated information from the observation period, which was not met in this case.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice regarding the administration and documentation of physician-ordered medications and treatments for two residents. For one resident with a history of bipolar disorder, depression, and suicidal ideation, the Medication Administration Record (MAR) indicated that an antidepressant medication was administered on specific dates, but a nurse admitted to falsely documenting the administration when the medication was not actually given. There was also no documentation that the provider was notified of the missed dose, as required by professional standards and facility policy. For another resident with a complex medical history including a right foot amputation, diabetes, and impaired skin integrity, the Treatment Administration Record (TAR) showed multiple omissions in the documentation and completion of wound care treatments as ordered by the physician. Observations revealed that the resident's wound dressing had not been changed for several days, despite documentation indicating otherwise. The wound care nurse confirmed that the dressing had not been changed since a specific date, and the wound was observed to be swollen and at risk of dehiscence. There was no documentation of treatment refusals or provider notification regarding missed treatments. Interviews with nursing staff and the Director of Nursing confirmed that treatments and medications were not administered or documented according to orders and policy. Staff acknowledged that refusals and missed treatments were not consistently documented, and that provider notification did not occur as required. Facility policy and professional nursing standards require accurate documentation and timely communication with providers regarding missed medications and treatments, which was not followed in these cases.
Failure to Provide Adequate ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a dependent resident, specifically in the area of hair care. The resident, who had hemiplegia and hemiparesis following a cerebral infarction and required assistance with personal care and had reduced mobility, was observed on multiple occasions with greasy and unkempt hair. Documentation showed that showers or bed baths were scheduled and recorded on certain days, but there were gaps in documentation and no record of refusals or incomplete care. The resident reported that her hair was not being washed as frequently as she preferred, and staff interviews confirmed that hair washing was expected to be part of shower or bed bath routines, but it was not always performed or documented. Observations over several days revealed the resident wearing the same clothing and with consistently greasy hair, despite scheduled care. Staff interviews indicated confusion or lack of clarity regarding whether hair washing had been completed, and there was no separate documentation for shampooing in the CNA records. The care plan indicated a preference for bed baths, but there was no evidence that hair care was consistently provided as part of this routine. The lack of documentation and inconsistent care led to the resident's unkempt appearance and unmet personal hygiene needs.
Failure to Administer Medications and Provide Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with physician orders and professional standards, as evidenced by two separate incidents involving two residents. In the first case, a resident with a history of bipolar disorder, depression, and suicidal ideations did not receive her prescribed Wellbutrin XL 150 mg for depression as ordered. During a medication administration observation, the registered nurse reported the medication was not available and did not notify the provider or search for extra medication in the designated area. Further review revealed inconsistent documentation, with one nurse falsely documenting administration of the medication and later admitting the error. The medication had been available in the medication cart, but it was not administered as ordered, and the provider was not notified of missed doses. The nurse practitioner was unaware of the missed doses, despite the resident's complex psychological needs and recent medication adjustments due to worsening symptoms. In the second case, a male resident with a right foot trans metatarsal amputation, diabetes, and a history of foot ulcers did not receive wound care as ordered. The resident's care plan and physician orders specified twice-daily wound care, including cleansing and application of Bacitracin Zinc Ointment, as well as daily monitoring for signs of infection. However, review of the treatment administration record (TAR) revealed multiple omissions in the documentation and completion of wound care treatments. During an observation, the wound care nurse discovered that the resident's dressing had not been changed for several days, with the last documented change occurring several days prior. The nurse confirmed that the dressing should have been changed twice daily, as ordered, and that the omission was not due to resident refusal, as no refusals were documented in the record. Interviews with nursing staff and the director of nursing confirmed that treatments were not provided as ordered and that refusals, if they had occurred, were not documented according to facility policy. The facility's wound management policy requires that wound treatments be provided in accordance with physician orders and that refusals be documented and communicated to the provider. The failure to administer medications and provide wound care as ordered resulted in residents not receiving care in accordance with professional standards and physician directives.
