Bronson Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Mattawan, Michigan.
- Location
- 23332 Red Arrow Highway, Mattawan, Michigan 49071
- CMS Provider Number
- 235434
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Bronson Commons during CMS and state inspections, most recent first.
A resident with a history of falls, recent head trauma, and acute confusion was inaccurately assessed as not being at risk for elopement despite documented paranoia, agitation, wandering, and repeated statements about wanting to leave. Staff relied on the presence of a wander guard to identify elopement risk, did not reassess the resident’s status, and did not communicate her behaviors as elopement risk indicators. During a night shift, the resident was briefly supervised at the nurse’s station, then returned to bed; later, she independently wheeled to the main entrance, used the handicap door button, exited the building unnoticed, and was only discovered missing when an LPN went to administer medications and initiated a search that found her outside near a neighboring home. In a separate incident, another cognitively impaired, fully dependent resident was transferred from bed to chair with a Hoyer lift using a hygiene sling that had not been clinically assessed or ordered for her, and the care plan did not specify sling type. CNAs used the sling available in the room, but the resident could not maintain the upper body support required, slid out of the sling, fell onto the lift frame, and sustained a head laceration requiring staple repair in the ED, while therapy staff later confirmed that a standard full-body sling should have been used for such transfers.
The facility failed to maintain a full-time RN in the DON role when the DON also served as the Executive Director/NHA, resulting in the same individual being responsible for both clinical and administrative oversight. The DON reported extensive DON duties, including audits, education, policy updates, infection prevention, clinical oversight, and IDT meetings, while also overseeing rehab, activities, dietary, and social work as NHA. Because of the dual roles, the DON stated she could not attend all necessary meetings, was less available to staff, and delegated multiple DON responsibilities to unit coordinators and other staff, including safety committee participation and the nurse aide training program. Staff interviews confirmed reduced access to the DON and increased delegation of DON tasks, and facility records showed no separate Executive Director listed.
Two residents were injured when staff failed to follow prescribed transfer protocols, including not using a gait belt during a bathroom-to-bed transfer and using a slide board instead of a hoyer lift for toileting. These actions resulted in a hand laceration, a femur fracture, and bruising on the upper arms, as staff did not adhere to care plan instructions or use appropriate assistive devices.
The facility did not adequately inform or educate residents about the grievance process, and concern forms were not easily accessible. Residents were unaware of their right to file grievances, and staff, including an LPN and Activity Associates, were unfamiliar with the process or location of forms. Leadership confirmed that forms were not placed in resident-frequented areas and were typically initiated by staff, resulting in grievances not being properly documented, tracked, or resolved.
Three residents were allowed to self-administer medications or had medications left at their bedside without required assessments or provider orders. Staff confirmed that no assessments were completed and no orders were present, despite facility policy requiring both before permitting self-administration. Residents involved had various medical conditions and were observed or reported to have independently taken medications, with staff inconsistently following procedures.
A resident who was cognitively intact and dependent on staff for transfers was not consistently assisted to use a bedside commode as preferred, with staff often offering a bedpan instead during certain times due to staffing and time limitations. Staff acknowledged that the commode was only used when enough staff were available, despite documentation indicating the resident was not appropriate for bedpan use. The care plan lacked specific documentation of the resident's toileting preference, leading to dissatisfaction and a failure to fully support resident choice.
Two residents received PRN psychotropic medication orders for durations exceeding 14 days without documented physician rationale, contrary to federal requirements. One resident with severe cognitive impairment and another with anxiety disorder both had lorazepam orders renewed or written for extended periods, with staff confirming the absence of required documentation for the extended use.
A resident's MDS discharge assessment was incorrectly coded as a hospital transfer when the individual was actually discharged to home. The MDS Coordinator admitted to the error, and the MDS RN, responsible for final submission, acknowledged only performing spot checks rather than a full review, leading to the submission of inaccurate discharge data.
A resident was administered Apresoline for hypertension without verification or documentation of blood pressure as required by physician orders, despite the resident's report of low blood pressure and known side effects such as dizziness. Staff interviews and record review confirmed that the medication was given without the necessary assessment, resulting in a failure to meet professional standards of nursing practice.
A resident with depression and intact cognition reported that the facility did not support her preferred activities, including pet therapy, evening programs, and opportunities to serve others. Activity calendars confirmed a lack of evening activities, pet therapy, and community outings, and the resident described the available activities as unfulfilling. Facility leadership acknowledged that activity needs assessments were limited and had not recently evaluated the need for evening or community-based activities.
A resident with severe cognitive impairment and renal insufficiency did not have water within reach at the bedside, despite facility policy and staff expectations. Observations showed the water cup was repeatedly left across the room, and the resident expressed thirst. Staff interviews confirmed the requirement for water to be accessible and replenished, but this was not consistently done.
