Medilodge Of Campus Area
Inspection history, citations, penalties and survey trends for this long-term care facility in East Lansing, Michigan.
- Location
- 2815 Northwind Drive, East Lansing, Michigan 48823
- CMS Provider Number
- 235517
- Inspections on file
- 28
- Latest survey
- August 11, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Medilodge Of Campus Area during CMS and state inspections, most recent first.
A resident with a history of hypotension, COPD, and acute respiratory failure experienced a significant decline after staff failed to consistently monitor vital signs and follow physician orders for PRN Midodrine and Albuterol. Despite clear signs of deterioration and new orders for medication and monitoring, staff did not document required assessments or administer all prescribed treatments, resulting in the resident becoming unresponsive, requiring CPR, and ultimately being transferred to the hospital for comfort care.
The facility failed to maintain an effective QAPI program, as the LNHA could not provide specifics on projects or address concerns like medication storage and food temperatures. The LNHA was unaware of several issues until the State Survey Process, indicating a lack of comprehensive understanding and documentation of the program's activities.
The facility failed to maintain a safe and homelike environment, with issues such as torn laminate, loose sink counters, and persistent urine odors in resident rooms. A resident reported frequent noise and inappropriate staff behavior, while resident council minutes highlighted ongoing concerns about staff phone use and noise levels. Maintenance and housekeeping efforts were inadequate, as confirmed by staff.
The facility failed to maintain adequate staffing levels, resulting in delayed care for residents. CNAs were often assigned up to 20 residents, making it impossible to complete all care tasks. Residents reported waiting over an hour for call light responses, and staff confirmed that management did not assist during shortages. Essential care tasks were frequently left incomplete, leaving residents in soiled conditions.
The facility failed to maintain preferred food temperature and acceptable palatability for three residents, leading to a deficiency citation. A resident with multiple health conditions reported that the food was always cold, and observations confirmed that the scrambled eggs were below the preferred temperature. Another resident, who is cognitively intact, also reported cold food and was told to eat in the dining room for warm meals. Observations showed that his lunch items were not at the correct temperatures. A third resident expressed dissatisfaction with the food, describing it as unappetizing and often cold, with observations confirming the poor quality of her meal.
The facility failed to maintain resident dignity by allowing staff to engage in disrespectful behavior, such as using personal cell phones and being noisy, which disturbed residents' peace and sleep. A resident reported staff complaints about workload and other residents, while another experienced rude communication from staff. Additionally, a resident felt his concerns about therapy services were not taken seriously. The facility's Quality Assistance Forms did not show resolution of these issues to the residents' satisfaction.
The facility failed to address resident grievances effectively, as evidenced by repeated concerns raised in Resident Council meetings about staff behavior, noise levels, and call light response times. Despite some staff education efforts, issues persisted, and the Social Services Director was reported as unresponsive. A resident confirmed these ongoing problems, and the new NHA could not explain the lack of resolution.
The facility did not provide necessary beneficiary notifications to two residents, resulting in potential uninformed private pay charges and inability to appeal. One resident was missing a SNF-ABN, and another had an incomplete NOMNC. The SSD could not explain the omissions or locate the missing documents.
A resident with multiple medical conditions expressed concerns about medication administration, food temperature, room cleanliness, and noise levels. Despite these grievances being documented, the facility failed to accurately record and resolve them, with incomplete documentation and unresolved issues. Interviews with the DON and LNHA revealed a lack of understanding and resolution of the resident's concerns.
A facility failed to accurately complete an MDS assessment for a resident by incorrectly documenting that the resident did not use corrective lenses. Despite the resident's admission of wearing glasses and a progress note confirming an eye exam and glasses order, the MDS Coordinator marked the section as 'no' in error. This discrepancy was identified during a review of the resident's medical record, which included a picture showing the resident wearing glasses.
A facility failed to timely notify the local state mental health authority of PASARR changes for a resident with mental health and developmental disorders. The resident's significant change in condition was not reported until over three months after a legal guardian was appointed, due to delays in obtaining a level II assessment and communication issues between the Social Service Director and the Community Mental Health Authority.
A facility failed to document and communicate a resident's dental needs, specifically the use of upper dentures, in the care plan and Kardex. The resident, who was cognitively intact and had multiple medical conditions, reported missing his dentures, which were not documented in his care plan. The Social Services Director and MDS Coordinator were unaware of the issue, indicating a deficiency in the facility's documentation and communication processes.
