West Woods Of Bridgman
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgman, Michigan.
- Location
- 9935 Red Arrow Hwy, Bridgman, Michigan 49106
- CMS Provider Number
- 235625
- Inspections on file
- 23
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 53 (1 serious)
Citation history
Health deficiencies cited at West Woods Of Bridgman during CMS and state inspections, most recent first.
A resident with dementia and psychiatric comorbidities developed fatigue, poor appetite, flank and abdominal pain, and was suspected by an NP to have a UTI, with hand‑written orders for CBC, CMP, and UA/C&S that were never entered into the EMR or completed. During a later night shift, the resident experienced an acute decline, becoming lethargic and then unresponsive, with fluctuating vitals, cold extremities, and poor SpO2 readings; CNAs alerted RNs, and an on‑call PA agreed the resident required hospital evaluation. While one RN, who was in orientation, focused on completing transfer paperwork and calling report to the ED, 911 was not promptly called, an abandoned 911 call from the facility was later reported as “no emergency,” and EMS ultimately arrived to find the resident unconscious without CPR in progress, leading to emergent transport and subsequent death the same day.
The facility failed to provide sufficient licensed nursing staff on a night shift when census and its own staffing matrix called for three nurses, leaving only two nurses on duty, one of whom was still in orientation. Staff interviews described frequent short staffing on nights, high-acuity back units where many residents required two staff for care, and CNAs caring for 15–16 residents with delayed call-light response. On the cited night, two residents required hospital transfer, and the orienting RN focused on completing transfer paperwork for a resident with hypotension, lethargy, cool skin, edema, and heel blisters while relying on another RN, who went to eat, for guidance on calling 911. Conflicting accounts from the two RNs and 911/EMS records showed that after an initial EMS call for another resident, an abandoned 911 call from the facility, and a return call in which staff reported no emergency, the local ED and ambulance service had to contact 911 to initiate EMS response for an unresponsive resident the facility said it could not get through to 911 about, resulting in a delayed emergent transfer for that resident, who later died in the hospital.
A newly hired RN, who had not completed orientation and had never transferred a resident to a hospital before, was responsible for two resident transfers during one shift, including a resident who became unresponsive and required emergent EMS transport. The RN reported she was still being trained on the hospital transfer process, including required paperwork and steps, and was left to continue paperwork while the assisting RN went to eat. 911 and EMS records showed an abandoned 911 call from the facility, a return call where staff reported no emergency, and subsequent involvement of the local ED and ambulance service before EMS was dispatched for a reported cardiac arrest. EMS found the resident unconscious, hypoxic, and minimally responsive, and hospital records documented severe clinical instability on arrival. The DON and NHA stated new nurses receive five days of training and an orientation checklist covering emergency procedures and rapid transport, but the DON acknowledged the checklist does not have to be completed before return, had not been turned in for this RN, and she did not know which training items were finished, demonstrating a failure to ensure and monitor effective training for new nursing staff.
A resident admitted with a C6 cervical fracture, syncope, and weakness had provider orders and discharge instructions to wear an Aspen collar at all times, with documentation confirming the fracture and collar use. However, the facility did not develop a care plan addressing the cervical fracture or Aspen collar, even though interdisciplinary notes described the resident as confused, repeatedly removing the collar despite education, and requiring two-person assistance for mobility and transfers. During interviews, the IPM/RN and DON acknowledged that a care plan for the fracture and collar should have been created by the assigned clinical care coordinator at admission but was not.
A resident with a history of bipolar disorder, dementia, and delusional disorder had an order for metoprolol succinate ER 25 mg daily with instructions to hold the dose and notify the provider if systolic BP was <110 or pulse <60. Review of MARs over several months showed that nursing staff repeatedly administered metoprolol on days when documented systolic BP readings were below 110, and there was no record of provider notification when BP readings were outside the ordered parameters. In interviews, an LPN confirmed that medications with parameters should be held when vital signs are outside those limits, the PA and NP stated the metoprolol should have been held under those conditions, and the DON acknowledged that giving the medication without contacting the provider when BP was outside parameters was a medication error.
The facility did not complete required annual performance evaluations for two CNAs, as identified through record review and staff interviews. One CNA hired more than a year earlier had no evaluation on file, and another CNA’s last documented evaluation was not updated on an annual basis. The NHA stated that the DON was responsible for conducting evaluations and HR for tracking due dates, but the DON reported she was unaware of this responsibility and had not completed any evaluations since assuming her role. Regional clinical leadership confirmed that evaluations were expected annually on each employee’s hire-date anniversary, yet no current evaluations for the two CNAs were available during the survey.
