West Hickory Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Michigan.
- Location
- 3310 W Commerce Rd, Milford, Michigan 48380
- CMS Provider Number
- 235262
- Inspections on file
- 28
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at West Hickory Haven during CMS and state inspections, most recent first.
A resident with severe dementia, significant behavioral symptoms, and a known history of aggression and wandering was admitted after hospital evaluation, despite extensive pre-admission documentation of behavioral issues. Following multiple episodes of exit-seeking and physical aggression toward staff, the resident was transferred to the hospital, and when EMS later attempted to return the resident, nursing staff—under orders from the DON and Administrator—refused readmission, stating the facility could not meet the resident’s needs and issuing a verbal "do not return" directive. The resident’s representative was informed only verbally that the resident would not be accepted back, and the ombudsman was contacted by phone without written notice. Review of records showed incomplete transfer documentation, lack of required written involuntary discharge notices and appeal information, and outdated policies referencing obsolete regulations, despite a bed-hold/readmission policy that called for holding a bed and readmitting residents with an expectation of return unless specific criteria were met.
A resident with severe cognitive impairment, dementia, and significant behavioral symptoms was transferred emergently to a hospital after assaultive behavior toward staff, and when EMS later attempted to return the resident, nursing staff informed EMS and the hospital that the resident would not be accepted back due to aggressive and combative behavior. The resident’s spouse, identified as the responsible party and POA, was verbally told by a nurse that the resident would not be readmitted, but there was no evidence that a written transfer/discharge notice, bed-hold information, or appeal rights (FIT-100/ITD-100) were provided to the representative, nor that a written copy was sent to the Ombudsman. Review of the transfer checklist showed the regulatory notice items and second nurse witness signature were not completed, the Ombudsman information on the form was outdated, and the facility’s bed-hold policy contained obsolete regulatory references.
A resident with Alzheimer’s disease, DM with neuropathy, and peripheral vascular disease, who required substantial assistance with bed mobility and lacked sensation in the lower extremities, sustained a burn to the plantar surface of the right great toe when the bed was positioned directly adjacent to a metal baseboard heater. An LPN observed the resident sleeping on the side without apparent distress during early rounds and did not identify the foot on or against the heater. Within a short time, a CNA entered to provide ADL care, found the resident’s right great toe resting on the heater, and, upon removing it, noted bleeding. Subsequent assessments by nursing, hospice, and medical providers documented a large blister and open areas on the bottom of the right great toe, consistent with a thermal burn, and the facility’s incident investigation concluded that the bed’s placement next to the wall-mounted heating register created the environmental hazard that led to the injury.
An unlocked medication cart allowed a resident with moderate cognitive impairment and a history of diabetes, urinary retention, and falls to obtain three pill packets and several loose pills belonging to another resident. The RN responsible for the cart reported being very busy, walked away to assist another resident with breakfast, and failed to lock the cart. A CNA later observed pill packets in the resident’s pocket, and upon confrontation, the resident claimed another resident had the medications and took them. All medications were reconciled except for one dose of Namenda, which was not recovered.
A resident with severe cognitive impairment and on hospice was found with her shirt sleeves tied together by a CNA, restricting her movement for staff convenience during care. The restraint was applied without proper documentation, notification, or individualized care planning, and the resident was left unattended until discovered by oncoming staff. Facility policy prohibits such use of restraints, and the incident resulted in psychosocial harm to the resident.
A resident with severe dementia and Alzheimer's Disease was found with her shirt sleeves tied together by two CNAs, leaving her unable to move her arms. The incident was not immediately reported to the Abuse Coordinator or State Survey Agency, resulting in a delay of approximately 22 hours before the incident was reported. The CNAs involved continued to work subsequent shifts, and the nurse who discovered the incident did not escalate the report as required by facility policy.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
Two residents with severe cognitive impairment exited the facility and were redirected back inside by staff, but their responsible parties were not notified of the elopement incidents as required by facility policy. Interviews and record review confirmed the lack of notification.
Surveyors found that the facility did not review and update its emergency preparedness plan on an annual basis, as required. This deficiency was confirmed through record review and interviews with the Facility Maintenance Director and Administrator, potentially affecting all occupants in the event of a disaster.
The facility did not provide documentation of the required 30-second test, inspection, and maintenance for its battery-powered emergency light, as confirmed by the Maintenance Director and Administrator. This deficiency could affect all occupants in the event of a fire emergency.
The facility did not conduct or document the required quarterly fire drill for the first shift during the fourth quarter, as confirmed by facility leadership during record review. This deficiency could affect all occupants in the event of a fire emergency.
