Bronson Commons
Inspection history, citations, penalties and survey trends for this long-term care facility in Mattawan, Michigan.
- Location
- 23332 Red Arrow Highway, Mattawan, Michigan 49071
- CMS Provider Number
- 235434
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Bronson Commons during CMS and state inspections, most recent first.
A resident with a history of falls, recent head trauma, and acute confusion was inaccurately assessed as not being at risk for elopement despite documented paranoia, agitation, wandering, and repeated statements about wanting to leave. Staff relied on the presence of a wander guard to identify elopement risk, did not reassess the resident’s status, and did not communicate her behaviors as elopement risk indicators. During a night shift, the resident was briefly supervised at the nurse’s station, then returned to bed; later, she independently wheeled to the main entrance, used the handicap door button, exited the building unnoticed, and was only discovered missing when an LPN went to administer medications and initiated a search that found her outside near a neighboring home. In a separate incident, another cognitively impaired, fully dependent resident was transferred from bed to chair with a Hoyer lift using a hygiene sling that had not been clinically assessed or ordered for her, and the care plan did not specify sling type. CNAs used the sling available in the room, but the resident could not maintain the upper body support required, slid out of the sling, fell onto the lift frame, and sustained a head laceration requiring staple repair in the ED, while therapy staff later confirmed that a standard full-body sling should have been used for such transfers.
The facility failed to maintain a full-time RN in the DON role when the DON also served as the Executive Director/NHA, resulting in the same individual being responsible for both clinical and administrative oversight. The DON reported extensive DON duties, including audits, education, policy updates, infection prevention, clinical oversight, and IDT meetings, while also overseeing rehab, activities, dietary, and social work as NHA. Because of the dual roles, the DON stated she could not attend all necessary meetings, was less available to staff, and delegated multiple DON responsibilities to unit coordinators and other staff, including safety committee participation and the nurse aide training program. Staff interviews confirmed reduced access to the DON and increased delegation of DON tasks, and facility records showed no separate Executive Director listed.
Two residents were injured when staff failed to follow prescribed transfer protocols, including not using a gait belt during a bathroom-to-bed transfer and using a slide board instead of a hoyer lift for toileting. These actions resulted in a hand laceration, a femur fracture, and bruising on the upper arms, as staff did not adhere to care plan instructions or use appropriate assistive devices.
The facility did not adequately inform or educate residents about the grievance process, and concern forms were not easily accessible. Residents were unaware of their right to file grievances, and staff, including an LPN and Activity Associates, were unfamiliar with the process or location of forms. Leadership confirmed that forms were not placed in resident-frequented areas and were typically initiated by staff, resulting in grievances not being properly documented, tracked, or resolved.
Three residents were allowed to self-administer medications or had medications left at their bedside without required assessments or provider orders. Staff confirmed that no assessments were completed and no orders were present, despite facility policy requiring both before permitting self-administration. Residents involved had various medical conditions and were observed or reported to have independently taken medications, with staff inconsistently following procedures.
A resident who was cognitively intact and dependent on staff for transfers was not consistently assisted to use a bedside commode as preferred, with staff often offering a bedpan instead during certain times due to staffing and time limitations. Staff acknowledged that the commode was only used when enough staff were available, despite documentation indicating the resident was not appropriate for bedpan use. The care plan lacked specific documentation of the resident's toileting preference, leading to dissatisfaction and a failure to fully support resident choice.
Two residents received PRN psychotropic medication orders for durations exceeding 14 days without documented physician rationale, contrary to federal requirements. One resident with severe cognitive impairment and another with anxiety disorder both had lorazepam orders renewed or written for extended periods, with staff confirming the absence of required documentation for the extended use.
A resident's MDS discharge assessment was incorrectly coded as a hospital transfer when the individual was actually discharged to home. The MDS Coordinator admitted to the error, and the MDS RN, responsible for final submission, acknowledged only performing spot checks rather than a full review, leading to the submission of inaccurate discharge data.
A resident was administered Apresoline for hypertension without verification or documentation of blood pressure as required by physician orders, despite the resident's report of low blood pressure and known side effects such as dizziness. Staff interviews and record review confirmed that the medication was given without the necessary assessment, resulting in a failure to meet professional standards of nursing practice.
A resident with depression and intact cognition reported that the facility did not support her preferred activities, including pet therapy, evening programs, and opportunities to serve others. Activity calendars confirmed a lack of evening activities, pet therapy, and community outings, and the resident described the available activities as unfulfilling. Facility leadership acknowledged that activity needs assessments were limited and had not recently evaluated the need for evening or community-based activities.
A resident with severe cognitive impairment and renal insufficiency did not have water within reach at the bedside, despite facility policy and staff expectations. Observations showed the water cup was repeatedly left across the room, and the resident expressed thirst. Staff interviews confirmed the requirement for water to be accessible and replenished, but this was not consistently done.
A deficiency occurred when staff failed to use enhanced barrier precautions, specifically gown and gloves, during tube feeding administration for a resident with a feeding tube. Despite facility policy and posted instructions requiring EBP for high-contact care involving indwelling devices, an LPN administered the feeding without proper PPE, and staff interviews revealed inconsistent understanding and application of EBP requirements.
The facility did not make survey results and plans of correction easily accessible to residents. Residents reported being unaware of their right to review these documents, and staff, including an LPN and an Activity Associate, were unsure of the location or process for resident access. The survey reports were stored on a high shelf in an area not frequently visited by residents, further limiting accessibility.
The facility failed to provide a written notice of transfer for a resident with moderately impaired cognition, resulting in the potential for residents and/or their representatives to be uninformed of the reason for transfer and their rights. Staff interviews revealed that the required transfer/discharge notices were not included in the paperwork sent with residents.
The facility failed to store CPAP masks properly for three residents, leading to potential respiratory infection risks. Despite staff and residents acknowledging the correct storage procedures, masks were repeatedly found uncovered on nightstands or in drawers.
The facility failed to ensure proper communication and coordination with the dialysis provider for a resident requiring dialysis services. There was no pre and post dialysis treatment assessment communication, and the facility did not have an established agreement with the dialysis provider. Interviews with staff revealed irregular communication and no formal contract, leading to potential risks for the resident's care.