A resident with mild cognitive impairment, schizophrenia, and a seizure disorder was not included in the care plan development after readmission to the facility. Despite expressing a desire to be discharged back to the community, the resident was not involved in a care conference, and there was no documentation of attempts to include her or her guardian. The Social Service Director acknowledged the lack of documentation and involvement.
The facility failed to adhere to physician orders for three residents, resulting in deficiencies in care. A resident awaiting prosthetics did not have a fitting appointment scheduled, another received medication after meals instead of before, and a third was not wearing a required cervical spine collar. Staff were unable to provide explanations for these oversights.
A resident with Type 2 Diabetes Mellitus experienced discomfort due to long toenails, as the facility failed to provide timely podiatry services. Despite an order for podiatry as needed, no services were documented, and the resident's toenails were observed to be long and causing discomfort. The Social Services Director, responsible for ancillary services, was unaware of the need for podiatry, and the Director of Nursing had not yet addressed the issue. The facility's nail care policy, which includes special considerations for diabetic residents, was not followed.
A resident admitted with multiple health conditions experienced a delay in receiving prescribed medications, Pregabalin and Diazepam, due to the facility's failure to provide controlled prescriptions to the pharmacy in a timely manner. The Director of Nursing confirmed the delay, which was not in accordance with the facility's expectation for medication delivery within 24 hours of admission.
A facility failed to ensure a physician documented the rationale for disagreeing with a medication review recommendation for a resident on hospice care. The resident was prescribed Atorvastatin, and the review suggested discontinuation. The physician disagreed but did not provide a documented rationale, only a handwritten note to continue the medication. The DON stated that providers should document their rationale, but this was not done.
The facility failed to ensure that two residents were free from unnecessary medications. A resident was prescribed a nicotine patch for smoking cessation but continued to smoke, and the order was not discontinued timely. Another resident had orders for Tylenol and Norco that, if given as prescribed, would exceed the maximum dose of acetaminophen. The DON confirmed the doses exceeded the safe limit.
A facility's medication error rate exceeded 5% when an RN failed to provide necessary instructions during the administration of Spiriva and Advair inhalers to a resident. The RN did not instruct the resident to wait 2 minutes between inhalers or to rinse their mouth after using the Advair inhaler, leading to a medication error rate of 7.41%. The DON confirmed that these instructions are expected during administration.
The facility failed to ensure proper medication storage and administration for two residents and one medication cart. A resident with multiple medical conditions was found with a cup of pills without an order for self-administration. Another resident had medications left at the bedside, and an LPN stored pre-pulled medications in the cart. The DON confirmed these practices were not acceptable.
A resident with multiple health conditions and dental issues was not assisted by the facility in obtaining a second opinion or arranging for necessary dental procedures. The resident expressed a desire for a second opinion from a personal dentist, but the Social Services Director did not facilitate this request, nor did they assist in arranging an appointment with an oral surgeon as recommended. The lack of documentation and assistance resulted in a deficiency in addressing the resident's dental needs.
The facility failed to honor the dietary preferences of three residents, leading to a deficiency in nutritional care. A resident with intact cognition reported not receiving requested double portions and specific items like whole milk. Another resident expressed dissatisfaction with food quality and lack of menu choices, receiving items he disliked. A third resident with mild cognitive impairment reported frequently not receiving ordered items, leading her to order food out-of-pocket. The dietary manager acknowledged the issues but could not explain the discrepancies.
The facility failed to track employee illnesses effectively, delayed implementing TBP for a COVID-19 positive resident, and improperly cleaned and stored a resident's CPAP mask. A resident's COVID-19 status was not acted upon promptly, and another resident's CPAP mask was mishandled, leading to potential infection risks.
The facility failed to obtain consent or declination for flu and pneumonia vaccinations for a resident with heart failure, COPD, and end-stage renal disease. Despite attempts to contact the resident's Guardian and Responsible Party, no consents were documented, and no immunizations were administered. The ADON noted that immunizations are offered yearly, with consent efforts beginning in August.
The facility failed to offer COVID-19 booster immunizations to three residents, resulting in a deficiency. A resident with a guardian last received a COVID-19 immunization in late 2023, with no further booster offers documented. Another resident, dependent on a medical Power of Attorney, last received an immunization in 2021, with no consents or declinations recorded despite attempts to contact the guardian. A third resident, responsible for their own decisions, also lacked documentation of booster offers after their last immunization in 2023. The ADON noted that boosters were offered when available, but documentation gaps persisted.
A resident with severe cognitive impairment and multiple diagnoses was physically restrained by a CNA after striking the CNA. The CNA held the resident's arms down while the resident was on the floor, which was deemed inappropriate and a violation of the facility's abuse policy. Witnesses confirmed the CNA's actions, leading to the substantiation of the abuse allegation.