Surveyors identified that the facility did not complete or document the required annual inspection, testing, and maintenance of fire door assemblies as per NFPA 80 standards. The most recent available inspection record was over a year old, and this lapse was confirmed by facility leadership during the survey.
The facility failed to return residents' personal clothing from the laundry, affecting multiple residents. During a Resident Council meeting, several residents reported missing items, including a special football shirt and sweaters. One resident's Durable Power of Attorney had to repeatedly buy clothing due to losses, despite items being labeled. The facility's policy on missing items was not effectively implemented, and staff struggled with labeling and returning clothes correctly.
The facility failed to ensure staff could promptly identify a resident's code status during an emergency, leading to a delay in CPR initiation. An agency LPN struggled to find the code status in the electronic medical record and had to call the DON for guidance. The facility's documentation system was unclear, and agency staff were not trained on the code status system, affecting multiple residents.
Two residents in an LTC facility experienced falls due to staff failing to follow transfer protocols. One resident, with hemiplegia, was transferred by a single CNA despite needing two-person assistance, while another resident, with severe cognitive impairment, fell due to lack of non-skid footwear and inadequate assistance. Both incidents highlight a failure to adhere to care plans and provide adequate supervision.
A resident receiving hospice care experienced inadequate care coordination at the facility. The resident, who had multiple diagnoses and was cognitively intact, reported frequent moderate pain and delays in receiving pain medication. The facility failed to maintain accessible hospice documentation, hindering effective care coordination. Additionally, there was a lack of communication between the facility and the hospice provider, resulting in unaddressed symptoms of agitation and anxiety for the resident.
A facility's kitchen was found to have multiple sanitation and food storage deficiencies, including undated and expired food items, unsanitary conditions, and improper labeling. The kitchen lacked a supervisor, and the Corporate Registered Dietician was overseeing operations remotely. Observations revealed food crumbs in utensil drawers, moldy and compromised food items, and a leak causing ice buildup in the freezer. These issues violated the facility's policy and FDA Food Code, potentially affecting all residents consuming meals from the kitchen.
A facility failed to document and monitor the use of PRN anti-anxiety medication for a resident with schizophrenia and bipolar disorder. The resident received 46 doses of lorazepam over three weeks without evidence of targeted symptoms or non-pharmacological interventions. Staff interviews revealed a lack of adherence to the facility's policy on psychotropic medication use.
A resident with dementia and aggressive behaviors physically assaulted two other residents, causing psychosocial harm. The facility failed to manage the resident's behaviors and protect other residents, despite known issues and previous incidents. Staff reported a general atmosphere of fighting and hyperactivity on the unit.
A resident with multiple sclerosis and a compromised immune system reported feeling unwell during a COVID-19 outbreak. Despite requesting physician contact, the nurse did not perform an assessment or notify the physician. The resident called 911 and was hospitalized for five days with COVID-19. Interviews revealed the nurse failed to document or assess the resident's condition, leading to a deficiency.
A resident with severe cognitive impairment fell between the bed and the wall during a brief change, resulting in bruising and a hospital transfer. The incident occurred because a CNA attempted the task alone, despite the resident requiring two-person assistance. The CNA rolled the resident incorrectly, leading to the fall. The facility failed to provide adequate supervision and assistance, contributing to the deficiency.
An incident occurred where a resident with moderately impaired cognition pushed another resident, leading to a right arm fracture for the victim. The altercation followed a verbal dispute, with a witness reporting loud arguing and the victim expressing distress before a loud crash was heard. Both residents involved had documented cognitive impairments, including encephalopathy, adjustment disorder with anxiety, stroke, dementia, anxiety, and insomnia.
The facility failed to maintain a system to account for the accurate usage and reconciliation of controlled medications for two residents, resulting in potential medication errors and drug diversion. Discrepancies were found in the administration records of Morphine, Lorazepam, and Oxycodone, with multiple instances where medications were removed but not signed off on the MARs. The DON was unable to explain these discrepancies and admitted that audits were only performed monthly.
The facility failed to promptly resolve grievances and provide adequate care for a resident with a history of frequent UTIs and meal assistance needs. Despite requests for follow-up care and meal assistance, the resident was hospitalized with sepsis and pneumonia and later placed on hospice. The facility's response to grievances was delayed, and there was no timely follow-up or resolution documented.
