The Laurels Of Carson City
Inspection history, citations, penalties and survey trends for this long-term care facility in Carson City, Michigan.
- Location
- 620 North Second Street, Carson City, Michigan 48811
- CMS Provider Number
- 235636
- Inspections on file
- 25
- Latest survey
- April 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Laurels Of Carson City during CMS and state inspections, most recent first.
Staff failed to use PPE as required for a resident on contact precautions for suspected MRSA, did not document interventions for repeated low chlorine levels in the facility's water management program, and did not dispose of soiled linens in a sanitary manner after providing peri-care to a resident with dementia and right-sided weakness.
Several residents dependent on staff for toileting and transfers experienced delayed call light responses, especially during evening and night shifts, leading to prolonged discomfort, incontinence, and feelings of embarrassment. Staff were observed turning off call lights without meeting residents' needs, and some were described as rough or inattentive. These actions were inconsistent with facility policies requiring timely and respectful care.
A resident with a history of sepsis, CHF, and endocarditis received hydralazine for hypertension despite a physician order to hold the medication if systolic blood pressure was below 140. The MAR showed multiple instances where the medication was administered with SBP values under the threshold, and the DON confirmed there was no documentation that the medication was held as ordered.
A resident with dementia and right-sided paralysis following a stroke was not provided with a prescribed hand splint to maintain range of motion, as outlined in her care plan. Observations showed the splint was not applied during multiple care interactions, and staff did not offer or ask about the splint, despite its availability at the bedside.
A resident with dementia, morbid obesity, and right-sided paralysis was assisted with bed mobility by only one CNA, despite a care plan requiring two staff for such assistance. The CNA instructed the resident to roll onto her sides without the required second staff member present, contrary to the documented safety intervention.
Surveyors observed that the facility did not provide a battery pack emergency light at the transfer switch in the main electrical room, failing to meet requirements for automatic emergency lighting. This was confirmed by the environmental supervisor and could impact all occupants, staff, and visitors if emergency power systems fail.
A wheelchair battery charger was found in use within a resident room in the sub-acute rehab wing, and the area lacked the required fire barrier or automatic fire extinguishing system. The environmental supervisor confirmed that wheelchair batteries are charged in resident rooms as needed, and the necessary fire protection measures, including self-closing doors, were not in place.
The facility did not provide documentation for the required semi-annual kitchen hood cleaning and monthly hood suppression inspection, as confirmed by regional staff during surveyor interviews. These deficiencies could potentially impact kitchen staff and occupants in the affected smoke compartment.
A resident with a history of heart issues experienced chest pain and took multiple doses of nitroglycerin without proper assessment or monitoring by the nursing staff. The LPN focused on removing the nitroglycerin bottle rather than evaluating the resident's condition, and vital signs were not documented. The ADON instructed the LPN to check vital signs, but this was not done, and the nurse practitioner was not informed of the chest pain. The DON confirmed that such complaints require immediate evaluation.
The facility failed to accurately assess, provide treatments as ordered, and ensure physician oversight for wounds for two residents, leading to significant deterioration of their conditions. One resident developed osteomyelitis due to delayed treatment, while another experienced worsening of a stage 3 pressure ulcer and the development of a new wound. The facility's documentation and follow-up were inconsistent, and necessary wound care supplies were not always available, exacerbating the residents' conditions.
The facility failed to promptly identify and manage outbreaks of COVID-19, Influenza, and RSV, leading to widespread transmission among residents and staff. There was inadequate implementation of transmission-based precautions, lack of prompt testing, and insufficient documentation of outbreak investigations and contact tracing.
The facility failed to provide the pneumococcal immunization to a resident who had consented to receive it. The resident was later admitted to the hospital with RSV and pneumonia. The Infection Control Preventionist admitted to missing the requirement, despite the facility's policy mandating the vaccine for residents aged [AGE] years or older or those with underlying conditions.
The facility failed to administer controlled medications following physician orders and professional standards of practice for six residents, resulting in medication errors and the withholding of medications without a physician order. Additionally, medications were not administered according to physician-ordered parameters for several residents, and there were issues with insulin administration and potential staff impairment.
The facility failed to ensure the DON did not serve as a charge nurse, leading to missed treatments and negative resident outcomes. The DON worked over 110 hours as a charge nurse, resulting in missed laboratory tests, treatments, and medications. An Immediate Jeopardy was identified due to improper pressure ulcer care and LPNs administering IV medications without proper training.
The facility failed to ensure call lights were within sight and reach for a resident with multiple diagnoses, including acute respiratory failure and COPD. The call light was observed out of reach on several occasions, despite the facility's policy requiring it to be within easy reach.