A facility failed to timely identify, investigate, and report a staff-to-resident allegation of abuse involving a resident with severe cognitive impairment. The incident involved a resident attacking a CNA, who then improperly restrained the resident. Witnesses did not report the incident immediately, assuming the DON would handle it. The NHA was informed over a week later, delaying the investigation and reporting to the State Agency.
A facility failed to provide necessary assistance with ADLs for a resident with multiple medical conditions, resulting in unmet care needs. Despite the resident's clear preferences and cognitive ability to communicate, staff did not routinely offer or document scheduled showers or bed baths, leading to a lack of proper hygiene care.
Failure to Monitor and Follow Physician Orders Leads to Resident Decline
Penalty
Summary
The facility failed to assess, monitor, and follow physician orders for a resident with multiple diagnoses, including hypotension, COPD, and acute respiratory failure with hypoxia. The resident was cognitively intact and had recently been seen by a nurse practitioner for acute hypoxia and shortness of breath, resulting in new orders for PRN Midodrine for hypotension and Albuterol for shortness of breath. Despite these orders, documentation showed that vital signs were not consistently monitored or recorded as required, and the resident did not receive the ordered Albuterol when experiencing shortness of breath. On the day of the incident, the resident's blood pressure was critically low, and a dose of Midodrine was administered. However, after this administration, there was a lack of ongoing monitoring, as no additional vital signs were documented after a certain point, and no further doses of Midodrine were considered despite continued hypotension. Staff interviews confirmed that the resident was observed to be declining, lethargic, and nonverbal, deviating from his baseline condition, but these changes were not adequately addressed through timely assessment or intervention. The resident ultimately became unresponsive and went into cardiac arrest, requiring CPR and emergency transfer to the hospital. Hospital records indicated the resident suffered from septic shock, lactic acidosis, and was placed on comfort care. The failure to follow physician orders for monitoring and medication administration, as well as the lack of timely assessment and response to a significant change in condition, directly contributed to the poor outcome.
Deficiency in QAPI Program Implementation
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. The facility's policy, implemented on 10/24/22, outlined key components for the QAPI program, including tracking and measuring performance, establishing goals, identifying quality deficiencies, analyzing underlying causes, and developing corrective actions. However, during an interview, the Licensed Nursing Home Administrator (LNHA) was unable to provide specific details about the QAPI projects implemented since the last survey, indicating a lack of comprehensive understanding and documentation of the program's activities. The LNHA mentioned projects related to staff retention, food tray pass, water pass, tray removal, and noise level but could not provide specifics without consulting the team. When asked about concerns such as medication storage, cell phone usage, food temperature, grievances, smoking, Activities of Daily Living, and vaccinations, the LNHA was unaware of these issues until the State Survey Process. The LNHA only provided temperature logs from the dietary department and had no additional information or performance improvement plans for food temperatures, highlighting a deficiency in the facility's QAPI program.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In multiple resident rooms, issues such as torn laminate on countertops, loose sink counters, and torn gripper strips on the floor were noted. Additionally, a resident's wheelchair had visibly torn armrests, and a closet door had a hole. The Maintenance Supervisor confirmed that no work orders had been received to address these issues, indicating a lack of effective communication and maintenance procedures. Furthermore, the facility did not provide a peaceful environment for its residents, as reported by a resident who frequently heard staff yelling and using inappropriate language in the hallways. Resident council minutes from previous months also highlighted ongoing concerns about staff using phones in common areas and excessive noise levels during night shifts. Additionally, persistent urine odors were detected in certain rooms, which housekeeping staff were unable to eliminate despite multiple attempts. These findings demonstrate a failure to uphold residents' rights to a comfortable and dignified living environment.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to maintain sufficient staffing levels to ensure adequate and timely resident care, affecting four residents out of a total census of 65. Interviews with staff and residents revealed that staffing levels were primarily based on facility census, leading to situations where certified nursing assistants (CNAs) were assigned an unmanageable number of residents. CNAs reported being assigned up to 20 residents at times, making it impossible to complete all necessary care tasks. This staffing shortage was exacerbated by frequent call-ins, with no replacements being brought in, leaving the facility understaffed. Residents reported significant delays in call light response times, often waiting over an hour for assistance. One resident described waiting three hours for a call light to be answered, while another resident, who is bedridden, frequently waited over an hour for help with basic needs such as getting a drink of water. These delays in response times were consistent across multiple residents, indicating a systemic issue with staffing and care delivery. Interviews with staff further highlighted the severity of the staffing issues. CNAs and nurses reported that management did not assist on the floor when staffing was short, and some staff members were observed ignoring call lights. The workload was described as extremely heavy, with essential care tasks such as showers, oral care, and brief changes not being completed. The facility's inability to maintain adequate staffing levels resulted in residents being left in soiled conditions and experiencing extended wait times for care.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to maintain preferred food temperature and acceptable palatability for three residents, leading to a deficiency citation. Resident #41, who has multiple health conditions including COPD, PVD, and dementia, reported that the food was always cold. During an observation, the scrambled eggs served to Resident #41 were found to be at 105.2°F, which the resident described as cold. The Dietary Manager explained that the temperature should be to the resident's palatability, but the resident expressed dissatisfaction with the temperature. Resident #318, who is cognitively intact and has conditions such as atherosclerotic heart disease and Barrett's esophagus, also reported that his food was always cold. He was told by the facility that he needed to come to the dining room for warm food. During an observation, the temperatures of his lunch items were found to be below the acceptable range, with pizza at 112°F and salad and peaches above the required cold temperature. Resident #11 expressed dissatisfaction with the food, describing it as unappetizing and often cold. An observation of her lunch tray revealed overcooked and tasteless steamed broccoli and lemon baked tilapia lacking flavor.