Failure to Prevent Elopement and Unsafe Hoyer Transfer Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to elopement risk and safe mechanical lift transfers. One resident with a history of falls, multiple rib fractures, and recent head trauma was admitted from a hospital with documented confusion, agitation, paranoia, and impulsive behaviors. On admission, the RN completing the elopement assessment marked the resident as not at risk for elopement, despite her own verbal report that the resident was terrified, disoriented, repeatedly stated she wanted to leave, believed people were trying to harm her, and was frequently up and wandering in the room. Progress notes and the admission history and physical documented that the resident was quite confused, agitated, impulsive, and exhibiting abnormal behaviors, including asking staff to help her commit a mass murder, making accusations that hospital staff and paramedics had stolen from her, and expressing delusional beliefs about being harmed. The care plan addressed potential changes in mental status and mood but did not identify or address elopement risk. Nursing and CNA staff interviews showed that staff relied primarily on the presence of a wander guard to identify elopement risk and did not reference other assessments or tools to determine risk. Staff reported that when a resident was identified as an elopement risk, a wander guard was applied and this was communicated in shift report; if a resident was not assessed as a risk, no wander guard was used and no reevaluation occurred unless triggered by preset intervals or events. The admitting RN initially stated she believed she had documented the resident as an elopement risk, but later clarified she had not, explaining she did not think the resident was physically capable of reaching the door and was hopeful the resident would adjust. Subsequent nursing staff on the night shift were informed only that the resident was new, had fallen at home, had a knot on her head, and was "fine," and they were unaware she was an elopement risk. During that night, the CNA and LPN observed the resident as confused, wanting to call her son, not knowing how she arrived at the facility, asking for her husband and son, and stating she wanted to leave. The resident was kept at the nurse’s station for a time, then assisted back to bed around 3:30 AM. Later, camera footage showed the resident self-propelling in a wheelchair to the main entrance, using the handicap button to open the door, and exiting the building without staff awareness. She walked away from the facility and was not discovered missing until the LPN went to administer medications and found her room empty, prompting a search that ended with the resident being located outside near a neighboring house. A second deficiency involved the facility’s failure to ensure safe use of a mechanical lift and appropriate sling selection for another resident with moderate cognitive impairment and generalized weakness, who was dependent on staff for all bed mobility and transfers. During a transfer from bed to recliner using a Hoyer lift, two CNAs used a hygiene sling that was present in the resident’s room and that they reported had been used for months. As the lift was pulled away from the bed, the resident was unable to maintain the upper body and arm support required for that type of sling, slid out of the sling, and fell onto the legs of the lift, sustaining a head laceration that required four staples in the emergency department. Therapy staff, including the supervisor of rehabilitation, PT, and OT, later stated that the hygiene sling is a specialized sling intended for toileting, requires sufficient shoulder engagement and core strength, and is not appropriate for routine bed-to-chair transfers without prior assessment. They confirmed that therapy had not assessed this resident for hygiene sling use and had expected a standard full-body Hoyer sling to be used. The RN unit coordinator acknowledged that the hygiene sling had been used, described it as the resident’s preference, but could not provide documentation of such a preference or any assessment supporting its safety for this resident. Interviews with nursing and therapy staff further revealed that CNAs typically used whatever sling was in the resident’s room and that the resident’s care plan did not specify the type of sling to be used for transfers. There was no documented assessment by therapy or nursing indicating that the resident had the necessary upper body strength and core stability to safely use a hygiene sling for non-toileting transfers. As a result, the resident, who had dementia and Alzheimer’s disease and was dependent for transfers, was transferred with a sling that did not provide adequate support for her condition, directly leading to her fall and head injury during the Hoyer lift transfer.
Removal Plan
- Review elopement and missing person policies and procedures.
- Modify the elopement assessment tool scoring to enhance identification of safety risks.
- Reassess all residents for elopement risk.
- Initiate wander guards for residents identified as elopement risks based on the updated elopement assessment tool.
- Check all wander guards and alarms for functionality.
- Provide comprehensive education on elopement prevention, including ongoing assessments, definitions, exit-seeking behaviors, and role expectations, to all licensed nursing staff and certified nursing assistants.
- Provide education to remaining employees prior to the start of their next working shift.
- Review education material and completion quarterly at the QAPI meeting.
- Perform weekly audits of new admissions for 4 weeks to ensure elopement assessments are completed on admission, kept up to date, and that a care plan addresses any identified risk.
- Create a workstation at the main entrance and schedule staff to monitor traffic in and out of the building.
- Install a Red Box Audible Alarm at the main entrance.
- Maintain the alarm by the entrance attendant.
- Activate the alarm any time the door is opened.
Failure to Maintain a Full-Time RN Director of Nursing
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) served full time in the role of Director of Nursing (DON), as required, because the DON simultaneously held the position of Executive Director/Nursing Home Administrator (NHA). When surveyors entered the facility, they were informed that the NHA and DON were the same person, and the DON confirmed she had been functioning in both roles since the previous NHA left. The facility assessment listed the same individual as both Interim Executive Director and DON, and the employee report did not list any separate Executive Director. The DON described her DON responsibilities as including auditing and education, new processes, policy updates, employee issues, payroll and budget tasks, staff meetings, skills fairs, infection prevention meetings, clinical oversight, and IDT meetings, while also assuming responsibility for rehabilitation, activities, dietary, and social work departments as NHA. Due to the dual roles, the DON reported she was one person doing 40 hours of work in two positions, was not always performing quality work, and could not attend certain meetings or complete some DON functions. She stated that her DON responsibilities were delegated to unit coordinators, and staff interviews confirmed multiple delegations from the DON and that access to the DON had become limited. Staff reported the DON was less available to discuss issues and less hands-on with clinical staff than before. The DON also reported she could no longer serve on the safety committee or run the nurse aide training program, which were reassigned to a unit coordinator and staff development RN, respectively. A unit coordinator reported being placed into the safety committee role shortly after starting and learning the role “on the fly,” further illustrating that DON duties were shifted to other staff because the DON was covering both DON and NHA positions instead of serving full time as DON.
Failure to Follow Transfer Protocols Results in Resident Injuries
Penalty
Summary
The facility failed to ensure that appropriate transfer techniques were implemented for two residents, resulting in injuries. One resident, a female admitted for physical and occupational therapy following a previous femur fracture, was assessed as requiring limited assistance for transfers, with therapy recommendations including the use of a front-wheeled walker, wheelchair, gait belt, and verbal cues. During an assisted transfer from the bathroom to the bed, the CNA did not use a gait belt as required by the resident's care plan. While the CNA was pulling down the bedding, the resident let go of her walker to point at the bed control and fell backward, sustaining a hand laceration and a new acute fracture to her distal femur. The CNA admitted to not checking the care plan and not realizing a gait belt was required for the transfer. Another resident, a female with gastroparesis and dependent for care, was to be transferred with a hoyer lift to the toilet and a slide board only for bed-to-wheelchair transfers. Over a weekend, staff used a slide board transfer to the toilet instead of the required hoyer lift, and when the process took too long, staff reportedly picked the resident up and placed her on the toilet, resulting in bruising on her inner upper arms. Multiple interviews confirmed that the resident's care plan specified a hoyer lift for toilet transfers, and staff were either unaware of or did not follow these instructions. The resident and several staff members reported the improper transfer and resulting bruising. In both cases, the deficiencies were due to staff not following the residents' care plans and not using the required assistive devices or transfer techniques. Staff either did not check the care plans or made assumptions about the residents' transfer status, leading to improper handling and injury. The incidents were witnessed, reported, and confirmed through interviews, observations, and record reviews.
Plan Of Correction
1. One of the residents had discharged at the time of the survey. The care plans of the other affected resident were reviewed and updated by the Interdisciplinary Team (IDT). Updated level of assistance and transfer status were shared with clinical teams by leadership to ensure understanding and compliance. 2. All residents have the potential to be affected. 3. Clinical Oversight Committee will audit care plans to ensure clear direction and appropriate levels of assistance. Refreshed education was provided to clinical staff on where to locate care plan information on EMR devices, and they were reminded to always carry these devices to be ready to verify care plans and assistance levels. Policies were reviewed, and no necessary updates were identified. 4. Routine audits of five care plans are conducted weekly at Clinical Oversight meetings for clarity of assistance levels. Additionally, five weekly audits are performed on transfers to ensure the transfer aligns with care plans. There are also five weekly audits of staff demonstrating where to locate care plan information on devices, and audits to ensure devices are on staff members at all times to guarantee they are always ready to access the care plan. 5. The Executive Director is responsible for compliance.