The facility failed to maintain safe water temperatures, with measurements showing excessively high temperatures in bathroom sinks and spa rooms, posing a scalding risk to residents. The Maintenance Director admitted that the water temperature was turned up to 140 degrees last year and some sinks were missing point-of-use mixing valves, which had not yet been installed. Water temperature logs from January to April 2024 consistently showed temperatures exceeding 120 degrees in various locations.
The facility failed to ensure appropriate catheter care for a resident with dementia and other conditions. LPNs performed unnecessary catheter flushes without proper protective equipment, and the origin of the order was unclear. The resident's urologist confirmed that the flushes were not recommended, posing a significant infection risk.
The facility failed to follow best practice standards for two residents receiving supplemental oxygen. One resident had undated oxygen tubing and lacked proper documentation, while another had no documented oxygen delivery rate or regular observations, and her care plan lacked necessary interventions for COPD.
A facility failed to ensure IV medications were administered by trained and licensed nurses, leading to an LPN administering IV antibiotics to a resident without the required specialized training. The DON confirmed the lack of documentation for such training.
The facility failed to maintain clean ventilation filters, resulting in reduced air quality and circulation in several resident rooms. A resident reported that maintenance had not changed the filter since before winter, and the air seemed to come out slower. The Maintenance Director stated that filters are supposed to be checked monthly and changed as needed, but the facility's preventative maintenance program requires filters to be replaced or thoroughly cleaned every three months. The maintenance log showed the task was last completed on 3/31/2024.
The facility failed to properly assess and manage pain for a cognitively impaired resident with a history of stroke and contracture. Despite displaying signs of pain, the resident was not consistently assessed using the PAINAD scale, and there was inadequate documentation of pain characteristics. This led to an increased perception of pain and unmet pain needs, highlighting a significant deficiency in the facility's pain management practices.
A resident was administered an antibiotic daily for 12 days without a proper order from the urologist. The facility staff failed to verify the medication order and demonstrated a lack of knowledge regarding criteria for antibiotic use in residents with indwelling catheters.
A resident with chronic kidney disease was inappropriately prescribed Augmentin for a suspected UTI without waiting for urinalysis and culture results. The resident exhibited no UTI symptoms and did not meet the McGeer Criteria, leading to inappropriate antibiotic use.
Infection Control Failures in PPE Use, Water Management, and Linen Handling
Penalty
Summary
The facility failed to properly implement its infection prevention and control program in several areas. For one resident with dementia and muscle weakness, who was under contact precautions due to a suspected MRSA infection in a heel wound, staff did not follow required protocols. Despite clear signage on the resident's door instructing staff to don gloves and a gown before entry, a certified nursing assistant entered the room without the appropriate personal protective equipment. The infection preventionist confirmed that the resident's status had recently changed to contact precautions and that gloves and gowns were required prior to room entry. Additionally, the facility did not follow its water management policy and procedures. Chlorine level testing records showed multiple instances where chlorine levels were below the acceptable range, but there was no documentation of interventions or use of the Water Management Team Meeting Minutes form as required by policy. Furthermore, during peri-care for another resident with dementia and right-sided weakness following a stroke, a certified nurse aide placed soiled washcloths on the resident's over-bed table and did not clean or sanitize the table before leaving the room, failing to dispose of soiled linens in a sanitary manner.
Plan Of Correction
F tag 880 Infection Prevention and ControlSS=F 1. Staff member involved was immediately educated on the use of PPE for all residents in isolation. Soiled washcloths were immediately bagged and placed in the soiled utility room for laundering and the bedside stand disinfected. The water management meeting was held on 5/6/25. The following departments attended the meeting: Environmental Service Director, Maintenance, Infection Control (IC), Nursing, and NHA. 2. Residents residing in the house are at risk related to the deficient practice. Residents in the house were reviewed by the nursing team to ensure there was no spread of infection for failure to follow proper IC protocols when entering a room without proper PPE, no s/sx of legionella, and lack of proper handling of linen. The city's water department was contacted regarding the chlorine levels that were noted to be outside of parameters. A visit is scheduled for the week of 5/12 to test the facility's chlorine levels, using their device. If it is determined that the results are not within parameters, we will work with the water dept to regulate chlorine levels to appropriate parameters. 3. The QAPI Committee reviewed the policies and procedures related to Multi Route Transmission Based Precautions, Infection Control, and the Water Management Program and deemed it appropriate. Facility staff were re-educated by the DON/Designee on Multi Route Transmission Based Precautions and Infection Control. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. The Maintenance Director and ICP were re-educated on the water management program and the requirement of monthly meetings. The Maintenance Director was educated that if levels are not within parameters, an action plan needs to be developed and implemented to include rechecks on the levels. 4. The Infection Control Preventionist/Designee will observe 5 residents on isolation weekly times four weeks to ensure that staff are adhering to all IC protocols including Donning and Doffing PPE, handling of linen, water management program, then monthly for 3 months. The results of these audits will be forwarded to the QAPI Committee for further direction and guidance. The IC Preventionist is responsible for ongoing compliance. The NHA will review the monthly Water Management meetings to ensure that chlorine levels are within parameters. The NHA is responsible for ongoing compliance of the Water Management Program.