A deficiency occurred when staff failed to use enhanced barrier precautions, specifically gown and gloves, during tube feeding administration for a resident with a feeding tube. Despite facility policy and posted instructions requiring EBP for high-contact care involving indwelling devices, an LPN administered the feeding without proper PPE, and staff interviews revealed inconsistent understanding and application of EBP requirements.
The facility did not make survey results and plans of correction easily accessible to residents. Residents reported being unaware of their right to review these documents, and staff, including an LPN and an Activity Associate, were unsure of the location or process for resident access. The survey reports were stored on a high shelf in an area not frequently visited by residents, further limiting accessibility.
The facility failed to provide a written notice of transfer for a resident with moderately impaired cognition, resulting in the potential for residents and/or their representatives to be uninformed of the reason for transfer and their rights. Staff interviews revealed that the required transfer/discharge notices were not included in the paperwork sent with residents.
The facility failed to store CPAP masks properly for three residents, leading to potential respiratory infection risks. Despite staff and residents acknowledging the correct storage procedures, masks were repeatedly found uncovered on nightstands or in drawers.
The facility failed to ensure proper communication and coordination with the dialysis provider for a resident requiring dialysis services. There was no pre and post dialysis treatment assessment communication, and the facility did not have an established agreement with the dialysis provider. Interviews with staff revealed irregular communication and no formal contract, leading to potential risks for the resident's care.
Failure to Prevent Elopement and Unsafe Hoyer Transfer Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to elopement risk and safe mechanical lift transfers. One resident with a history of falls, multiple rib fractures, and recent head trauma was admitted from a hospital with documented confusion, agitation, paranoia, and impulsive behaviors. On admission, the RN completing the elopement assessment marked the resident as not at risk for elopement, despite her own verbal report that the resident was terrified, disoriented, repeatedly stated she wanted to leave, believed people were trying to harm her, and was frequently up and wandering in the room. Progress notes and the admission history and physical documented that the resident was quite confused, agitated, impulsive, and exhibiting abnormal behaviors, including asking staff to help her commit a mass murder, making accusations that hospital staff and paramedics had stolen from her, and expressing delusional beliefs about being harmed. The care plan addressed potential changes in mental status and mood but did not identify or address elopement risk. Nursing and CNA staff interviews showed that staff relied primarily on the presence of a wander guard to identify elopement risk and did not reference other assessments or tools to determine risk. Staff reported that when a resident was identified as an elopement risk, a wander guard was applied and this was communicated in shift report; if a resident was not assessed as a risk, no wander guard was used and no reevaluation occurred unless triggered by preset intervals or events. The admitting RN initially stated she believed she had documented the resident as an elopement risk, but later clarified she had not, explaining she did not think the resident was physically capable of reaching the door and was hopeful the resident would adjust. Subsequent nursing staff on the night shift were informed only that the resident was new, had fallen at home, had a knot on her head, and was "fine," and they were unaware she was an elopement risk. During that night, the CNA and LPN observed the resident as confused, wanting to call her son, not knowing how she arrived at the facility, asking for her husband and son, and stating she wanted to leave. The resident was kept at the nurse’s station for a time, then assisted back to bed around 3:30 AM. Later, camera footage showed the resident self-propelling in a wheelchair to the main entrance, using the handicap button to open the door, and exiting the building without staff awareness. She walked away from the facility and was not discovered missing until the LPN went to administer medications and found her room empty, prompting a search that ended with the resident being located outside near a neighboring house. A second deficiency involved the facility’s failure to ensure safe use of a mechanical lift and appropriate sling selection for another resident with moderate cognitive impairment and generalized weakness, who was dependent on staff for all bed mobility and transfers. During a transfer from bed to recliner using a Hoyer lift, two CNAs used a hygiene sling that was present in the resident’s room and that they reported had been used for months. As the lift was pulled away from the bed, the resident was unable to maintain the upper body and arm support required for that type of sling, slid out of the sling, and fell onto the legs of the lift, sustaining a head laceration that required four staples in the emergency department. Therapy staff, including the supervisor of rehabilitation, PT, and OT, later stated that the hygiene sling is a specialized sling intended for toileting, requires sufficient shoulder engagement and core strength, and is not appropriate for routine bed-to-chair transfers without prior assessment. They confirmed that therapy had not assessed this resident for hygiene sling use and had expected a standard full-body Hoyer sling to be used. The RN unit coordinator acknowledged that the hygiene sling had been used, described it as the resident’s preference, but could not provide documentation of such a preference or any assessment supporting its safety for this resident. Interviews with nursing and therapy staff further revealed that CNAs typically used whatever sling was in the resident’s room and that the resident’s care plan did not specify the type of sling to be used for transfers. There was no documented assessment by therapy or nursing indicating that the resident had the necessary upper body strength and core stability to safely use a hygiene sling for non-toileting transfers. As a result, the resident, who had dementia and Alzheimer’s disease and was dependent for transfers, was transferred with a sling that did not provide adequate support for her condition, directly leading to her fall and head injury during the Hoyer lift transfer.