The facility did not ensure that a CNA completed the required 12 hours of annual in‑service training, including dementia care and abuse prevention. Record review showed that the CNA, hired several months earlier, had not attempted any of the electronically assigned in‑service modules. The NHA confirmed that in‑services were assigned at the beginning of the year and monthly, that CNAs were notified electronically of new trainings, and that the HR staff member responsible for tracking completion was not available during the survey. This failure created the potential for decreased resident safety due to lack of required CNA education.
Multiple residents with significant care needs experienced prolonged delays in call light response, resulting in unmet toileting and hygiene needs. Staff interviews confirmed that complaints about long wait times were common, and some staff admitted to turning off call lights before completing care, contrary to facility policy. These actions led to discomfort and distress for residents and concern from families.
A resident was readmitted after a hospital stay with orders for occupational and physical therapy evaluation and treatment, but the facility did not complete a therapy evaluation. Staff believed that if the resident returned at baseline, therapy was not needed, despite hospital documentation indicating ongoing therapy requirements.
The facility failed to develop person-centered care plans for two residents, leading to deficiencies in their care. One resident, who is bed-bound, was observed unkempt and unshaven, with staff unaware of his preference to be shaved by a family member. Another resident, diagnosed with PTSD, had a care plan lacking interventions for his condition, with staff unaware of his diagnosis and triggers. The facility's policy emphasizes person-centered care, but the care plans did not reflect this, resulting in inconsistent care.
A resident experienced a skin tear due to the facility's failure to update her transfer status from a one-person assist to a two-person assist after a hospital readmission. Despite therapy's recommendation for increased assistance, the care plan was not revised, leading to the incident during a transfer by a CNA who followed the outdated care plan.
A resident who was bed-bound and required total care was observed with long and soiled fingernails, despite being scheduled for showers twice a week where nail care was supposed to be provided. Staff interviews revealed that nail care was expected during showers, but the resident's nails remained unkempt. The DON confirmed the deficiency, acknowledging that the nails should have been trimmed.
The facility failed to use gait belts during transfers for two residents, leading to potential injury risks. One resident, with increased weakness, was transferred without a gait belt, resulting in a skin tear. Another resident, with impaired mobility, was frequently transferred without a gait belt, as observed by a family member. Staff interviews confirmed the expectation of gait belt use, but the facility lacked a specific policy, and gaps in staff training were identified.
A facility failed to identify and address PTSD triggers for a resident, who had a history of aggression and past trauma. Despite having a care plan for potential acute changes related to PTSD, no specific interventions were in place. The Social Services Director was initially unaware of the resident's PTSD diagnosis and related triggers, contributing to the deficiency in trauma-informed care.
The facility did not ensure the Medical Director attended QAPI meetings at least quarterly, as required. Sign-in sheets from January to April 2024 showed the Medical Director's absence, which was acknowledged by the NHA. The facility's policy mandates the Medical Director's attendance at these meetings.
The facility failed to ensure proper use of PPE for enhanced barrier precautions for two residents. One resident, with a stroke and diabetes, did not have PPE worn by CNAs during care despite signage. Another resident, with cerebral palsy and a gastrostomy tube, lacked signage indicating PPE requirements. Staff were either unaware or did not comply with PPE protocols.
A resident with atrial fibrillation and high blood pressure experienced an overdose of blood thinner medication due to incorrect transcription of warfarin orders at an LTC facility. Despite protocols for triple-checking medication orders, the facility failed to accurately transcribe and verify the complex dosing schedule, leading to a significant medication error. Interviews revealed a lack of effective communication and documentation among the healthcare team, contributing to the deficiency.
A resident with atrial fibrillation was overdosed on Warfarin due to incorrect transcription of hospital discharge orders, leading to a critically high INR. The facility failed to promptly address the error, resulting in delayed intervention and communication with the provider. This incident highlights lapses in medication management and monitoring processes.