Failure to Ensure Timely Call Light Response and Dignified Care
Penalty
Summary
The facility failed to ensure dignified care for four residents who were dependent on staff for assistance with toileting and transfers. Multiple residents reported delayed responses to call lights, particularly during evening and night shifts, resulting in prolonged periods of discomfort and incontinence. One resident described staff turning off the call light and promising to return, but then failing to do so, leaving the resident wet and uncomfortable for extended periods. Another resident reported that staff were sometimes rough during transfers and that delays in call light response led to episodes of incontinence and soreness from sitting for long periods. Residents also reported that staff behavior varied, with some being attentive while others were described as crabby or rough. One resident noted that call lights were answered more promptly when family members were present, but otherwise, waits could exceed 30 minutes, sometimes resulting in accidents. Staff interviews confirmed that some staff members turned off call lights without meeting residents' needs, which is against facility policy. Observations included a resident waiting over 30 minutes for assistance after activating a call light, with staff walking past the room without responding. Facility policies require call lights to be answered in a timely manner and not to be turned off until the resident's needs are met. The failure to respond promptly to call lights and provide timely assistance with toileting and transfers compromised residents' dignity and comfort, as evidenced by their reports of embarrassment, discomfort, and feeling unwanted.
Plan Of Correction
F tag 550 Resident Rights/Exercise of Rights SS=E 1. Residents R50, and R4 have no LTC affects from not having their call lights answered in a timely manner. Resident R11 and R75 no longer reside at the facility. 2. Residents who reside in the facility are at risk of being affected by this deficient practice. Residents in-house were interviewed by the IDT team through Quality Rounds to ensure their needs are addressed timely. Any concerns were addressed through the guest assistance concern process. 3. The QAPI Committee reviewed the Call light Policy and Resident Rights Policy and deemed them appropriate. Facility staff were re-educated by the NHA/Designee on the policies and procedures related to Call lights, and Resident Rights. Staff who have not been educated by Date of Compliance will be re-educated prior to returning to work. 4. The IDT Team will interview 10 residents weekly to ensure that their needs are being met timely through the Quality Rounds Program. These audits will continue weekly times four than monthly x 3 months. The results of these audits will be forwarded to the QAPI Committee for further direction. The NHA is responsible for continued compliance.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A deficiency was identified when the facility failed to administer blood pressure medication in accordance with a physician's order for one resident. The resident, who had diagnoses including sepsis, congestive heart failure, and endocarditis, had an active order for hydralazine 25 mg by mouth twice daily, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 140. Despite this order, the Medication Administration Record (MAR) showed that hydralazine was administered multiple times when the resident's SBP was below 140, with recorded SBP values ranging from 106 to 138 at the time of administration. Interviews with the Director of Nursing (DON) confirmed that the medication was given contrary to the physician's order on several occasions, and a review of the electronic medical record did not reveal any documentation that the medication had been appropriately held on those dates. The facility's policy requires medications to be administered according to written physician orders, but this was not followed in the case of this resident.
Plan Of Correction
F tag 658 Services Provided Meet Professional Standards SS=D 1. Resident R69 no longer resides at the facility. On 4/24, the DON notified the Nurse Practitioner of the findings. Patients' charts and vitals were reviewed. The patient was assessed and showed no signs of distress. Education was initiated. Resident discharged home with her spouse on 5/4/2025. 2. Residents residing in the facility receiving blood pressure medications are at risk of being affected by this deficient practice. Residents receiving BP meds with parameters were reviewed by the DON to ensure that medications were held if the BP was not within parameters. Any concerns were addressed. 3. The QAPI Committee reviewed the Medication Administration Policy and deemed it appropriate. Nursing staff were re-educated by the DON/Designee on the policies and procedures related to Medication Administration specific to medications with parameters. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review 5 residents weekly times four to ensure that physician orders are followed regarding medication parameters then monthly x 3 months. The results of these audits will be forwarded to the QA Committee for further guidance and direction. The NHA is responsible for continued compliance.
