The Orchards at Big Rapids
For profit - Corporation
100 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
13/100
#245 of 422 in MI
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Orchards at Big Rapids has received a Trust Grade of F, indicating significant concerns and a poor overall reputation among nursing homes. It ranks #245 out of 422 facilities in Michigan, placing it in the bottom half for quality of care, and it is ranked #2 out of 2 in Mecosta County, meaning there is only one other local option that is better. While the facility shows a trend of improvement, dropping from 9 issues in 2024 to 4 in 2025, the high staffing turnover rate of 61% is concerning and above the state average of 44%. Staffing is rated at 4 out of 5 stars, indicating some strengths, but there are serious concerns with $71,552 in fines, which is higher than 80% of Michigan facilities. Specific incidents include a resident suffering third-degree burns due to inadequate safety measures and another resident developing an unstageable pressure ulcer due to improper care. Overall, while there are some positive aspects, families should be cautious given the critical issues identified.
- Trust Score
- F
- In Michigan
- #245/422
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $71,552 in fines. Higher than 54% of Michigan facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 52 minutes of Registered Nurse (RN) attention daily — more than average for Michigan. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 29 deficiencies on record. Higher than average. Multiple issues found across inspections.
13/100
Bottom 42%
Review needed
9 → 4 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 4 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Michigan average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 61%
15pts above Michigan avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $71,552
Well above median ($33,413)
Moderate penalties - review what triggered them
Staff turnover is elevated (61%)
13 points above Michigan average of 48%
The Ugly 29 deficiencies on record
1 life-threatening 4 actual harm
Mar 2025
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow standards of practice for medication administr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow standards of practice for medication administration for two of six residents (Resident #1 and Resident #17) reviewed for professional standards.
Findings:
Resident #1 (R1)
Review of a Face Sheet revealed R1 was a 69 tear old male, last admitted to the facility on [DATE], with pertinent diagnoses of seizure disorder, muscle weakness, cognitive communication deficit, glaucoma, and mild cognitive impairment.
During an observation on 03/11/25 at 9:09 AM, R1's morning medications sat on the bedside table in a plastic medication cup. R1 stated that he would take the medications in a bit.
During a review of R1's electronic health record (EHR) revealed that there was not an assessment completed for R1 to self administer medications.
During an interview on 03/11/25 at 12:17 PM, the Administrator indicated that none of the residents has been successfully assessed to self administer their medications.
Resident #17 (R17)
Review of a Face Sheet revealed R17 was a [AGE] year old male that admitted to the facility on [DATE].
During an observation on 03/11/25 at 9:46 AM, R17's morning medications sat on the over-bed table in a plastic medication cup. R17 stated that they usually leave my medications for me to take.
During a review of R17's EHR revealed that there was not an assessment completed for R17 to self administer medications.
During an interview on 03/12/25 at 1:51 PM, Registered Nurse (RN) I indicated that leaving medications bedside for a resident without an assessment for the resident to safely administer the medications, was not a standard of practice at this facility.
Review of the facility policy Self-Administration of Medication reflected .Each resident is offered the opportunity to self administer his or her medications during a routine assessment by the facility's interdisciplinary team . If the resident wishes to self administer medications, the interdisciplinary team must assess the resident's cognitive, physical, and visual ability to administer his or her own medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain sanitary oxygen supplies in 3 (R19, R29 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain sanitary oxygen supplies in 3 (R19, R29 and R115) of 4 residents reviewed for respiratory care from a total sample of 17 residents.
Findings:
Resident #19 (R19)
Review of a Resident Face Sheet reflected R19 admitted to the facility on [DATE].
Review of a Nursing progress note dated 2/19/25 reflected R19 was having low oxygen saturations of 79%-80% and oxygen at 2 liters per nasal cannula was applied by the nurse. On 2/20/25 R19 was diagnosed with bronchitis and prescribed an antibiotic.
Review of a General Administration History: 02/01/2025 - 02/28/2025 reflected Change Oxygen tubing, humidification, all oxygen supplies, date new supplies, every Sunday and as needed. Order As Needed Frequency Special Instructions Diagnosis 02/25/2025 - Open Ended Start/End Date 2/25/2025 - open ended.
During an observation on 3/12/25 at 7:58 AM, oxygen tubing was draped over the handle to the portable oxygen tank, a clean plastic bag was not present to secure the oxygen tubing.
During an observation on 3/12/25 at 12:51 PM, oxygen tubing draped over the handle to the portable oxygen tank, a clean plastic bag was not present to secure the oxygen tubing.
Resident #29 (R29)
Review of a Resident Face Sheet reflects R29 admitted to the facility with pertinent diagnoses that included chronic respiratory failure with hypoxia (low blood oxygen), sleep apnea and (severe) obesity with alveolar hypoventilation (a breathing disorder that affects some people with obesity).
Review of a Care Plan initiated 4/10/2024 indicated R29 has the potential for alteration in respiratory function related to chronic obstructive pulmonary disease (COPD), chronic respiratory failure (CRF) did not reflect any directions for staff care of oxygen supplies.
During an observation on 3/11/25 at 9:46 AM, R29's nasal cannula and oxygen tubing is draped over a fan on the resident over bed table, a clean plastic bag was not in the vicinity of the supplemental oxygen tubing.
During an observation on 03/12/25 at 2:35 PM, R29's oxygen tubing is draped over a fan on the resident over the bed table. Additional oxygen tubing, detached from any oxygen supply, was on a blue plastic storage bin in front of the resident dresser, not secured in a clean plastic bag.
Resident #115 (R115)
Review of a Resident Face Sheet reflected R115 admitted to the facility on [DATE] with pertinent diagnoses that included acute on chronic diastolic (congestive) heart failure, Sarcoidosis (a chronic inflammatory disease characterized by the formation of granulomas, which are small clusters of immune cells, in various organs of the body) and chronic obstructive pulmonary disease (COPD).
During an observation and interview on 3/11/25 at 9:23 AM, R115 reported she only wears the oxygen at night. R115's oxygen nasal canula which was connected to tubing attached to the oxygen concentrator is resting in the garbage can and does not appear dated.
During an observation on 3/12/25 at 12:47 PM, R115's oxygen nasal canula is resting on top of the oxygen concentrator next to the trash bin, a clean plastic bag is not observed near the oxygen tubing.
Review of a Treatment Administration History: 03/01/2025 - 03/12/2025 reflected Change oxygen tubing once a week on Sunday, and PRN (as needed) Order as Needed Frequency Special Instructions Diagnosis 03/11/2025 - open ended. The order does not indicate a requirement for any additional supplies or date marking requirement.
During an interview on 03/13/25 at 8:23 AM it was reported by Registered Nurse (RN) F the resident oxygen tubing should be held in a clean plastic bag which is changed weekly.
Review of a facility policy Respiratory Treatment Oxygen updated 5/19/21 reflected To provide supplementary oxygen to the respiratory system through oxygen therapy while maintaining appropriate infection control measures to reduce the risk of transmission of infectious agents. The policy specified 4. Date all equipment being used (oxygen tubing, nasal canula, mask, plastic storage bag and humidification bottle if indicated). 10. When oxygen is not in use store in dated plastic bag. 11. Change oxygen tubing, nasal canula, mask, humidification bottles and plastic storage bag every (7) days and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to 1.) involve the resident representative in the psychotropic medicat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to 1.) involve the resident representative in the psychotropic medication management process for 2 residents (Resident #3 and #45) and 2.) failed to monitor laboratory studies for 1 resident (Resident #33) out of 6 residents reviewed for psychotropic medication use.
Findings:
Resident #3 (R3)
Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: anoxic brain damage, anxiety, depression, major depressive disorder, and seizure disorder.
Review of R3's Psychiatric Consultation Note dated 4/21/25 revealed, .Anoxic brain damage .Plan: He can be impulsive at times. He is on 17.5mg Zyprexa daily, no GDR (Gradual Dose Reduction) have been done per wife's wishes .would recommend to continue to discuss with wife about GDRs .
Review of R3's Pharmacy Recommendation signed by the provider 2/28/25 revealed, (R3) is currently taking .olanzapine (Zyprexa) 15 mg .(R3) is due for a dose reduction evaluation at this time .Please evaluate if a dose reduction would be appropriate at this time. If a GDR is contraindicated, please consider writing a risk vs. benefit statement documenting the clinical rationale for no reduction . Agree was circled below indicating a GDR would be attempted and was signed by the provider.
During an interview on 03/12/25 at 01:07 PM, Resident Representative (RR) H reported that she received a phone call by a facility staff member and was told that the State of Michigan was forcing them to reduce his (psychotropic) medications. RR H reported that his behaviors were stable, and he was doing well and therefore felt the dose reduction of R3's Zyprexa would result in a decline in R3's psychosocial wellbeing. RR H reported that R3 was not over sedated and was appropriately interacting with other staff and residents. She was concerned that any changes in his medication regimen would result in increased behaviors and outbursts and wanted to keep the regimen as it was because he was psychologically stable and doing well. RR H also reported that R3's Zyprexa was not just for behavior but also for neurological issues. RR H stated, I told them his psych meds were not to be touched, and they said it's forced by the State, and it has to be done. RR H stated she felt forced into consenting to the medication change because the State regulations were threatened.
