Bronson Commons

Inspectors wroteThis citation pertains to intakes: #2790330, #2794131, #2798407Based on observation, interview and record review the facility failed to 1.) accurately assess and prevent an elopement of 1 (Resident #100) of 3 residents reviewed for elopement risk, resulting in an immediate jeopardy when Resident #100 left the premises on 2/14/26 at 5:04 AM, alone, unbeknownst to staff and was later located by staff at 5:55 AM approximately 100 yards from the facility; 2). Ensure safety during a mechanical lift transfer to 1(Resident #104) of 2 residents reviewed for safe transfers resulting in a fall with a head laceration.

Inspectors wroteBased on interview and record review the facility failed to ensure a Registered Nurse (RN) served full time in the role of Director of Nursing potentially affecting all 89 residents that reside in the facility.

Inspectors wroteThis citation pertains to Intake MI00151630 Based on observation, interview, and record review, the facility failed to ensure appropriate transfer techniques were implemented for 2 (Resident #172 and #65) of 4 residents reviewed for falls resulting in a fall with a hand laceration and a fracture for Resident #172 and an improper transfer with a slide board resulting in bruising on the bilateral (both) upper arms for Resident #65.

Inspectors wroteBased on interview and record review the facility failed to inform residents and/or educate residents and effectively implement the grievance process for six of six residents from a confidential group meeting and all 85 residents that reside in the facility, resulting in the potential for residents to not meet their highest practicable level of wellbeing due to grievances not being documented, tracked, and the results of conclusions and/or resolutions not being recorded.

Inspectors wroteResident #13 Review of an admission Record revealed Resident #13 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: cancer, heart failure (chronic condition in which the heart does not pump blood as well as it should), anxiety and depression (persistent depressed mood or loss of interest in activities causing significant impairment in daily life). Review of a Minimum Data Set (MDS) assessment for Resident #13 with a reference date of 4/26/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #13 was cognitively intact. Section N of the MDS revealed Resident #13 received antianxiety, antidepressant, a diuretic (drug that causes the kidneys to make more urine) and opioid (class of drug used to reduce moderate to severe pain) medications. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure activities of daily living (ADL) cares and assistance were provided per resident preference for 1 (Residents #17) of 2 residents reviewed for resident preferences, resulting in dissatisfaction with care and the potential for decline in sense of physical, mental, and psychosocial well-being.

Inspectors wroteResident #17 Review of Resident #17's Physician Orders revealed, Lorazepam (Ativan) tablet 0.5 mg .Frequency: Daily as needed for anxiety .Duration: 30 days Start Date/Time (after last modification): 5/19/25 .End Date/Time: 6/18/25 . The most recent dose was given on 6/6/25 at 7:36 AM. An attempt to interview Medical Director (MD) III on 06/12/25 at 12:18 PM was made, with no return phone call prior to survey exit. This surveyor requested physician rationale for Resident #17's order for PRN (as needed) Lorazepam written for greater than 14 days at a time. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately assess 1 (Resident #70) of 1 resident reviewed for minimum data set (MDS) discharge encoding resulting in inaccurate discharge location data being submitted.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 1 residents (Resident #3) of 18 reviewed for the provision of nursing services, resulting in medication not administered following physician ordered parameters, the lack of assessment, and the potential for medication adverse effects and complications

Inspectors wroteBased on observation, interview, and record review the facility failed to provide meaningful activities to promote psychosocial well-being for 1 (Resident #42) of 1 resident reviewed for activities. This deficient practice resulted in decreased feelings of connectedness to the community, a lack of meaningful leisure involvement and increased boredom.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of five residents (Resident #26) had water available at the bedside, resulting in the potential for dehydration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that enhanced barrier precautions (EBP) were maintained during tube feeding administration for 1 (Resident #21) of 1 resident reviewed for tube feeding administration resulting in the potential for introduction of infection, cross-contamination, and disease transmission.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents in the facility, with a census of 85 residents, resulting in the residents not being informed of identified deficiencies and solutions as written in the plan of correction.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer for 1 of 3 residents (Resident #65) reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and their rights.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oxygen services per the professional standards of practice when storing CPAP (continuous positive airway pressure) masks in 3 (Resident #8, Resident #13, Resident #59) of 3 residents reviewed for infection control practices when storing CPAP masks resulting in the potential for the development of a respiratory infection.

Inspectors wroteBased on interview and record review the facility failed to ensure that (1) pre and post dialysis treatment assessment and monitoring communication between themselves (the facility) and the dialysis provider (Name Omitted) was maintained and (2) that an agreement between themselves (the facility) and the dialysis provider (Name Omitted) was established and maintained in 1 (Resident #54) of 1 resident reviewed for dialysis services resulting in the potential for unrecognized adverse reactions, and/or resident decline related to dialysis treatments and the potential for a disruption in the continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure cleanliness of food and non-food contact surfaces; 2. Securely store food product after opened; 3. Properly label/date opened food products; and 4. Discard expired food items. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all residents who consume food/supplement from the kitchen and all residents who consume food from the pantry refrigerators/freezers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was clinically approriate for self-administration of medications in 1of 17 residents (R40) reviewed for medication administration, resulting in the potential for missed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement comprehensive person-centered care plans for 2 of 17 residents (R8 and R45) reviewed for care plans, resulting in the potential for additional falls for Resident #8 and unmet psychosocial care needs for Resident #45.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify Post Traumatic Stress Disorder (PTSD) triggers and implement interventions to mitigate these triggers for 1 of 24 Residents (Resident #45) reviewed for trauma informed care, resulting in the potential risk for re-traumatization and unmet care needs.

Inspectors wroteThis citation pertains to intake MI00128560. Based on observation, interview, and record review, the facility failed to take appropriate measures to prevent the possible spread of COVID-19 by failing to: 1.) ensure that accurate isolation precaution signage was posted outside the room of a resident diagnosed with COVID-19 and 2.) ensure staff donned appropriate PPE (personal protective equipment) prior to entering a COVID-19 isolation room for 1 (Resident #65) of 1 resident reviewed for transmission based infection control practices, resulting in the potential for spread of infection to a vulnerable population.