Removal Plan
- Review elopement and missing person policies and procedures.
- Modify the elopement assessment tool scoring to enhance identification of safety risks.
- Reassess all residents for elopement risk.
- Initiate wander guards for residents identified as elopement risks based on the updated elopement assessment tool.
- Check all wander guards and alarms for functionality.
- Provide comprehensive education on elopement prevention, including ongoing assessments, definitions, exit-seeking behaviors, and role expectations, to all licensed nursing staff and certified nursing assistants.
- Provide education to remaining employees prior to the start of their next working shift.
- Review education material and completion quarterly at the QAPI meeting.
- Perform weekly audits of new admissions for 4 weeks to ensure elopement assessments are completed on admission, kept up to date, and that a care plan addresses any identified risk.
- Create a workstation at the main entrance and schedule staff to monitor traffic in and out of the building.
- Install a Red Box Audible Alarm at the main entrance.
- Maintain the alarm by the entrance attendant.
- Activate the alarm any time the door is opened.
Failure to Maintain a Full-Time RN Director of Nursing
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) served full time in the role of Director of Nursing (DON), as required, because the DON simultaneously held the position of Executive Director/Nursing Home Administrator (NHA). When surveyors entered the facility, they were informed that the NHA and DON were the same person, and the DON confirmed she had been functioning in both roles since the previous NHA left. The facility assessment listed the same individual as both Interim Executive Director and DON, and the employee report did not list any separate Executive Director. The DON described her DON responsibilities as including auditing and education, new processes, policy updates, employee issues, payroll and budget tasks, staff meetings, skills fairs, infection prevention meetings, clinical oversight, and IDT meetings, while also assuming responsibility for rehabilitation, activities, dietary, and social work departments as NHA. Due to the dual roles, the DON reported she was one person doing 40 hours of work in two positions, was not always performing quality work, and could not attend certain meetings or complete some DON functions. She stated that her DON responsibilities were delegated to unit coordinators, and staff interviews confirmed multiple delegations from the DON and that access to the DON had become limited. Staff reported the DON was less available to discuss issues and less hands-on with clinical staff than before. The DON also reported she could no longer serve on the safety committee or run the nurse aide training program, which were reassigned to a unit coordinator and staff development RN, respectively. A unit coordinator reported being placed into the safety committee role shortly after starting and learning the role “on the fly,” further illustrating that DON duties were shifted to other staff because the DON was covering both DON and NHA positions instead of serving full time as DON.
Failure to Follow Transfer Protocols Results in Resident Injuries
Penalty
Summary
The facility failed to ensure that appropriate transfer techniques were implemented for two residents, resulting in injuries. One resident, a female admitted for physical and occupational therapy following a previous femur fracture, was assessed as requiring limited assistance for transfers, with therapy recommendations including the use of a front-wheeled walker, wheelchair, gait belt, and verbal cues. During an assisted transfer from the bathroom to the bed, the CNA did not use a gait belt as required by the resident's care plan. While the CNA was pulling down the bedding, the resident let go of her walker to point at the bed control and fell backward, sustaining a hand laceration and a new acute fracture to her distal femur. The CNA admitted to not checking the care plan and not realizing a gait belt was required for the transfer. Another resident, a female with gastroparesis and dependent for care, was to be transferred with a hoyer lift to the toilet and a slide board only for bed-to-wheelchair transfers. Over a weekend, staff used a slide board transfer to the toilet instead of the required hoyer lift, and when the process took too long, staff reportedly picked the resident up and placed her on the toilet, resulting in bruising on her inner upper arms. Multiple interviews confirmed that the resident's care plan specified a hoyer lift for toilet transfers, and staff were either unaware of or did not follow these instructions. The resident and several staff members reported the improper transfer and resulting bruising. In both cases, the deficiencies were due to staff not following the residents' care plans and not using the required assistive devices or transfer techniques. Staff either did not check the care plans or made assumptions about the residents' transfer status, leading to improper handling and injury. The incidents were witnessed, reported, and confirmed through interviews, observations, and record reviews.