Failure to Implement Hand Splint Intervention for Resident with Limited ROM
Penalty
Summary
A deficiency was identified when a resident with dementia and right-sided weakness and paralysis following a stroke was not provided with appropriate interventions to maintain or improve range of motion (ROM) as outlined in her care plan. The care plan specified that the resident should wear a right hand resting splint from morning to bedtime. However, multiple observations over several days revealed that the resident consistently did not have the splint on her right hand, despite the splint being present on the bedside table. Staff were observed providing care without offering or applying the splint, and the resident reported that staff had not asked her if she wanted the splint on during those times. The lack of adherence to the care plan was confirmed through both staff actions and resident interviews. The resident was observed in bed and in a wheelchair, participating in activities such as bingo, without the splint in place. At no point during the observed care interactions did staff attempt to apply the splint or inquire about its use, despite the resident's care plan directive. This failure to implement the prescribed intervention resulted in the facility not providing appropriate care to maintain or improve the resident's ROM.
Plan Of Correction
F tag 688 Increase/Prevent/Decrease in ROM/Mobility SS=D 1. Resident #25 was evaluated to determine if the resident had any new discomfort or worsening of contracture due to the staff's failure to offer and utilize her right-hand splint. The care plan was reviewed and updated as needed. 2. Residents residing in the facility with splints or other contractual devices have the potential to be affected by the deficient practice. The nursing team reviewed patients with contractual devices to ensure devices were being offered and utilized by physician order. Any refusals were documented, and care plans were updated to reflect preferences. 3. The QAPI Committee reviewed the Brace and Splint Program and deemed it appropriate. Nursing staff were re-educated by the DON/Designee on the Brace and Splint Program. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review 5 residents weekly for four weeks to ensure that their devices are being utilized by physician order, then monthly for 3 months. The results of these audits will be forwarded to the QAPI Committee for further guidance and direction. The NHA is responsible for continued compliance.
Failure to Follow Two-Person Assist for Bed Mobility
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) provided peri-care to a female resident with dementia, morbid obesity, and right-sided weakness and paralysis following a stroke, without following the resident's care plan intervention. The care plan specified that the resident was dependent on two staff members for bed mobility. However, during the observed care, only one staff member was present to assist the resident with bed mobility, and the CNA instructed the resident to roll onto her sides without additional assistance. This action was not in accordance with the documented safety intervention for the resident.
Plan Of Correction
F tag 689 Accidents SS=BAccidents 1. Resident #25 was evaluated to determine if any injuries were sustained due to staff's failure to follow the care plan/Kardex during repositioning the resident. No injuries noted due to deficient practice. The CNA involved received 1:1 education. 2. Residents who reside in-house are at risk due to the deficient practice. Residents in-house who sustained an accident in the last 10 days were reviewed by the nursing team to ensure that the care plan was followed and that the accident didn't occur based on failure to follow the care plan. Any concerns will be addressed. 3. The QAPI Committee reviewed the Standards of CNA/STNA Practice and deemed it appropriate. CNA's were re-educated by the DON/Designee on the Standards of CNA/STNA Practice. Staff who have not been educated by the Date of Compliance will be re-educated prior to returning to work. 4. The DON/Designee will review residents with accidents weekly times four to ensure that their care plans are being followed, then monthly x 3 months. The results of these audits will be forwarded to the QAPI Committee for ongoing direction and further guidance. The NHA is responsible for continued compliance.
Failure to Provide Emergency Lighting at Main Electrical Room Transfer Switch
Penalty
Summary
During an observation on April 24, 2025, at approximately 10:29 am, it was found that the facility did not provide a battery pack emergency light at the transfer switch located in the main electrical room. This was identified as a failure to ensure automatic emergency lighting in accordance with section 7.9. The deficiency was confirmed through an interview with the facility's environmental supervisor at the time of the observation. This deficiency could affect all occupants, staff, and visitors in the event that the emergency power systems fail to operate as designed during an electrical utility power outage.
Plan Of Correction
K291 Emergency Lighting SS=F 1. A battery pack emergency light was installed at the transfer switch located in the main electrical room on 5/15/25. 2. Residents residing within the facility have the potential to be affected. 3. Facility administrator has re-educated the maintenance director on the regulatory requirement for an emergency backup light at the transfer switch. The facility preventative maintenance system (TELS) has been updated to ensure that back up lighting is testing per regulatory standards. 4. Facility Administrator and/or designee will verify regulatory compliance with emergency backup lighting monthly x4. Findings will be reported to the QAPI committee for further review and/or recommendations. The Administrator is responsible for sustained compliance.
Failure to Provide Required Fire Protection for Hazardous Area
Penalty
Summary
A deficiency was identified when a wheelchair battery charger was observed in use within a resident room located in the sub-acute rehab wing. The facility failed to ensure that hazardous areas, such as those where battery charging occurs, were protected by a fire barrier with a 1-hour fire resistance rating and 3/4 hour fire rated doors, or by an automatic fire extinguishing system as required by code. The doors to these areas were also not self-closing or automatic-closing as specified by the regulations. During the survey, the environmental supervisor confirmed that residents' wheelchair batteries are charged within their rooms as needed. This practice was directly observed and verified through staff interviews. The deficiency was cited due to the lack of appropriate fire protection measures in areas where hazardous activities, such as battery charging, take place.