Failure to Readmit Hospitalized Resident and Provide Required Written Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return following a hospital transfer and failure to provide required written discharge notices. The resident had been admitted with multiple cognitive and behavioral diagnoses, including severe vascular dementia with behavioral disturbance, other dementia with behavioral disturbance, mild cognitive impairment, and age-related cognitive decline. The admission MDS documented severe cognitive impairment, behavioral symptoms directed toward others and not directed toward others that significantly interfered with care and activities, behaviors that put others at significant risk of physical injury and significantly disrupted the living environment, and wandering that placed the resident at significant risk or intruded on others. Hospital records available to the facility before admission described a long history of dementia, agitation, prolonged behavioral outbursts, aggression, wandering, incontinence, and prior placement difficulties, confirming that the facility had access to extensive information about the resident’s behavioral history when it accepted the admission. After admission, facility progress notes documented multiple incidents of exit-seeking and physical behaviors such as swinging, kicking, spitting, and swearing, for which staff obtained additional IM psychotropic medications. On the night of the transfer, the resident reportedly assaulted staff, including a one-to-one staff member, and was sent to the hospital. A nurse’s note from the early morning hours documented that EMS attempted to return the resident, but nursing staff informed EMS that the facility could not provide care due to the resident’s behavior and that there were orders for a “do not return” because the facility was unable to meet the resident’s needs related to aggressive and combative behavior. The same note indicated that hospital staff called to inquire why the resident was refused, and the nurse explained that the resident had again attacked a staff member and that the DON and Administrator had ordered that the resident not be accepted back. Interviews with staff confirmed that the decision not to readmit the resident was made by facility leadership and communicated verbally. The social services staff member stated they were not involved in the admission decision or the later decision not to allow the resident to return, but understood that the refusal was due to exit-seeking and aggression and that the facility had discussed more appropriate locked memory care placement with the family. The DON reported that when the hospital called to ask if the resident could return, the facility said no and that they had a phone conversation with the ombudsman about not accepting the resident back, but there was no written notification. A nurse reported telling the resident’s wife by phone that the facility would not accept the resident back because the abuse that night was very dangerous and that their orders from the DON and Administrator were to send the resident out with a “no return.” Record review showed that the facility completed a “Facility-Initiated Transfer for Nursing Homes” form citing that the resident’s behavioral needs could not be met and describing combative behavior with staff, but the transfer packet documentation was left incomplete, including missing sections that required a second nurse witness signature. The facility’s policies on bed hold, hospital and therapeutic leave, readmission, and notice of transfer or discharge were reviewed. The bed hold/readmission policy stated that the facility would hold a bed for 10 days for emergency medical treatment and would readmit a discharged resident with an expectation of return unless the discharge was necessary for the resident’s welfare or the safety of individuals in the facility was endangered due to the resident’s clinical or behavioral status; this policy referenced obsolete federal regulations and had not been updated since 2017. The notice of transfer or discharge policy described requirements for facility-initiated transfers and involuntary discharges, including use of specific forms (FIT-100 and ITD-100), provision of written notice to the resident or representative with appeal information, submission of notice to the state agency, and written approval of transfer or discharge plans, but the facility did not provide evidence that these written notices and processes were followed for this resident. The Administrator acknowledged that the ombudsman had only been notified by phone, that written notification was not provided, that the local ombudsman information in facility materials was outdated, and that the relevant policy had not been updated.
Failure to Provide Written Transfer/Discharge Notice and Ombudsman Copy After Refusal to Readmit Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a written notice of transfer/discharge to a resident’s legal representative and to send a copy of that notice to the Ombudsman when the facility refused to readmit the resident after a hospital transfer. The resident was admitted in mid-February and transferred to the hospital in early March, after which the facility did not allow the resident to return. The clinical record identified the resident’s wife as the responsible party, emergency contact, and power of attorney for care and financial decisions. The admission MDS documented severe cognitive impairment, multiple dementia-related diagnoses, behavioral symptoms directed and not directed toward others that interfered with care and activities, wandering behavior that placed the resident and others at risk, and frequent bowel and bladder incontinence. Progress notes showed that EMS attempted to return the resident to the facility, but nursing staff informed EMS that the facility could not provide care due to the resident’s behavior and that there were orders for a “do not return” because the facility was unable to meet the resident’s needs related to aggressive and combative behavior. The nurse documented that the hospital called to inquire why the resident was refused and was told the resident had again attacked a staff member and that there was a “do not return” order. Transfer documentation included an “Emergent Transfer Requirement” checklist, which showed that regulatory items requiring completion with the resident or responsible party at the time of transfer—specifically the prepared transfer notice form with signed or witnessed acknowledgment and the bed-hold policy, as well as the FIT-100 form with appeal information—were not checked off. The associated Admission, Transfer, Discharge Rights form was signed by only one nurse, with the witnessing nurse section left blank, and it listed an outdated local Ombudsman contact. Interviews with the DON and nursing staff confirmed that the facility decided not to accept the resident back after the hospital transfer because they believed the resident’s behavioral needs could not be met and that the resident had assaulted staff. The DON reported that the hospital called to ask if the resident could return and was told no, and that the DON had a phone conversation with the Ombudsman about not accepting the resident back, but there was no written notification. The DON and a nurse stated that the transfer packet, including bed-hold information and notice of transfer, was sent with the resident via EMS, and the nurse reported verbally informing the resident’s wife that the resident would not be accepted back. However, the family was not present at the time of transfer, and there was no evidence that the legal representative received a written notice of transfer/discharge or that a written copy was sent to the Ombudsman. The facility’s policies on bed hold and notice of transfer/discharge were provided, but the bed-hold policy contained outdated regulatory references, and the process described in the notice policy (including FIT-100 and ITD-100 forms and written notices with appeal information) was not documented as having been followed for this resident.