Failure to Inform and Implement Grievance Process
Penalty
Summary
The facility failed to inform and educate residents about the grievance process and did not effectively implement procedures for documenting, tracking, and resolving grievances. During a confidential group meeting, all six residents present reported that they repeatedly discussed the same concerns in resident council meetings without resolution. These residents were unaware that they could have their private concerns documented on a form, that staff could assist them in completing the form, or that they could submit concerns anonymously. They also did not know that concern forms were available or how to access them, but indicated they would use the forms if they were accessible. Observations revealed that blank concern forms were stored in a binder on a shelf located 4-5 feet up on the wall in a sitting area near the main lobby, making them not easily accessible to residents. Interviews with staff, including an LPN and two Activity Associates, showed a lack of awareness about the location and use of concern forms. The LPN stated she did not know where to find the forms or assist residents with them, and one Activity Associate was unfamiliar with the forms altogether. The other Activity Associate, who conducted resident council meetings, reported that she emailed concerns to relevant departments but did not follow up to ensure concerns were addressed, only discussing responses from previous meetings if available. Further interviews with facility leadership, including the Nursing Home Administrator and DON, confirmed that concern forms were not placed in areas frequented by residents and were posted high on the wall, making them difficult to access. The DON also noted that staff, rather than residents, typically initiated the concern forms. As a result, the facility did not ensure that residents were properly informed about their right to file grievances, did not make the process accessible, and failed to document, track, and record the resolution of grievances as required.
Plan Of Correction
1. The facility moved concern/grievance forms to a tabletop location that is prominent and easily accessible in the lobby. A prominent notice was placed to guide residents to the location. 2. All residents who have concerns about their care have potential to be affected. 3. The facility created a log of concerns and grievances to monitor follow-up and ensure each concern is resolved. The log also enables the facility to track and trend concerns to identify opportunities for continuous quality improvement. The facility will report the number and nature of concerns, resolution status, and trends at monthly Quality Assurance Performance Improvement (QAPI) meetings, where the QAPI Committee will use the information to direct performance improvement projects as warranted. The facility will also provide written information to all residents on the right to air concerns or grievances, and the location of self-reporting forms. This information will be provided to the Resident Council at the July meeting. Going forward, this information will also be included in the admission packet. Education will be provided to all employees about the right to air concerns and grievances, and how residents can submit concerns or grievances using forms that are available in the lobby or with confidential help from an employee. Education will include how these are tracked for continuous quality improvement. 4. During routine daily leadership rounds, each leader will interview at least one resident for awareness how to report a concern or grievance for at least the next 12 weeks. During monthly QAPI meetings the committee will review the number, nature and status of concerns and will determine if opportunities are present for performance improvement. 5. The executive director is responsible for compliance.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the appropriateness of self-administering medications, as required by policy and regulation. Three residents were observed or reported to have self-administered medications or had medications left at their bedside without a completed assessment or physician order authorizing self-administration. In each case, staff confirmed that no assessment had been completed and no orders were present to allow self-administration, despite the facility's policy requiring both an assessment and a provider order before permitting this practice. One resident, with a history of gastroparesis and dependence for care, was observed independently instilling eye drops at her bedside. Staff confirmed there was no physician order for the eye drops, no assessment for self-administration, and that the resident had a history of having unauthorized items removed from her bedside. Another resident, diagnosed with end stage kidney disease and on dialysis, reported that nurses inconsistently left her chewable tablet (Fosrenal) at her bedside to take after meals, as prescribed. Staff acknowledged that this resident had not been assessed for self-administration, and that the facility did not have a process in place for such assessments, even though the medication was being left for her to take on her own. A third resident, with diagnoses including cancer, heart failure, anxiety, and depression, reported that nurses sometimes left her medications, such as supplements and vitamins, for her to take independently. She recounted an incident where she nearly attempted to pick up a dropped pill herself, despite a history of falls. Staff confirmed that no residents on her unit had been assessed for self-administration of medications. Review of facility policy indicated that an assessment and provider order are required before allowing residents to self-administer medications or have medications left with them, but these procedures were not followed for the residents involved.
Plan Of Correction
1. One of the three residents was found to have medications in their possession. This was retrieved and locked up. Education was provided to residents and assigned nurses regarding self-administration of medication and expectations related to protocol. One affected resident has discharged from the facility. The other two will be assessed for their ability to self-administer medications safely per policy. 2. Any resident has potential to be affected. 3. Education will be provided to admission staff related to self-administration of medication policy, to include asking if the resident has any kind of over-the-counter or prescribed medication in their possession, and explaining expectations related to this policy. Specified scripting will be provided. Education will be refreshed with nursing employees related to the existing self-administration policy. It will be added to new hire orientation checklist for new employee education. An additional step will be added to the new admission checklist to include a discussion with the nurse and resident regarding the self-administration policy. Nurses will be instructed to include a comment in Admission Navigator Section of the EMR to reflect that the conversation was completed. The Self-Administration of Medication policy was updated to include an explanation to residents upon admission related to the policy and its expectations. Five weekly audits will be completed of admission documents and nursing assessments to ensure the policy is discussed as expected for the next 12 weeks. Five verbal weekly audits will also be completed with nurses to seek their understanding of the policy for the next 12 weeks. The Executive Director is responsible for compliance with this policy.
Failure to Honor Resident's Toileting Preferences Due to Staffing Constraints
Penalty
Summary
A deficiency was identified when a cognitively intact resident, who was dependent on staff for toileting and transfers, was not consistently provided with assistance according to her preferences. The resident preferred to use a bedside commode for toileting, as documented in her care guide, but staff frequently offered a bedpan instead, particularly during nighttime and mealtimes. Staff interviews confirmed that the use of the commode was limited by staffing levels and time constraints, with staff indicating that using the mechanical lift for commode transfers was too time-consuming. The resident expressed dissatisfaction with being offered the bedpan, which she found uncomfortable, and reported that her requests to use the commode were sometimes denied unless there were enough staff available. Review of the resident's care plan indicated a goal for her to be clean, dry, and odor-free, with interventions to encourage her to verbalize toileting needs and keep her call light within reach. However, the care plan did not specifically document her preference for the commode. Progress notes and occupational therapy documentation further supported that the resident was encouraged to use the commode and was not appropriate for bedpan use. Despite this, staff practice did not consistently align with the resident's preferences, resulting in care that did not fully support her right to self-determination and choice in daily living activities.
Plan Of Correction
1. A care conference will be scheduled with the Interdisciplinary Team (IDT) and resident to identify preferences and discuss how the facility can best meet resident's needs. Care plan will then be updated to reflect the discussion. 2. All residents have the potential to be affected. 3. Existing "Interdisciplinary Long-Term Care Resident Review Protocol" was updated to include: Resident and/or resident representative interview should include a discussion about care preferences and will be completed by a member of the IDT. Standard care preference questions should include the following: toileting, sleep and wake preferences, meals, and other care preferences the resident would like to share. With this information, care plans will be updated at least quarterly with resident and/or representative input and subsequently implemented into how their care is provided. 4. Bi-weekly long-term care resident review meetings will include an audit of all residents due for quarterly review to ensure that interviews were completed and identified preferences were implemented into the care plan for at least the next 12 weeks. 5. The Executive Director is responsible for compliance.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days Without Physician Rationale
Penalty
Summary
Surveyors identified that the facility failed to comply with federal requirements regarding the use of PRN (as needed) psychotropic medications for two residents. Specifically, the facility did not limit the duration of PRN psychotropic medication orders to 14 days, nor did it ensure that the prescribing physician documented a clinical rationale for extending these orders beyond the 14-day limit, as required by regulation. For one resident with Alzheimer's disease and major depressive disorder, a PRN order for lorazepam was in place for a period exceeding 14 days. The resident was severely cognitively impaired and had no documented behaviors during the assessment period. The medication order for lorazepam was renewed multiple times without evidence of a physician's documented rationale for the extended duration. Facility staff confirmed the ongoing order and acknowledged the lack of compliance with the required documentation. Another resident with generalized anxiety disorder also had a PRN lorazepam order written for 30 days. Although the resident reported some anxiety and staff noted the medication was beneficial, there was no documentation from the physician providing a rationale for extending the PRN order beyond 14 days. The pharmacy's monthly review did not identify any irregularities or make new recommendations regarding this medication order.