Failure to Apply and Document Prescribed Positioning Devices for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a positioning device was consistently applied for a resident with a right-sided contracture following a stroke. The resident's care plan and Kardex specified that a right upper extremity hand splint should be applied for four hours daily in the morning and a carrot splint should be used as tolerated during the day and night. However, during multiple observations, the resident was seen without any splint or positioning device on his right hand. Interviews with staff, including a CNA and an LPN, revealed that they were unaware of any splint or device to be used for the resident, and the CNA reported never having seen a splint on the resident in her seven months at the facility. Further review of the resident's medical record showed no documentation that the splint or carrot device had been applied as directed in the care plan and Kardex. The Senior Director of Nursing confirmed that the care plan and Kardex included instructions for splinting, and that staff should have documented the application of these devices, but there was no such documentation present. This lack of consistent application and documentation of the prescribed positioning devices constituted a failure to provide appropriate care to maintain or improve the resident's range of motion.
Failure to Ensure Safe Respiratory Care and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, resulting in deficiencies related to oxygen administration and CPAP use. For one resident with a history of hemiplegia, hemiparesis, and congestive heart failure, observations revealed that her oxygen concentrator was consistently set above the physician-ordered range of 2-4 liters per minute, with settings noted at 4.5 to 5 liters. The nasal cannula was also observed to be improperly applied on several occasions, and staff interviews indicated a lack of clarity regarding responsibility for verifying and adjusting oxygen settings. Another resident with diagnoses including pulmonary embolism and obstructive sleep apnea was observed using a CPAP machine without an active physician order for its use. The resident reported that her CPAP mask had never been cleaned since admission, and the mask was visibly soiled. Although there were orders for daily rinsing of the mask and weekly cleaning of the straps, staff interviews and documentation review revealed inconsistent cleaning practices and a lack of documentation for some days. Staff confirmed that a physician order was required for CPAP use, but none was present in the resident's record. Facility policy required review of physician orders for respiratory equipment and specified cleaning protocols. However, the observed practices did not align with these requirements, as evidenced by improper oxygen administration, lack of active orders for CPAP use, and inadequate cleaning of respiratory equipment. These failures were confirmed through staff interviews, record reviews, and direct observation.
Failure to Document and Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that post-dialysis assessment and monitoring were completed and documented for a resident with end stage renal disease who was dependent on renal dialysis. Review of the resident's records showed there were no current physician's orders for monitoring and assessment upon return from dialysis, and no documentation of post-dialysis assessments, including vital signs, weight, and monitoring of the dialysis access site, after a certain date. Interviews with nursing staff confirmed that the expected practice was to obtain post-dialysis weight, vital signs, assess the dialysis access site, and document findings in a progress note and on the hemodialysis communication record form. However, these assessments and documentation were not completed as required. Further review of medication and treatment administration records revealed that orders for post-dialysis monitoring, including weight, vital signs, and assessment of the AV shunt site, had been discontinued and not reinstated, resulting in a lack of documentation for these parameters over a period of several months. The Director of Nursing acknowledged that the orders had been discontinued and that there was no evidence to show that post-dialysis assessments were completed during this time. This failure resulted in the potential for the resident to not achieve his highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Trauma-Informed Care and Individualized Interventions
Penalty
Summary
The facility failed to identify and address trauma-related triggers and develop individualized care plan interventions for two residents with significant trauma histories. For one resident, who had a complex medical and psychiatric background including bilateral below-knee amputations, schizoaffective disorder, substance use disorder, and a history of homelessness, sexual abuse, and family suicide, the care plan did not include trauma-informed interventions. Despite documentation of nightmares, anxiety, and a history of psychiatric hospitalizations, the social services director confirmed that no trauma assessment or trauma-specific care plan was in place, and staff were not informed of the resident's trauma history or potential triggers. Another resident, who experienced the traumatic loss of her home and pets in a house fire, was observed to be emotionally distressed and reported ongoing anxiety, depression, and stress related to her circumstances. Although her care plan addressed general psychiatric needs such as anxiety and depression, it did not include interventions specific to her trauma from the fire or the loss of her pets. The director of social services was unaware of any trauma-related care plan interventions for this resident and had not referred her to psychological services, despite a physician order for such a consult. The resident expressed that her emotional needs were unmet and that she had not received counseling or guidance regarding her living situation or trauma. Both cases demonstrated that the facility did not conduct adequate trauma assessments or develop trauma-informed care plans, despite clear evidence of traumatic experiences and ongoing emotional distress. The lack of individualized interventions and failure to inform staff of residents' trauma histories resulted in the potential for re-traumatization and unmet emotional needs, as staff were not equipped to recognize or mitigate trauma-related triggers during care.
Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
A deficiency occurred when a resident with diagnoses of acute respiratory failure, generalized anxiety disorder, and major depressive disorder did not receive the necessary behavioral health care and services as required. The resident, who was cognitively intact and admitted for rehabilitation after being rescued from a house fire, reported that she was told she would receive emotional support upon admission but had not received any such services. She expressed a need for psychological support due to trauma from the fire and the loss of her belongings, and stated she previously had a counselor at home. Record review showed a physician's order for a psychological consult for anxiety and a care plan that included behavioral health consults and referrals to social services as needed. However, the Director of Social Services confirmed that no referral to psychological services or counseling had been made, citing the resident's short-term stay as the reason and stating she was unaware of the physician's order. As a result, the resident's psychological support service recommendations were not addressed and support services were not initiated as ordered.
Medication Error Rate Exceeds 5% Due to Insulin, Antidepressant, and Opioid Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration observations, as evidenced by errors involving two residents. For one resident, a registered nurse administered Lantus insulin from a pen that had been opened 38 days prior, exceeding the manufacturer’s guideline to discard after 28 days from opening. The nurse stated she followed the manufacturer’s expiration date rather than the open date, and the unit manager confirmed that while facility policy required discarding insulin pens 30 days after opening, this was not included in orientation education and was expected knowledge from nursing school. Another resident did not receive a scheduled dose of Wellbutrin 150 mg because the nurse reported the medication was not available and did not check the medication cart’s bottom drawer, where extra medications were stored. The medication administration record showed inconsistent documentation, with the medication marked as given on days when it may not have been administered. Additionally, the same resident was given Oxycodone 5 mg instead of the scheduled Morphine Sulfate ER, and the nurse documented that Morphine had been administered. The nurse later acknowledged the error and indicated she would correct the documentation. Facility policies required medications to be stored according to manufacturer recommendations and for staff to verify medication details, including expiration dates, prior to administration. Observations and interviews revealed lapses in following these policies, including inadequate checks for medication availability and improper administration and documentation of medications. These actions resulted in a medication error rate above the acceptable threshold.
Failure to Store and Manage Medications per Manufacturer and Facility Policy
Penalty
Summary
Facility staff failed to store and manage medications according to manufacturer instructions and facility policy. During medication administration, a registered nurse was observed using an insulin pen that had been opened 38 days prior, despite manufacturer guidelines stating it should be discarded 28 days after opening. Additional insulin pens on the medication cart were found to be opened for 51 and 33 days, both exceeding the facility's policy of discarding after 30 days. The unit manager confirmed that monitoring medication storage was assigned to the third shift, but acknowledged that all nurses should check expiration dates before administering medications. It was also noted that knowledge of insulin pen disposal was not included in the facility's orientation education. Further observations revealed an inhaler left out in a resident's room instead of being stored in the medication cart, and the medication cart itself was disorganized, with medication cards not alphabetized or separated by room. Another inhaler was found in the cart without an open date, making it impossible to determine if it was still within the 6-week usage period specified by the manufacturer. Review of facility policies confirmed that medications are to be stored per manufacturer recommendations and that medication carts should be kept clean and organized, with expiration dates checked prior to administration.