Burn Injury from Bed Placement Next to Baseboard Heater
Penalty
Summary
The deficiency involves the facility’s failure to ensure the resident’s bed was positioned to avoid contact with a nearby metal baseboard heater, creating an accident hazard that resulted in a thermal burn to the resident’s right great toe. The resident had diagnoses including Alzheimer’s disease, type 2 diabetes mellitus with neuropathy, peripheral vascular disease, and cerebral atherosclerosis, and was on hospice services. An MDS assessment documented moderately impaired cognition and a need for substantial/maximal assistance with rolling in bed. Due to neuropathy, the resident did not have sensation in the feet or lower legs and was therefore unaware of the burn while the toe was in contact with the heater. On the morning of the incident, an LPN began the shift and conducted rounds at approximately 6:45 AM, observing the resident sleeping on their side with the right foot lying over the left foot. The LPN called the resident’s name, obtained a response, and noted no signs of distress, but did not identify that the resident’s foot was on or near the heater. Within approximately 10–30 minutes, a CNA entered the room to provide ADL care and discovered the resident’s right great toe had been resting on the baseboard heating unit next to the bed. When the CNA removed the foot from the heater, bleeding was observed from the right great toe. Subsequent assessments documented a significant injury to the plantar surface of the right great toe. The LPN’s alert note described the toe as bloody and newly injured, with the resident appearing confused. The DON’s examination identified an open blister on the bottom of the right great toe measuring 4 cm by 3 cm with serous fluid, and an adjacent open area measuring 0.5 cm by 0.3 cm by 0.2 cm, with no sensation in the feet or lower legs. Hospice documentation and provider notes confirmed the injury as a burn to the plantar surface of the right great toe, with erythema, swelling, warmth, a dry denuded blister, and underlying hematoma. The facility’s own incident report and investigation identified that the bed had been placed adjacent to the wall-mounted heating register, and that this bed placement created the environmental hazard that led to the resident’s thermal injury while positioned in bed.
Unlocked medication cart allowed resident access to another resident’s medications
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments when a medication cart (Sapphire Cart) was left unlocked, allowing a resident to access another resident's medications. A facility reported incident indicated that at 9:30 AM, the resident was observed with three pill packets and several loose pills in their left pant pocket. When the medications were reconciled, all were accounted for except one dose of Namenda, a medication used to treat moderate to severe dementia, which was never recovered. The resident involved had been admitted for long-term care with a medical history including diabetes, urinary retention, and falls related to muscle weakness. They were independent in a wheelchair for short distances, alert and oriented to person and place, their own responsible party, and had a BIMS score of 8/15 indicating moderate cognitive impairment. In a telephone interview, the RN assigned to the Sapphire Cart acknowledged and accepted full responsibility for leaving the cart unlocked, explaining they had been very busy, walked away from the cart to assist another resident with breakfast, and did not lock it. The RN reported being informed by a CNA that the resident had pill packets hanging from their pant pocket; when confronted, the resident stated another resident had the medications, took them from them, and that they were going to tell staff.
Improper Use of Physical Restraint for Staff Convenience
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with Alzheimer's Disease, who was dependent on staff for all activities of daily living and enrolled in hospice, was found with her shirt sleeves tied together, restricting her arm movement. This action was taken by a Certified Nursing Assistant (CNA) during care, reportedly to prevent the resident from scratching or pinching staff. The CNA, working without the required second staff member for assistance, tied the resident's sleeves together and then left the room to assist with another resident, forgetting to return and untie the sleeves. The resident was left unattended in this restrained state for an extended period. Interviews and record reviews revealed inconsistencies in staff accounts regarding who was present and involved in the incident. The CNAs involved provided conflicting statements about their roles and awareness of the restraint. There was no documentation of behaviors or incidents justifying the use of a restraint on the date in question, and the resident's care plan did not include individualized interventions for such behaviors prior to the incident. Additionally, the nurse on duty was not notified of any behavioral issues or the use of a restraint, and the restraint was only discovered by oncoming staff during shift change. Facility policy prohibits the use of physical restraints for staff convenience or discipline, defining a restraint as any method that restricts a resident's freedom of movement and cannot be easily removed by the resident. The investigation found that the restraint was used for staff convenience rather than as a last resort or with appropriate documentation and oversight. The resident, who was unable to communicate and was described as frail and contracted, experienced psychosocial harm as a result of being restrained in this manner.