Plan Of Correction
1. Medical records will be reviewed by providers and the Interdisciplinary Team (IDT) to determine the necessity of medication and frequency. Medications will be discontinued or frequency modified accordingly. All residents have the potential to be affected. 2. EMR Reports will be utilized to identify those with orders for PRN psychotropic medications. Behavior Management Program Policy was updated to include: "When pharmacological interventions are utilized, the duration of order must meet regulatory requirements. PRN psychotropic medications should not exceed more than 14 days unless clinical documentation by a provider is present to provide rationale. Orders will be reviewed during the Behavioral Health Committee meeting to ensure pharmacological interventions meet criteria for use and regulatory requirements." 3. Antipsychotic Medication Management policy was updated to include: "When pharmacological interventions are utilized, the duration of order must meet regulatory requirements. PRN Psychotropic medications should not exceed more than 14 days unless clinical documentation by a provider is present to provide rationale." Education will be provided to nurses, providers, and social services teams regarding policy updates and expectations. External partners providing pharmacy and behavioral health services will receive this refreshed education as well. Weekly Clinical Oversight meetings will monitor these medications utilizing EMR report on a weekly basis. 4. Behavioral Health Committee will review a report of all PRN psychotropic medications during monthly routine meetings to determine the necessity of medication and appropriate frequency. Medications will be discontinued or frequency modified accordingly. Weekly Clinical Oversight meetings will monitor these medications utilizing EMR report on a weekly basis. Five weekly audits to ensure compliance will be completed by Social Services or designee utilizing EMR report for the next 12 weeks. The executive director is responsible for compliance.
Inaccurate MDS Discharge Assessment Coding
Penalty
Summary
A deficiency occurred when a resident's Minimum Data Set (MDS) discharge assessment was inaccurately coded and submitted. The resident, who was admitted with diagnoses including weakness and a need for personal assistance, was documented on the MDS as having been discharged to a short-term general hospital. However, review of the resident's medical record revealed no documentation of a hospital transfer, and it was later confirmed by the MDS Coordinator that the resident had actually been discharged to home, not to a hospital. The MDS Coordinator acknowledged during an interview that she had incorrectly coded the discharge status and that the error was present at the time of submission. The Nursing Home Administrator confirmed the inaccuracy of the submitted MDS and stated that the MDS Registered Nurse was ultimately responsible for ensuring the accuracy of the data submitted. The MDS Registered Nurse admitted to only performing spot checks rather than a full review of the assessment before submission, resulting in the inaccurate discharge information being reported.
Plan Of Correction
1. The MDS Nurse appropriately modified and resubmitted the MDS assessment with corrected discharge destination. 2. All residents have the potential to be affected. 3. Bronson Commons MDS RN will double check discharge destination on all assessments prior to signing and submitting to provide a second check of MDS LPN assessments. Policies were reviewed and no necessary updates were identified. 4. The Director of Nursing will complete five weekly audits of discharge location on MDS assessments to ensure accuracy for the next 12 weeks. 5. The Executive Director is responsible for compliance.
Failure to Follow Blood Pressure Parameters for Antihypertensive Medication Administration
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of nursing practice for medication administration for one resident. The resident, who was prescribed Apresoline for hypertension with specific physician orders to hold the medication if systolic blood pressure (SBP) was less than 130, reported that a registered nurse did not listen to her concerns about low blood pressure and administered the medication despite her warning. Documentation review showed that the resident's blood pressure was 112/56 earlier that day, and there was no record of a blood pressure reading prior to the evening dose when the medication was given. The medication administration record indicated the medication was given in the evening, and there was no documentation of a blood pressure reading or assessment for dizziness at that time. Interviews with staff confirmed that the resident was knowledgeable about her medications and often reminded nurses when her blood pressure was too low for antihypertensive administration. Staff also reported that the medication was frequently held due to low SBP, and dizziness was a known side effect for this resident when her blood pressure was low. The Director of Nursing stated that nurses were expected to verify and document blood pressure readings in accordance with physician orders before administering such medications, but this was not done in this instance. The failure to obtain and document the required assessment prior to medication administration led to the deficiency.
Plan Of Correction
The nurse of the affected resident was provided one-to-one education about the parameters. Nurses will continue to be educated on expectations related to parameters and medication administration. All residents have potential to be affected. Education will be provided to all nurses regarding medication administration expectations for orders with specified parameters. Medication administration expectations related to parameters will be included in new hire orientation. Medication administration policies were reviewed and no necessary updates were identified. The Clinical Oversight Committee will complete five weekly audits of medications with ordered parameters to ensure compliance for the next 12 weeks. The Executive Director is responsible for compliance.
Failure to Provide Meaningful and Individualized Activities
Penalty
Summary
The facility failed to provide meaningful activities tailored to the interests and needs of a resident with a diagnosis of depression, as required by their care plan and comprehensive assessment. The resident, who was cognitively intact and expressed a strong preference for choosing her own bedtime, being around pets, and participating in favorite activities, reported that the facility did not support her involvement in activities of interest. Observations showed the resident often remained in her room, and interviews revealed she felt the activities program did not meet her needs, particularly due to the lack of evening activities, pet therapy, and opportunities to serve others or participate in community outings. Review of activity calendars and participation records confirmed that group activities were only offered during daytime hours, with no evening activities, pet therapy, or community outings available. The activity program did not include activities that allowed residents to serve others or gain a sense of purpose, and the last such activity was a one-time event several months prior. The resident described the available group activities as unfulfilling and childish, and expressed feelings of boredom, lack of purpose, and disconnection from the community. Interviews with facility leadership revealed that resident activity needs were assessed primarily through MDS assessments, and there had been no recent assessment of the need for evening activities. The facility had not provided community outings in years and relied on family or friends for residents' participation in community-based leisure. The activity director was unaware of the need for evening activities and did not routinely review activity assessments, resulting in a lack of individualized programming to meet the diverse needs and preferences of residents.
Plan Of Correction
1. Activities staff visited with the resident to update the resident's needs and preferences, and encouraged the resident to express wishes for activities. The resident provided ideas and suggestions that will be implemented. 2. All residents who would like help to plan or participate in activities have the potential to be impacted. 3. The facility reviewed the Patient Activities Assessment policy, assessment tools, and documentation tools, and determined they are appropriate to capture individual resident preferences and participation. The facility reviewed the policy Patient Activities Program and added a quality assurance process to ensure the program meets the needs of the resident population. Beginning July 2025, the activities calendar will include evening activities and opportunities to serve others. Seasonal outings will begin in August. The activities department will audit resident participation monthly to ensure group activities are well attended. At least monthly, the activities department will ask residents to evaluate a group activity for opportunities to improve or replace it. Education will be provided to all employees about the right to participate in activities that meet the interests and needs of each resident and how the facility supports these activity pursuits through group and individual programs. The resident council will also receive this education in the July meeting. 4. The activities department will interview five residents monthly to ensure each individual resident is offered activities that are meaningful to them personally, for at least the next 12 weeks. 5. The Executive Director is responsible for compliance.
Failure to Provide Accessible Water at Bedside
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease and renal insufficiency, who was severely cognitively impaired, did not have water available at the bedside as required. Multiple observations over two days showed that the resident's water cup was consistently placed on the sink counter, approximately eight feet away from the bed, and not within the resident's reach. The resident was observed lying in bed with dry lips and reported feeling thirsty. No other beverages were present in the room during these observations. Interviews with staff confirmed that the expectation was for water to be kept within reach of residents and replenished at least every shift. Staff also acknowledged that the resident had difficulty holding the standard maroon cup and should have been provided with a more suitable cup. The facility's policy required fresh water to be available to residents at all times, but this was not followed for the resident in question, as evidenced by the repeated lack of accessible water and low recorded fluid intake.