Failure to Act on Change in Condition and Delay in Activating 911 for Unresponsive Resident
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to an acute change in condition for one resident, including failure to follow provider orders for diagnostic testing and failure to promptly activate 911 EMS when the resident became unresponsive and hypotensive. The resident was an elderly female with bipolar disorder, dementia, and delusional disorder who had been evaluated by a nurse practitioner two days prior for fatigue, poor appetite, right flank/low back pain, and lower abdominal tenderness. The NP suspected a UTI and hand‑wrote orders on a Doctor’s Orders sheet for CBC, CMP, and urinalysis with C&S if indicated. These orders were to be entered into the EMR by clinical care coordinators, but the Infection Prevention Manager later confirmed that no such orders were entered and no labs or UA were completed, and there were no results in the lab system. During the overnight shift, multiple CNAs reported that the resident was her usual self at the beginning of the shift but later became very lethargic, unable to keep her eyes open, and then completely unresponsive. CNAs stated they notified the nurse, and that two RNs (one being newly oriented) repeatedly assessed the resident, took vital signs several times, and made numerous phone calls. One CNA recalled that one RN wanted to send the resident to the hospital while the other RN was not convinced this was necessary. The orienting RN reported that both nurses assessed the resident and noted fluctuating vital signs, pain, lack of responsiveness except to painful stimuli (sternal rub), cold hands, and difficulty obtaining pulse oximetry readings. She contacted the on‑call PA, who agreed the resident required hospital evaluation, and she documented that the focus at that time was on facilitating transport and maintaining safety while awaiting transfer. The orienting RN described that she and the other RN were the only two nurses in the building that night and that she was being trained on the transfer process, including completing a transfer checklist and packet. She stated she had already transferred another resident earlier in the shift and had learned that 911 arrived quickly and would not wait for incomplete paperwork, so for this resident she took extra time to complete all transfer forms, call the family, and call report to the ED before calling 911. She reported asking the other RN whether they should call 911 and being told to finish the packet while the other RN went to eat. She then completed the electronic transfer form, including documenting last vital signs and that report was called to the ED, but she did not call 911 and believed the other RN would do so. EMS and 911 records show an abandoned 911 call from the facility, a return call in which staff stated there was no emergency, and subsequent calls from the local ED and ambulance service indicating the facility had called the ED with report on an unresponsive resident but had not sent the patient. EMS ultimately received a dispatch at approximately 5:37 a.m. for a 77‑year‑old female in cardiac arrest, arrived to find the resident unconscious but with spontaneous respirations and a pulse, and documented that no CPR or ventilations were in progress on arrival. The resident was transported emergently to the hospital, where she was found comatose, hypotensive, tachycardic, cool and cyanotic, and later died the same day. The PA who had been contacted by the facility stated that, based on the nurse’s documentation, the resident should have been sent to the hospital right after their call and that he would not have told staff to delay transfer. Additional interviews with leadership clarified that the DON expected nurses to assess residents with a change in condition, call the on‑call provider, complete transfer forms, and call 911 EMS for transport, with immediate transfer for an unresponsive resident. The DON acknowledged that night shift staffing could be as low as two nurses and that she believed there was little to do after evening med pass. The Infection Prevention Manager stated she did not receive any call from the facility during the overnight hours and arrived at work as EMS was taking the resident out on a stretcher. The Nursing Home Administrator reported there was no phone outage on the dates in question, although the facility’s voice‑over‑IP phone system could go down and be switched to another Wi‑Fi connection, and staff were expected to use personal cell phones if needed. 911 service records documented that when 911 returned the abandoned call from the facility, staff told them there was no emergency, and only after subsequent calls from the ED and ambulance service was EMS dispatched for the resident described as unresponsive and in cardiac arrest.
Removal Plan
- All licensed nurses were re-educated that 911 EMS must be called without delay for any resident exhibiting signs of an acute decline, including but not limited to unresponsiveness, hypotension, altered mental status, respiratory distress, or other emergent conditions.
- Staff were instructed that contacting the emergency department or hospital does not replace activation of 911 EMS.
- Emergency response protocol reeducation requiring immediate activation of 911 followed by notification of the supervisor or administrator on call.
- The monthly on call schedule was posted at the nurse's station.
- The Director of Nursing or designee are available 24 hours a day, 7 days a week to support clinical decision-making during all shifts.
- Re-education will be completed in person or by telephone prior to staff’s next scheduled shift being worked.
- No licensed staff will be allowed to start a shift or give care until education is completed.
- Medical director was notified.
- Facility health care providers will enter their own orders into the electronic medical record.
- A facility wide review of all current residents was initiated to identify those at risk for acute clinical decline.
- All residents exhibiting signs of deterioration were immediately assessed and transferred via EMS per the emergency response protocol.
- A licensed nurse will conduct a chart review of all current residents for change in condition and follow through with health care practitioner orders.
- All licensed nurses will receive education prior to their next worked shift, including those on leave of absence upon return.
- Agency licensed nurses will be educated and will complete a competency test prior to their shift worked.
- The facility change in condition policy was reviewed by the interdisciplinary team and updated to clearly require activation of 911.
- Emergency condition decision-support tools were implemented at the nurse's station.
- Leadership oversight was implemented to review all emergency transfers.