Failure to Timely Report Alleged Abuse and Delay in Investigation
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of abuse involving a resident with severe dementia and Alzheimer's Disease, who was non-communicative and dependent on staff for all activities of daily living. The incident involved two CNAs who tied the resident's shirt sleeves together to prevent her from scratching and pinching during care. The resident was left unattended with her sleeves tied for approximately an hour, and the incident was not immediately reported to the Abuse Coordinator or the State Survey Agency as required by regulation. The incident was discovered by oncoming CNAs at the start of their shift, who found the resident unable to move her arms due to her sleeves being tied together. The nurse on duty was notified, and the sleeves were untied. However, the nurse did not report the incident to the Director of Nursing or the Abuse Coordinator, citing being busy with other duties. The CNAs who discovered the incident also did not immediately escalate the report beyond notifying the nurse, assuming the nurse would handle the reporting process. It was only after several hours that one of the CNAs contacted the Director of Nursing directly. A review of time records showed that the CNAs involved in restraining the resident continued to work subsequent shifts after the incident, as the delay in reporting prevented immediate administrative action. The facility's policy required immediate reporting of abuse allegations, but the actual reporting to the State Agency occurred approximately 22 hours after the incident. The failure to promptly report the incident resulted in a delay in investigation and allowed the alleged perpetrators to continue working with the resident.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Responsible Parties of Resident Elopement
Penalty
Summary
The facility failed to notify the responsible parties of two residents who eloped from the facility. Both residents had severely impaired cognition, with one diagnosed with Alzheimer's disease, adjustment disorder, mood disorder, and delirium, and the other with dementia, traumatic brain injury, falls, and muscle weakness. On two separate occasions, each resident exited the facility through the front doors and was observed and redirected back inside by staff. However, there was no documentation in either resident's clinical record indicating that their responsible parties had been informed of these elopement incidents. Interviews confirmed that at least one family member was not made aware of the elopement. The facility's own policy required that the family or legal representative be notified upon the return of an eloped resident, but this was not followed. The deficiency was identified through a complaint received by the State Agency and confirmed by record review and interviews.
Failure to Annually Review and Update Emergency Preparedness Plan
Penalty
Summary
The facility failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually, as required by federal regulations. During a record review conducted on March 13, 2025, it was found that the emergency preparedness plans and policies had not been updated on an annual basis. This deficiency was identified through documentation review and confirmed in interviews with the Facility Maintenance Director and the Administrator at the time of the record review. This lapse in compliance could potentially affect all 70 occupants in the event of a facility-wide disaster. The report does not mention any specific residents or their medical conditions, nor does it describe any adverse events that occurred as a result of this deficiency. The findings are based solely on the lack of timely review and update of the emergency preparedness plan as observed by surveyors.
Failure to Document Emergency Lighting Inspection and Maintenance
Penalty
Summary
The facility failed to provide documentation of the required 30-second test, inspection, and maintenance for the battery-powered emergency light located in the building. This deficiency was identified during a record review conducted on March 13, 2025, at approximately 10:00 AM. The absence of this documentation indicates that the facility did not ensure automatic emergency lighting was provided in accordance with the applicable code section 7.9. The Facility Maintenance Director and Administrator confirmed the lack of documentation during the exit interview and at the time of record review. This deficiency could potentially affect all 70 occupants in the event of a fire emergency, as noted in the findings.
Failure to Conduct and Document Required Quarterly Fire Drill
Penalty
Summary
The facility failed to conduct and document the required quarterly fire drill for the first shift during the fourth quarter of 2024, as identified during a record review on March 13, 2025. According to the report, fire drills are mandated to be held at least quarterly on each shift, including the transmission of a fire alarm signal and simulation of emergency fire conditions. The absence of documentation for the required fire drill was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of record review. This deficiency could potentially affect all 70 occupants in the event of a fire emergency, as the required procedures for fire safety preparedness were not followed for the specified period.
Failure to Complete Annual Fire Door Inspections and Documentation
Penalty
Summary
The facility failed to conduct and document the required annual inspection, testing, and maintenance of fire door assemblies in accordance with NFPA 80, 2010 edition. During a record review, surveyors found that the most recent fire door inspection record available was dated over a year prior to the survey, indicating that the annual requirement had not been met. This deficiency was confirmed by both the Facility Maintenance Director and the Administrator during the exit interview and at the time of record review. The lack of current documentation for fire door inspections and testing could potentially affect all 70 occupants in the event of a fire emergency, as stated in the findings. No specific residents or their medical conditions were mentioned in the report.