Plan Of Correction
Corrective action took place immediately upon identification of the issue by moving the water within the resident's reach. All residents have the potential to be affected. Education to all staff related to ensuring water is within patient reach at all times in the resident's room. Policies were updated to reflect that water must be within the resident's reach in their room: Water Pass policy, TEMP Purposeful Rounding policy. Five weekly audits of water location within resident's reach in their room will be completed for the next 12 weeks. The Executive Director is responsible for compliance.
Failure to Maintain Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
A deficiency was identified when staff failed to maintain enhanced barrier precautions (EBP) during the administration of tube feeding for a resident with a percutaneous gastrostomy tube. The resident, who had a history of stroke and was admitted with a feeding tube, was under EBP as indicated by signage outside her room and documented in her care plan. Despite these precautions, an LPN administered a bolus feeding without wearing a gown, contrary to facility policy and posted instructions. The LPN stated that EBP was only necessary for CNAs and not for nurses, as she believed she did not come into direct contact with the feeding tube. Further interviews revealed inconsistent understanding and application of EBP among staff. One RN reported that EBP was not used during tube feeding administration, while another LPN stated that both gown and gloves were required for such procedures. A CNA indicated that EBP did not apply to her as she did not administer tube feedings. The facility's policy specified that EBP, including gown and gloves, should be used during high-contact care involving indwelling medical devices such as feeding tubes. The failure to follow these precautions during tube feeding administration resulted in a deficiency related to infection prevention and control.
Plan Of Correction
1. The Infection Prevention Nurse provided one-to-one education on enhanced barrier precautions (EBP) with the resident's nurse. 2. All residents have the potential to be affected if they meet criteria for EBP. 3. Education will be provided to clinical employees related to EBP standard work. The following policies were updated to include verbiage related to using the appropriate personal protective equipment (PPE) as ordered, including EBP: Enteral Feeding, Indwelling Catheter, Peripherally Inserted Central Catheter Change, Irrigating Foley Catheter, Peripheral Intravenous Therapy Procedure, Male Straight Catheter, Female Straight Catheter, Care-Cleaning Urinary Drainage Bags, Pressure Injuries and Wound Care, Wound Culture. 4. Five weekly audits will be completed by the Infection Prevention Nurse or designee to ensure compliance with using EBP when appropriate, for the next 12 weeks. 5. The Executive Director is responsible for compliance.
Survey Results and Plan of Correction Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure that the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents. During a confidential group meeting, all six residents present reported that they were unaware they could read the survey reports and did not know who to ask or where to find them. An observation revealed that the binder containing survey reports was placed on a shelf approximately 4-5 feet up on the wall in a sitting area next to the main lobby, making it difficult for residents to access. Interviews with staff further confirmed the deficiency. An LPN stated she did not know where the survey reports were located or how residents could access them. The Nursing Home Administrator acknowledged that the reports were kept in an area not frequently visited by residents and were not easily accessible. Additionally, an Activity Associate who conducts monthly resident council meetings was not aware of how residents could obtain access to the survey reports. These findings demonstrate that the facility did not make survey results and plans of correction readily accessible to residents as required.
Plan Of Correction
The facility moved the binders containing survey results to a prominent location in the lobby on a table that residents, family members, and legal representatives can reach either standing or sitting in a wheelchair. The public binders include survey results for the current year and the previous 3 years along with plans of correction. The facility also placed a prominent notice at the table stating that survey and advocacy information is available here. All residents who want this information have the potential to be affected. The facility created the policy: Facility Required Postings. The facility created the flier "Where to Find Survey Reports" and will distribute it to all patients and residents. The flier will also be added to the facility admission packet. Education will be provided to all employees about where survey information can be found. The resident council will also be given this information at the July meeting. During daily routine leadership rounds, each leader will interview at least one resident for awareness where to locate survey results, for at least the next 12 weeks. The executive director is responsible for compliance.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide a written notice of transfer for a resident reviewed for hospitalizations, resulting in the potential for residents and/or their representatives to be uninformed of the reason for transfer and their rights. Resident #65, who had a moderately impaired cognition with a BIMS score of 12, was admitted on 1/17/2024 and had several discharges to the emergency room and a hospital admission. During an interview, the resident could not recall receiving a written transfer notice each time she went to the hospital. A review of the resident's chart revealed no evidence of written transfer notices being provided, which should have included specific information such as the reason for transfer, effective date, location, appeal rights, and contact information for relevant advocacy agencies. During interviews with facility staff, it was discovered that the paperwork sent with residents when they leave the facility did not include a transfer/discharge notice. A registered nurse was unaware of what the transfer/discharge notice was, and the Executive Director confirmed that they had not been sending out such notices with residents. This oversight indicates a failure to comply with regulatory requirements for notifying residents and their representatives about transfers or discharges, including their rights to appeal.
Improper Storage of CPAP Masks
Penalty
Summary
The facility failed to provide oxygen services per professional standards of practice by improperly storing CPAP masks for three residents, leading to potential respiratory infection risks. Resident #8, diagnosed with obstructive sleep apnea, was observed multiple times with his CPAP mask laying uncovered on top of the CPAP machine on his nightstand. Despite being cognitively intact and able to remove the mask himself, Resident #8 reported that staff assisted with storing the mask, which was not done according to infection control practices. Resident #13, with diagnoses including dysphagia and hypoxemia, also had her CPAP mask improperly stored. Observations revealed the mask laying uncovered on top of the CPAP machine or on a plastic bag inside the nightstand drawer. Although Resident #13 could remove the mask herself, she relied on staff for proper storage, which was not consistently done. She confirmed that staff had been in to take care of the mask, yet it was still found uncovered. Resident #59, diagnosed with Parkinson's disease and dementia, had similar issues with CPAP mask storage. His mask was found uncovered in the nightstand drawer or on top of the CPAP machine. Despite being able to remove the mask, Resident #59 required staff assistance to put it on. Interviews with staff, including an LPN, CNA, Unit Coordinator, Respiratory Therapist, and the DON, confirmed that CPAP masks should be stored in bags when not in use, which was not adhered to during the survey period.
Failure to Ensure Proper Communication and Agreement with Dialysis Provider
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis provider for a resident requiring dialysis services. Specifically, there was no pre and post dialysis treatment assessment and monitoring communication between the facility and the dialysis provider. Additionally, the facility did not have an established agreement with the dialysis provider. This deficiency was identified for a resident with renal failure who was dependent on dialysis three times a week. The resident's medical record lacked documented communications from the facility to the dialysis center before dialysis and from the dialysis center to the facility after dialysis treatments. Interviews with facility staff, including the Executive Director, Licensed Practical Nurse, Unit Coordinator, Unit Clerk, and Director of Nursing, revealed that there was no regular communication with the dialysis center unless there was an abnormality. The facility staff also confirmed that there was no contract or agreement with any dialysis provider, and the post dialysis treatment information uploaded to an electronic record program was not consistently reviewed by the facility staff. This lack of communication and formal agreement resulted in the potential for unrecognized adverse reactions and disruptions in the continuity of care for the resident receiving dialysis treatments.
Latest citations in Michigan
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, a history of elopement, and daily wandering exited the building in the early morning while wearing an electronic elopement-prevention device. When the front door and device alarms sounded, the DON shut off the main alarm without an immediate overhead headcount or clear communication about which door had alarmed, and staff, affected by frequent door alarms from smokers, were confused about whether it was an elopement. While staff searched inside and around the building, the resident walked a significant distance along a main road without a coat in freezing weather before being located by nursing staff. Three additional residents with severe cognitive impairment and wandering behaviors were found to be wearing electronic devices, but for some there were no physician orders, no documented device checks, missing inclusion on the elopement risk list, and care plans that did not include the devices as interventions, demonstrating inconsistent elopement risk identification and planning.