Review of R3's Progress Note dated 03/05/2025 at 05:22 PM revealed, Received recommendation from pharmacy to perform GDR on one of (R3's) psychoactive medications. We have attempted to discuss this change with (RR H), who declined changes. (Contracted psychiatric consultant) also saw resident and recommended changes. On 3/4/25, we were able to discuss with (RR H) the fact that as a resident here, and subject to the rules and regulations set by the State of Michigan, resident does require a GDR of antipsychotic. (RR H) acknowledged that this is what must happen, but states, you guys have fun with that. He was a bear last time they messed with his meds. He was angry and mean and then would just cry, just sob. Staff offered support and reassurance and explained that we will monitor resident closely and make changes as necessary. Order placed to decrease Zyprexa to 7.5 nightly.
Resident #45 (R45)
Review of an admission Record revealed R45 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with psychotic disturbances.
Review of R45's Order Summary dated 02/07/2025-03/05/2025 revealed, Depakote (divalproex) tablet, delayed release (DR/EC); 125 mg; amt: 125mg; oral Special Instructions: psychotic disturbance within Unspecified Dementia Twice A Day
Review of R45's Progress Note dated 03/04/2025 revealed, Per (psychiatric consultants) recommendation, Depakote level increased to 250 (mg) BID (twice a day) .Provider agreed. Order placed. Will monitor for changes to behavior and report to provider as necessary.
Review of R45's Progress Note dated 03/05/2025 revealed, Received recommendation from pharmacy to GDR resident's Lorazepam (antianxiety medication). Resident has continued to have anxious behaviors, crying, moaning, repetitive vocalizations, pacing. IDT (interdisciplinary team) and Provider made determination to decline recommendation at this time. Recommendation received from (psychiatric consultant) to increase resident's Depakote. Will re-evaluate resident's response to medication change and determine if GDR is appropriate at that time.
Review of R45's Order Summary dated 03/05/2025 revealed, Depakote (divalproex) tablet, delayed release (DR/EC); 250 mg; amt: 250mg; oral Special Instructions: Psychotic disturbance within unspecified dementia Twice A Day.
Review of R45's Electronic Medication Record revealed no documentation that R45's responsible party was involved in the decision to increase R45's depakote on 3/4/25-3/5/25.
Review of R45's Progress Note dated 03/10/2025 revealed, Resident continues to be agitated, restless, tearful. She paces up and down halls with repetitive vocalizations, will break out into moments of screaming and crying, completely inconsolable. Discussed behaviors with IDT and reviewed meds with (unit name omitted) Hall Coordinator, Provider, and resident's family. Reviewed resident's (psychotropic medication genetic testing) and determination was made that Xanax may be a better medication to try to address resident's anxiety. Provider gave order for 0.5mg twice daily, PRN every 8 hours as needed. Order written, nurse notified, family aware of change. Will monitor and report changes to provider as necessary.
During an interview via email on 03/12/2025 at 6:41 PM, Nursing Home Administrator (NHA) stated, On 03/10/25 DON (Director of Nursing) met with guardian on unit and completed medication review due to behaviors. Confirming R45's guardian was not made aware of the increase in depakote at the time the order was changed.
Resident #33 (R33)
Review of an admission Record revealed R33 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: paraphilia.
Review of the National Library of Medicine revealed Paraphilias are persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature. (https://www.ncbi.nlm.nih.gov/books/NBK554425/) Paraphilias are persistent and recurrent sexual interests, urges, fantasies, or behaviors of marked intensity involving objects, activities, or even situations that are atypical in nature.
Review of R33's Order Summary dated 3/16/24 revealed, Provera (medroxyprogesterone) tablet; 5 mg; amt: 10 mg; oral. Special Instructions: paraphilia Once A Day.
Review of R33's Electronic Health Record revealed no documentation that R33 was followed by the contracted psychiatric consultant following the diagnosis of paraphilia and the subsequent order for Provera. R33's records did not reveal that he had had a liver function tests (LFTs), serum testosterone, LH, or FSH labs completed since the initiation of the Provera.
During an interview via email on 03/12/2025 at 6:41 PM, NHA reported the facility physician was responsible for the management of R33's Provera order and monitoring. R33's physician did not order any labs due to the indication of use for the Provera.
Review of the National Library of Medicine research article titled Medroxyprogesterone (Provera) last updated 02/29/2024 revealed, .If patients are currently prescribed medroxyprogesterone for paraphilia/hypersexuality, liver function tests (LFTs), complete blood count (CBC), serum testosterone, LH, FSH, and glucose require regular monitoring. Also, consider an annual bone scan if serum testosterone markedly decreases . [NAME] A, [NAME] P, Gerriets V. Medroxyprogesterone. [Updated 2024 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559192/
During an interview on 03/13/2025 10:11 AM, Nursing Home Administrator (NHA) reported that the Behavior Management Team follows the resident and/or resident representatives' direction when it comes to the GDR process and ensure all parties are educated on the process and the risk versus benefits of the psychotropic medications prior to any medication changes.
During an interview on 03/12/25 at 02:27 PM, Social Services (SS) G reported that she had been the Social Services staff member for the facility for approximately 3 years until she transitioned to a different position the end of January 2025. SS G reported that the psychiatric consultation group assesses all residents prescribed a psychotropic medication and the facility Behavior Management Team would follow their recommendations for treatment. SS G reported the Behavior Management Team also followed the guidelines in the State Operations Manual regarding the GDR process and the team would try to respect their wishes. SS G stated that the facility was required per State guidelines to attempt a GDR for residents on psychotropic medications that were not exhibiting any behaviors to ensure residents were not overmedicated. SS G reported that RR H had previously refused all GDR attempts for R33 due to her fear that he would decline, and his behaviors would increase. SS G reported that R33's behavior documentation (lack of behaviors) didn't support his use of psychotropic medications and therefore a GDR was required to take place despite SS G's confirmation that R33 was not over sedated, and his representative was against the recommendation. SS G reported that RR H was concerned that R33 would have increased behaviors with any changes to his medications. SS G reported that she had not discussed with R33's representative the recommendation of increasing the depakote.
Review of the facility policy Medication Management (A) (no date) revealed, .Procedure-The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis (quarterly) .2. The resident is evaluated before initiating, withdrawing, or withholding medication(s), or using non-pharmacologic approaches. A. The extent of the evaluation will vary according to the resident's current condition, but may include .ii. Resident's goals and preferences .iv. History of prior and current medications .vi. Refusal of care and treatment, including the basis for declining it and the identification of pertinent alternatives. vii. An evaluation of medication risk vs. benefits will include/summarizing the rationale for necessary for (sic) medication therapy. 3. Information gathered during the initial and ongoing evaluations are incorporated into a comprehensive care plan that reflects appropriate medication-related goals and parameters for monitoring the resident's condition and ongoing need for the medication(s) .a. The care planning team defines quantitative and qualitative monitoring parameters using a variety of resources .clinical practice guidelines or clinical standards of practices; medication references; and clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals .9. When a resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, and/or non-pharmacological interventions, including behavioral interventions, have been effective in reducing the sumptoms (sic), the resident is evaluated for the appropriateness of a taper or gradual dose reduction (GDR) of the medication. A. Antipsychotics. If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated .2. The continued use is in accordance with relevant current standard of practice and the physician documents the clinical rationale of why any additional attempted dose reductions would likely impair the resident's function, increase distressed behavior, or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder .
Medroxyprogesterone Last Update: February 29, 2024. If patients are currently prescribed medroxyprogesterone for paraphilia/hypersexuality, liver function tests (LFTs), complete blood count (CBC), serum testosterone, LH, FSH, and glucose require regular monitoring. Also, consider an annual bone scan if serum testosterone markedly decreases . [NAME] A, [NAME] P, Gerriets V. Medroxyprogesterone. [Updated 2024 [DATE]]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559192/
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment potentially effecting 64 residents, resulting in the increased likel...
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Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment potentially effecting 64 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.
Findings include:
On 03/11/25 between 9:15 AM and 10:20 AM during the initial tour with Dietitian (B) the following concerns were observed:
The hand sink basin was observed visibly soiled from a build-up of grime and scale. Further observation of the hand sink revealed a leak in the plumbing fixture.
The drain boards, the backsplash and inside sink basins of the 3-compartment sink (located across from the hand sink) was observed to be soiled and had build-up scale, grime and debris.
Walk In Cooler's door (including door handle, ledge, and opening), the shelving and fan compressor grate were visibly soiled with a build-up of dust, food residues/debris, mold and mildew.
Walk in Freezer's door, (door handle, ledge, opening) and the flooring were visibly soiled.
Kitchen shelving units (located on wall between hood system and the hallway door) had build-up of residues/debris.