Plan Of Correction
1. One of the residents had discharged at the time of the survey. The care plans of the other affected resident were reviewed and updated by the Interdisciplinary Team (IDT). Updated level of assistance and transfer status were shared with clinical teams by leadership to ensure understanding and compliance. 2. All residents have the potential to be affected. 3. Clinical Oversight Committee will audit care plans to ensure clear direction and appropriate levels of assistance. Refreshed education was provided to clinical staff on where to locate care plan information on EMR devices, and they were reminded to always carry these devices to be ready to verify care plans and assistance levels. Policies were reviewed, and no necessary updates were identified. 4. Routine audits of five care plans are conducted weekly at Clinical Oversight meetings for clarity of assistance levels. Additionally, five weekly audits are performed on transfers to ensure the transfer aligns with care plans. There are also five weekly audits of staff demonstrating where to locate care plan information on devices, and audits to ensure devices are on staff members at all times to guarantee they are always ready to access the care plan. 5. The Executive Director is responsible for compliance.
Failure to Inform and Implement Grievance Process
Penalty
Summary
The facility failed to inform and educate residents about the grievance process and did not effectively implement procedures for documenting, tracking, and resolving grievances. During a confidential group meeting, all six residents present reported that they repeatedly discussed the same concerns in resident council meetings without resolution. These residents were unaware that they could have their private concerns documented on a form, that staff could assist them in completing the form, or that they could submit concerns anonymously. They also did not know that concern forms were available or how to access them, but indicated they would use the forms if they were accessible. Observations revealed that blank concern forms were stored in a binder on a shelf located 4-5 feet up on the wall in a sitting area near the main lobby, making them not easily accessible to residents. Interviews with staff, including an LPN and two Activity Associates, showed a lack of awareness about the location and use of concern forms. The LPN stated she did not know where to find the forms or assist residents with them, and one Activity Associate was unfamiliar with the forms altogether. The other Activity Associate, who conducted resident council meetings, reported that she emailed concerns to relevant departments but did not follow up to ensure concerns were addressed, only discussing responses from previous meetings if available. Further interviews with facility leadership, including the Nursing Home Administrator and DON, confirmed that concern forms were not placed in areas frequented by residents and were posted high on the wall, making them difficult to access. The DON also noted that staff, rather than residents, typically initiated the concern forms. As a result, the facility did not ensure that residents were properly informed about their right to file grievances, did not make the process accessible, and failed to document, track, and record the resolution of grievances as required.
Plan Of Correction
1. The facility moved concern/grievance forms to a tabletop location that is prominent and easily accessible in the lobby. A prominent notice was placed to guide residents to the location. 2. All residents who have concerns about their care have potential to be affected. 3. The facility created a log of concerns and grievances to monitor follow-up and ensure each concern is resolved. The log also enables the facility to track and trend concerns to identify opportunities for continuous quality improvement. The facility will report the number and nature of concerns, resolution status, and trends at monthly Quality Assurance Performance Improvement (QAPI) meetings, where the QAPI Committee will use the information to direct performance improvement projects as warranted. The facility will also provide written information to all residents on the right to air concerns or grievances, and the location of self-reporting forms. This information will be provided to the Resident Council at the July meeting. Going forward, this information will also be included in the admission packet. Education will be provided to all employees about the right to air concerns and grievances, and how residents can submit concerns or grievances using forms that are available in the lobby or with confidential help from an employee. Education will include how these are tracked for continuous quality improvement. 4. During routine daily leadership rounds, each leader will interview at least one resident for awareness how to report a concern or grievance for at least the next 12 weeks. During monthly QAPI meetings the committee will review the number, nature and status of concerns and will determine if opportunities are present for performance improvement. 5. The executive director is responsible for compliance.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the appropriateness of self-administering medications, as required by policy and regulation. Three residents were observed or reported to have self-administered medications or had medications left at their bedside without a completed assessment or physician order authorizing self-administration. In each case, staff confirmed that no assessment had been completed and no orders were present to allow self-administration, despite the facility's policy requiring both an assessment and a provider order before permitting this practice. One resident, with a history of gastroparesis and dependence for care, was observed independently instilling eye drops at her bedside. Staff confirmed there was no physician order for the eye drops, no assessment for self-administration, and that the resident had a history of having unauthorized items removed from her bedside. Another resident, diagnosed with end stage kidney disease and on dialysis, reported that nurses inconsistently left her chewable tablet (Fosrenal) at her bedside to take after meals, as prescribed. Staff acknowledged that this resident had not been assessed for self-administration, and that the facility did not have a process in place for such assessments, even though the medication was being left for her to take on her own. A third resident, with diagnoses including cancer, heart failure, anxiety, and depression, reported that nurses sometimes left her medications, such as supplements and vitamins, for her to take independently. She recounted an incident where she nearly attempted to pick up a dropped pill herself, despite a history of falls. Staff confirmed that no residents on her unit had been assessed for self-administration of medications. Review of facility policy indicated that an assessment and provider order are required before allowing residents to self-administer medications or have medications left with them, but these procedures were not followed for the residents involved.