Failure to Implement Policy for Storage of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to fully implement its policy regarding the use and storage of foods brought in by family members and visitors for residents. During a kitchen tour, surveyors observed several food items in the resident refrigerator that were not labeled with opened or discard dates, including prepared macaroni salad, sweet tea, thickened lemon water, and ranch dressing. Additionally, prepackaged apples were found with a 'good through' date that had already passed. These observations indicated that the facility was not consistently ensuring that food items were properly labeled and discarded according to policy. In an interview, the Regional Registered Dietitian (RRD) acknowledged that the resident refrigerator was often in poor condition after weekends and that the Dietary Manager typically checked and discarded unlabeled or outdated items on Monday mornings. The facility's policy required all prepared foods brought in by family or visitors to be labeled with content and date, and to be consumed within three days. The lack of adherence to these procedures resulted in unknown discard dates and potentially hazardous foods being stored past their safe consumption period.
Failure to Implement Safety Measures Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the safety of residents by not fully implementing a documented intervention of 1:1 supervision to prevent a fall for one resident and not ensuring an enabler bar was securely engaged before moving another resident in bed. Resident #102, who had Alzheimer's disease and a history of repeated falls, was supposed to be under 1:1 supervision due to her fall risk. However, the CNA assigned to her left her unattended to assist another resident, during which time Resident #102 attempted to walk without her walker and fell, resulting in a head injury. Resident #102's fall occurred after she was found on the floor by a nurse, having self-transferred without her walker. Despite being on 1:1 supervision, the CNA left her to address another resident's needs, leading to Resident #102 falling and sustaining a head injury. The resident was later found to have multiple hematomas and a large scalp hematoma, indicating a significant injury from the fall. Resident #103, who was cognitively intact, experienced a fall due to an improperly secured enabler bar. While receiving morning care, the resident rolled over and grabbed the bar, which was not locked in place, causing him to fall out of bed and sustain a skin tear on his right forearm. The CNA providing care at the time confirmed that the bar was not properly engaged, leading to the resident's fall.
Failure to Address Call Light Response Concerns
Penalty
Summary
The facility failed to address resident concerns regarding lengthy call light wait times, as documented in the Resident Council Minutes from meetings held on 7/18/24, 10/24/24, and 1/15/25. Despite repeated mentions of the issue, there was no indication of follow-up actions being taken to resolve the concerns. The minutes from these meetings highlighted ongoing dissatisfaction with call light response times, particularly during the 2nd and 3rd shifts and on weekends. Interviews with residents and staff further corroborated the issue. Resident #107 reported waiting up to an hour for call light responses, while Resident #106 experienced wait times of up to 30 minutes, especially during late-night and early-morning hours. Resident #101 noted that response times varied depending on staffing levels, with longer waits occurring when only one CNA was available. Staff members, including CNA J and CNA F, confirmed that residents had complained about long wait times, which were exacerbated by staffing shortages and breaks.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to provide food at a palatable temperature for two residents, resulting in dissatisfaction with meals. Resident #106, who has type 2 diabetes mellitus with diabetic nephropathy and is on long-term insulin use, reported that the food was hardly ever hot enough. Similarly, Resident #101, also diagnosed with type 2 diabetes mellitus, expressed that the food was not always hot, particularly during breakfast. Both residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15. Interviews with multiple staff members, including Certified Nurse Aides (CNAs) and a Registered Nurse (RN), confirmed that residents had complained about the food being served cold. The review of temperature logs showed that while there were no concerns documented for 2/16/25, there were no recorded temperatures for 2/17/25, and no documented temperatures for breakfast or lunch on 2/18/25. This lack of documentation and the consistent complaints from residents and staff highlight the facility's failure to ensure that food was served at a safe and appetizing temperature.
Failure to Provide Requested Food Items
Penalty
Summary
The facility failed to ensure that residents received the food items they requested, leading to dissatisfaction with meals and the potential for nutritional decline. Resident #106, who has type 2 diabetes mellitus and diabetic nephropathy, reported not receiving the correct breakfast items and not getting the substitutions she requested for items she did not eat, such as pork or shellfish. Similarly, Resident #101, also with type 2 diabetes mellitus, reported not receiving the cottage cheese she ordered, instead receiving a hot dog and coleslaw, which she did not request. Interviews with staff, including an LPN, CNAs, and an RN, revealed that residents frequently complained about not receiving their ordered meals. The LPN noted that there was often a delay in updating meal preferences on tray tickets, and sometimes preferences were not communicated to the kitchen. CNAs and the RN reported that residents sometimes did not receive requested beverages, nutritional supplements, or specific meal items, and when attempts were made to retrieve the correct items, they were told the kitchen did not have them. This issue led to residents ordering food from local restaurants instead of eating the meals provided by the facility.