Insufficient Night-Shift Nursing Staff Led to Delayed EMS Transfer After Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient licensed nursing staff on the night shift to meet resident needs and maintain residents’ highest practicable well-being, which contributed to a delayed emergency transfer for a resident who experienced an acute change in condition and later died. The facility used a corporate staffing matrix based solely on census, without documented consideration of resident acuity, despite a facility assessment stating that staffing levels would be based on acuity and diagnoses. On the night in question, the census was 75, and the staffing matrix and facility assessment both indicated there should be three nurses on the night shift; however, only two nurses (one of whom was still in orientation) were on duty for the entire overnight shift after a scheduled nurse called in. The DON acknowledged that the facility often worked with only two nurses at night and believed three nurses were not needed after the evening medication pass, and the staffing manager confirmed that when there was a call-in, a day-shift nurse might stay over only long enough to complete the evening medication pass, leaving the night shift short. Resident #1 was a female resident with bipolar disorder, dementia, and delusional disorder. On the cited night, two residents, including Resident #1, required transfer to the hospital. CNA interviews described that staffing on nights was frequently short, with only two nurses and five CNAs at times, and that the south and east (back) units had higher-acuity residents, many of whom required two staff for care. CNAs reported that when CNAs working 8‑hour segments left mid‑shift, remaining CNAs were left with 15–16 residents each, and that residents sometimes waited 20 minutes or more for call lights to be answered, especially when showers were being completed. One CNA stated that once staff were in the back units, they did not go to other parts of the building due to the high acuity and needs of those residents. During the night in question, the two nurses on duty were RN V, who was still completing orientation, and RN P, who was assisting RN V with orientation tasks, including learning how to transfer a resident to the hospital. According to RN V, around 3:00 a.m. two residents, including Resident #1, needed to be transported to the hospital. RN V reported that she had earlier transferred another resident that night and had learned that EMS would not wait if paperwork was not ready, so she took extra time to complete all transfer paperwork correctly for Resident #1. She stated she asked RN P whether they should call 911, and RN P told her to finish the paperwork while RN P went to eat and would help afterward. RN V believed RN P called 911; however, she later stated she did not call 911 herself. RN P, in contrast, initially stated she did not call 911 and then expressed uncertainty about who had called. Documentation by RN V, entered later that morning, indicated that at 3:16 a.m. the PA was notified of Resident #1’s change in condition (hypotension, lethargy, cool skin, significant bilateral lower-extremity edema, and fluid-filled blisters on the heels), that the PA agreed the resident required hospital evaluation, and that the hospital was notified and preparations for transfer were initiated. EMS and 911 records showed that 911 received a call at 3:20 a.m. for another resident, with that call clearing at 5:01 a.m., and that an abandoned call from the facility occurred at 5:24 a.m., which was returned and staff reported no emergency. At 5:29–5:30 a.m., the local emergency department and the ambulance service contacted 911, reporting that the facility had called the hospital with report on a patient over an hour earlier but the patient had not arrived, and that the facility had reported difficulty reaching 911 due to phone issues. A subsequent call detail report documented that 911 initially closed the call after being told there was no emergency, then reactivated it when the ambulance service called back with information that a 77‑year‑old female at the facility was hypertensive, unresponsive, and in cardiac arrest, and that the facility said they could not get through to 911. EMS was dispatched around 5:37 a.m. and arrived to find the resident unconscious but breathing with a pulse, on oxygen via nasal cannula, with no CPR or ventilations in progress. EMS documented severe hypoxia requiring escalation of oxygen support and transported the resident to the emergency department. Hospital records indicated that upon arrival to the emergency department, the resident was comatose, hypotensive, tachycardic, cool, and cyanotic, and was intubated, with crushed pill remnants noted in the back of the throat and concern for polypharmacy versus aspiration of medication. The resident was found to have a UTI and developed complications including unstable SVT, cardiogenic shock on top of sepsis, and DIC, ultimately leading to death later that day. The facility’s own data for the date of the incident showed that, with a census of 75, 35 residents required two or more staff for care such as transfers. Multiple CNAs and nurses reported that night shifts were often short-staffed, that there were not enough nurses to cover nights, and that they frequently did not get lunch breaks. The combination of working with only two nurses instead of the three indicated by the facility’s matrix and assessment, the high acuity and dependency of many residents, and the orientation status of one of the two nurses on duty contributed to delays and confusion in arranging timely EMS transport for Resident #1 after an acute change in condition.