Plan Of Correction
1. One of the three residents was found to have medications in their possession. This was retrieved and locked up. Education was provided to residents and assigned nurses regarding self-administration of medication and expectations related to protocol. One affected resident has discharged from the facility. The other two will be assessed for their ability to self-administer medications safely per policy. 2. Any resident has potential to be affected. 3. Education will be provided to admission staff related to self-administration of medication policy, to include asking if the resident has any kind of over-the-counter or prescribed medication in their possession, and explaining expectations related to this policy. Specified scripting will be provided. Education will be refreshed with nursing employees related to the existing self-administration policy. It will be added to new hire orientation checklist for new employee education. An additional step will be added to the new admission checklist to include a discussion with the nurse and resident regarding the self-administration policy. Nurses will be instructed to include a comment in Admission Navigator Section of the EMR to reflect that the conversation was completed. The Self-Administration of Medication policy was updated to include an explanation to residents upon admission related to the policy and its expectations. Five weekly audits will be completed of admission documents and nursing assessments to ensure the policy is discussed as expected for the next 12 weeks. Five verbal weekly audits will also be completed with nurses to seek their understanding of the policy for the next 12 weeks. The Executive Director is responsible for compliance with this policy.
Failure to Honor Resident's Toileting Preferences Due to Staffing Constraints
Penalty
Summary
A deficiency was identified when a cognitively intact resident, who was dependent on staff for toileting and transfers, was not consistently provided with assistance according to her preferences. The resident preferred to use a bedside commode for toileting, as documented in her care guide, but staff frequently offered a bedpan instead, particularly during nighttime and mealtimes. Staff interviews confirmed that the use of the commode was limited by staffing levels and time constraints, with staff indicating that using the mechanical lift for commode transfers was too time-consuming. The resident expressed dissatisfaction with being offered the bedpan, which she found uncomfortable, and reported that her requests to use the commode were sometimes denied unless there were enough staff available. Review of the resident's care plan indicated a goal for her to be clean, dry, and odor-free, with interventions to encourage her to verbalize toileting needs and keep her call light within reach. However, the care plan did not specifically document her preference for the commode. Progress notes and occupational therapy documentation further supported that the resident was encouraged to use the commode and was not appropriate for bedpan use. Despite this, staff practice did not consistently align with the resident's preferences, resulting in care that did not fully support her right to self-determination and choice in daily living activities.
Plan Of Correction
1. A care conference will be scheduled with the Interdisciplinary Team (IDT) and resident to identify preferences and discuss how the facility can best meet resident's needs. Care plan will then be updated to reflect the discussion. 2. All residents have the potential to be affected. 3. Existing "Interdisciplinary Long-Term Care Resident Review Protocol" was updated to include: Resident and/or resident representative interview should include a discussion about care preferences and will be completed by a member of the IDT. Standard care preference questions should include the following: toileting, sleep and wake preferences, meals, and other care preferences the resident would like to share. With this information, care plans will be updated at least quarterly with resident and/or representative input and subsequently implemented into how their care is provided. 4. Bi-weekly long-term care resident review meetings will include an audit of all residents due for quarterly review to ensure that interviews were completed and identified preferences were implemented into the care plan for at least the next 12 weeks. 5. The Executive Director is responsible for compliance.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days Without Physician Rationale
Penalty
Summary
Surveyors identified that the facility failed to comply with federal requirements regarding the use of PRN (as needed) psychotropic medications for two residents. Specifically, the facility did not limit the duration of PRN psychotropic medication orders to 14 days, nor did it ensure that the prescribing physician documented a clinical rationale for extending these orders beyond the 14-day limit, as required by regulation. For one resident with Alzheimer's disease and major depressive disorder, a PRN order for lorazepam was in place for a period exceeding 14 days. The resident was severely cognitively impaired and had no documented behaviors during the assessment period. The medication order for lorazepam was renewed multiple times without evidence of a physician's documented rationale for the extended duration. Facility staff confirmed the ongoing order and acknowledged the lack of compliance with the required documentation. Another resident with generalized anxiety disorder also had a PRN lorazepam order written for 30 days. Although the resident reported some anxiety and staff noted the medication was beneficial, there was no documentation from the physician providing a rationale for extending the PRN order beyond 14 days. The pharmacy's monthly review did not identify any irregularities or make new recommendations regarding this medication order.