Failure to Preserve Resident Dignity and Address Complaints
Penalty
Summary
The facility failed to preserve the dignity of several residents by allowing staff behavior that was disrespectful and disruptive. Resident #2 reported that staff frequently complained about their workload and other residents, particularly Resident #32, while also being observed using personal cell phones instead of attending to call lights. This behavior was described as common knowledge and treated as acceptable within the facility. During a confidential group meeting, multiple residents expressed frustration over staff using personal cell phones and being noisy, especially at night and early in the morning, which disturbed their sleep and peace. Resident #32 experienced rude communication from staff, particularly when using the call light, and there was no evidence that the nurse involved received the promised re-education. Resident #318 also reported feeling that the facility did not honor his dignity due to staff yelling and using inappropriate language in the hallways. Additionally, he felt that his concerns about therapy services were not taken seriously by the Director of Therapy. The facility's Quality Assistance Forms did not demonstrate that these issues were resolved to the satisfaction of the residents involved.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances from residents were promptly documented, investigated, tracked, and resolved. This deficiency was evident in the Resident Council (RC) meetings where multiple concerns were repeatedly raised without resolution. Issues such as staff not wearing name tags, delayed call light response times, high noise levels at night, and staff using personal phones in common areas were consistently reported in RC minutes from September 2024 to March 2025. Despite the Nursing Home Administrator (NHA) attending some meetings and reporting that inservices were conducted, residents continued to express dissatisfaction with the lack of resolution to their concerns. Additionally, the Social Services Director was reported to be unresponsive and rude, further exacerbating the residents' grievances. Resident #2, who was cognitively intact, voiced similar concerns about food, call light response times, noise, and staff behavior, indicating that these issues were longstanding and unresolved. The resident mentioned that these concerns were regularly brought up in RC meetings but were not addressed effectively. The new NHA, who had been employed for only a week, was unable to provide explanations for the ongoing issues. The involvement of the Ombudsman was sought due to the high volume of unresolved concerns, lack of accurate documentation, and inadequate follow-through on resident grievances.
Failure to Provide Beneficiary Notifications
Penalty
Summary
The facility failed to provide the necessary beneficiary notifications, specifically the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), to two residents, R323 and R325, out of three reviewed. This resulted in the potential for these residents or their representatives to be uninformed about potential private pay charges for continued services and their inability to file an appeal. During the review, it was found that R323 was missing a SNF-ABN, and the NOMNC for R325 was incomplete, lacking the second page where the resident or their representative would sign to acknowledge receipt and understanding. The Social Services Director (SSD) reported that she typically provides a SNF-ABN with every NOMNC but could not explain why R323 did not receive one. Additionally, the SSD was unable to locate the missing second page of the NOMNC for R325 or any 2024 beneficiary documents.
Failure to Resolve Resident Grievances
Penalty
Summary
The facility failed to accurately record and promptly resolve grievances for a resident who was admitted with multiple medical conditions, including atherosclerotic heart disease and hypertension. The resident, who was cognitively intact, expressed concerns about not receiving medications as ordered, receiving cold food, room cleanliness, and noise levels. Despite these grievances being documented on Quality Assistance Forms, the forms lacked completion dates and resolutions, and the resident refused to sign them due to incorrect information. Interviews with the Director of Nursing and the Licensed Nursing Home Administrator revealed a lack of detailed understanding and resolution of the resident's concerns. The facility's grievance process was not followed as expected, with incomplete documentation and unresolved issues. The administrator could not explain why the forms did not include more detail or demonstrate a satisfactory conclusion to the resident's grievances.