The flooring in the dry storage area beneath the shelving and along the floor/wall junctures had an accumulation of dirt and debris.
The flooring in the hallway (leading to the outside/dumpster area) had an accumulation of rock salt, dust and debris.
According to the 2017 FDA Food Code section 6-501.18 Cleaning of Plumbing Fixtures, PLUMBING FIXTURES such as the HANDWASHING SINKS, toilets, and urinals shall be cleaned as often as necessary to keep them clean.
According to the 2017 FDA Food Code section 5-205.15 System maintained in Good Repair, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW and (B) Maintained in good repair.
According to the 2017 FDA Food Code section 4-501.14 Warewashing Equipment, Cleaning Frequency, A WAREWASHING machine; the compartments of sinks, basins, or other receptacles used for washing, and rinsing EQUIPMENT, UTENSILS, or raw FOODS, or laundering wiping cloths; and drainboards or other EQUIPMENT used to substitute for drain boards or specified under 4-301.13 shall be cleaned: (A) Before use; (B) Throughout the day at a frequency necessary to prevent recontamination of EQUIPMENT and UTENSILS and to ensure that the EQUIPMENT performs its intended function; and (C) If used, at least every 24 hours.
According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.
Mar 2024
9 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed prevent a facility-acquired pressure ulcer, and measure, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed prevent a facility-acquired pressure ulcer, and measure, assess and promote the healing with an appropriate dressing change for one resident (Resident #63) of 1 resident reviewed for pressure ulcers. This deficient practice resulted in Resident #63 developing an unstageable pressure ulcer on the heel.
Findings include:
The facility provided a policy for Pressure Injuries: Assessment, Prevention and Treatment (undated and unsigned) for review. The policy reflected, 2. Skin will be assessed routinely for the presence of developing pressure injuries and documented on the Nursing Skin Tool .12. Float heels - keep heels off the bed .15. Check placement of splints, casts, and positioning devices to assure they are not causing friction on the resident's skin .
Resident #63 (R63):
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R63 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represents R63 had severe cognitive impairment. The MDS reflected the R63 required 2 staff assistance with all activities of daily living.
According to the MDS dated [DATE], R63 was identified as risk for ulcers/injuries and had no unhealed pressure ulcers/injuries upon admission to the facility.
The facility provided a copy of the policy for Wound Care undated and unsigned for review. The policy reflected, Steps in the Procedure 1. Clean hands. 2. Establish clean field. Place all items to be used during procedure on the clean field .
During an observation and interview on 3/12/24 at 9:38 AM, Registered Nurse (RN) R was observed while she changed the dressing to R63's heel wound with the assistance of State Trained Nursing Assistant (STNA) U who held her leg and assisted with positioning. RN R opened her dressing supplies at the corners and placed them on the stand next to the TV without preparing a clean dressing field. RN R removed the blue cushioned bootie from the left foot and the inside of the bootie was heavily soiled, which was in direct contact with the outer portion of the wound dressing. RN R stated she would see about replacing the soiled bootie. RN R removed the dressing, and an open area was visible to the bottom of the heel. The wound was cleansed, redressed with a clean dressing and the soiled blue cushioned bootie was reapplied. According to the policy the staff will establish a clean field to use for the procedure and the dressing supplies.
The facility provided a copy of the Orthopedic consult for review dated 1/10/24 signed by the physician on 1/11/24. The note reflected, Non communicative. X-rays: fracture healed (to left leg) .large unstageable posterior heel pressure ulcer. A/P (assessment and plan) = Bimalleolar (type of fracture) ankle fracture healed. Posterior heel pressure ulcer. (Name of boot that protects heel from all pressure) provided today - only needed for her pressure sore. She no longer requires bracing (splint to entire left left) for her fracture. Wound care for ulcer. No f/u (follow up) needed.
The facility provided all wound measurements for review. The first wound measurements were done on 1/19/24 (9 days after the Orthopedic made note of the pressure ulcer). The assessment reflected, Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed .Original wound onset date 1/19/24 .Size (Length X Width X Depth) 3.4 cm x 5.2 cm x 0.3 cm.
The facility provided a copy of Etiology of Skin Breakdown 1/19/24 for review. The document identified risk factors that contributed to the pressure ulcer development as significant weight, loss since admission, a full leg immobilizer, and residents shifting and scooting while her leg was in the brace. The document reflected, On 1/19/24 the staff reported heel breakdown and was noted to have an unstageable heel pressure injury. A (name of boot that protects from pressure) was implemented by her Orthopedic Physician. According to the Orthopedic note dated 1/10/24, R63 presented with a new pressure ulcer to the left heel and the protective boot was provided at the time of the consultation evaluation (1/10/24). There was no evidence the facility took action with interventions and treatment orders on the day the pressure ulcer was first noted by the Orthopedic.
The following weekly measurements were provided for review from 1/19/24 - 3/6/24:
1/19/24 3.4 x 5.2 x 0.3
1/31/24 3.3 x 4.2 x unable to determine.
2/7/24 2.1 x 1.7 x unable to determine.
2/14/24 1.6 x 1.3 x unable to determine.
2/21/24 0.7 x 0.3 x 0.4
2/28/24 0.8 x 0.3 x 0.3
3/6/24 1.9 x 0.5 x 0.8 (decline in healing noted)
According to the Medication Administration Record (MAR) for January 2024 reflected, Skin prep (a medication that creates an invisible layer on the skin to protect it from friction) to bil (both) heels Q (every) shift as preventative 12/4/23 - Open Ended, and an order for, Left Heel: Cleanse with NS (normal saline) and pat dry. Apply medi honey (wound healing agent) gel to the wound and cover with bordered foam. Change daily and prn (as needed) started on, 1/19/24 - Open Ended. The MAR reflects 2 different treatments to be applied to the left heel, one dressing daily and a skin treatment every shift. According to the January MAR, the healing agent was not started until 9 days after the Orthopedic noted the wound and recommended wound care for the ulcer.
The weekly skin assessment from 2/1/24 to 3/11/24 were requested for review for R63. The facility provided copies of the Nursing Skin Tool dated 2/19/24, 2/26/24, and 3/4/24 for review. The Nursing Skin Tool was incomplete and did not reflect the signature of any nurse for over 5 weeks.
During an interview on 3/13/24 at approximately 11:00 AM and a follow-up interview at approximately 1:00 PM, the Director of Nursing (DON) stated that R63 was admitted on [DATE] and wore an immobilizer to the left that extended from her upper thigh to just above the ankle for a leg fracture. The DON stated that R63 wore the splint until it was discontinued on 1/22/24 (12 days after seeing the Orthopedic Physician who directed to discontinue it on 1/10/24). The DON stated the staff first noted the pressure ulcer to the left heel on 1/19/24 which was the first time it was assessed, measured and a new treatment was put into place to facilitate the healing. The DON stated that a blue offloading boot was added to the care plan on 2/5/24. The DON identified other causative factors that contributed to the development of the pressure ulcer such as weight loss, the leg immobilizer that would slip down her leg and frequent scooting and shifting of her leg. The DON stated it was the expectation that a nurse assess residents weekly and document the findings on the Nursing Skin Tool sheet.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R23:
R23 was admitted to the facility on [DATE], with diagnosis that included dementia, essential hypertension, Combined forms o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R23:
R23 was admitted to the facility on [DATE], with diagnosis that included dementia, essential hypertension, Combined forms of age-related cataract, bilateral, chronic diastolic (congestive) heart failure, venous insufficiency, stage 2 Pressure ulcer of the left heel, muscle weakness and feeding difficulties.
A review of R23's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/03/24, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 1 which revealed R23 is severely cognitively impaired.
During a dining observation on 3/11/24 at 12:27 PM, staff are in the back of the dining room assisting two residents with their lunch. During R23's lunch, State Trained Nursing Assistant ([NAME]) S gets out of her chair, goes around resident's wheelchair, and stands on resident's right side. After looking around the main dining room [NAME] S picks up a bowl and beings assisting R23 with her lunch. [NAME] S stands over R23 during the remainder of residents' lunch.
During an interview on 3/11/24 at approximately 12:37 PM, [NAME] S revealed standing over the resident, has become an issue in the last couple of months, (while assisting residents to eat) due to a large pillar blocking staffs view of the rest of the dining room.
Based on observation, interview, and record review the facility failed to provide a dignified dining experience for 2 residents (Residents #23) R23 and (Resident #63) R63 observed for dining.
Findings include:
R63:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R63 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represents R63 had severe cognitive impairment. The MDS reflected the R63 required 2 staff assistance with all activities of daily living.
During an observation of the East Hall on 3/11/24 at approximately 9:29 AM, State Trained Nursing Assistant (STNA) U was observed standing next and over R63 as she fed breakfast to R63. R63 was non communicative and was not able to be interviewed regarding the incident. The reasonable person would find it undignified to be assisted with dining while the staff member stood over them instead of seated at the same level.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide dependent residents with assistance to shower a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide dependent residents with assistance to shower and with personal hygiene for 3 of 4 residents (Resident #23) R23, (Resident #47) R47 and (Resident #63) R63.