Plan Of Correction
1. Medical records will be reviewed by providers and the Interdisciplinary Team (IDT) to determine the necessity of medication and frequency. Medications will be discontinued or frequency modified accordingly. All residents have the potential to be affected. 2. EMR Reports will be utilized to identify those with orders for PRN psychotropic medications. Behavior Management Program Policy was updated to include: "When pharmacological interventions are utilized, the duration of order must meet regulatory requirements. PRN psychotropic medications should not exceed more than 14 days unless clinical documentation by a provider is present to provide rationale. Orders will be reviewed during the Behavioral Health Committee meeting to ensure pharmacological interventions meet criteria for use and regulatory requirements." 3. Antipsychotic Medication Management policy was updated to include: "When pharmacological interventions are utilized, the duration of order must meet regulatory requirements. PRN Psychotropic medications should not exceed more than 14 days unless clinical documentation by a provider is present to provide rationale." Education will be provided to nurses, providers, and social services teams regarding policy updates and expectations. External partners providing pharmacy and behavioral health services will receive this refreshed education as well. Weekly Clinical Oversight meetings will monitor these medications utilizing EMR report on a weekly basis. 4. Behavioral Health Committee will review a report of all PRN psychotropic medications during monthly routine meetings to determine the necessity of medication and appropriate frequency. Medications will be discontinued or frequency modified accordingly. Weekly Clinical Oversight meetings will monitor these medications utilizing EMR report on a weekly basis. Five weekly audits to ensure compliance will be completed by Social Services or designee utilizing EMR report for the next 12 weeks. The executive director is responsible for compliance.
Inaccurate MDS Discharge Assessment Coding
Penalty
Summary
A deficiency occurred when a resident's Minimum Data Set (MDS) discharge assessment was inaccurately coded and submitted. The resident, who was admitted with diagnoses including weakness and a need for personal assistance, was documented on the MDS as having been discharged to a short-term general hospital. However, review of the resident's medical record revealed no documentation of a hospital transfer, and it was later confirmed by the MDS Coordinator that the resident had actually been discharged to home, not to a hospital. The MDS Coordinator acknowledged during an interview that she had incorrectly coded the discharge status and that the error was present at the time of submission. The Nursing Home Administrator confirmed the inaccuracy of the submitted MDS and stated that the MDS Registered Nurse was ultimately responsible for ensuring the accuracy of the data submitted. The MDS Registered Nurse admitted to only performing spot checks rather than a full review of the assessment before submission, resulting in the inaccurate discharge information being reported.
Plan Of Correction
1. The MDS Nurse appropriately modified and resubmitted the MDS assessment with corrected discharge destination. 2. All residents have the potential to be affected. 3. Bronson Commons MDS RN will double check discharge destination on all assessments prior to signing and submitting to provide a second check of MDS LPN assessments. Policies were reviewed and no necessary updates were identified. 4. The Director of Nursing will complete five weekly audits of discharge location on MDS assessments to ensure accuracy for the next 12 weeks. 5. The Executive Director is responsible for compliance.
Failure to Follow Blood Pressure Parameters for Antihypertensive Medication Administration
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of nursing practice for medication administration for one resident. The resident, who was prescribed Apresoline for hypertension with specific physician orders to hold the medication if systolic blood pressure (SBP) was less than 130, reported that a registered nurse did not listen to her concerns about low blood pressure and administered the medication despite her warning. Documentation review showed that the resident's blood pressure was 112/56 earlier that day, and there was no record of a blood pressure reading prior to the evening dose when the medication was given. The medication administration record indicated the medication was given in the evening, and there was no documentation of a blood pressure reading or assessment for dizziness at that time. Interviews with staff confirmed that the resident was knowledgeable about her medications and often reminded nurses when her blood pressure was too low for antihypertensive administration. Staff also reported that the medication was frequently held due to low SBP, and dizziness was a known side effect for this resident when her blood pressure was low. The Director of Nursing stated that nurses were expected to verify and document blood pressure readings in accordance with physician orders before administering such medications, but this was not done in this instance. The failure to obtain and document the required assessment prior to medication administration led to the deficiency.
Plan Of Correction
The nurse of the affected resident was provided one-to-one education about the parameters. Nurses will continue to be educated on expectations related to parameters and medication administration. All residents have potential to be affected. Education will be provided to all nurses regarding medication administration expectations for orders with specified parameters. Medication administration expectations related to parameters will be included in new hire orientation. Medication administration policies were reviewed and no necessary updates were identified. The Clinical Oversight Committee will complete five weekly audits of medications with ordered parameters to ensure compliance for the next 12 weeks. The Executive Director is responsible for compliance.
Failure to Provide Meaningful and Individualized Activities
Penalty
Summary
The facility failed to provide meaningful activities tailored to the interests and needs of a resident with a diagnosis of depression, as required by their care plan and comprehensive assessment. The resident, who was cognitively intact and expressed a strong preference for choosing her own bedtime, being around pets, and participating in favorite activities, reported that the facility did not support her involvement in activities of interest. Observations showed the resident often remained in her room, and interviews revealed she felt the activities program did not meet her needs, particularly due to the lack of evening activities, pet therapy, and opportunities to serve others or participate in community outings. Review of activity calendars and participation records confirmed that group activities were only offered during daytime hours, with no evening activities, pet therapy, or community outings available. The activity program did not include activities that allowed residents to serve others or gain a sense of purpose, and the last such activity was a one-time event several months prior. The resident described the available group activities as unfulfilling and childish, and expressed feelings of boredom, lack of purpose, and disconnection from the community. Interviews with facility leadership revealed that resident activity needs were assessed primarily through MDS assessments, and there had been no recent assessment of the need for evening activities. The facility had not provided community outings in years and relied on family or friends for residents' participation in community-based leisure. The activity director was unaware of the need for evening activities and did not routinely review activity assessments, resulting in a lack of individualized programming to meet the diverse needs and preferences of residents.