Plan Of Correction
K321 Hazardous Areas SS=E 1. The power chair in room 121 was unplugged immediately and relocated for charging. The resident residing in room 121 was educated that the facility will need to charge the chair in a safe area (Therapy Room). 2. Residents residing within the facility have the potential to be affected. Residents utilizing power chairs have been educated that chairs need to be charged in the Therapy Dept and not within their rooms. 3. Staff have been educated that wheelchairs cannot be charged in resident rooms but only in the Therapy Room. 4. The Maintenance Director and/or designee will audit weekly x4, monthly x3 to ensure that wheelchairs are being charged in the designated area. Findings will be reported to the QAPI Committee for further review and recommendations. The Administrator is responsible for sustained compliance.
Failure to Maintain Required Kitchen Hood Cleaning and Inspection Documentation
Penalty
Summary
The facility failed to provide documentation of the required semi-annual hood cleaning service report for the kitchen hood system, as required by NFPA 96. Although an invoice for the hood service was provided by regional staff, the actual cleaning report was not available for review. Additionally, the facility did not provide documentation of the required owner's monthly hood suppression inspection, as mandated by NFPA 17A. Both deficiencies were confirmed through interviews with regional staff at the time of observation. These lapses could potentially affect kitchen staff and 23 occupants within the nearest smoke compartment in the event of a fire within the kitchen hood system.
Plan Of Correction
K324 Cooking Facilities SS=E1. The required semiannual hood cleaning was completed on 4/9/25. The monthly hood suppression inspection was completed May 1, 2025, and signed off through TELS and signed off on the tag that is located in the dietary dept. The NHA validated that the TELS system has a monthly task to complete the monthly hood suppression inspection and that it was signed off in a timely manner by the Maintenance Director. The NHA educated the Maintenance Director on obtaining and uploading service inspections into the TELS system and completing the monthly hood suppression inspection. The NHA will validate that the monthly hood suppression inspections are completed and checked off monthly for 3 months and that service reports are uploaded into the TELS system from the Date of Compliance. The results of these audits will be forwarded to the QA Committee to ensure continued compliance. The NHA is responsible for ongoing compliance.
Failure to Monitor Resident with Chest Pain
Penalty
Summary
The facility failed to adequately assess and monitor a resident, identified as Resident #101, who was experiencing chest pain and using nitroglycerin. Resident #101, who was cognitively intact and had a history of congestive heart failure and hypertensive heart, reported chest pain to a family member over the phone. Despite the resident's complaints and the family member's insistence, the nurse on duty focused on removing the nitroglycerin bottle from the resident's room rather than assessing the resident's condition or taking vital signs. The nurse did not return to the resident's room for an extended period, during which the resident took multiple doses of nitroglycerin without proper monitoring. The nurse, identified as LPN B, documented the presence of the nitroglycerin bottle and the resident's refusal to relinquish it but failed to document any vital signs or assessments related to the resident's chest pain. The nurse contacted the Assistant Director of Nursing (ADON) and the on-call physician but did not communicate the resident's chest pain or nitroglycerin use. The ADON instructed the nurse to check vital signs every hour, but no such documentation was found in the resident's electronic medical record. The nurse practitioner was also not informed of the resident's chest pain or nitroglycerin use. Interviews with other staff members, including a CNA and RN, revealed that the resident's complaints of chest pain were not properly addressed, and the necessary evaluations were not conducted. The Director of Nursing (DON) confirmed that residents with chest pain should be promptly evaluated, including taking vital signs after each dose of nitroglycerin. The failure to assess and monitor the resident's condition resulted in incomplete information being communicated to medical practitioners and the potential for unnoticed cardiovascular compromise.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to accurately assess, provide treatments as ordered, and ensure physician oversight for wounds for two residents, resulting in significant deficiencies. Resident #276, a male with a history of chronic osteomyelitis and other conditions, was not provided care in accordance with professional standards. His left heel wound was not accurately assessed or treated promptly, leading to the development of osteomyelitis. Despite the wound being identified on 12/21/23, appropriate treatment was delayed, and the wound deteriorated significantly, showing signs of infection and requiring hospitalization for severe bone infection and surgical intervention. The facility's documentation and follow-up were inconsistent, and the wound team did not adequately monitor or update the treatment plan, resulting in further complications for the resident. Additionally, the facility failed to ensure the availability of necessary wound care supplies, further delaying treatment and exacerbating the resident's condition. Resident #64 experienced a similar lack of proper wound care. The resident's right heel wound, initially identified as a stage 3 pressure ulcer, was not treated consistently as per the orders. The dressing changes were not performed as scheduled, and the wound showed signs of maceration and significant deterioration. A new wound on the left heel was also identified but not promptly addressed. The facility's documentation of wound measurements was inconsistent, and there was a lack of manual measurements and depth recording, leading to inadequate monitoring and treatment of the wounds. The care plan for this resident did not focus on healing or preventing the worsening of the wound, and the facility failed to ensure timely and appropriate wound care interventions. The deficient practices in the facility placed all residents at risk for pressure injuries and delayed wound healing. The facility's failure to accurately assess, document, and treat wounds as ordered, along with inadequate physician oversight and lack of timely interventions, resulted in significant harm to the residents. The facility's policies and procedures for wound care were not followed, leading to the deterioration of existing wounds and the development of new pressure injuries. The lack of proper wound care management and oversight highlights serious deficiencies in the facility's ability to provide adequate care for residents with skin integrity issues.