Findings include:
R47:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R47 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represents R47 was cognitively intact. The MDS reflected the R23 required 1-2 staff assistance with all activities of daily living.
During an observation and interview on 3/11/24 at 3:35 PM, Registered Nurse (RN) R was observed removing both R47's socks to inspect his feet. Both socks were soiled, and the right sock had a hole in the heel that was the size of a silver dollar. RN R acknowledged the condition of the socks and stated they would be replaced.
During an observation and interview on 3/13/24 at 11:10 AM, R47 was seated in his wheelchair next to his bed. R47's grip socks were visibly soiled, and the right sock had a hole in the heel approximately the size of silver dollar. When asked if the staff were able to provide a new pair of grip socks to R47, RN R stated, I will get him some.
According to the shower sheets dated 2/1/24 - 3/11/24 provided for review, R47 had not had a shower in 14 days. R47's last shower was documented on 2/26/24.
R23:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R23 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 1 out of 15 which represents R23 had severe cognitive impairment. The MDS reflected the R23 required 2 staff assistance with all activities of daily living.
During an observation on 3/11/24 at approximately 8:40 AM and 3/12/24 at approximately 9:00 AM, R23 was observed seated in a wheelchair in the East Hall with her eyes closed resting. R23's hair was soiled with oil and several facial hairs were noted to the chin that were approximately 1 cm in length.
According to the Activities of Daily Living care plan dated 11/21/19, the approach of 1-Provide nail care and shampoo hair with showers per weekly schedule. 2-Groom hair daily and encourage (name of R23) to participate as able. 3-Provide/assist with am & pm care, encourage (name of R23) to participate with hygiene as tolerated. 4-Assist with and/or shave facial hairs QD PRN (everyday as needed) or per (name of R23) preference.
The weekly skin assessment/shower forms dated 2/1/24 to 3/11/24 were requested for review for R23. The facility provided copies of the Nursing Skin Tool dated 2/5/24 and 2/12/24 for review. The form reflected a bed bath was given on both dates and there was no evidence a shower was given as the care plan reflected. There was no bathing assistance provided since 2/12/24 (for over 4 weeks).
R63:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R63 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represents R63 had severe cognitive impairment. The MDS reflected the R63 required 2 staff assistance with all activities of daily living.
During an observation on 3/11/24 at approximately 9:08 AM and 3/13/24 at approximately 10:00 AM, R63 was seated in a reclining wheelchair in the East Hall. R63 had oily hair that was uncombed/tangled in the back and several long white chin hairs that were approximately 2 cm in length.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly utilize resident equipment for one resident (Resident #53), ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly utilize resident equipment for one resident (Resident #53), resulting in the potential for serious injury from falls or entanglement for residents not receiving assistance with propelling in wheelchairs.
Findings include:
Resident #53 (R53):
R53 was admitted to the facility on [DATE], with diagnoses that include repeated falls, muscle weakness, unsteadiness on feet, dysphagia, cognitive communication deficit, and vascular dementia.
During an observation on 3/12/24 at 12:25 PM, R53 was observed just walking past South/West Nurse's Station in his wheelchair when State Trained Nursing Assistant (STNA) M approached and asked, Are you ready to go to lunch?STNA M stated to R53, OK pick your feet up. [NAME] M proceeded to push R53 down South Hall and the entire length of the service hall into the dining room without foot pedals on the wheelchair. STNA M pushed R53 to his table, and set him up with his lunch and left.
During the observation on 3/12/24 at 12:25 PM, R53's ankles were observed to be crossed and dangling a couple inches above the flooring during his ride to the dining room.
During an interview on 3/12/24 at 1:38 PM, the Nursing Home Administrator (NHA) was asked if there was an issue with pushing a resident without foot pedals. The NHA stated it's ok if, it is backwards for an emergency purpose. The NHA was informed that the surveyor observed R53 being pushed forward and not for an emergency purpose. The NHA stated, Yes, it's a safety concern, and expectation would be to use food pedals.
During an interview on 3/12/24 at 1:50 PM, Registered Nurse (RN) N was asked if an aide should do anything prior to pushing a resident in a wheelchair besides say, pick up your feet. RN N replied, Yeah, they can't do that. It is a safety issue because they could get their feet caught. Resident could accidentally put their feet down and get them caught up in their wheelchair. RN N further stated, resident could potentially fall and get hurt.
During an interview on 3/12/24 at 2:06 PM, State Trained Nursing Assistant (STNA) O stated, You need to make sure the foot pedals are on, and if not go get them. Then make sure the resident's feet are properly on them prior to transferring them. STNA O stated she uses the foot pedals, so the resident does not get hurt while transferring them and potentially break their ankles or legs when they put their feet down.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 3 of 67 facility residents [Resident #11 (R11), Resident #14 (R14), and Resident #121 (R121)], resulting in the potential for unauthorized access to resident medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information.
Findings include:
During an observation on 03/11/24 from 3:20 PM, the computer screen, located on the South Medication Cart was left unattended near the West/South Nurse's Station and open to R14's electronic medication administration record (e-MAR). R14's name, date of birth , payer source, and physician's name were visible to anyone walking by the medication cart. In addition, the computer screen was open to a documentation page, there was partial documentation that had been entered in R14's e-MAR, and the cursor was blinking to indicate the nurse had not been finished with the documentation and more could be added. Licensed Practical Nurse (LPN) F was within sight of the South Medication Cart, but she was busy retrieving items out of the treatment cart located a couple of rooms down the hall and was not paying attention to the South Medication Cart (as evidenced by the surveyor standing in front of the medication cart looking at, and writing down, information and LPN F did not look down the hall towards the surveyor or say anything/react when she walked by the medication cart with the exposed computer screen). After LPN F retrieved the items she needed from the treatment cart, walked past the South Medication Cart, and walked down the hall to a resident's room, the medication cart was left unattended and out of view of any staff members until Registered Nurse (RN) E (the nurse assigned to the South Medication Cart) returned to the cart and continued to document in R14's e-MAR.
During an interview on 03/11/24 at 03:40 PM, LPN F stated she will close her computer screen on the medication cart when she walks away because of HIPAA (Health Insurance Portability and Accountability Act- a federal law that sets a national standard for the protection of medical records and other personal health information).
During an interview on 03/11/24 at 3:45 PM, RN E stated that she hits the walk away button on the computer screen on the medication cart before she walks away from it because of HIPAA. She stated that button will close the computer screen so no one can view it when she is not at the medication cart.
During an observation on 03/12/24 at 09:45 AM, the computer Kiosk across from the Cafe on the Speret Hall was left unattended and open to R11's personal information (name, age, date of birth , sex, room number, primary physician's name, allergies, and diagnoses). Residents were in the hallway and within view of the kiosk. As the surveyor was writing down the information that was left visible to anyone who cared to read it, State Trained Nursing Assistant (STNA) D walked up to the surveyor at the kiosk and said, I left that open didn't I. STNA D stated she should have pushed the walk away button on the kiosk screen to hide the information before she walked away from it. She also stated the nurses frequently leave their computer screens on their medication carts open to resident information and unattended.
During an observation on 03/13/24 at 10:35 AM, the computer Kiosk next to room [ROOM NUMBER] was left unattended and open to R121's personal information (name, age, date of birth , sex, room number, primary physician's name, allergies, and diagnosis). A resident was sitting in a wheelchair diagonally across the hall from the kiosk. R121's nurse aide charting could have been accessed by anyone walking up to the kiosk and using it. In addition, since the computer kiosk was logged into other residents' charts could have been accessed (there was a window on the left side of the computer screen that listed the names and pictures of other residents with a scroll bar and would enable anyone by just simply clicking on the button with the resident's name and picture to access their personal information and charting information).
During an interview on 03/13/24 at 10:40 AM, STNA C stated she was the one who left the computer kiosk next to room [ROOM NUMBER] open and unattended. She stated she had left the kiosk screen open when she went to answer a call light. STNA C stated she should have closed the screen before leaving the computer kiosk.
A review of the facility's Confidentiality and Trade Secrets policy, dated January 2018, revealed, In accordance with the HIPAA Privacy Rule, employees must at all times protect the confidentiality and privacy of the residents.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to 1.) Accurately document administration of controlled substances and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to 1.) Accurately document administration of controlled substances and 2.) Ensure that narcotic medications were administered following the physicians' orders for 4 residents (Resident #5, Resident #7, Resident #9, and Resident #54), reviewed for controlled substances, resulting in medication errors.
Findings include:
Resident #5 (R5):
Review of an admission Record revealed R5 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: peripheral vascular disease.
Review of R5's Physician Order revealed, gabapentin capsule; 100mg; once a day to be administered at 10:00 AM.
Review of R5's Physician Order revealed, gabapentin capsule; 300mg; once a day to be administered at 10:00 PM.