Plan Of Correction
1. Activities staff visited with the resident to update the resident's needs and preferences, and encouraged the resident to express wishes for activities. The resident provided ideas and suggestions that will be implemented. 2. All residents who would like help to plan or participate in activities have the potential to be impacted. 3. The facility reviewed the Patient Activities Assessment policy, assessment tools, and documentation tools, and determined they are appropriate to capture individual resident preferences and participation. The facility reviewed the policy Patient Activities Program and added a quality assurance process to ensure the program meets the needs of the resident population. Beginning July 2025, the activities calendar will include evening activities and opportunities to serve others. Seasonal outings will begin in August. The activities department will audit resident participation monthly to ensure group activities are well attended. At least monthly, the activities department will ask residents to evaluate a group activity for opportunities to improve or replace it. Education will be provided to all employees about the right to participate in activities that meet the interests and needs of each resident and how the facility supports these activity pursuits through group and individual programs. The resident council will also receive this education in the July meeting. 4. The activities department will interview five residents monthly to ensure each individual resident is offered activities that are meaningful to them personally, for at least the next 12 weeks. 5. The Executive Director is responsible for compliance.
Failure to Provide Accessible Water at Bedside
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease and renal insufficiency, who was severely cognitively impaired, did not have water available at the bedside as required. Multiple observations over two days showed that the resident's water cup was consistently placed on the sink counter, approximately eight feet away from the bed, and not within the resident's reach. The resident was observed lying in bed with dry lips and reported feeling thirsty. No other beverages were present in the room during these observations. Interviews with staff confirmed that the expectation was for water to be kept within reach of residents and replenished at least every shift. Staff also acknowledged that the resident had difficulty holding the standard maroon cup and should have been provided with a more suitable cup. The facility's policy required fresh water to be available to residents at all times, but this was not followed for the resident in question, as evidenced by the repeated lack of accessible water and low recorded fluid intake.
Plan Of Correction
Corrective action took place immediately upon identification of the issue by moving the water within the resident's reach. All residents have the potential to be affected. Education to all staff related to ensuring water is within patient reach at all times in the resident's room. Policies were updated to reflect that water must be within the resident's reach in their room: Water Pass policy, TEMP Purposeful Rounding policy. Five weekly audits of water location within resident's reach in their room will be completed for the next 12 weeks. The Executive Director is responsible for compliance.
Failure to Maintain Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
A deficiency was identified when staff failed to maintain enhanced barrier precautions (EBP) during the administration of tube feeding for a resident with a percutaneous gastrostomy tube. The resident, who had a history of stroke and was admitted with a feeding tube, was under EBP as indicated by signage outside her room and documented in her care plan. Despite these precautions, an LPN administered a bolus feeding without wearing a gown, contrary to facility policy and posted instructions. The LPN stated that EBP was only necessary for CNAs and not for nurses, as she believed she did not come into direct contact with the feeding tube. Further interviews revealed inconsistent understanding and application of EBP among staff. One RN reported that EBP was not used during tube feeding administration, while another LPN stated that both gown and gloves were required for such procedures. A CNA indicated that EBP did not apply to her as she did not administer tube feedings. The facility's policy specified that EBP, including gown and gloves, should be used during high-contact care involving indwelling medical devices such as feeding tubes. The failure to follow these precautions during tube feeding administration resulted in a deficiency related to infection prevention and control.
Plan Of Correction
1. The Infection Prevention Nurse provided one-to-one education on enhanced barrier precautions (EBP) with the resident's nurse. 2. All residents have the potential to be affected if they meet criteria for EBP. 3. Education will be provided to clinical employees related to EBP standard work. The following policies were updated to include verbiage related to using the appropriate personal protective equipment (PPE) as ordered, including EBP: Enteral Feeding, Indwelling Catheter, Peripherally Inserted Central Catheter Change, Irrigating Foley Catheter, Peripheral Intravenous Therapy Procedure, Male Straight Catheter, Female Straight Catheter, Care-Cleaning Urinary Drainage Bags, Pressure Injuries and Wound Care, Wound Culture. 4. Five weekly audits will be completed by the Infection Prevention Nurse or designee to ensure compliance with using EBP when appropriate, for the next 12 weeks. 5. The Executive Director is responsible for compliance.