Failure to Manage Respiratory Illness Outbreaks
Penalty
Summary
The facility failed to promptly identify and manage an outbreak of acute respiratory illness, including COVID-19, Influenza, and Respiratory Syncytial Virus (RSV). The facility did not implement transmission-based precautions for residents showing symptoms, nor did it ensure prompt testing and documentation of surveillance for respiratory infections. This led to widespread transmission among residents and staff. Specific instances included a CNA testing positive for COVID-19 without subsequent contact tracing or testing of potentially exposed individuals, and multiple residents and staff members testing positive for COVID-19 over several months without adequate outbreak investigation or containment measures being documented or implemented. The facility also failed to manage an influenza outbreak effectively. Staff members and residents who exhibited symptoms or tested positive for influenza were not promptly isolated or treated with antiviral medications. For example, a resident who tested positive for Influenza A was not placed in droplet isolation while symptomatic, and there was no documentation of contact tracing or offering of antiviral medications to exposed individuals. This lack of action contributed to the spread of influenza within the facility. Additionally, the facility did not properly handle an RSV outbreak. Residents and staff who tested positive for RSV were not placed in appropriate isolation, and there was no outbreak investigation or contact tracing conducted. The facility's infection control practices were inadequate, as evidenced by the lack of training and proper implementation of transmission-based precautions. This resulted in multiple residents testing positive for RSV over several months without adequate measures to prevent further transmission.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide the pneumococcal immunization to a resident as per consent and CDC recommendations. The resident, a [AGE] year-old female, was admitted to the facility on 1/23/24 and had consented to receive the pneumonia vaccine on the same day. However, the resident did not receive the vaccine before being discharged. The resident was later admitted to the hospital with RSV and right lobe pneumonia, which was confirmed by a chest x-ray. The Infection Control Preventionist acknowledged that the resident did not receive the vaccine and admitted to missing this requirement. The facility's policy on pneumococcal vaccination, last revised on 3/27/23, states that all residents aged [AGE] years or older, or younger residents with underlying conditions, should receive the pneumococcal vaccine. Despite this policy, the resident did not receive the vaccine, leading to a failure in adhering to the established guidelines. This oversight was identified during an interview with the Infection Control Preventionist, who confirmed the lapse in administering the vaccine to the resident.
Medication Administration Deficiencies and Staff Conduct Issues
Penalty
Summary
The facility failed to administer controlled medications following physician orders and professional standards of practice for six residents, resulting in medication errors and the withholding of medications without a physician order. For example, Resident #13 did not receive a scheduled dose of gabapentin, and the documentation was inconsistent between the Controlled Substances Proof of Use form and the Medication Administration Record. Similarly, Resident #25 did not receive multiple doses of tramadol, despite documentation indicating otherwise. Resident #58 also missed a dose of tramadol, with discrepancies noted in the records. The Director of Nursing confirmed these medication errors and reported immediate education on narcotic administration would begin. Additionally, the facility failed to administer medications according to physician-ordered parameters for several residents. Resident #11 received metoprolol despite having a heart rate below the prescribed threshold on multiple occasions. Resident #275 was administered glipizide even when blood sugar levels were below the specified limit. Resident #43 received midodrine despite having a systolic blood pressure above the ordered parameter. These actions indicate a lack of adherence to physician orders and professional standards of practice. Furthermore, there were issues with the administration of insulin and potential staff impairment. Resident #2's insulin was administered without priming the pen or holding it to the skin for the required time, contrary to manufacturer guidelines. Resident #225 reported that an LPN who administered her nighttime medications appeared to be under the influence of alcohol. These incidents highlight significant lapses in medication administration and staff conduct, contributing to the overall deficiencies noted in the facility.