Failure to Ensure Effective Orientation and Emergency Transfer Training for Newly Hired RN
Penalty
Summary
The deficiency involves the facility’s failure to provide and monitor an effective training program for a newly hired RN, specifically related to emergency procedures and hospital transfers, which contributed to a delayed response to a resident’s acute change in condition and emergent transfer. The facility’s DON and NHA stated that new nurses receive five days of training and an orientation checklist that includes emergency procedures, hospitalization, transfer forms, and emergency access for rapid transport. However, the DON acknowledged that the checklist does not have to be completed before being returned and that the orientation checklist for the involved RN had not been turned in, leaving the DON unaware of which training items had been completed. The orientation checklist for this RN was not provided to surveyors by the time of exit. The newly hired RN reported that she started at the end of the prior month and had not completed all of her training, including training on transferring a resident to an acute care hospital. On the night in question, she had to transfer two residents to the hospital for changes in condition and stated she had never done this before. She reported that another RN was assisting her with the orientation training checklist and with completing the paperwork, steps, and packet required for a hospital transfer. The assisting RN confirmed that the new RN appeared overwhelmed and unfamiliar with the transfer process and that she tried to help with the required paperwork. The new RN stated that she asked whether they should just call 911 for the resident and was told by the assisting RN to finish the paperwork while the assisting RN went to eat and would help again afterward. During this same shift, EMS and 911 records show multiple calls associated with the facility and a delay in EMS activation for the resident who was ultimately found unresponsive. 911 records documented an abandoned call from the facility, a return call from 911 during which facility staff reported no emergency, and subsequent calls from the local emergency department and ambulance service indicating that the hospital had received report on a patient from the facility but had not yet received the patient. EMS documentation for the resident later transported described dispatch for a cardiac or respiratory arrest, arrival to find the resident unconscious, minimally responsive, hypoxic, and requiring escalating oxygen support and eventual transfer to the emergency department. Hospital records documented that the resident, an older adult with dementia with psychotic features, major depressive disorder, and atrial fibrillation on Eliquis, was brought in unresponsive, hypotensive, tachycardic, cool, and cyanotic, and was intubated for airway protection. The combination of incomplete orientation, lack of verified competency in emergency transfer procedures, and the facility’s failure to ensure the new RN was effectively trained and monitored in these processes led to a delay in treatment and emergent hospital transfer for this resident. The DON confirmed that she did not know which emergency procedure and transfer-related training items the new RN had completed because the orientation checklist had not been returned. The Licensed Nurse Orientation and Skill Check form included items such as emergency procedures, hospitalization, transfer form from the electronic record, and emergency access for rapid transport, but there was no evidence these competencies had been completed or validated for the new RN. The new RN’s own statements that she had never transferred a resident to the hospital before, had not yet completed all of her training, and did not complete the first transfer’s paperwork correctly further demonstrate that the facility did not maintain an effective training and monitoring process for new nurses in critical emergency and transfer procedures, contributing to the deficient practice identified by surveyors.
Failure to Care Plan for Cervical Fracture and Aspen Collar Use
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan addressing a resident’s C6 cervical fracture and ordered Aspen collar use. The resident, a male admitted with diagnoses including a displaced fracture of the sixth cervical vertebra, syncope, collapse, and weakness, had a history and physical dated 12/6/25 documenting a syncopal episode with a fall, head strike, neck pain, and a scalp laceration requiring sutures. MRI showed an anterior superior vertebral body fracture, and he was stabilized in an Aspen collar with a recommendation for continued collar use and follow-up imaging. An after-visit summary dated 12/12/25 directed that the Aspen collar be worn at all times, and a provider note dated 12/15/25 confirmed the C6 fracture and Aspen collar, noting the resident was seen heading to therapy in the collar. Despite these documented orders and clinical findings, review of the resident’s care plan revealed no care plan related to the cervical fracture or the use of the Aspen collar. Interdisciplinary documentation on 12/16/25 described the resident as alert and oriented with some confusion, continuously removing the Aspen collar despite education to keep it in place per provider orders, and being unsteady, requiring assistance of two for bed mobility, transfers, and ambulation. During interviews, the Infection Prevention Manager/RN and the DON both confirmed there was no care plan in place for the C6 fracture or Aspen collar and stated that a care plan should have been created at admission by the assigned clinical care coordinator/RN responsible for the resident’s unit.
Failure to Follow Metoprolol Hold Parameters Resulting in Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of metoprolol succinate ER. The resident, a female with bipolar disorder, dementia, and delusional disorder, had a physician’s order for metoprolol succinate ER 25 mg by mouth once daily for hypertension, with instructions to hold the medication if the systolic blood pressure was less than 110 or the pulse was less than 60, and to notify the physician. Review of the Medication Administration Records (MARs) for October, November, and December 2025 showed multiple instances where the resident’s systolic blood pressure was documented below 110, yet the metoprolol was still administered on those dates. Specific blood pressure readings below the ordered parameter included systolic values of 107, 102, 106, 107, 94, and 107 in October; 103, 106, 100, 100, 108, 105, and 109 in November; and 103, 104, 104, 106, 109, and 104 in December, all with documentation that the medication was given. The resident’s medical record contained no documentation that any provider was notified when blood pressure readings were outside the ordered parameters. In interviews, an LPN stated that medications with hold parameters should not be given if vital signs are outside those parameters. The physician assistant and nurse practitioner both reported that, based on the written order, the metoprolol should have been held whenever the systolic blood pressure was below 110, and the nurse practitioner did not recall being notified of any holds. The DON stated her expectation that medications be given per physician orders and acknowledged that if the provider was not contacted and the medication was given when blood pressure was outside parameters, it constituted a medication error.