Inaccurate MDS Assessment for Resident's Use of Corrective Lenses
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #6, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, and other significant health conditions. The MDS assessment, with an Assessment Reference Date of November 14, 2024, incorrectly documented that the resident did not use corrective lenses, despite evidence to the contrary. During an observation and interview, the resident mentioned that she usually wears glasses and was in the process of having them replaced. A progress note from February 13, 2025, confirmed that the resident had been seen by an eye physician and had glasses ordered. The MDS Coordinator, responsible for completing the assessment, stated that she had never personally seen the resident wearing glasses and had marked the section regarding corrective lenses as 'no' in error. This discrepancy was identified during a review of the resident's medical record, which included a picture showing the resident wearing glasses. The error in the MDS assessment highlights a failure in accurately documenting the resident's use of corrective lenses, which is a critical component of ensuring each resident receives an accurate assessment.
Delayed PASARR Notification for Resident with Mental Health Needs
Penalty
Summary
The facility failed to notify the local state mental health authority of Pre-Admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) changes for a resident with mental health and developmental disorders. The resident was admitted with diagnoses including end-stage renal disease, developmental disorder of scholastic skills, and bipolar disorder. The resident's level one screening indicated a mental illness and learning disability, with a level II screen showing a 30-day exemption for expected discharge. However, a significant change in the resident's condition was not reported in a timely manner, as the next screening was delayed until several months after a legal guardian was appointed. The Social Service Director (SSD) reported that the delay in obtaining a level II assessment was due to the Omnibus Budget Reconciliation Act (OBRA) refusing to conduct the assessment until a significant change in status was established. The SSD also mentioned that the corporate Social Worker, responsible for completing the necessary documentation, was unavailable. Despite communication with a Licensed Master Social Worker (LMSW) from the Community Mental Health Authority, who advised holding off on submitting the screening until the resident's capacity and guardianship were established, the significant change PASARR was not completed until over three months after guardianship was granted. This delay was acknowledged as untimely by the LMSW, and the SSD could not provide an explanation for the extended delay.
Failure to Document and Communicate Resident's Dental Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was admitted with multiple complex medical conditions, including multiple sclerosis, paraplegia, and type 2 diabetes. The resident, who was cognitively intact, reported missing his upper dentures, which he had received in the fall of 2024. However, the resident's care plan and Kardex did not include any information about his upper dentures, indicating a lack of documentation and communication regarding his dental needs. During interviews, the Social Services Director and the MDS Coordinator were unaware of the missing dentures, despite the resident having received them recently. The MDS Coordinator, responsible for updating care plans, confirmed that the resident's partial upper dentures were not included in his care plan or Kardex. This oversight highlights a deficiency in the facility's process for ensuring that all aspects of a resident's care, including dental needs, are documented and communicated effectively among staff members.
Resident Excluded from Care Plan Development
Penalty
Summary
The facility failed to include a resident in the care plan development process, which is a requirement for ensuring that residents' needs and preferences are considered. The resident, who has mild cognitive impairment, schizophrenia, and a seizure disorder, expressed dissatisfaction with her current living situation and a desire to be discharged back to the community. She reported that during her initial stay, she was involved in her care planning, but since her readmission, she has not been included in any care conferences. The resident attempted to discuss her concerns with the Social Service Director (SSD) but felt dismissed and unheard. The SSD confirmed that the resident was discharged to an adult foster care facility and later readmitted to the facility. Despite this being a new admission, the SSD did not hold a care conference upon the resident's return, citing that the resident was not gone long enough to warrant one. A care conference was eventually held months later, but neither the resident nor her guardian attended, and there was no documentation of attempts to involve them. The SSD claimed that the guardian attended, but this was not documented, and there was no record of the resident being invited. The SSD acknowledged that documentation could have been better.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to follow physician orders for three residents, leading to deficiencies in their care. One resident, who had undergone bilateral leg amputations, was eager to receive prosthetics. Despite a referral for a prosthetic fitting being entered into the medical record, the appointment had not been scheduled. The Assistant Director of Nursing confirmed the oversight and could not explain why the appointment had not been requested earlier. Another resident was supposed to receive Protonix before meals for GERD management. However, the medication was consistently administered after meals, contrary to the physician's order. The Director of Nursing was unable to provide an explanation for this discrepancy, despite the resident's repeated complaints about the timing of the medication administration. A third resident, who was supposed to wear a cervical spine collar at all times, was observed without it on multiple occasions. The collar was out of the resident's reach, and there were no documented refusals for its use. A Certified Nursing Assistant acknowledged the resident's need for the collar but was unaware of its purpose, indicating a lack of communication and adherence to the care plan.