Review of R5's Controlled Substance Proof of Use Form for gabapentin 100mg revealed that on 3/4/24 at 9:12 AM and on 3/4/24 at 9:26 PM a dose of gabapentin was administered. Indicating the incorrect dose of gabapentin was administered on 3/4/24 at 9:26 PM.
Review of R5's Controlled Substance Proof of Use Form for gabapentin 300mg revealed that on 3/4/24 (no time documented) a dose of gabapentin was administered. Indicating 400mg of gabapentin was administered instead of 300mg).
Review of R5's Controlled Substance Proof of Use Form for gabapentin 100mg revealed that on 3/8/24 at 9:00 AM a dose was administered, on 3/9/24 at 8:14 PM a dose was administered, and on 3/9/24 at 9:12 AM a dose was administered.
Review of R5's Controlled Substance Proof of Use Form for gabapentin 300mg revealed that on 3/8/24 there was no dose administered. Indicating R5 received a dose of gabapentin 100mg instead of 300mg at that time.
Resident #7 (R7):
Review of an admission Record revealed R7 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: seizures.
Review of R7's Physician Order revealed, Briviact; 10mg/ml; 8ml via peg tube; twice a day.
Review of R7's Medication Administration Record revealed both doses of Briviact were administered on 3/11/24 with a note Given by previous shift, per night shift RN (registered nurse).
Review of R7's Controlled Substance Proof of Use Form for Briviact 8ml (80mg) revealed a dose was administered on 3/11/24 at 8:48 PM. Indicating there was no morning dose of Briviact administered.
Resident #9 (R9):
Review of an admission Record revealed R9 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain.
Review of R9's Physician Order revealed, tramadol; 50mg tablet. Administer 25mg twice a day.
Review of R9's Controlled Substance Proof of Use Form for Tramadol revealed that on 3/8/24 a dose was administered at 9:01 AM. There was no evening dose of tramadol documented as administered.
Review of R9's Medication Administration Record revealed that both the morning and evening dose of tramadol were documented as administered on 3/8/24.
Resident #54 (R54):
Review of an admission Record revealed R54 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: neuropathic pain (nerve pain).
Review of R54's Physician Order revealed, Neurontin; 100mg capsule. Amount to administer: 200mg twice a day.
Review of R54's Controlled Substance Proof of Use Form for gabapentin revealed that on 3/10/24 a dose was administered at 8:47 AM. There was no evening dose of tramadol documented as administered. On 3/11/24 a dose was administered at 11:56 AM. There was no evening dose of tramadol documented as administered.
Review of R54's Medication Administration Record revealed that both the morning and evening doses of tramadol were documented as administered on 3/10/24 and 3/11/24.
During an interview on 3/13/24 at 1:30 PM, Nursing Home Administrator confirmed that there were discrepancies with the above narcotic medications and reported the Director of Nursing would be completing licensed nurse education and disciplinary action.
Review of the facility policy, Administering Medications (no date) revealed, .Administration .2. Medications are administered I accordance with written orders of the attending physician .Documentation: 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented .
Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement B
This Citation pertains to Intake Number M100142728.
Based on interview and record review, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement B
This Citation pertains to Intake Number M100142728.
Based on interview and record review, the facility failed to ensure that one resident (Resident #7) of 1 resident reviewed, received the medications necessary to prevent seizures.
Findings include:
Resident #7 (R7):
Review of a Face Sheet revealed R7 originally admitted to the facility on [DATE] with pertinent diagnosis of epilepsy.
In an interview on 3/11/24, Family Member (FM) P reported two weeks after R7 admitted to the facility he started to act differently and realized he was not getting his seizure medications which then led to him having a seizure and going to the hospital.
Review of the Hospital discharge medications dated 1/20/24 for R7 included brivaracetam (Briviact, an anticonvulsant) 80 mg per G (gastro) tube 2 times daily and Oxcarbazepine (Trileptal, an anticonvulsant) 600 mg per G tube 2 times daily.
Review of the Hospital Records dated 1/28/24 revealed R7 went to the hospital with diagnoses of acute seizure and chronic oromandibular dystonia (a neurological condition affecting the jaws, face, and mouth.) Living facility to call head and reported that she had not been getting his seizure medication for several days. The patient experienced repetitive eye blinking today,
Review of the January Medication Administration Record (MAR) for R7 revealed he received Briviact 8 mL (milliliters) twice a day 1/21/24 to 1/23/24, and the morning dose on 1/24/24. Briviact is documented as unavailable from the 1/24/24 evening dose through 1/28/28. There is no record the resident received Trileptal in January.
During an interview on 3/12/24 at 3:15 PM, Registered Nurse (RN) R reported that she was the nurse that completed R7's admission on [DATE]. RN R reported that she had not completed an admission independently prior and had made errors. RN R reported that she had not entered all the medications into the EMR (electronic medical record) prior to the end of her shift and the oncoming nurse was to finish the medication reconciliation, which was not completed.
Pharmacy:
In an interview on 3/12/24 at 3:15 PM, Registered Nurse (RN) R reported that multiple attempts were made with the pharmacy to get R7's refill of Briviact, and the pharmacy would not release the medication without an updated prescription.
In an interview on 3/13/24 at 1:00 PM, the Director of Nursing (DON) reported they had talked to the pharmacy extensively and there was some miscommunication on their end. This situation happened over the weekend.
Review of an email correspondence thread between the facility and the pharmacy revealed that the pharmacy needed a new prescription for the Briviact before they could send it to the facility.
Review of a Pharmacy Contract revealed Delivery: . agrees to deliver to [entity] six (6) days per week, Monday through Saturday, with an additional delivery if an emergency arises, except for circumstances and conditions beyond its control [entity] is available for assistance 24 hours per day, 365 days a year.
Review of a pharmacy policy titled Orders/Delivery of Medications revealed: Medications will be ordered from [Pharmacy] in a manner that allows delivery to the facility on a timely basis. Timeliness will be assessed and will factor in the following: continuity of care, condition of the resident (severity/instability), category of medication, (antibiotic/analgesic) and the physician ordered start time. The facility will maintain accurate records of drug order and receipt.
This citation has 2 separate Deficient Practice Statements A and B.
Deficient Practice Statement A:
Based on observation, interview, and record review the facility failed to routinely assess, monitor, and respond to new skin breakdown for 3 of 4 residents, (Resident #23) R23, (Resident #47) R47 and (Resident #63) R63. This deficient practice resulted in R47 impaired skin integrity to go unassessed, unmonitored and untreated.
Findings include:
The facility provided a policy for Pressure Injuries: Assessment, Prevention and Treatment (undated and unsigned) for review. The policy reflected, 2. Skin will be assessed routinely for the presence of developing pressure injuries and documented on the Nursing Skin Tool .
The facility provided a policy for Alteration in Skin Integrity (partial thickness) undated and unsigned for review. The policy reflected, The facility will identify residents with alteration is skin integrity and implement appropriate measures to promote healing. Upon first assessment the clinician is expected to document the following in the medical record: underlying condition contributing to the scab, scab edges and wound bed, location, shape, and condition of surrounding tissues. Procedure: 1. Upon identification of a new alteration in skin integrity, a Licensed nurse will assess the area and enter documentation in the clinical record to reflect the appearance of the wound .
R47:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R47 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represents R47 was cognitively intact.
During an initial tour on 3/11/24 at approximately 8:20 AM, R47 was observed in his room seated in a wheelchair with a dressing to the right lower leg that did not contain a date nor initials. When asked about the dressing to his leg, R47 stated that he did not know who put it on or how long it had been on.
The weekly skin assessment from 2/1/24 to 3/11/24 were requested for review for R47. The facility provided copies of the Nursing Skin Tool dated 2/5/24 which was signed by the nurse and 2/15/24, 2/19/24, and 2/26/24 that were not signed by the nurse. The Nursing Skin Tool was incomplete and did not reflect the signature of any nurse for over 3 weeks. There was no indication on the Nursing Skin Tool what was under the dressing to the right leg.
The progress notes from 2/1/24 - 3/11/24 were reviewed and did not reflect any skin breakdown or indication for a dressing to the right lower leg.
On 3/11/24 the Medication Administration Record for March 2024 was reviewed, and it did not reflect any treatment orders for the right lower leg.
During an observation on 3/11/24 at 3:35 PM, Registered Nurse (RN) R stated she did not know what the skin condition was under the right lower leg dressing and noted there were no orders to treat the area. R47 was asked about the skin issue but could not recall when it happened, who put the dressing on nor when it was applied. RN R confirmed there was no date or initials on R47's dressing and was observed as she removed it. The dressing had a large amount of drainage that covered most of the dressing. The Surveyor and RN R observed 4 small open areas of light pink skin (approximately 0.5 cm each) that had active weeping of clear fluid coming from each area. After assessing the right lower leg, RN R stated she would notify the physician and obtain a treatment order.
R23:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R23 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 1 out of 15 which represents R23 had severe cognitive impairment. The MDS reflected the R23 required 2 staff assistance with all activities of daily living.