Failure to Administer Oxygen Per Physician Order
Penalty
Summary
The facility failed to administer oxygen to a resident according to the physician's order and professional standards of practice. The resident, who had severe cognitive impairment and multiple diagnoses including obstructive lung disease and heart failure, was observed multiple times without the prescribed continuous oxygen therapy. The oxygen concentrator in the resident's room was found turned off, and the oxygen tubing was improperly stored, not in the designated storage bag, which could lead to cross-contamination. Interviews with staff revealed a lack of awareness and adherence to the resident's oxygen orders. A Licensed Practical Nurse initially stated that the resident did not have orders for oxygen, but later confirmed the resident was on oxygen after reviewing the orders. A Certified Nursing Assistant was observed adjusting the oxygen concentrator to the correct flow rate after noticing it was not set properly. The facility's policy on oxygen administration emphasized the need for proper storage of oxygen delivery devices and adherence to physician orders, which was not followed in this case.
Sanitary Conditions and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all 87 residents. During an initial kitchen tour, it was observed that the reach-in refrigerator had an outside temperature gauge reading of 53 degrees and an inside temperature gauge reading of 46 degrees, both above the recommended 41 degrees Fahrenheit. Despite these high temperatures, the refrigerator remained packed with food. The Maintenance Director attempted to fix the issue by chipping away ice from the fan and using a flame to remove ice, which further increased the temperature. The Dietary Director instructed staff to avoid opening the refrigerator to prevent further temperature increases and later decided to discard all perishable food items. Further observations revealed that the refrigerator was eventually cleared of most food items, except for some condiments and tomatoes, which were later removed. The Nursing Home Administrator was initially unaware of the temperature issue. A follow-up tour found that the three-door continental refrigeration unit was struggling to maintain temperature, and a vendor was scheduled to assess it. Additionally, a spray bottle containing an unidentified green solution was found in the kitchen, and shredded lettuce was improperly stored behind raw pork chops, posing a risk of cross-contamination. These findings indicate a failure to adhere to safe food handling practices as outlined in the FDA Food Code.
Hot Water Temperature Exceeds Safe Levels in B Hall
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F in the B hall, resulting in an increased risk of injury among residents. During a tour of the B hall shower room, the hot water was measured at 127°F using a rapid read digital thermometer. Similarly, the hot water in the B hall soiled utility room sink reached 128°F. The Maintenance Director (MD) confirmed that each hall has its own hot water system, and the outgoing hot water to the B hall domestic fixtures was recorded at 128°F without any mixing valves to temper the water. The Maintenance Director was unsure if the temperatures varied throughout the day, as the Maintenance staff typically checks the temperatures in the morning and does not track fluctuations during the day as demand changes.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices for several residents, leading to potential risks of infection and cross-contamination. Observations revealed that Enhanced Barrier Precautions (EBP) were not consistently implemented for residents with indwelling medical devices, such as catheters and feeding tubes. For instance, residents with catheters did not have EBP signs posted outside their rooms, and staff did not consistently use personal protective equipment (PPE) when providing care. Additionally, CPAP machines and tubing were not properly cleaned or stored, increasing the risk of infection. In several instances, staff failed to adhere to proper wound care protocols. During wound dressing changes, supplies were placed directly on bed linens without barriers, and contaminated items were not disposed of properly. Staff did not change gloves between tasks, and contaminated scissors were used repeatedly without cleaning. These practices were observed during wound care for residents with pressure ulcers and other wounds, further compromising infection control measures. The facility also demonstrated lapses in maintaining cleanliness of medical equipment and resident areas. Nebulizer machines, IV poles, and feeding pumps were observed with splatters of substances and dust, indicating inadequate cleaning. Feeding tube lines were found on the floor without end caps, posing a risk of contamination. Wheelchairs and other resident equipment were not properly maintained, with non-cleanable surfaces and debris present. These deficiencies highlight a systemic issue with infection control practices within the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, specifically involving two