Survey Results and Plan of Correction Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents. During a confidential group meeting, all six residents present reported that they were unaware they could read the survey reports and did not know who to ask or where to find them. An observation revealed that the binder containing survey reports was placed on a shelf approximately 4-5 feet up on the wall in a sitting area next to the main lobby, making it difficult for residents to access. Interviews with staff further confirmed the deficiency. An LPN stated she did not know where the survey reports were located or how residents could access them. The Nursing Home Administrator acknowledged that the reports were kept in an area not frequently visited by residents and were not easily accessible. Additionally, an Activity Associate who conducts monthly resident council meetings was not aware of how residents could obtain access to the survey reports. These findings demonstrate that the facility did not make survey results and plans of correction readily accessible to residents as required.
Plan Of Correction
The facility moved the binders containing survey results to a prominent location in the lobby on a table that residents, family members, and legal representatives can reach either standing or sitting in a wheelchair. The public binders include survey results for the current year and the previous 3 years along with plans of correction. The facility also placed a prominent notice at the table stating that survey and advocacy information is available here. All residents who want this information have the potential to be affected. The facility created the policy: Facility Required Postings. The facility created the flier "Where to Find Survey Reports" and will distribute it to all patients and residents. The flier will also be added to the facility admission packet. Education will be provided to all employees about where survey information can be found. The resident council will also be given this information at the July meeting. During daily routine leadership rounds, each leader will interview at least one resident for awareness where to locate survey results, for at least the next 12 weeks. The executive director is responsible for compliance.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident reviewed for hospitalizations, resulting in the potential for residents and/or their representatives to be uninformed of the reason for transfer and their rights. Resident #65, who had a moderately impaired cognition with a BIMS score of 12, was admitted on 1/17/2024 and had several discharges to the emergency room and a hospital admission. During an interview, the resident could not recall receiving a written transfer notice each time she went to the hospital. A review of the resident's chart revealed no evidence of written transfer notices being provided, which should have included specific information such as the reason for transfer, effective date, location, appeal rights, and contact information for relevant advocacy agencies. During interviews with facility staff, it was discovered that the paperwork sent with residents when they leave the facility did not include a transfer/discharge notice. A registered nurse was unaware of what the transfer/discharge notice was, and the Executive Director confirmed that they had not been sending out such notices with residents. This oversight indicates a failure to comply with regulatory requirements for notifying residents and their representatives about transfers or discharges, including their rights to appeal.
Improper Storage of CPAP Masks
Penalty
Summary
The facility failed to provide oxygen services per professional standards of practice by improperly storing CPAP masks for three residents, leading to potential respiratory infection risks. Resident #8, diagnosed with obstructive sleep apnea, was observed multiple times with his CPAP mask laying uncovered on top of the CPAP machine on his nightstand. Despite being cognitively intact and able to remove the mask himself, Resident #8 reported that staff assisted with storing the mask, which was not done according to infection control practices. Resident #13, with diagnoses including dysphagia and hypoxemia, also had her CPAP mask improperly stored. Observations revealed the mask laying uncovered on top of the CPAP machine or on a plastic bag inside the nightstand drawer. Although Resident #13 could remove the mask herself, she relied on staff for proper storage, which was not consistently done. She confirmed that staff had been in to take care of the mask, yet it was still found uncovered. Resident #59, diagnosed with Parkinson's disease and dementia, had similar issues with CPAP mask storage. His mask was found uncovered in the nightstand drawer or on top of the CPAP machine. Despite being able to remove the mask, Resident #59 required staff assistance to put it on. Interviews with staff, including an LPN, CNA, Unit Coordinator, Respiratory Therapist, and the DON, confirmed that CPAP masks should be stored in bags when not in use, which was not adhered to during the survey period.
Failure to Ensure Proper Communication and Agreement with Dialysis Provider
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis provider for a resident requiring dialysis services. Specifically, there was no pre and post dialysis treatment assessment and monitoring communication between the facility and the dialysis provider. Additionally, the facility did not have an established agreement with the dialysis provider. This deficiency was identified for a resident with renal failure who was dependent on dialysis three times a week. The resident's medical record lacked documented communications from the facility to the dialysis center before dialysis and from the dialysis center to the facility after dialysis treatments. Interviews with facility staff, including the Executive Director, Licensed Practical Nurse, Unit Coordinator, Unit Clerk, and Director of Nursing, revealed that there was no regular communication with the dialysis center unless there was an abnormality. The facility staff also confirmed that there was no contract or agreement with any dialysis provider, and the post dialysis treatment information uploaded to an electronic record program was not consistently reviewed by the facility staff. This lack of communication and formal agreement resulted in the potential for unrecognized adverse reactions and disruptions in the continuity of care for the resident receiving dialysis treatments.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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