The weekly skin assessment from 2/1/24 to 3/11/24 were requested for review for R23. The facility provided copies of the Nursing Skin Tool dated 2/5/24 and 2/12/24 for review. The Nursing Skin Tool was incomplete and did not reflect the signature of any nurse for over 5 weeks.
R63:
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R63 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 0 out of 15 which represents R63 had severe cognitive impairment. The MDS reflected the R63 required 2 staff assistance with all activities of daily living.
The weekly skin assessment from 2/1/24 to 3/11/24 were requested for review for R63. The facility provided copies of the Nursing Skin Tool dated 2/19/24, 2/26/24, and 3/4/24 for review. The Nursing Skin Tool was incomplete and did not reflect the signature of any nurse for over 5 weeks.
During an interview on 3/13/24 at approximately 11:00 AM, the Director of Nursing (DON) stated that she expected the nurses to assess and document skin assessments on the Nursing Skin Tool weekly.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record reviews, the facility failed to ensure: 1.) Hand sink was being used and properly maintained 2.) Food contact surfaces were being maintained in a clean an...
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Based on observations, interviews, and record reviews, the facility failed to ensure: 1.) Hand sink was being used and properly maintained 2.) Food contact surfaces were being maintained in a clean and sanitary condition free from contamination, and 3.) Effectively maintain food and non-food contact areas, affecting 67 residents, resulting in the increased likelihood for cross-contamination and bacterial growth.
Findings include:
During the initial tour of the kitchen on 3/11/24 between 7:50 AM to 8:30 AM the following issues were observed:
An observation of an unidentified man (he disappeared upon entry to the kitchen)was washing a soiled 3 to 4 round black rubber/plastic ring and a piece of drainpipe (from a torn apart 3- compartment sink) in the hand sink.
Continuation of hand sink observation, unidentified man waved his hand and activated the automatic paper towel dispenser. A cart of resident mugs (blue) were being stored beneath the paper towel dispenser. The food contact portion of the mug was potentially contaminated when the automatic paper towel dispenser was activated by dripping wet and/or contaminated hands.
Observation of hand sink revealed scale, dark black grime/sludge mixed with a few inches of ice in the bottom of sink.
Observation of the Walk In Cooler (WIC) revealed dust, grime, and debris on the shelving and on the fan compressor grate.
According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing Sink, (A) A HANDWASHING SINK shall be maintained so that it accessible at all times for EMPLOYEE use. (B) A HANDWASHING SINK may not be used for purposes other than handwashing.
According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
According to the 2017 FDA Food Code section 6-501.18 Cleaning of Plumbing Fixtures, PLUMBING FIXTURES such as HANDWASHING SINKS, toilets and urinals shall be cleaned as often as necessary to keep them clean.
According to the 2017 FDA Food Code section 4-602.13, NONFOOD CONTACT SURFACES. NONFOOD CONTACT SURFACES OF EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
During the 2nd Kitchen observation on 3/11/24 at 11:35 AM, next to hand sink is 5 tier cart storing clean lids, was partially over the sink exposing the lids to potential cross-contamination and splash during the hand washing process.
According to the 2017 FDA Food Code section 4-902.12 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (Paragraph) (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE- SERVICE and SINGLE USE ARTICLES shall be stored: (1) In a clean; dry location: (2) Where they are not exposed to splash, dust, or other contamination; . (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (Paragraph) (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.
Dec 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00138274
Based on interview and record review, the facility failed to 1.) allow a resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00138274
Based on interview and record review, the facility failed to 1.) allow a resident to return to the facility after an emergency room (ER) evaluation and 2.) notify the residents DPOA (Designated Power of Attorney) in writing of their appeal rights for 1 resident (Resident #105) reviewed for facility initiated transfers, resulting in Resident #105 being denied return to the facility, the inability of Resident #105's guardian to appeal the involuntary discharge, and the potential for increased stress and lack of appropriate and safe living accommodations.
Findings include:
Resident #R105 (R105)
Review of an admission Record revealed R105 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: intellectual disabilities, anxiety, restlessness, and agitation. R105 required a guardian for decision making.
Review of R105's Social Services Note written by Social Services Coordinator (SSC) R and dated 7/10/23 at 3:46 PM revealed, Writer called guardian to discuss (name omitted) AFC. AFC is private pay and do not work with the waiver program and resident cannot private pay. Case manager (name omitted) suggested that resident go to (hospital name omitted) for psych evaluation rather than Indiana (psych facility) d/t (due to) multiple refusals of care, medication, and violent behavior toward staff. Per guardian's request transportation has been set up with (transportation company name omitted) to pick resident up from facility around 4:30 pm and transfer down. Guardian and case manager will advocate for resident to not return to facility as it is not suited for resident and will be advocating resident be transferred closer to guardian .
Review of R105's Nursing Note dated 7/10/23 at 4:12 PM revealed, Resident has been refusing medications from multiple staff members for the past three weeks. Resident is combative towards staff including physical harm. Resident is verbally abusive towards staff and other residents, refusing care from multiple staff members including showers, changing clothes, using restroom, and allowing staff to clean room. Resident has been observed having physical altercations with other residents. Resident is verbally abusive to other resident's making continuous threats on a daily basis. Staff has educated and redirected resident but has been unsuccessful in all attempts to re-direct. Since resident has refused medication administration his behavior has worsened making him a direct harm to himself. Family notified and specifically requested to send resident to (hospital name omitted) in Grand Rapids, MI with the hope that he will go to a psychiatric facility. 0 further concerns voiced at present time. Writer attempted to give report to staff member at (hospital name omitted) Grand Rapids MI, hospital staff representative from (name omitted) Hospital in Grand Rapids MI refused report. Resident is in route via (name omitted) transportation. Confirming the receiving facility was not aware or willing to receive R105.
During an interview on 12/06/2023 at 1:29 PM, SSC R reported that R105's behaviors began escalating in January 2023 and he had spent time in an inpatient psychiatric facility (4/24/23- 5/22/23). SSC R reported that R105's behaviors did not improve after the inpatient psychiatric stay, and the interdisciplinary team had discussed with G Q that the Long-Term Care environment was not appropriate for him due to it being overstimulating. SSC R reported that she had been working with G Q to find appropriate placement for R105 however other facilities wouldn't take him because of behaviors. SSC R reported that on 7/10/23 she had spoken with G Q about transferring R105 out of the facility and stated it was her understanding that (hospital name omitted) had a psych ER (psychiatric emergency room.) SSC R reported that transportation was set up and the facility nursing staff were to give report to the receiving psychiatric unit. SSC R reported she did provide documentation, notify G Q, or know if a bed hold or appeal documentation was sent with R105. SSC R stated the business office sets that up.
During an interview on 12/06/2023 at 9:48 AM, Guardian (G) Q reported that SSC R contacted him and reported that in order to get R105 admitted to a psychiatric facility they would send R105 through the emergency room. G Q stated, I wasn't sure how that was going to work. G Q reported that R105 arrived at the hospital, but the hospital staff had not received report, documentation, did not know why he was there, and had to release him. G Q reported that the hospital staff contacted him and told him if he did not pick up R105 immediately that Adult Protective Services would be contacted. G Q reported that the facility never reached out to him and he contacted the facility 5 days later and they said we took him out of the hospital and at this point we won't take him back. G Q stated that he never implied that I wanted to take him home and was given no other choice by the hospital. G Q stated, The whole process was a mess. I feel they handled it wrong. G Q reported that prior to R105's transfer and following his hospitalization he had never been provided a Transfer Notice or any appeal paperwork and it had not been discussed with him during the conversation he had with SSC R. G Q reported he is unfamiliar with the Long-Term Care rules and regulations, relied on the facility, and stated that he knows that the hospital transfer was not how the process works. G Q stated, What they did was they lost patience and wanted him out. G Q stated that since R105's admission to the facility, His behaviors never changed, they were the same as they always were, (R105) gets mood swings. One minute he's happy and the next he's crying, they got tired of it and threw their hands in the air, and this was their way out. G Q stated, We were looking for another place. But it wasn't moving fast enough for them.
During an interview on 12/06/2023 at 8:57 AM, Hospital Nurse Supervisor (HNS) P reported that on 7/10/23 she was the Hospital Nursing Supervisor on duty and received a phone call from facility staff attempting to give nurse to nurse report to the psychiatric unit. HNS P reported that she notified the facility nursing staff that there was no planned admission to the psychiatric unit planned for R105 and he could not be transferred and/or admitted at that time. HNS P reported that round 5:00 PM a transport company requested entrance to the psychiatric unit with R105 and reported he was to be admitted . HNS P reported that no nurse-to-nurse report had been given, there was no documentation regarding R105's needs or reason for a direct admission, and she did not know what facility he was coming from. HNS P reported that she had to bring R105 to the Emergency Department and he was kept in the ED as a social admit. HNS P reported she contacted the facility and was told by facility staff that they couldn't take him back and provided no additional contact information or solutions.