Failure to Ensure Proper Oversight and Care by Director of Nursing
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse in a facility with a daily average census of more than 60 residents. This resulted in a lack of consistent clinical services oversight and negative resident outcomes. The DON worked as a charge nurse for over 110 hours since January 2024, which prevented her from fulfilling her full-time responsibilities as the DON. This led to missed laboratory testing, treatments, and medications, as reported by a Licensed Practical Nurse (LPN). The DON admitted to working as a charge nurse and acknowledged the difficulty in keeping track of her hours for the Payroll Based Journal (PBJ) report. The deficiency was further highlighted by the identification of an Immediate Jeopardy (IJ) at F-686, Pressure Ulcer Prevention and Care. This began when facility licensed nurses failed to accurately assess, provide treatments as ordered, and ensure physician oversight for a resident's newly identified pressure injury. Another resident experienced the worsening of a wound on his right heel and developed an additional wound on his left heel due to missed treatments and delayed care. Additionally, it was found that LPNs were administering IV medications through Peripherally Inserted Central Catheters (PICC) lines without evidence of specialized training or oversight, which is outside the scope of practice for LPNs.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure call lights were within sight and reach for a resident reviewed for call light placement. The resident, a [AGE] year old female with diagnoses including acute respiratory failure with hypoxia, COPD, chronic pain, retention of urine, and severe protein-calorie malnutrition, was observed multiple times with the call light out of reach. On several occasions, the call light was draped over the footboard or curled up at the head of the bed, making it inaccessible to the resident. This was confirmed through interviews and observations over several days, despite the facility's policy requiring call lights to be within easy reach when a resident is in bed or confined to a chair.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain safe water temperatures, resulting in the potential for scalding residents. On 4/22/24, the hot water temperatures in the bathroom sinks of two rooms and the 200 hall spa room were measured and found to be excessively high, ranging from 123 to 130 degrees Fahrenheit. Resident #52 confirmed that the water gets very hot. During an interview, the Maintenance Director admitted that the water temperature was turned up to 140 degrees last year and some sinks were missing point-of-use mixing valves, which had not yet been installed. The facility's water temperature logs from January to April 2024 consistently showed temperatures exceeding 120 degrees in various locations, including the Beauty Shop Hair Sink and multiple showers in the 300 Spa area.
Failure to Ensure Appropriate Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatments and orders were in place to prevent catheter-associated urinary tract infections for a resident with a primary diagnosis of unspecified dementia, pressure ulcer, MSSA, and obstructive and reflux uropathy. During an observation, two LPNs were seen performing a catheter flush on the resident using normal saline, despite not knowing the reason for the procedure. They did not use gowns or face shields, increasing the risk of infection. The order for the catheter flush had been in place since the resident's admission, but neither the LPNs nor the Director of Nursing (DON) could identify its origin or necessity. The DON speculated that the order might have come from a hospitalization but could not confirm this. Upon contacting the resident's urologist, it was confirmed that the urologist did not order the catheter flushes and would not recommend them due to the significant risk of infection from opening the closed drainage system twice a day. This lack of clarity and improper procedure led to the potential for complications from cross-contamination and infections.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to ensure best practice standards for residents receiving supplemental oxygen. Resident #67, a female with chronic obstructive pulmonary disease and obstructive sleep apnea, was observed receiving oxygen at 2.5 liters per minute via nasal cannula on multiple occasions without a date on the oxygen tubing indicating when it had last been changed. This lack of documentation and monitoring could lead to potential health risks for the resident. Resident #70, a female with acute respiratory failure with hypoxia and chronic obstructive pulmonary disease, also experienced deficiencies in her respiratory care. Her electronic medication and treatment administration record did not contain an order for the rate of oxygen delivery, nor did it document regular observations by nursing staff to ensure the oxygen was set correctly. Additionally, her care plan lacked interventions for supplemental oxygen use and concerns for COPD. Observations revealed undated oxygen tubing and humidifier bottles, and reports indicated that the oxygen concentrator was sometimes set incorrectly. The Director of Nursing was unable to explain the discrepancies in the dating of the oxygen tubing.
Untrained LPN Administers IV Medication
Penalty
Summary
The facility failed to ensure that intravenous (IV) medications were administered by licensed nurses who had demonstrated proficiency with IV medication administration through training and monitoring in accordance with State professional standards of practice. This deficiency was observed when a Licensed Practical Nurse (LPN) administered IV antibiotics to a resident without having the required specialized training. The facility's Charge Nurse Job Description and Medication Administration policy both emphasize the need for safe and accurate medication administration by qualified personnel, but these standards were not met in this instance. The Director of Nursing (DON) confirmed that the LPN did not have specialized training at the facility and could not provide proof of such training from any other facility. The incident involved a resident who was admitted with diagnoses including discitis of the lumbosacral region, cellulitis of the back, streptococcus infection, and a pressure ulcer of the sacral region. The resident had an order for Penicillin G Potassium to be administered intravenously for sepsis and wound care. During an observation, the LPN was seen performing tasks such as flushing the PICC line and administering the IV antibiotics, which are outside the scope of practice for an LPN in the State of Michigan. The DON later confirmed that there was no documentation of specialized training for any LPN to administer IV medications through PICC lines at the facility.