Failure to Complete Annual Performance Evaluations for CNAs
Penalty
Summary
The facility failed to complete required annual performance evaluations for two CNAs out of five reviewed, resulting in potential for unidentified CNA performance concerns, lack of training related to performance review outcomes, and potential unmet care needs. Documentation provided by the NHA showed that one CNA hired on 8/24/24 had no performance evaluation completed, and another CNA hired on 3/9/15 had their last documented performance evaluation on 3/19/24, with no current annual review. During interviews, the NHA acknowledged that these two CNAs did not have completed performance reviews and stated that the DON was responsible for completing evaluations while HR was responsible for tracking due dates. The DON reported she was unaware that she was responsible for CNA performance evaluations and had not completed any since starting in her role about five months earlier. The Regional Clinical Support confirmed that performance evaluations were expected annually on each employee’s hire-date anniversary, and no evaluations for the two CNAs were available by the end of the survey. A cited reference from a healthcare performance review resource noted that performance reviews lead to improved performance, greater productivity, and a better overall experience for patients. No specific residents or their medical conditions were mentioned in relation to this deficiency, and the report focused solely on staff performance evaluation practices and related documentation and interviews.
Failure to Ensure Required CNA In‑Service Training Completion
Penalty
Summary
The facility failed to ensure a certified nurse assistant (CNA) completed the required 12 hours of in‑service training needed to ensure continued competency. Interview and record review showed that one CNA, identified as CNA F, was hired on 8/24/24 and, as of the time of survey, had completed 0 hours of in‑service training. A list of assigned in‑service trainings for this CNA documented that none of the assigned trainings had been attempted. The Nursing Home Administrator (NHA) reported that in‑services were assigned at the beginning of the year and monthly, and that CNAs were notified electronically when new training was assigned. The NHA confirmed that CNA F did not have 12 hours of completed in‑service trainings and stated that the Human Resources staff member responsible for maintaining the list of employees and training completions was unavailable during the survey. This deficiency resulted in the potential for a decrease in resident safety, as the facility did not ensure that this CNA had the required in‑service education, including dementia care and abuse prevention, as required for ongoing competency.
Failure to Ensure Timely Call Light Response and Dignified Care
Penalty
Summary
The facility failed to provide care and services that promote dignity and respect for multiple residents, as evidenced by prolonged call light response times and unmet personal care needs. Several residents, all with significant physical or cognitive impairments requiring assistance with personal care and toileting, reported waiting extended periods—ranging from 30 minutes to several hours—for staff to respond to their call lights. In some cases, residents remained in soiled briefs or with full urinals for hours, causing discomfort and distress. Family members also observed and reported these delays, noting that staff sometimes turned off call lights before completing the requested assistance and occasionally forgot to return to fulfill the resident's needs. Staff interviews corroborated the residents' and families' accounts, with multiple CNAs and an LPN acknowledging that residents frequently complained about long call light wait times. One CNA admitted to turning off call lights before completing the task, intending to return later, while the facility's orientation materials specifically instructed staff not to turn off call lights until the resident's need was met. Despite these guidelines, the practice of prematurely turning off call lights persisted, leading to further delays and unmet care needs. The affected residents had diagnoses such as major depressive disorder, paraplegia, muscle weakness, paralysis, and cognitive communication deficits, making timely assistance with toileting and hygiene essential. The failure to respond promptly to call lights and to provide necessary personal care services resulted in residents experiencing discomfort and a lack of dignity, as well as frustration and concern from both residents and their families.
Failure to Complete Therapy Evaluation After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a therapy evaluation was completed for a resident upon readmission following an inpatient hospital stay. The resident, who had diagnoses including muscle weakness and required assistance with personal care, was discharged from the facility, hospitalized, and then readmitted. Upon return, the resident reported feeling weaker and more easily fatigued than before her hospitalization. Despite hospital discharge documentation and orders explicitly stating the need for occupational and physical therapy evaluation and treatment at the receiving facility, no therapy evaluation was conducted after her readmission. Interviews with facility staff revealed that the therapy manager and clinical care coordinator did not consider hospitalization alone as a reason to screen for therapy services, and believed that if a resident returned at their baseline, no therapy referral was necessary. However, hospital records indicated the resident required further skilled occupational therapy, and discharge instructions included orders for therapy evaluation and treatment at the facility. The interim director of nursing confirmed that the resident was not evaluated by therapy upon readmission, contrary to expectations.