Failure to Provide Diabetic Foot Care
Penalty
Summary
The facility failed to provide appropriate diabetic foot care to a resident, resulting in long toenails and discomfort. The resident, who was admitted with Type 2 Diabetes Mellitus and required assistance with personal care and had reduced mobility, had an order for podiatry services as needed. However, there were no progress notes indicating that podiatry services had been provided. Observations revealed that the resident's toenails were long, extending past the toes, causing discomfort and scraping the resident's legs. The resident and a family member reported waiting a long time for toenail trimming, and the family member had trimmed all but the big toenails. The Social Services Director, responsible for ancillary services, reported that they had taken over the role three weeks prior and had not been alerted to any need for podiatry services for the resident. The Director of Nursing was aware of the concern but had not yet seen the resident's toenails. The facility's policy on nail care requires assessments on admission and regular trimming and filing, with special considerations for diabetic residents. Despite these policies, the resident's toenails remained untrimmed, indicating a failure to adhere to the facility's nail care policy.
Delay in Medication Administration for Resident
Penalty
Summary
The facility failed to provide timely pharmaceutical services to a resident, resulting in a delay in medication administration. The resident, who was admitted with multiple diagnoses including atherosclerotic heart disease, vertigo, hyperlipidemia, hypertension, anemia, and Barrett's esophagus, did not receive prescribed medications, Pregabalin and Diazepam, in a timely manner. The resident reported not receiving these medications until several days after admission, despite having physician orders dated shortly after admission. The Medication Administration Record (MAR) and progress notes indicated that Pregabalin was not available for several days due to awaiting drug delivery, and Diazepam was not administered until four days after the order was placed. The Director of Nursing confirmed the delay and attributed it to the lack of controlled prescriptions being provided to the pharmacy in a timely manner, which was not in line with the facility's expectation of medication delivery within 24 hours of admission.
Failure to Document Rationale for Medication Review Disagreement
Penalty
Summary
The facility failed to ensure that the attending physician documented the rationale for not implementing a medication review recommendation for a resident. The resident, who was admitted with a diagnosis of vascular dementia and was on hospice care, had a current order for Atorvastatin Calcium 20 mg. A medication regimen review conducted on 5/7/2024 recommended discontinuing the atorvastatin due to the resident's hospice status. However, the physician disagreed with this recommendation on 5/21/2024, marking the response as disagree without providing a documented rationale in the medical record. Instead, a handwritten note stating 'keep on statin' was found at the bottom of the document. During an interview, the Director of Nursing stated that providers are expected to complete a rationale if they disagree with pharmacy recommendations, but this was not fulfilled by the survey exit.
Failure to Ensure Residents are Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary medications. Resident #6 was prescribed a transdermal nicotine patch for smoking cessation, which was never used as the resident continued to smoke cigarettes. Despite the resident's refusal to use the patch, the order was not discontinued in a timely manner, leading to a discrepancy in the resident's medication record. The Licensed Practical Nurse and Director of Nursing acknowledged that the order should have been discontinued earlier, as the resident was not using the patch and continued to smoke. Resident #50 had physician orders for both Tylenol and Norco, which, if administered as prescribed, would exceed the maximum allowable dose of acetaminophen. The orders lacked parameters for the maximum dose, creating a risk of overdose. The Director of Nursing confirmed that the ordered doses exceeded the prescribed parameter of 3000 mg of acetaminophen, indicating a failure to ensure safe medication administration practices for the resident.