Failure to Maintain Clean Ventilation Filters
Penalty
Summary
The facility failed to maintain clean ventilation filters, resulting in reduced air quality and circulation in resident rooms 204, 214, 326, and 327. On multiple occasions, PTAC units in these rooms were observed to be caked with dust. A resident reported that maintenance had not changed the filter since before winter, and the air seemed to come out slower. The Maintenance Director stated that filters are supposed to be checked monthly and changed as needed, but the facility's preventative maintenance program requires filters to be replaced or thoroughly cleaned every three months. The maintenance log showed the task was last completed on 3/31/2024.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to operationalize policies and procedures to appropriately evaluate and assess pain for a resident, resulting in the absence of pain assessments and unmet pain needs. Resident #27, a [AGE] year-old female with severe cognitive impairment and a history of stroke with right-sided hemiplegia and contracture, was not consistently assessed for pain using the appropriate Pain Assessment in Advanced Dementia (PAINAD) scale. Despite having a history of pain and being prescribed pain medication, the resident's pain was not adequately monitored or documented, leading to an increased perception of pain and unmet pain needs. Observations and interviews revealed that the resident displayed signs of pain, such as facial grimacing and verbalizing pain, but staff did not consistently use the PAINAD scale to assess her pain. The resident's pain assessments were sporadic, with significant gaps between assessments, and there was a lack of documentation regarding the type, severity, onset, duration, location, or quality of pain. This inconsistency in pain assessment and documentation indicates a failure to follow the facility's pain management policy, which requires regular monitoring and evaluation of pain, especially for residents with cognitive impairments. The facility's policy on pain management emphasizes the importance of evaluating and identifying pain, developing a care plan, and monitoring residents for pain regularly. However, the facility did not adhere to these guidelines, as evidenced by the lack of consistent pain assessments and inadequate documentation of the resident's pain. This failure to properly assess and manage pain for Resident #27 highlights a significant deficiency in the facility's pain management practices, resulting in the resident's increased perception of pain and unmet pain needs.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that Resident #64 received medications as ordered. Resident #64 was admitted with a primary diagnosis of unspecified dementia, pressure ulcer of the right heel, stage 3, Methicillin Susceptible Staphylococcus Aureus (MSSA), and obstructive and reflux uropathy. The resident was seen by a urologist for urinary retention and bilateral hydronephrosis, and the urologist prescribed a single-day antibiotic prophylaxis. However, the facility administered the antibiotic Bactrim DS daily from 4/16/2024 to 4/28/2024 without an order from the urologist to do so. During interviews, the Medical Assistant for the urologist confirmed that the antibiotic was intended for one day only. The Director of Nursing was unable to explain why the antibiotic was started without a proper order, and the Infection Control Nurse admitted to not having a copy of the urologist's order and failing to verify the transcription. The Infection Control Nurse also demonstrated a lack of knowledge regarding McGeer's criteria for starting an antibiotic in a resident with an indwelling catheter.
Inappropriate Antibiotic Utilization
Penalty
Summary
The facility failed to ensure that a resident who required an antibiotic was prescribed the appropriate antibiotic. A resident, a [AGE] year-old female with chronic kidney disease, was admitted to the facility and later reported not voiding for 12 hours. A straight catheterization was performed, and a urine dipstick test indicated a urinary tract infection (UTI). Consequently, the resident was prescribed Augmentin 500 mg three times a day for 10 days without waiting for the results of a urinalysis and culture and sensitivity test. The resident received the antibiotic from the morning of 4/14/24 through the evening of 4/23/24, despite the absence of a positive urinalysis and culture and sensitivity results. The Infection Control Preventionist (ICP) confirmed that the resident exhibited no signs or symptoms of a UTI, did not meet the McGeer Criteria for diagnosing a UTI, and had no history of UTIs. The facility's policy on antibiotic stewardship emphasizes the importance of prescribing antibiotics only when appropriate and discourages the use of broad-spectrum antibiotics while a culture is pending. The ICP reported that a culture and sensitivity should be reviewed prior to initiating antibiotic treatment to ensure the appropriate antibiotic is prescribed. The facility's failure to adhere to these guidelines resulted in inappropriate antibiotic utilization for the resident.
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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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