residents. Resident #15, who was cognitively impaired with a BIMS score of 11, had a history of aggressive behavior, including verbal threats and physical aggression towards staff and other residents. On one occasion, Resident #15 admitted to slapping another resident and expressed a willingness to repeat such actions. Family members were aware of Resident #15's violent behavior, which had occurred multiple times in the past. Resident #40, also cognitively impaired with a BIMS score of 12, was involved in a physical altercation with Resident #15. An incident report detailed that Resident #15 punched Resident #40 in the face after a verbal exchange, where Resident #40 allegedly insulted Resident #15. Staff attempted to intervene but were unable to prevent the physical altercation. Observations noted that Resident #15 continued to exhibit loud and inappropriate behavior, including making sexually inappropriate remarks, without adequate supervision. Interviews with staff revealed ongoing concerns about the interactions between Resident #15 and Resident #40, as both residents were known to treat staff poorly. Despite attempts to monitor and separate the residents, they continued to have verbal and physical altercations. The Nursing Home Administrator was unaware of a recent verbal altercation between the two residents, indicating a lack of effective communication and supervision within the facility.
Failure to Prevent Resident Abuse During Investigation
Penalty
Summary
The facility failed to implement interventions to prevent further abuse during an ongoing investigation involving two residents. Resident #15, who was cognitively impaired with a BIMS score of 11, had a history of aggressive behavior, including verbal aggression and physical altercations with other residents. Despite these behaviors, the facility did not adequately monitor Resident #15, as evidenced by an incident where he punched Resident #40 in the face after a verbal altercation. The care plan for Resident #15 included monitoring when he was around other residents, but this intervention was not effectively implemented. Resident #40, also cognitively impaired with a BIMS score of 12, reported being easily irritated by Resident #15. On one occasion, Resident #15 was left unsupervised in the hallway, where he engaged in loud and inappropriate behavior, leading to another altercation with Resident #40. Staff interviews revealed that the residents frequently encountered each other, exacerbating tensions. Despite the ongoing investigation and previous incidents, the facility did not ensure adequate supervision or separation of the residents to prevent further conflicts.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide the required transfer or discharge notice to two residents, R43 and R30, when they were transferred to the hospital. R43, who was cognitively intact with a BIMS score of 15/15, was transferred to the hospital on 1/27/24 due to an emergency but did not receive the necessary transfer documentation. The Nursing Home Administrator confirmed the absence of the emergent transfer notification for R43. Similarly, R30, who also had a high BIMS score indicating cognitive intactness, was discharged to the hospital due to congestion and shortness of breath but did not receive a written notice of transfer. The medical records for R30 lacked evidence of the required transfer notice documentation. Interviews with facility staff revealed a lack of adherence to the policy regarding transfer/discharge notices. RN AA admitted that she does not send written transfer notices with residents when they are discharged to the hospital. The Director of Nursing, DON B, acknowledged that the transfer/discharge notice should be included in the packet sent to the hospital and recorded in the electronic medical record, but was unsure if this was being consistently done. The facility's policy requires that transfer notices be provided as soon as practicable, but this was not followed in the cases of R43 and R30.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to notify two residents of the bed hold policy in writing upon their transfer to a hospital, as required by the facility's policy. Resident #30, who was cognitively intact, was discharged to the hospital due to congestion and shortness of breath but did not receive a written bed hold policy notice. During interviews, both the resident and the Director of Nursing confirmed the absence of such documentation in the resident's electronic medical record. The Registered Nurse also admitted that she does not provide a written bed hold policy to residents upon hospital discharge. Similarly, Resident #43, who was also cognitively intact, was transferred to the hospital and did not receive a written bed hold policy notice. The facility's records and an email from the Nursing Home Administrator confirmed the lack of documentation regarding the bed hold policy for this resident. The facility's policy, revised in 2022, mandates that residents or their representatives receive written notice of the bed hold policy at the time of transfer, which was not adhered to in these cases.