Medication Error Rate Exceeds 5% Due to Inadequate Instructions
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.41% due to two observed medication errors out of 27 opportunities for a resident. During a medication administration, a registered nurse (RN) prepared and administered Spiriva and Advair inhalers to a resident without providing the necessary instructions. The RN did not instruct the resident to wait 2 minutes between inhalers, which is the standard protocol. Additionally, the RN failed to instruct the resident to rinse their mouth after using the Advair inhaler, a steroid, to prevent potential throat irritation and infection. The Director of Nursing confirmed that the expectation was for nursing staff to provide these specific instructions during administration.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and administration of medications for two residents and one medication cart. Resident #41, who has multiple medical conditions including COPD, dementia, and anxiety, was observed with a cup containing nine pills that he had not taken immediately. The resident explained that nurses usually watch him take his medication, but sometimes they leave the medication with him. There was no order or assessment in the medical record indicating that Resident #41 was capable of self-administering medication. The Director of Nursing confirmed that Resident #41 was not allowed to self-administer medication, and no explanation was provided for why this occurred. Resident #55 was found with a medication cup containing five pills on the nightstand, and the resident reported that medications were sometimes left at the bedside. The Assistant Director of Nursing confirmed that no residents were approved for self-administration of medication and that nurses were expected to ensure medications were consumed in their presence. Additionally, an LPN was observed storing pre-pulled medications in the medication cart, which included Tylenol and other medications for a resident who was sleeping. The Director of Nursing stated that storing medications in this manner was not acceptable.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to address the dental needs of a resident who was admitted with conditions including congestive heart failure, chronic obstructive pulmonary disease, and morbid obesity. The resident, who was cognitively intact, was observed to have multiple missing and discolored teeth and reported experiencing mouth pain. A dental consult at the facility recommended extractions and dentures to improve the resident's nutrition and general health, with the extractions to be performed by an oral surgeon. However, the resident expressed a desire to seek a second opinion from a personal dentist in a neighboring town. The Social Services Director (SSD) was aware of the resident's request for a second opinion but did not assist in making arrangements, stating that the resident needed an oral surgeon rather than a second opinion. The SSD also did not assist in making an appointment with an oral surgeon, claiming the resident refused to see one. There was no documentation provided to support the claim that the resident refused treatment, and the SSD did not respond when asked if it was her decision to deny the resident's request for a second opinion. This lack of assistance and documentation led to the deficiency in addressing the resident's dental needs.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to meet the dietary needs and preferences of three residents, leading to a deficiency in nutritional care. Resident 60, who has intact cognition, reported that his requests for double portions and specific dietary preferences, such as whole milk and additional brown sugar, were often not honored. Despite his meal ticket indicating these preferences, they were not consistently followed. Similarly, Resident 319, with a history of fractures and other health issues, expressed dissatisfaction with the food quality and the lack of menu choices. He reported receiving items he disliked, such as a banana, and not receiving requested beverages like coffee or hot tea, despite assurances from the dietary manager that his preferences would be considered. Resident 29, who has mild cognitive impairment and other health conditions, also experienced issues with meal service. She reported that her food preferences were frequently not honored, leading her to order food out-of-pocket. During an observation, her meal tray lacked items listed on her meal ticket, such as fruit cups and a dinner roll with margarine. The dietary manager acknowledged the availability of these items but could not explain why they were not provided. The facility's dietary manager stated that staff were trained to follow meal tickets, but discrepancies in meal service were evident, and no audits were conducted to ensure accuracy.
Infection Control and Equipment Handling Deficiencies
Penalty
Summary
The facility failed to effectively track and trend employee illnesses, as there was no formatted document for this purpose. The Assistant Director of Nursing (ADON) reported that call-ins were discussed in morning meetings and with the Scheduler, but the data was only entered into the infection watch system when trends were noticed. This lack of a structured tracking system led to a delay in identifying and responding to potential outbreaks among staff. A resident, who was admitted with severe cognitive impairment and other medical conditions, tested positive for COVID-19 during a hospital visit. However, Transmission-Based Precautions (TBP) were not implemented until two days after the resident returned to the facility, despite the hospital's After Visit Summary indicating a positive COVID-19 test result. The delay in implementing TBP was attributed to the facility not being aware of the resident's COVID-19 status until informed by a Cardiology office. Another resident's CPAP mask was not appropriately cleaned or stored. The resident reported that the mask had fallen on the floor multiple times without being cleaned, and it was not consistently stored in a plastic bag as required by the facility's policy. Observations confirmed that the mask was often left on the floor or nightstand without proper storage, and staff used inappropriate cleaning methods, such as Super Sani-Cloth Germicidal Wipes, which are not recommended for respiratory equipment.
Failure to Obtain Immunization Consents for a Resident
Penalty
Summary
The facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for Resident #18, who was admitted with diagnoses including heart failure, COPD, and end-stage renal disease requiring dialysis. The medical record showed no immunizations were administered, and there were no consents or declinations documented. The Assistant Director of Nursing reported that immunizations were offered yearly, with attempts to obtain consents starting in August. A progress note from December indicated multiple messages were left for the resident's Guardian regarding the need for consents, but no calls were returned. Another note from February documented a call to the resident's Responsible Party, requesting a return call regarding immunization consents.