A resident with a known history of attempting to leave the facility exited through the front door in the early morning, triggering both the door alarm and an elopement prevention device. The DON shut off the main alarm, looked outside but did not immediately exit the front door or make an overhead announcement, leading to confusion among staff about which door had alarmed and whether anyone was missing. CNAs searched the grounds, and an LPN used a car to search nearby streets, eventually locating the resident walking with a walker near a gas station, cold and without a coat, in freezing temperatures along a main highway. An RN then assisted in persuading the resident to return, with the total time away exceeding 25 minutes. The incident, which posed a risk to the resident’s health and safety, was not reported to the State Agency as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident at risk for elopement exited the facility through a front door in the early morning, triggering both the door alarm and an elopement device alarm. The DON shut off the main alarm and looked outside but did not immediately exit the front door, while CNAs and an LPN searched the building and surrounding areas. The resident, wearing everyday clothes and no coat in freezing weather, was eventually located by an LPN walking with a walker near a gas station on a busy road, and a second nurse assisted in persuading the resident to return. The facility’s investigation failed to preserve or document key information from available video footage, did not record specific times, route, distance traveled, or weather conditions, and included incomplete and delayed risk management documentation with limited witness statements, contrary to facility policy requiring prompt incident reporting and medical record entries after an elopement event.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with stroke-related hemiparesis, abnormal gait, dementia, CKD, and hypertension, care planned as at risk for falls, experienced an unwitnessed fall while attempting to use the bathroom, having taken an IV pole instead of a walker and tripping over IV tubing. A CNA found the resident on the bathroom floor, sitting upright and holding assist bars, and, seeing no obvious injury, helped the resident back to bed before notifying an LPN. The LPN’s documentation and post-fall evaluation reflected assessment only after the resident was already in bed, with no injuries identified. Facility leadership and written fall management guidelines state that after a fall, the nurse must be notified immediately and must evaluate the resident for possible head, neck, spine, and extremity injuries prior to moving them, which did not occur in this case.
A resident with hemiplegia, dementia, and moderate cognitive impairment had a documented ADL self-care deficit and a care plan specifying assisted evening showers on Mondays, Wednesdays, and Fridays per his and his family’s request. Facility records, including the Kardex and nursing notes, reflected this schedule, but shower documentation for one month showed three missed, undocumented showers out of 13 scheduled. A family member reported that showers were not always completed as scheduled, and the DON confirmed the three-times-weekly schedule but could not provide documentation that showers were offered or completed on the missing dates, contrary to the facility’s ADL policy requiring provision and documentation of hygiene care.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with dementia, heart disease, and multiple pressure and skin wounds had a complex care plan with numerous updates for conditions such as cognitive fluctuation, UTI, anemia, hypothyroidism, constipation risk, and nutritional risk, but the POA reported never receiving a copy of the care plan. Care conference documentation left the “Plan of Care” section blank, and although the SW stated it was standard to offer and provide the plan, there was no evidence this occurred. The resident’s representatives and POA repeatedly reported poor communication, including not being informed when PT and OT services ended and not receiving timely responses to messages and emails about care concerns. Wound orders and conditions changed over time, including new wounds and merging buttock wounds, yet the record did not show that the POA was notified of these significant changes, contrary to facility policy requiring notification of the resident and representative for major changes in condition and treatment.
Two residents did not receive appropriate treatment and care according to orders and needs. A resident with DM, peripheral vascular disease, prior toe amputation, and osteomyelitis had an in-house–acquired right second toe ulcer that was documented and treated, but dark eschar on the right third toe seen in a wound photo and described by a PA as eschar on the second and third toes was not added to the wound tracking spreadsheet or clearly documented as a separate wound before the resident was later hospitalized and underwent amputation of the second and third toes. Nursing notes and NP documentation focused on the second toe only, and staff interviews showed uncertainty about whether the entire foot was consistently assessed during dressing changes. Another resident with dementia and severe cognitive impairment had increasing difficulty hearing; the guardian reported requesting that the resident’s hearing be checked due to suspected earwax buildup, but no assessment or intervention was documented.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Prevent Elopement and Inadequate Elopement/Wandering Safeguards
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement and to ensure adequate elopement and unsafe wandering safeguards for multiple residents identified as at risk. One resident with severe cognitive impairment, a history of elopement, and documented daily wandering exited the building in the early morning hours while wearing an electronic elopement-prevention device. The front door alarm and the device alarm sounded, but the DON shut off the main alarm and did not immediately initiate an overhead headcount or clearly communicate which door had alarmed. Staff described confusion about whether the alarm was due to smokers using the door or an elopement, and some staff reported they could not hear the device alarm from certain halls. While staff searched rooms and areas inside the building and around the exterior, the resident walked away from the facility in freezing temperatures without a coat. Interviews and record review showed that the resident who eloped had multiple psychiatric and cognitive diagnoses, a BIMS score indicating severely impaired cognition, and an MDS indicating daily wandering. The resident’s care plan identified her as an elopement risk with exit-seeking behavior, a history of elopement, and triggers such as frustration, desire to leave, and difficulty with change. On the same night as the elopement, documentation showed the resident was aggressive, frustrated, and disoriented after a room change, which matched her identified triggers. Despite these known risks and triggers, when the alarm sounded early that morning, staff did not immediately verify at the front door whether the resident had exited, did not keep the elopement alarm active until she was found, and relied on delayed, word-of-mouth communication to begin a headcount and search. Staff ultimately located the resident approximately a half mile away on a main road, walking with a walker and no coat, and reported that she was cold and initially refused to return. The deficiency also includes failures in elopement risk identification and care planning for three additional residents who wore electronic elopement-prevention devices. One resident with severely impaired cognition and documented wandering behavior was observed wearing a device, which triggered an alarm when she attempted to go through a service hallway door toward an outside exit. However, there was no physician order for the device, no order to check its function, and her care plan for wandering did not include the use of the device. Another resident with severely impaired cognition and daily wandering had a physician order to check the device’s function and was listed on the facility’s elopement risk list, but her care plan did not include the device as an intervention. A third resident with severely impaired cognition and daily intrusive wandering also wore a device and had an order to check its function, yet her care plan did not include the device, and she was not listed on the elopement risk list. The staff member responsible for tracking elopement risk residents presented a handwritten list that was supposed to include all residents with devices, but at least two residents wearing devices were not on that list, demonstrating inconsistent identification and care planning for elopement risk. Facility policy on Unsafe Wandering and Elopement Prevention stated that every effort would be made to prevent unsafe wandering and elopement while maintaining the least restrictive environment, and that nursing personnel must report and investigate all reports of missing residents. Staff interviews revealed frequent door and alarm use by smokers, contributing to what staff described as “alarm fatigue” and confusion when alarms sounded. In the elopement incident, staff reported that the elopement protocol required leaving the device alarm on and calling an overhead headcount, but this did not occur as required. The combination of alarm fatigue, failure to follow elopement procedures, incomplete or missing physician orders and care plan interventions for residents wearing devices, and inconsistent maintenance of the elopement risk list led to the cited deficiency for failure to ensure the environment was free from accident hazards and that adequate supervision and elopement prevention measures were in place.