Review of R105's Electronic Health Record revealed no additional nursing notes or documentation following the Nursing Note written on 7/10/23 at 4:12 PM.
Review of a Witness Statement written by Licensed Practical Nurse (LPN) U dated 7/25/23 revealed, .This writer overheard the nurse on duty call (hospital name omitted) and give report on resident (R105). This writer overheard staff member on duty stating that she was attempting to give report and the staff member from (hospital name omitted) was refusing to accept report. Resident was already on the way to the hospital during attempted phone call . Confirming the facility failed to ensure the receiving facility was notified of and prepared for R105's transfer until after the resident had left the facility (Note SSC R's progress note written at 3:46 PM with R105's transfer time schedule for 4:30 PM allowed facility nursing staff sufficient time to ensure a safe and effective transition of care.)
Review of a Witness Statement written by Registered Nurse (RN) I (no date) revealed, .The social worker from (hospital name omitted) called the facility at approximately 2030 (8:30 PM) saying 'there is no reason for (R105) to be in our facility we are sending him back to you.' I asked the social worker how long (R105) had been in their facility. They responded, 'a couple hours.' I asked them why he wasn't being admitted for observation, to which they responded, 'he doesn't need to be.' I asked if he had received any of his medications to which they responded he refused them, but he's calm and cooperative so if the facility or guardian doesn't come pick him up, they will call adult protective services and the ombudsman. I explained to the social worker that it wasn't that we didn't want him back at this facility, it was that we couldn't accept him with his uncooperative and violent behaviors, as it's a risk for the other residents in the building. I hung up with the social worker and called the floor nurse .I then called the DPOA (power of attorney), (G Q), myself and explained what the floor nurse had said .I then called the floor nurse back and informed her of what the DPOA had said, and she responded that she would let the provider know and that she didn't think it was necessary for the DPOA to drive there at that point because they didn't have a plan yet. I told her to call the facility back with a plan. There was no call received from (hospital name omitted) for the remainder of the night.
Review of R105's Electronic Health Record revealed no documentation that the Director of Nursing or the Nursing Home Administrator were aware that the facility nursing staff refused R105's return to the facility at that time.
During an interview on 12/07/2023 at 9:00 AM, Nursing Home Administrator (NHA) reported that R105 had been sent out for psychiatric hospitalization prior and had always been able to return to the facility. NHA reported that at the time of R105's transfer, it was expected that he would return once stabilized. NHA reported that the management team had not been notified by the hospital or G Q that G Q had taken R105 home on 7/10/23 and G Q did not contact the facility until 7/21/23 to report that R105 had been discharged to his care.
Transfer Documentation
Review of R105's Electronic Health Record revealed no documentation that at the time of R105's transfer for hospitalization, G Q was notified and/or provided the Bed Hold and Transfer notice (which included the appeal process). G Q had discussed R105's transfer with SSC R prior to R105's transfer. The Electronic Health Record did not contain documentation that a copy of the Bed Hold Policy and Transfer Notice was sent with R105 to the hospital.
Review of R105's Bed Hold Notification revealed an attempt to reach R105's guardian via telephone on 7/11/23 to provide the Bed Hold Notification and Transfer Form (containing the appeal process) with documentation that the form was delivered or mailed on 7/12/23. (Confirming G C was not notified of the facility's Bed Hold policy or Transfer Notice/Appeal Process prior to R105's transfer.)
Review of the facility LTC Ombudsman Monthly Discharge Tracking form revealed R105's Primary Reason for Emergency Tracking was documented as Acute Care and not for Psychiatric or Mental Health.
Review of R105's Transfer Notice provided by the facility contained contact information for the incorrect local ombudsman, incorrect local ombudsman telephone number, and incorrect Michigan Long-Term Care Ombudsman email address. The facility Transfer Notice included the correct Michigan Department of Licensing and Regulatory Affair ([NAME]) P.O. box address but also included the street address of [NAME] as an alternate address which is not reflected on the current [NAME] transfer form. The facility Transfer Notice referenced the incorrect form utilized for the [NAME] facility-initiated transfer appeal process.
Review of the facility's email correspondence revealed the LTC Ombudsman Monthly Discharge Tracking form was emailed to the ombudsman on 9/29/23 (approximately 80 days after his transfer).
During an interview via email on 12/06/2023 at 2:23 PM, Ombudsman (O) O stated, I have no knowledge of an involuntary discharge for (R105). I am not regularly made aware of ITD's (Involuntary Transfers/Discharges) from this home. On occasion the resident will notice the section stating to call the LTCO (Long-Term Care Ombudsman) if concerned but that did not happen with this individual.
During an interview via email on 12/07/2023 at 11:47 AM, NHA confirmed that the business office manager/business coordinator had been responsible for notifying the ombudsman of facility initiated/involuntary transfer notification and stated that the ombudsman should be notified utilizing the LTC Ombudsman Monthly Discharge Tracking form at end of month/ early next month, there are a couple occasion where it was delayed as you can see. I am going to revamp our process on this and place it back on social services plate.
References:
Review of the facility policy Discharge Planning last updated 11/16 did not contain the procedure for facility-initiated transfers specifically (contained sections titled Discharge Plan, Discharge to Community, Transfer or Discharge to Post-Acute Provider, Discharge Summary, and Documentation Requirements for Involuntary Discharge).5. Documentation Requirements for Involuntary Discharge
Review of the Michigan Department of Licensing and Regulatory Affair LTC (Long-Term Care)-Involuntary Transfer or Discharge Process revealed, .Facility-Initiated Transfer-This form and process will only be used when there is a transfer of a resident from the federally certified nursing home to another facility, such as an acute care hospital, with the expectation that the resident will return to the federally certified nursing home. FIT-100 Facility-Initiated Transfer and Appeal Form Basic Steps *Prepare FIT-100 form, completing all informational boxes. *Completed FIT-100 form must be provided to the resident or resident representative along with an envelope and postage for appeal request. *A copy of the notice must be placed in the resident's medical record. *A monthly list of all facility-initiated transfers shall be provided to the Michigan Long Term Care Ombudsman at MLTCOP@meji.org .
Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, A hand-off report is defined by The Joint Commission (TJC) as a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real-time process of passing patient-specific information from one caregiver to another or from one team of health care providers to another for the purpose of ensuring the continuity and safety of the patient's care (TJC, 2014). Hand-offs also occur when patients are transferred from one unit or area of care to another. Effective communication through hand-offs can improve health care providers' perceptions of accuracy, completeness, and types of interventions provided to patients during a previous shift or level of care. Typically when nurses and other health care providers consult on a patient's condition, each contributes information about the patient. There can be problems with hand-off communication unless each member of the team assumes responsibility for either giving or receiving a complete and accurate report (TJC, 2017) (Box 16.3). Potential for patient harm is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed to provide care (TJC, 2017). Hand-off information is vital for you to be able to assess and understand a patient's most current health care needs. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 215). Elsevier Health Sciences. Kindle Edition.
Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Hand-Off Reporting Part of planning is transferring essential information (along with responsibility and authority) from one nurse to the next during transitions in care (e.g., end of shift, during a patient transfer to a new care unit, discharge to another setting). Hand-off reporting is a real-time process that offers a health care provider accepting the care of a patient the opportunity to ask questions to clarify and confirm important details about a patient's plan of care, patient progress, and continuing needs during the transfer of information. Quality hand-off information enables nurses to quickly recognize changes in patient status and to anticipate risks, thereby promoting safe patient care (Birmingham et al., 2015). A correctly formulated nursing care plan facilitates a hand-off report as one nurse communicates to another. You learn to focus your reports on the nursing care, treatments, patient goals, and expected outcomes documented in your care plans. During a hand-off report always provide accurate, up-to-date, and pertinent information to the next nurse assuming patient care. The hand-off is a critical time to ensure continuity of care for a patient and prevent errors or delays in providing nursing interventions. Recent research identifies approaches to use for effective hand-offs and barriers to their effectiveness (Box 18.4). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 250-251). Elsevier Health Sciences. Kindle Edition.
Review of the State Operations Manual revealed If a facility does not permit a resident who went on therapeutic leave to return, the facility must meet the requirements for a facility-initiated discharge .Because the facility was able to care for the resident prior to therapeutic leave, documentation related to the basis for discharge must clearly show why the facility can no longer care for the resident.
Review of the State Operations Manual revealed Residents who are sent emergently to an acute care setting, such as a hospital, must be permitted to return to the facility (§483.15(e)(1), F626). In a situation where the facility initiates discharge while the resident is in the hospital following emergency transfer, the facility must have evidence that the resident's status at the time the resident seeks to return to the facility (not at the time the resident was transferred for acute care) meets one of the criteria at §483.15(c)(1)(i)(A) through (D). Additionally, the resident has the right to return to the facility pending an appeal of any facility-initiated discharge unless the return would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that the failure to transfer or discharge would pose .
For facility-initiated transfers or discharges of a resident, prior to the transfer or discharge, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Additionally, the facility must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. The intent of sending copies of the notice to a representative of the Office of the State LTC Ombudsman is to provide added protection to residents from being inappropriately transferred or discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Office of the State LTC Ombudsman is aware of facility practices and activities related to transfers and discharges .