Inconsistent IV Antibiotic Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice for medication administration, specifically concerning the administration of IV antibiotics to a resident. The resident, who was admitted with severe sepsis and cellulitis, was prescribed Cefazolin to be administered intravenously three times a day. However, the medication was consistently administered outside the physician-ordered parameters. Observations and interviews revealed that the medication was given late multiple times, and the resident expressed uncertainty about whether the medication was administered at all on some occasions. The Medication Administration Record showed that all 17 doses were administered outside the recommended timeframe. Interviews with nursing staff and the Director of Nursing highlighted a lack of clarity and consistency in administering the medication. A registered nurse admitted to administering the medication late and not labeling the IV bag or tubing. The Director of Nursing mentioned a permissible one-hour window for administration, but the medication was still given outside this timeframe. A nurse practitioner clarified that the medication should be administered every eight hours to maintain consistent blood levels, but this was not reflected in the orders or practice. The lack of specific administration times in the updated order further contributed to the inconsistency in medication administration.
Failure to Provide Necessary ADL Assistance and Equipment
Penalty
Summary
The facility failed to identify and address the need for increased assistance with Activities of Daily Living (ADL) for Resident #67, who was dependent on staff for assistance due to pyogenic arthritis. Despite being cognitively intact, Resident #67 reported worsening knee pain and an inability to walk safely with a walker, which was not addressed by the facility. The resident communicated his need for a wheelchair to the nursing staff, doctor, and therapy department, but no action was taken to provide one. This lack of response resulted in the resident struggling with mobility, experiencing incontinence, and being unable to maintain personal hygiene. Interviews with facility staff revealed a lack of awareness and communication regarding Resident #67's increased needs. The Certified Occupational Therapy Assistant (COTA) assumed the resident had informed the nurses, while the Registered Nurse (RN) and Unit Manager (UM) were unaware of the resident's need for a wheelchair. The resident's family member also reported the resident's inability to walk and the need for assistance, which was not addressed by the facility. The resident's care plan and progress notes indicated a high risk for falling and ongoing knee pain, yet the necessary interventions were not implemented.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the worsening of pressure ulcers for Resident #15, who was cognitively impaired and had a history of heart and respiratory failure. The resident had a chronic stage 4 surgical ulcer on the left hip and an unstageable ulcer on the left heel. The care plan required daily dressing changes, but observations and interviews revealed that the dressings were not changed as frequently as ordered. The wound dressings were dated several days prior to the observation, indicating a lack of adherence to the prescribed treatment schedule. Interviews with the resident and a family member highlighted dissatisfaction with the wound care, noting infrequent dressing changes and a foul odor suggesting infection. The wound nurse and floor nurses were responsible for the wound care, but there was a lack of documentation and accountability for ensuring daily dressing changes. The treatment administration record inaccurately documented dressing changes, and there were no physician orders for wound care on specific dates, further indicating a lapse in care. Observations of the wounds showed signs of deterioration, including black crusting and maceration, which were not adequately addressed in the resident's records.
Failure to Maintain Dialysis Communication for a Resident
Penalty
Summary
The facility failed to maintain proper communication and documentation regarding dialysis treatments for a resident with end-stage renal disease who was dependent on dialysis. The resident, who was cognitively intact, had not had any dialysis communication forms uploaded to their medical record since February 17, 2024. Interviews with facility staff revealed that the dialysis communication binder, which was supposed to accompany the resident to and from the dialysis center, was missing, and no communication forms had been received for the past three months. Staff members, including a registered nurse, medical records personnel, and a licensed practical nurse, acknowledged the absence of the communication forms and the lack of documentation in the resident's medical record. The Director of Nursing confirmed that if the binder was missing, no communication was occurring between the facility and the dialysis center. The facility was unable to provide any documentation of communication regarding the resident's dialysis treatments between February 18, 2024, and the date of the survey exit.