Deficiency in Returning Residents' Personal Clothing
Penalty
Summary
The facility failed to ensure that residents' personal clothing was routinely returned to them from the laundry, affecting multiple residents. During a Resident Council meeting, several residents expressed concerns about their clothing not being returned after being sent to an outside laundry service. One resident mentioned a special football shirt that was never returned, while another reported missing sweaters. The residents indicated that the facility was aware of the issue but had not resolved it. Specific cases included a resident who entered the facility in February 2025 and reported missing shirts with local football players' names. This resident's clothes were not labeled, and they lacked the means to label them themselves. Another resident, who had been at the facility for several years, reported missing shirts and pajamas provided by family. The facility's laundry staff acknowledged that clothing should be labeled, but it often wasn't, leading to difficulties in returning items to the correct residents. The Durable Power of Attorney for another resident reported having to repeatedly buy clothing and blankets for the resident due to losses in the laundry. This resident's clothing was labeled, yet items still went missing, and other residents' clothes were found in their closet. The facility's policy on missing items states that lost personal clothing should be investigated and returned or a written response provided, but this was not effectively implemented. The facility lacked a label machine, and staff sometimes struggled to read names on clothing, contributing to the issue.
Deficiency in Identifying Resident Code Status
Penalty
Summary
The facility failed to ensure that all staff, including agency staff, could promptly identify a resident's code status in the event of an emergency. This deficiency was highlighted by an incident involving a resident who was found unresponsive by a CNA. The agency LPN on duty was unable to locate the resident's code status in the electronic medical record and had to call the Director of Nursing at home for guidance. The LPN eventually found the code status in a binder, but the document was unclear, leading to a delay in initiating CPR. Further investigation revealed that the facility's system for documenting and accessing residents' code statuses was inadequate. The physician orders did not clearly reflect the residents' wishes regarding their code status, and the facility's orientation documentation for agency staff did not include training on the code status system. This lack of training and clarity in documentation affected multiple residents, as evidenced by the review of records for other residents, which also showed inconsistencies and lack of clear documentation of code statuses. The facility's policy on Cardiopulmonary Resuscitation did not provide clear directives for staff on where to locate and identify residents' CPR or DNR status. The surveyors found that the facility's electronic medical record system had a link for code status that did not function properly, further complicating the ability of staff to access critical information in a timely manner. The facility's failure to ensure immediate identification of residents' code status in emergencies posed a risk to all residents in the facility.
Failure to Follow Transfer Protocols Leads to Resident Falls
Penalty
Summary
The facility failed to appropriately transfer two residents, R51 and R64, according to their assessed needs, leading to falls. R51, who has hemiplegia affecting the left side and requires a two-person assist for transfers, was transferred by a single CNA, resulting in a fall. Despite the care plan clearly indicating the need for two-person assistance, the CNA proceeded with the transfer alone, reportedly because R51 did not want to wait for additional help. This incident highlights a lack of adherence to the care plan and inadequate supervision during the transfer process. R64, who has severe cognitive impairment and requires a two-person assist for transfers, experienced a fall when being transferred from the toilet to a wheelchair. The CNA involved in the incident did not ensure that R64 was wearing non-skid footwear, as required by the care plan, which contributed to the fall. The care plan specified the need for two-person assistance and non-skid footwear during transfers, but these precautions were not followed, leading to the resident's feet sliding and a subsequent fall. Both incidents demonstrate a failure to follow established care plans and provide adequate supervision to prevent accidents. The care plans for both residents were clearly documented, yet the staff did not adhere to these guidelines, resulting in falls. The facility's Director of Nursing acknowledged the need for two-person assistance in both cases, but the staff's actions did not reflect this requirement, indicating a lapse in communication and execution of care protocols.