Failure to Report Resident Elopement in Freezing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to report an elopement incident to the State Agency (SA) as required by its abuse, neglect, and exploitation policy. A resident identified as R10, who was known by staff to have previously attempted to leave the facility and was considered an elopement risk, exited the building through the front door in the early morning hours. When R10 left, both the front door alarm and the elopement prevention device alarm were activated. The DON was in the building, went to the front door, shut off the main alarm, and realized the elopement prevention device was sounding. The DON looked outside but did not exit through the front door, and there was no immediate overhead announcement identifying which door had alarmed or whether a resident was missing, which created confusion among staff. Following the alarm, CNAs went outside to look in the parking lot and surrounding areas around the building, and another CNA spoke with the DON at the door. A head count was then called, and an LPN determined that R10 could not be found in the building. The LPN got into her car and drove to the main street to search for the resident. During this time, the service drive was described as snowed in with no footprints in the snow, and staff did not initially know which door had alarmed. The LPN eventually located R10 walking near a gas station but reported that the resident refused to get into the car, prompting an RN to drive to the location to assist. The RN later stated that it took about 20 minutes to find R10 and additional time to pick her up and convince her to get into the car. The facility’s investigation confirmed that R10 left the building at approximately 5:15 AM and was gone for over 25 minutes, walking with a walker outdoors. Historical weather data reviewed by the surveyor showed temperatures between 22 and 29 degrees Fahrenheit on the day of the incident, and the resident was described as cold and freezing, without a coat, while walking on a sidewalk next to the main highway. The surveyor determined that this situation represented a risk to the resident’s health and safety, and it was further found that the elopement incident was not reported to the SA, despite the facility’s policy requiring reporting of such events within specified timeframes.
Failure to Thoroughly and Timely Investigate Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete, thorough, and timely investigation of an elopement involving one resident. A complaint to the State Agency alleged that the resident left the facility in the early morning hours in freezing temperatures, walking several blocks on a highway with a walker and without a jacket, and that staff discovered the resident missing only after some time had passed. The complaint further alleged that the DON shut off the main door alarm that alerts staff when residents wearing an elopement prevention device leave the facility, did not immediately initiate a headcount, and returned to other tasks, while another nurse later determined that an elopement‑risk resident was not in the building and initiated a search. The resident was reportedly found 15–20 minutes later about a half mile away on a busy road and returned to the facility uninjured. The facility’s written investigation, presented nearly four weeks after the event, described that the resident exited the front door, triggering both the door alarm and the elopement device alarm. The DON responded to the alarm, shut off the main alarm, and looked outside but did not go out the front door, while CNAs searched the parking lot and surrounding areas and another CNA spoke with the DON. A headcount was called, and an LPN reported she could not find the resident, then drove her car to the main street, located the resident walking near a gas station, and reported that the resident initially refused to get into the car. A second nurse drove to the location, and together they persuaded the resident to return. The facility’s own summary of concerns noted that the resident was able to leave the building, that the DON did not go out the front door, that other staff exited through the back door, and that no one went immediately out the front door, and also noted that the resident had been triggered earlier and had previously attempted to leave the facility. The investigation was incomplete and inaccurate in multiple respects. The facility had camera footage of the exit door used by the resident, but the NHA reported that the footage was not saved because they did not know how to preserve it, and it was taped over. The Maintenance Director stated he viewed the video and could see the resident exit in everyday clothes and later re‑enter, but he did not record the times, and those times were not included in the investigation. The investigation did not document the time the resident exited, who went out the door, when the resident was found, or when she re‑entered the building. It did not address the route taken, did not measure the distance traveled, and did not document the weather conditions, even though historical data showed temperatures between 22–29°F and there was snow that might have shown the resident’s path. The risk management report, authored by the DON, contained an internal inconsistency in timing (stated as written before the alarm response time), included written witness statements from only a limited number of involved staff, omitted the second nurse who assisted in returning the resident, and the DON’s witness statement was linked to a late entry progress note written over two weeks after the event. A regional RN stated she would have expected the risk management report and documentation to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later, and the facility’s own elopement policy required completion and filing of an incident report and appropriate medical record entries upon the resident’s return, which was not timely or thoroughly done in this case.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Perform Nurse Assessment Before Moving Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall management policy and professional standards of practice by not ensuring a licensed nurse completed a comprehensive post-fall assessment before the resident was moved. The resident involved was a male with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia with moderate cognitive impairment (BIMS score of 9/15), chronic kidney disease, and hypertension with periods of hypotension. His care plan identified him as at risk for falls due to these conditions and potential medication side effects. On the date of the incident, an unwitnessed fall occurred in the resident’s room at approximately 1:15 AM. Documentation in the Incident/Accident Report and Post Fall Evaluation indicated the resident reported he had attempted to use the bathroom, took his IV pole instead of his walker, and tripped over the IV tubing. The report stated that upon the nurse’s entry to the room, the resident was sitting on the bed, his skin was assessed, vital signs were within normal limits, range of motion was performed, and neurological checks were initiated, with no injuries identified. The nursing progress note reflected similar information, indicating the fall was reported to the nurse by a CNA and that the assessment was conducted with the resident already in bed. However, interview statements revealed that the resident had actually been on the bathroom floor immediately after the fall. The CNA who responded to the bathroom call light reported finding the resident sitting upright on the floor with his hands on the assist bars and the IV pole in front of the sink. Believing he had no visible injuries, the CNA assisted him up from the floor and back to bed before notifying the nurse. The CNA stated she normally would not move a resident before the nurse’s assessment. The DON and ADON both reported that facility practice and the written Fall Management Guidelines require that when a resident falls or is found on the floor, the nurse must be notified immediately and the resident must be evaluated for possible injuries to the head, neck, spine, and extremities prior to moving the resident. This did not occur for this resident, resulting in the lack of a comprehensive assessment for injury by a licensed nurse while the resident was still on the floor post-fall.
Failure to Provide Scheduled Showers per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide bathing care according to a resident’s stated preferences and plan of care. A male resident with right-sided hemiplegia/hemiparesis following a stroke, abnormal gait/mobility, depression, dementia, and moderate cognitive impairment (BIMS score of 9/15) had a documented self-care ADL deficit related to CVA, cognitive impairment, and history of failure to thrive. His care plan, revised on 3/18/26, and the Kardex both specified that he preferred showers on the evening shift, scheduled on Mondays, Wednesdays, and Fridays, and that staff were to assist him to bathe/shower as preferred per the shower schedule and as needed. A nursing progress note dated 3/18/26 documented that his shower dates were updated per resident request to Monday, Wednesday, and Friday evenings. Review of shower/bath documentation for the month of April showed that, out of 13 scheduled showers, there was no documentation of showers being provided on three scheduled days: 4/3/26, 4/20/26, and 4/27/26. A family member reported that the resident was supposed to receive showers on Mondays, Wednesdays, and Fridays, but these were not always completed as scheduled. The DON confirmed that the resident’s shower schedule had been changed to three times per week on those days per family request and was unable to provide documentation of showers offered or completed on the three missing dates prior to survey exit. This was inconsistent with the facility’s ADL policy, which required provision of appropriate hygiene care and documentation of the assistance needed in the care plan and Kardex.