Failure to Offer COVID-19 Boosters to Residents
Penalty
Summary
The facility failed to offer COVID-19 booster immunizations to three residents, leading to a deficiency in their immunization protocol. Resident #6, who had a guardian, last received a COVID-19 immunization on December 2, 2023, but there was no documentation indicating that any further booster immunizations had been offered. Similarly, Resident #18, who had a medical Power of Attorney, last received a COVID-19 immunization on November 9, 2021, and there were no records of immunization consents or declinations. Despite multiple attempts to contact Resident #18's guardian for consent, no response was received. Resident #32, who was their own responsible party, last received a COVID-19 immunization on November 30, 2023, with no documentation of further booster offers. During an interview, the Assistant Director of Nursing (ADON) reported that COVID-19 booster immunizations were offered to residents when they became available, specifically mentioning a booster that became available in 2024. However, the lack of documentation for these three residents indicates a failure in the facility's process to ensure that all eligible residents were offered the booster immunizations. This deficiency highlights a gap in the facility's immunization offering and documentation practices, particularly in maintaining up-to-date records and ensuring communication with responsible parties for consent.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff. Resident #3, who had severe cognitive impairment and multiple diagnoses including Huntington's Disease and dementia, was involved in an incident where a Certified Nurse Aide (CNA) allegedly threw the resident against a wall during an altercation. The incident was reported by another resident who had heard about it from a third resident. The facility's investigation revealed that the CNA had improperly restrained the resident by holding her arms down while she was on the floor, which was deemed as abuse by the facility's standards. On the day of the incident, Resident #3 approached the CNA from behind and struck her in the head. The CNA responded by grabbing the resident's arms and lowering her to the floor, where she continued to hold the resident's arms down until help arrived. Witnesses, including another CNA and a Registered Nurse (RN), confirmed that the CNA had restrained the resident in a manner that was considered inappropriate. The Director of Nursing (DON) arrived at the scene and assisted the resident off the floor, noting that the resident did not suffer any physical or psychological harm but that the CNA's actions were improper. Interviews with staff and residents corroborated the sequence of events. The CNA admitted to holding the resident down to prevent further strikes, and witnesses confirmed this account. The facility's abuse policy, which prohibits such actions, was reviewed, and it was determined that the CNA had violated this policy by not walking away from the situation and instead restraining the resident. The facility substantiated the allegation of abuse based on these findings.
Failure to Timely Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to timely identify, investigate, and report a staff-to-resident allegation of abuse involving a resident with severe cognitive impairment. The incident occurred when a resident with Huntington's Disease and dementia allegedly attacked a CNA, who then improperly restrained the resident by holding her arms down while she was on the floor. Witnesses, including another CNA and an RN, observed the incident but did not report it immediately, assuming that the Director of Nursing (DON) would handle the situation. The Nursing Home Administrator (NHA) was not informed of the incident until over a week later, delaying the investigation and reporting to the State Agency. The resident involved in the incident was admitted to the facility with diagnoses including Huntington's Disease and dementia with behavioral disturbance. The resident had a severe cognitive impairment, as indicated by a BIMS score of 7. During the incident, the resident reportedly attacked the CNA from behind, prompting the CNA to restrain her by holding her arms down while she was on the floor. Witnesses confirmed that the CNA's actions were inappropriate and could be considered abuse, but they did not report the incident immediately, believing that the DON, who was present, would take the necessary steps. The delay in reporting the incident was further compounded by the fact that the DON did not take immediate action to report the abuse. The DON assumed that the situation was under control and did not realize the severity of the incident until it was reported by another resident over a week later. This delay in reporting and investigating the incident resulted in a failure to protect the resident and potentially allowed further allegations of abuse to go unreported.
Failure to Provide Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident, resulting in unmet care needs. The resident, who had multiple medical conditions including the absence of both legs above the knee, congestive heart failure, and mild cognitive impairment, was not routinely receiving scheduled showers or bed baths. Despite being cognitively intact and able to communicate her needs, the resident reported that staff had not been approaching her to discuss or provide the scheduled showers or bed baths, leading her to stop reminding them as they were aware of her preferences. The resident's care plan indicated a preference for showers or bed baths on Wednesday and Sunday evenings, with assistance from one person. However, documentation revealed that the resident had not been offered or provided a shower or bath on five out of nine scheduled days within a 30-day period. There were no entries or documentation for several scheduled shower dates, and no episodes of care refusal were recorded, contradicting the resident's care plan and progress notes. Interviews with staff, including a Certified Nurse Aide (CNA) and the Director of Nursing (DON), confirmed that the resident was scheduled for twice-weekly showers and that refusals should be documented. However, the DON could not explain why documentation reflected
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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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