Deficiencies in Person-Centered Care Plans for Two Residents
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in their care. Resident #8, who is bed-bound and requires assistance with personal care, was observed unkempt and unshaven on multiple occasions. Despite being scheduled for showers twice a week, during which shaving was expected to occur, Resident #8 remained unshaven. Interviews with staff revealed that Resident #8 preferred to be shaved by a family member, a preference that was not documented in his care plan. The care plan lacked interventions related to his preferences or refusals for care, and staff were unaware of these preferences, leading to inconsistent care. Resident #32, diagnosed with major depressive disorder, PTSD, and generalized anxiety disorder, had a care plan that did not address his PTSD diagnosis. The care plan focused on the potential for acute condition changes but lacked specific interventions related to PTSD. Interviews with staff indicated a lack of awareness of Resident #32's PTSD diagnosis and the absence of documented triggers or interventions to manage his condition. This oversight resulted in staff being unprepared to address his needs, potentially leading to angry outbursts and stress. The facility's policy on care planning emphasizes the importance of person-centered care, including understanding resident preferences and documenting refusals of care. However, the care plans for both residents did not reflect these principles, resulting in deficiencies in meeting their individual needs. The lack of documentation and communication among staff contributed to the failure to provide appropriate and consistent care for these residents.
Failure to Update Transfer Status Results in Resident Injury
Penalty
Summary
The facility failed to update the transfer status of a resident, resulting in a skin tear. The resident, who was cognitively intact, was initially admitted with diagnoses including unsteadiness on feet and difficulty walking. After a hospital stay, the resident was readmitted to the facility, and therapy assessed that her transfer status required a change from a one-person assist to a two-person assist due to increased weakness. However, this change was not updated in her care plan, leading to a skin tear during a transfer when a CNA followed the outdated care plan. Interviews revealed that the therapy director communicated the need for a change in transfer status to nursing staff, but the care plan was not updated accordingly. The CNA involved in the transfer was unaware of the change and relied on the care plan, which still indicated a one-person assist. The incident highlighted a breakdown in communication between therapy and nursing staff, as well as a failure to update the care plan to reflect the resident's current needs.
Failure to Provide Adequate Nail Care to a Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident who was dependent on staff for activities of daily living. The resident, who was bed-bound and required total care, was observed on multiple occasions with long and soiled fingernails. Despite being scheduled for showers twice a week, during which nail care was supposed to be provided, the resident's nails remained unkempt. Observations on different days confirmed the resident's unshaven and unkempt appearance, indicating a lack of personal care. Interviews with staff, including CNAs and the Director of Nursing, revealed that nail care was expected to be performed during the resident's scheduled showers. However, despite documentation indicating that a shower was completed, the resident's nails were still long and dirty. The Director of Nursing acknowledged the deficiency upon observation, confirming that the resident's nails should have been trimmed during the shower. This indicates a failure in the facility's process to ensure the resident's personal care needs were met as per their care plan.
Failure to Use Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to implement the use of gait belts during transfers for two residents, leading to potential injury risks. Resident #268 was admitted with diagnoses including unsteadiness on feet and required assistance with personal care. After a hospital readmission, her care plan indicated a one-person assist for transfers. However, a therapy screen revealed increased weakness, necessitating a two-person assist, which was not updated in her care plan. On a specific date, during a transfer without a gait belt, Resident #268 sustained a skin tear, highlighting the failure to adjust her care plan and use appropriate transfer aids. Resident #61, diagnosed with a neurocognitive disorder and a history of falls, required maximal assistance for transfers. Observations revealed that staff frequently transferred Resident #61 without using a gait belt, despite his impaired mobility. During one instance, a CNA assisted him to the toilet by placing her arms around his torso without a gait belt, as reported by a family member who regularly observed such practices. Interviews with staff, including the Therapy Director and Clinical Care Coordinator, confirmed that gait belts should be used for all transfers unless a mechanical lift is employed. The facility lacked a specific gait belt policy, relying on it as a standard of care. Additionally, a review of staff training revealed gaps in gait belt education, with some staff not receiving current training, contributing to the deficiency in safe transfer practices.
Failure to Address PTSD Triggers in Resident Care
Penalty
Summary
The facility failed to identify and implement interventions for PTSD triggers for a resident, leading to the potential for retraumatization and mental distress. The resident, who was admitted with diagnoses including major depressive disorder, PTSD, and generalized anxiety disorder, was cognitively intact as per a recent assessment. Despite having a care plan that mentioned the potential for acute condition changes related to PTSD, there were no specific interventions addressing the PTSD diagnosis. Additionally, a trauma-informed care life event screening identified past traumatic events, but no further trauma assessments were conducted by the facility staff. The Social Services Director (SSD) was initially unaware of the resident's PTSD diagnosis and any related triggers, despite the resident's history of physical aggression and past traumatic experiences, including abuse and significant personal losses. The resident had displayed aggressive behavior at the facility, such as breaking a window and threatening staff. The SSD later confirmed the PTSD diagnosis and the resident's history of violence but still lacked knowledge of specific PTSD triggers. This lack of awareness and intervention contributed to the deficiency in providing trauma-informed care.