Inaccurate and Incomplete Treatment Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, resulting in uncertainty about whether ordered care was provided and conflicting information between records and staff reports. For one resident with muscle weakness and type 2 diabetes, review of the Treatment Administration Record (TAR) showed repeated missing documentation for several ordered treatments, including daily compression stockings for edema, daily vital signs with SpO2 monitoring, use and replacement of a PureWick external catheter, application of Calmoseptine for MASD every shift, monitoring of an alternating pressure mattress every shift, application of lymphedema boots every shift with progress notes for refusals, and wound care to the right lateral thigh every shift. On multiple dates in April, there was no documentation indicating whether these treatments were completed or missed, and no reasons recorded for any missed care. The DON stated that nurses were supposed to document completion or missed treatments with reasons, and acknowledged there was no one ensuring that nurses completed all treatment documentation and that she was unaware of the multiple missing treatment records for this resident. For another resident admitted with repeated falls and difficulty walking, the TAR contained an order to encourage use of an incentive spirometer every four hours, with staff assistance, for respiratory health. On numerous entries, nursing staff documented the code “07-Other/See Progress Notes,” but there were no corresponding progress notes explaining what occurred with the treatment. The TAR also showed the treatment documented as administered at certain times, while interviews with the family member, NP, RN, and DON revealed conflicting accounts about whether the resident had an incentive spirometer available and whether it was being used. The family member reported believing staff were not using the spirometer and that it might have been lost. The NP reported the order was placed at the family’s request, that the resident was not capable of using the device, and that she had heard staff might have lost it, creating a conflict with TAR entries showing the treatment as given. An RN reported the facility did not have an incentive spirometer and did not think the resident ever had one, and could not explain why she had documented “07-Other/See Progress Notes” without any corresponding note. The DON confirmed the resident had been admitted with an incentive spirometer and that nurses were supposed to write a progress note when using the “07” code, but she could not explain why some nurses documented the treatment as administered while others used “07” without explanation, leaving her unable to confirm whether the treatment was actually offered. For a third resident with sarcoidosis and muscle weakness, who was cognitively intact per a recent MDS BIMS score, the TAR showed an order for Ipratropium-Albuterol (DuoNeb) inhalation solution three times daily for three days for asthma exacerbation. The TAR reflected the treatment as administered twice on the first day, three times on the second day, and once on the third day, with subsequent entries coded as “07-Other/See Progress Notes” by an LPN, but without any related progress notes in the record. Progress notes from the NP documented that nebulizer treatments had been ordered for wheezing and cough, but later entries stated that the resident reported she never received the nebulizer treatments and that these were never administered because staff could not locate a nebulizer. In interview, the resident reported having a severe cough and shortness of breath since early in the month and stated that although albuterol treatments were ordered, nursing staff never administered them despite her informing staff and the NP. The NP confirmed the resident’s report that she had not received the treatments and stated she had informed the DON. The LPN who documented “07-Other/See Progress Notes” reported she did so because the facility did not have a nebulizer and she had to call to get one ordered, and she could not explain why other nurses had documented the treatments as administered when there was no nebulizer available. The DON acknowledged there was a delay in obtaining a nebulizer, which delayed the resident’s ordered treatments, and could not explain why staff documented administration of treatments that could not have been given. The facility’s own documentation policy stated that documentation should be factual, objective, accurate, relevant, complete, and that false information would not be documented, which conflicted with the observed charting practices.
Failure to Provide Care Plan Copies and Notify Representative of Significant Care Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident and the resident’s representatives were provided with a copy of the person‑centered care plan and updates, and were adequately informed of significant changes in care and services. The resident, admitted on 03/27/26 with diagnoses including dementia, heart disease, and a sacral pressure ulcer, had severe cognitive impairment and was dependent on staff for most ADLs per the 04/02/26 MDS. The active care plan initiated at admission included multiple problem areas such as impaired vision and hearing, fall risk, chronic pain, self‑care deficit, indwelling urinary catheter, pressure ulcer, repositioning needs, and nutritional risk. Subsequent care plan additions documented multiple new or evolving conditions, including cognitive fluctuation, risk for behavior and mood changes, risk for dehydration, anemia, hypothyroidism, constipation risk, and an actual urinary tract infection, as well as nutrition‑related monitoring and RD involvement. Despite these care plan elements and changes, the resident’s POA reported not having received a copy of the care plan and recalled only an orientation meeting without receiving the plan at that time. Care conference notes dated 03/30/26 and 03/31/26 showed that section seven, titled “Plan of Care,” was left blank, indicating that documentation of offering or providing the care plan was not completed. The social worker stated that the POA and representatives attended the initial care conference and that the standard practice would be to offer and provide a copy of the plan of care and orders, but there was no evidence this occurred. The social worker also confirmed that any listed representative in the EMR could receive information, yet reported no prior contact with the resident’s representatives other than the POA. In addition, there were multiple documented concerns from the resident’s representatives and POA about lack of information and communication regarding the resident’s care, including therapy services and wound care. Representatives reported being told that PT and OT had stopped without explanation, and the Director of Rehab Services confirmed that the therapy end date was 04/27/26 and that no notification of the end of services had been given to the POA. The POA and representatives described leaving messages for the DON and emailing the social worker, administrator, and medical director about care concerns without timely responses. Progress notes and wound documentation showed changes in wound status, including order changes for heel wounds, a new right lower extremity wound, a skin tear on the left foot, and a note that three buttock wounds had merged into one, but there was no indication in the record that the POA was contacted about these changes in the care plan and wounds, despite facility policy requiring notification of the resident and representative for significant changes in condition and treatment.
Failure to Identify and Treat New Foot Wound and Address Reported Hearing Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify and appropriately treat a new wound on a resident’s right third toe and to address earwax buildup for another resident, despite reported concerns. One resident with diabetes mellitus, diabetic polyneuropathy, peripheral vascular disease, prior right great toe amputation, and a new diagnosis of acute osteomyelitis of the right ankle and foot was cognitively intact and able to make needs known. He reported that after his right great toe amputation, he developed a pressure ulcer on the top of the second toe and another on the third toe that tunneled through, and he stated staff never identified and did not treat the third toe wound appropriately. Review of his medical record and nursing progress notes showed documentation and ongoing treatment of a right second toe wound but no documentation of a third toe wound prior to the later amputation of additional toes. Wound care documentation and related tools showed that a new in-house–acquired wound on the right second toe was identified and tracked over several weeks, with measurements and treatments recorded on a spreadsheet used by the wound care nurse to communicate with the NP. However, a wound care note and photograph dated 03/09/2026 showed black/brown eschar on the tips of the right third and fourth toes, while the spreadsheet for that date did not list any new wound on the third toe. The wound care nurse stated she performed weekly skin assessments on Mondays and reported that there was nothing noted on the third toe on 03/09/2026, and she indicated she did not see concerns with the third and fourth toes in the photograph, attributing the dark areas to lighting until the surveyor zoomed in on the image. The NP reported that she did not make rounds with the wound care nurse and relied on the spreadsheet to write orders; her visit notes and wound care documentation referenced only the second toe ulcer and described it as stable, with no mention of a third toe wound. Additional record review revealed that a physician assistant note dated 03/11/2026 documented eschar present on the second and third toes of the right foot, with the third distal toe eschar described as irritated, and global swelling of the foot noted. Nursing progress notes showed frequent wound care entries referencing only the right second toe, including on the day before the resident went on a leave of absence, and a note on 03/15/2026 by the wound care nurse stating that upon the resident’s return there was a new open area on the right third toe and that the resident requested transfer to the hospital for wound evaluation. Hospital records from that admission described an infected ulcer on the right third toe with subcutaneous gas, recurrent diabetic foot ulcer, and chronic ulcer on the second toe, and the resident subsequently underwent amputation of the second and third toes. Interviews with nursing staff showed poor recall of the third toe wound, with one RN stating she usually assessed the entire foot during dressing changes but did not think she did so in this instance, and the wound care nurse and DON were unable to identify when the third toe wound was first recognized in facility documentation. The deficiency also includes failure to address reported earwax buildup for another resident with traumatic subdural hemorrhage and dementia, who had severe cognitive impairment on MDS assessment but only minimal hearing difficulty and did not use hearing aids. The resident’s guardian reported by telephone that the resident seemed to have increased difficulty hearing and that they had asked for the resident’s hearing to be checked, but nothing was done. There was no documentation in the report of assessment or treatment of earwax buildup or follow-up on the guardian’s request, indicating that the facility did not provide appropriate care in response to concerns about the resident’s hearing and possible cerumen impaction.
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