Inadequate Hospice Care Coordination for Resident
Penalty
Summary
The facility failed to provide adequate care coordination related to hospice services for a resident, identified as R52, who was receiving hospice care. R52 was admitted with diagnoses including lung disease, alcohol abuse, pressure ulcers, and dementia. Despite being cognitively intact, R52 experienced frequent moderate pain, which interfered with their sleep. The resident was observed to be thin, underweight, and expressed feelings of loneliness and discomfort. R52 reported delays in receiving pain medication, which was scheduled every four hours and as needed for breakthrough pain every two hours. The resident's pain management was not effectively coordinated, as evidenced by their frequent use of the call light and reports of high pain levels. The facility's failure to maintain and provide access to hospice documentation further contributed to the deficiency. During the survey, the hospice care book and communication notes for R52 were not readily available, and the facility staff, including the RN and unit managers, were unable to locate the current hospice plan of care. The Nursing Home Administrator (NHA) was also unable to provide the missing hospice documentation initially. The lack of accessible hospice records hindered the facility's ability to coordinate care effectively and address R52's ongoing pain and psychosocial needs. Additionally, there was a lack of communication and coordination between the facility and the hospice provider. The facility's physician, identified as Physician Q, was not made aware of R52's ongoing agitation, restlessness, and high anxiety, which could have been addressed with appropriate medication adjustments. The hospice nurse reported that they were not informed of R52's persistent symptoms and that there was a disconnect in communication regarding medication changes. The facility's hospice policy and contract with the hospice provider outlined the need for regular communication and documentation, which was not adhered to, leading to inadequate care coordination for R52.
Sanitation and Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment and properly manage food storage, which was observed during a survey following a complaint. The kitchen lacked a supervisor, and the Corporate Registered Dietician was overseeing operations remotely. During the inspection, several issues were noted, including a buildup of food crumbs in drawers containing clean utensils and scoops, undated food items in the reach-in cooler, and a soiled rag covering the coffee maker overflow tray. Further inspection revealed multiple food items in the reach-in refrigerator and freezer that were either undated or past their use-by dates, such as hard-boiled eggs, cheese slices, fruit cocktail, butter, banana pudding, and hash brown patties. The dry storage area contained items like chocolate chips, brownie mix, salad dressing packets, potatoes, marshmallows, imitation vanilla, chili sauce, hamburger buns, and white bread without proper labeling. Additionally, thickened orange juice cartons were found with compromised packaging and mold growth. The walk-in refrigerator and freezer also had issues, including cracked eggs with spillage, moldy grapes, undated bacon, and a leak from the cooling unit causing ice buildup. The facility's policy required food to be labeled with open and use-by dates, which was not adhered to, and the FDA Food Code mandates for cleanliness and food safety were not met. These deficiencies had the potential to affect all residents consuming meals from the kitchen.
Failure to Document and Monitor PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of specific targeted symptoms and behaviors, as well as attempts at non-pharmacological interventions, before administering PRN anti-anxiety medications to a resident. The resident, who had diagnoses including schizophrenia, bipolar disorder, and severely impaired cognition, was observed to have received 46 doses of lorazepam over a period of approximately three weeks. Despite the frequent administration of this medication, there was no evidence in the clinical record of identified target symptoms or behaviors, nor documentation of non-pharmacological interventions attempted prior to the medication's use. Interviews with facility staff, including the Social Services Director and the Director of Nursing, revealed a lack of awareness and adherence to the facility's policy on psychotropic medication use. The policy required that psychotropic medications should not be used without first determining the underlying causes of behaviors and attempting non-pharmacological interventions. The Director of Nursing acknowledged that there should be documentation of the behavior being treated, evidence of non-pharmacological interventions, and a follow-up assessment, none of which were present in the resident's records.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by incidents involving a resident, R806, who physically assaulted two other residents, R805 and R808. R806, who had diagnoses including dementia with anxiety and Alzheimer's disease, exhibited aggressive behaviors that were not adequately addressed by the facility. On one occasion, R806 ran over R805's foot with a walker and then punched R805 in the face, neck, and chest. This incident was witnessed by two staff members, and it was noted that R806 had a history of aggression towards staff and other residents. In another incident, R806 entered R808's room through a shared bathroom and punched R808 in the face. Although there were no direct witnesses to this event, R808, who had intact cognition, reported the incident, and staff confirmed R806's presence in the room. The facility's investigation into these incidents did not adequately address R806's prior aggressive behaviors, which included wandering into other residents' rooms, becoming combative, and exhibiting inappropriate behaviors such as throwing bowel movements. Interviews with staff revealed that R806 was known for aggressive interactions, and there was a general atmosphere of fighting and hyperactivity on the unit where R806 resided. Despite these known issues, the facility did not implement effective interventions to prevent repeated resident-to-resident abuse, as evidenced by the recurrence of such incidents. The facility's failure to manage R806's behaviors and protect other residents from harm resulted in psychosocial harm to R805 and R808.