Medical Director's Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Process Improvement (QAPI) meetings included the Medical Director as a mandatory attendee at least quarterly. This deficiency was identified through a review of the QAPI meeting sign-in sheets for January and February 2024, which revealed the absence of the Medical Director. Additionally, the Infection Control Meeting sign-in sheets, used for QAPI meetings in March and April 2024, also showed the Medical Director's absence. During an interview, the Nursing Home Administrator acknowledged that the Medical Director did not attend the meetings for four consecutive months, failing to meet the requirement of attending at least one meeting per quarter. The facility's Quality Assurance Performance Improvement Plan Policy, reviewed in May 2024, lists the Medical Director as a required attendee for these meetings.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure the proper use of personal protective equipment (PPE) for enhanced barrier precautions, which was observed in two residents. Resident #1, who had diagnoses including cerebral infarction and type 2 diabetes, was cognitively intact and required enhanced barrier precautions during high-contact care activities. Despite signage indicating the need for PPE, Certified Nurse Assistants (CNAs) L and S did not wear gowns or gloves while providing care to Resident #1. CNA S was unaware of the meaning of the signage, while CNA L acknowledged the requirement but did not comply. Resident #18, diagnosed with cerebral palsy and aphasia, required enhanced barrier precautions due to a gastrostomy tube. However, there was no signage on the door to indicate the need for PPE. Licensed Practical Nurse (LPN) BB confirmed the necessity of PPE when handling the tube. The Clinical Care Coordinator/Registered Nurse (CCC/RN) and the Director of Nursing (DON) both stated that enhanced barrier precautions were expected for residents meeting the criteria, yet these precautions were not properly implemented for Residents #1 and #18.
Medication Transcription Error Leads to Overdose
Penalty
Summary
The facility failed to ensure that a resident received care in accordance with professional standards of nursing practice, leading to an overdose of blood thinner medication. The resident, who had a history of atrial fibrillation and high blood pressure, was admitted with specific medication orders for warfarin. However, the facility transcribed the orders incorrectly, leading to the administration of an incorrect dosage. The hospital discharge summary specified a complex dosing schedule for warfarin, which was not accurately transcribed by the facility. Interviews with facility staff revealed a breakdown in the medication verification process. The nurse practitioner assumed that the pharmacy had correctly dosed the warfarin and did not verify the orders herself. The admission process involved multiple checks by different nurses, but these checks were not documented or retained, leading to a lack of accountability. The Clinical Care Coordinator noted that the order for pharmacy dosing of warfarin was not entered until days after the resident's admission, indicating a delay in the medication review process. Family members expressed concerns about the resident's medication regimen shortly after admission, highlighting the oversight in medication administration. Despite the facility's protocol for triple-checking medication orders, the failure to accurately transcribe and verify the warfarin dosage resulted in a significant medication error. The lack of effective communication and documentation among the healthcare team contributed to this deficiency, as noted in the review of nursing fundamentals.
Significant Medication Error Due to Incorrect Warfarin Dosing
Penalty
Summary
The facility failed to administer medications at the correct dose as per the physician's order for a resident, leading to a significant medication error involving an overdose of Warfarin, an anticoagulant. The resident, who had a history of atrial fibrillation and hypertension, was discharged from a local hospital with specific instructions for Warfarin dosing. However, the facility transcribed the orders incorrectly, resulting in the resident receiving 4.5 mg of Warfarin daily instead of the prescribed 2 mg or 2.5 mg. This error was not identified or corrected promptly, leading to a critically high INR level of 8.19, which was reported to the facility. Despite the critical lab results indicating a dangerously high INR, the facility did not take immediate action to address the overdose. The results were faxed to the pharmacy, but there was no documented follow-up with the provider regarding the critical lab results or the pharmacy's recommendation to administer Vitamin K. The resident's INR remained critically high, and there was a delay in obtaining a stat lab draw to reassess the INR levels. The lack of timely intervention and communication with the provider contributed to the resident's prolonged exposure to the risk of bleeding due to the Warfarin overdose. Interviews with facility staff revealed a breakdown in the medication administration and monitoring process. The nurse practitioner did not review the Warfarin orders closely, and the admission process failed to ensure accurate transcription and verification of medication orders. The facility's procedures for handling critical lab results and coordinating with the pharmacy and provider were inadequate, leading to a failure to address the resident's critical condition promptly. This deficiency highlights significant lapses in medication management and communication within the facility.
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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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