Medication Administration Errors Result in 16% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 16% error rate during the survey. This deficiency was observed in two residents. For Resident #7, there were multiple medication administration failures. The resident had active physician orders for Aripiprazole, Calcitriol, and Nepro, all of which were not administered on the day of observation due to unavailability. The Registered Nurse (RN) reported that the Aripiprazole and Calcitriol had been ordered but were not yet available, and the Nepro supplement was missing from the supply closet. These omissions were documented in the Medication Administration Record (MAR) as not given due to being unavailable. For Resident #340, a medication administration error occurred when the RN administered a lower dose of Fexofenadine than prescribed. The resident was ordered to receive 180 mg of Fexofenadine, but only 60 mg was initially given. Upon realizing the error, the RN acknowledged the mistake and planned to administer additional pills to meet the prescribed dose. These incidents highlight the facility's failure to ensure the availability and correct administration of medications, contributing to the elevated medication error rate.
Improper Medication Storage and Administration
Penalty
Summary
The facility failed to ensure proper storage and administration of medications, including controlled substances, for two residents. For one resident, a registered nurse left a medication cup with various pills, including a controlled substance, on the bedside table without observing the resident taking them. The resident expressed that this was not a usual practice and was unfamiliar with the nurse who left the medications. The resident's records did not indicate any orders or assessments for self-administration of medications, and the care plan lacked a focus on self-administration. Additionally, a self-administer medications evaluation had not been conducted for this resident. For another resident, a registered nurse left a medication cup containing two controlled substances on the bedside table while performing wound care, leaving the room multiple times for more than three minutes with the door closed and privacy curtain pulled. This resident was cognitively intact according to their BIMS score, but there were no orders for self-administration of medications, and the care plan did not include a focus on self-administration. A self-administer medications evaluation was also not present in the resident's medical chart. The Director of Nursing confirmed that no residents in the facility were authorized to self-administer medications, and medications should not be left at the bedside.
Inaccurate Documentation and Delayed Wound Care
Penalty
Summary
The facility failed to ensure accurate documentation and timely care for a resident with pressure ulcers, leading to potential issues in follow-up care and assessment. A family member reported that the resident's wound dressings were not changed as frequently as required, which they believed contributed to the lack of healing. During an observation, it was noted that the dressings on the resident's wounds were dated several days prior, indicating that the wound care had not been performed as scheduled. Interviews with staff revealed inconsistencies in the documentation and execution of wound care orders. The wound nurse could not confirm if care was provided on specific dates, and the Treatment Administration Record inaccurately reflected that wound care was completed on days when it was not. The resident's care plan required daily dressing changes, but there were no orders for care on certain dates, and the documentation did not match the observed condition of the dressings.
Failure to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for two residents, resulting in unclean rooms and bathrooms. Resident #33, who has diagnoses including unspecified dementia and anxiety disorder, was found to have a room with a persistent odor of urine, sticky floors, and flying insects. Observations over several days noted liquid on the floor, dirt and debris along the baseboards, and pieces of food on the floor. Family members expressed concerns about the cleanliness and the presence of urine on the floor. Resident #83, diagnosed with bladder-neck obstruction and a cognitive communication deficit, also experienced similar issues. His room and bathroom were observed to have an odor of urine, sticky floors, and flying insects. The resident was seen emptying his urinary drainage bag, which led to liquid on the floor. The bathroom was noted to be dirty with food and liquid that appeared to be urine. Interviews revealed that the resident was not able to properly manage his urinary drainage bag, leading to leaks and further contributing to the unclean environment. The District Housekeeping Manager acknowledged the issues, noting that the resident's room was a high-focus area for cleaning due to frequent problems with cleanliness and odors. The Interim Nursing Home Administrator was aware of the housekeeping issues and was working on resolving them. Despite daily cleaning assignments, the facility's failure to maintain a clean environment for these residents was evident through repeated observations and family member reports.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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