Failure to Assess Resident and Notify Physician
Penalty
Summary
The facility failed to thoroughly assess a resident with a change in condition and notify the physician, which led to a deficiency. The resident, who had multiple sclerosis and a compromised immune system, reported feeling unwell with a severe headache during a COVID-19 outbreak in the facility. Despite the resident's request, the nurse did not contact the physician, and the resident had to call 911 for assistance. The resident was diagnosed with COVID-19 and was hospitalized for five days, requiring intravenous fluids, medications, oxygen, and potassium supplementation. The facility's records showed that the resident had complained of a headache and was given pain medication, but no further assessment or vital signs were documented. The nurse on duty did not contact the physician despite the resident's request and the positive COVID-19 test. Interviews with the staff revealed that the nurse who was on duty when the resident went to the hospital did not perform the necessary assessments or document the situation. The Director of Nursing confirmed that the expectation was for the nurse to assess the resident, including taking vital signs, and to contact the medical provider, which was not done in this case.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a resident received proper care to prevent a fall, resulting in a deficiency. A complaint was filed alleging that a staff member attempted to conduct routine personal hygiene on a resident alone, leading to the resident falling between the bed and the wall. This incident caused bruising and required the resident to be transferred to the hospital. The resident, who was severely cognitively impaired and required assistance with personal care, was noted to need two persons for brief changes and activity in bed. However, the staff member involved attempted to perform the task alone, which led to the fall. The investigation revealed that the CNA involved in the incident rolled the resident incorrectly during a brief change, causing the resident to fall. The facility's documentation indicated that the CNA refused to participate in re-education following the incident. The interim DON, who was not employed at the time of the incident, reviewed the investigation and noted that the fall could have been prevented if the resident had been rolled correctly. The facility's failure to provide adequate supervision and assistance during personal care activities directly contributed to the resident's fall and subsequent injury.
Resident-to-Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident, resulting in a right arm fracture for the resident who was pushed to the floor. The incident occurred following a verbal altercation between the two residents, with the resident with moderately impaired cognition pushing the other resident, who also had cognitive impairments. The resident who witnessed the altercation reported hearing loud arguing and the victim saying, 'Let go of me! You're hurting me!' before a loud crash was heard. The victim was subsequently found on the floor in pain, leading to a hospital evaluation and diagnosis of a fractured right humerus. Both residents involved had documented cognitive impairments, with one resident having encephalopathy, adjustment disorder with anxiety, and stroke, while the other had dementia with anxiety and insomnia.
Failure to Accurately Reconcile Controlled Medications
Penalty
Summary
The facility failed to maintain a system to account for the accurate usage and reconciliation of controlled medications for two residents, resulting in potential medication errors and drug diversion. For one resident, discrepancies were found in the administration records of Morphine Oral Concentrate and Lorazepam, with multiple instances where the medication was removed but not signed off on the Medication Administration Records (MARs). Additionally, there were instances where Lorazepam was administered outside of the physician's orders without proper documentation or notification to the physician. The Director of Nursing (DON) was unable to explain these discrepancies and admitted that audits were only performed monthly, which was insufficient to catch these errors in a timely manner. For another resident, discrepancies were found between the Controlled Drug Receipt/Record/Disposition Forms (CDR) and the MARs for Oxycodone. Several instances were noted where Oxycodone was signed out on the CDR but not documented on the MAR, indicating the medication was not given. The resident reported difficulty in receiving pain medication when requested, which was corroborated by the discrepancies found in the records. The DON was unaware of these discrepancies and admitted that audits were only performed monthly, which was insufficient to catch these errors in a timely manner. The facility's policy on controlled medication storage, security, and disposition was not followed, leading to these discrepancies. The DON admitted that the process for documenting both scheduled and as-needed medications on the same CDR form was a practice of their pharmacy and had been in place for about seven months. Despite being asked for additional documentation, the DON was unable to provide any further records to explain the discrepancies identified during the survey.
Failure to Promptly Resolve Grievances and Provide Adequate Care
Penalty
Summary
The facility failed to provide and document evidence of prompt resolution to grievances identified by a family member for a resident. The family member reported that the resident, who had a history of frequent urinary tract infections (UTIs) and required assistance with meals, was not receiving adequate care. Despite the family member's request for a follow-up urinalysis after the completion of antibiotics, the physician assistant declined to order it, stating the resident was fine. Subsequently, the resident was sent to the emergency room, admitted to the ICU with sepsis and pneumonia, and later placed on hospice care. Additionally, the family member reported that the resident's dentures were missing and that staff were not assisting with meals, leading to weight loss due to unopened and improperly set-up food. The facility received a grievance from the ombudsman on behalf of the resident, highlighting issues with meal assistance and the need for adaptive silverware. The facility's response to the grievance was delayed, with documented follow-up occurring more than a month later, after the resident had already been discharged. The Director of Nursing (DON) claimed that grievances are typically addressed immediately and documented in progress notes, but in this case, there was no evidence of timely follow-up or resolution. The DON was also unaware of the missing dentures and provided staff education on meal assistance only after the surveyor's inquiry.
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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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