When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable before the transfer, according to 42 CFR §483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices at §483.15(c)(5) .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is related to intakes MI00135808, MI00140665, and MI00136503
Based on observation, interview, and record review, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is related to intakes MI00135808, MI00140665, and MI00136503
Based on observation, interview, and record review, the facility failed to ensure (a) call lights were within reach and (b) fluids were offered between meals throughout the day, for one of four residents (Resident #120) reviewed for accommodation of needs, resulting in the potential for unmet needs, the inability to summon help urgently, and dehydration.
Findings:
Resident #120 (R120)
Review of a face sheet revealed R120 was an [AGE] year-old female, originally admitted to the facility on [DATE], and was placed on hospice in August 2023. R102 had pertinent diagnoses of Dementia and seizure disorder, and was dependent on staff to meet her needs.
During an observation on 12/05/23 at 9:25 AM, R120's call lights (2 of them) laid on the floor at the head of the bed, tangled in the bed frame, out of sight and out of reach of R120. A full cup of water sat on the over bed table at the foot of the bed, out of reach of R120.
During an observation on 12/05/23 at 11:10 AM, R120's call lights laid on the floor at the head of the bed, in the same place as observed at 9:25 AM, out of reach and out of sight of the resident. A full cup of water sat on the over bed table at the foot of the bed, out of reach of R120.
During an observation on 12/05/23 at 12:00 PM, R120's call lights laid on the floor at the head of the bed, in the same place as observed at 9:25 AM and 11:10 AM, out of reach and out of sight of the resident. A full cup of water sat on the over bed table at the foot of the bed, out of reach of R120.
During an observation on 12/05/23 at 12:45 PM, Certified Nurse Aide (CNA) D assisted R120 with eating lunch.
During an observation on 12/05/23 at 1:02 PM, a paper towel sat on R120's chest, the call lights laid on the floor at the head of the bed, tangled in the bed frame, out of reach and out of sight of the resident. The over bed table and full water cup sat next to the head of the bed, however the water cup was not within reach of R120.
During an observation on 12/05/23 at 1:08 PM, CNA D and CNA E entered R120's room to reposition her.
During an interview on 12/05/23 at 2:30 PM, CNA F reported that per first shift report, R120 was just changed and repositioned. During an observation at the same time, R120's call lights laid on the floor at the head of the bed, tangled in the frame, out of reach and out of sight of the resident. The full cup of water for R120 sat out of the residents reach.
During an observation on 12/05/23 at 4:00 PM, R120's call light laid on the floor at the head of the bed, tangled in the bed frame. The full cup of water sat out of reach of R120.
Review of a Care Plan for R120 revealed the following care interventions: (1) encourage resident to use the call light for assistance, (2) provide fluids at bedside between meals, and (3) keep call light in reach in the event resident would use it.
Review of the facility policy Call lights reflected: (4) when the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident.
Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1319). Elsevier Health Sciences. Kindle Edition.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00136503
Based on interview and record review, the facility failed to 1.) accurately docum...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00136503
Based on interview and record review, the facility failed to 1.) accurately document the administration of controlled medications and 2.) ensure controlled medications were administered following the physician order for 5 residents (Resident #119, #122, #123, #125, and #126), reviewed for medication administration, resulting in controlled medications not being administered and the potential for overdose and/or ineffective management of pain, and the potential for drug diversion of controlled substances.
Findings include:
Resident #119 (R119)
Review of R119's Physician Order dated 10/9/23 revealed an order for hydrocodone-acetaminophen (pain medication) 5/325mg to be administered twice a day.
Review of R119's Controlled Drug Administration Log revealed that on 12/4/23 R119's hydrocodone-acetaminophen was administered 1 time at 6 PM.
Review of R119's December 2023 Medication Administration Record revealed documentation that R119 had received 2 doses of Norco on 12/4/23.
Resident #R122 (R122)
Review of R122's Physician Order dated 11/8/23 revealed an order for lorazepam (anxiety medication) 0.5mg to be administered twice a day.
Review of R122's Controlled Drug Administration Log revealed that on 12/5/23 R122 did not receive either dose of ativan.
Review of R122's December 2023 Medication Administration Record revealed documentation that R122 had received 2 doses of lorazepam on 12/5/23.
Resident #123 (R123)
Review of R123's Physician Order dated 2/11/23 revealed an order for oxycodone (pain medication) 5mg every 4 hours as needed.
Review of R123's Controlled Drug Administration Log revealed that on 12/3/23 R123 received 3 doses of oxycodone (2:00 AM, 12:13 PM, and 9:00 PM).
Review of R123's December 2023 Medication Administration Record revealed no documentation that R123 received any doses of oxycodone on 12/3/23.
Review of R123's Controlled Drug Administration Log revealed that on 12/4/23 R123 received 3 doses of oxycodone (3:00 AM, 11:10 AM, and 6:30 PM).
Review of R123's December 2023 Medication Administration Record revealed no documentation that R123's oxycodone was administered at 3:00 AM or 6:30 PM on 12/4/23.
Review of R123's Controlled Drug Administration Log revealed that on 12/5/23 R123 received 5 doses of oxycodone (2:00 AM, 8:00 AM, 1:00 PM, 6:00 PM, and 10:00 PM).
Review of R123's December 2023 Medication Administration Record revealed no documentation that R123's oxycodone was administered only 1 time at 9:14 AM (4 doses were not documented) on 12/5/23.
Resident #125 (R125)
Review of R125's Physician Order dated 11/22/23 revealed an order for Ativan (antianxiety medication) 0.5mg to be administered twice a day.
Review of R125's December 2023 Medication Administration Record revealed that on 12/4/23 R125's morning dose of ativan was documented as refused (not administered).
Review of R125's Controlled Drug Administration Log revealed that on 12/4/23 R125's morning dose of ativan was signed out as administered at 6:00 AM. The Ativan was not documented as wasted with a second nurses signature indicating it was witnessed.
Resident #126 (R126)
Review of R126's Physician Order dated 11/27/23 revealed an order for oxycontin (pain medication) 10mg every 12 hours (twice daily).
Review of R126's Controlled Drug Administration Log revealed that there were no doses of oxycontin administered on 12/1/23, 12/2/23, 12/3/23, or 12/4/23.
Review of R126's December 2023 Medication Administration Record revealed documentation that R126 received 2 doses on 12/1/23, 1 dose on 12/2/23, 2 doses on 12/3/23, and 1 dose on 12/4/23.
During an interview on 12/07/2023 at 12:20 PM, Director of Nursing (DON) and Assistant Director of Nursing (ADON) S confirmed that the above listed medication errors occurred, medication error incident reports would be completed, disciplinary action would be taken as needed, and all licensed nurses would receive education.
Review of the facility policy Controlled Medications-Accountability (no date) revealed, .3. If a dose is removed or prepared for administration but refused or not administered, as per facility protocol, the medication must be destroyed in the presence of two licensed nurses and the disposal documented on the Proof of Use form. This also applies to the disposal of partial tablets or portions of single dose ampoules or vials
Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/ or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 605). Elsevier Health Sciences. Kindle Edition.
Feb 2023
13 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has 3 DPS statements.
This citation refers in part to MI00133328:
DPS#1
Based on observation, interview and reco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has 3 DPS statements.
This citation refers in part to MI00133328:
DPS#1
Based on observation, interview and record review the facility failed to prevent accidents and hazards for 1 resident (R7) resulting in an Immediate Jeopardy (IJ) that began on 1/19/23, due to the facility's lack of policies and procedures to prevent hot liquid burns for R7. This deficient practice led to R7 experiencing multiple third degree burns and unnecessary pain and disfigurement and the potential for other residents in the facility to be at risk from burn, pain and injury.
Findings include:
A review of R7's Face Sheet, dated 2/15/23, revealed R7 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R7's Face Sheet revealed multiple diagnoses that included dementia, generalized muscle weakness, rheumatoid arthritis, and muscle spasms.
A review of R7's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/28/22, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 9 which revealed R7 was moderately cognitively impaired. In addition, R7's MDS revealed she needed supervision (oversight, encouragement, or cueing) for eating after staff setup her food and drinks.
On 2/7/23 at 11:51 AM an interview was conducted with R7. R7 reported that a couple of weeks prior she was in the Activities room and spilled coffee on her right leg and that she was burned bad. R7 reported that staff put paste on it but that it still hurts. R7 reported that she was told to wear a dress and not slacks or pants to allow air to get to the wounds. R7 exposed her R thigh which revealed a large irregularly shaped area of scabbing with other smaller areas of scabbing covering most of the front right thigh.
On 2/14/23 at 4:37 PM a follow up interview was conducted with R7 in her room. R7 indicated that the scabbing persisted on the right thigh and she exposed her left thigh to reveal scattered scabbing. R7 reported that this scabbing is also a result of the cup of coffee that spilled on her when she was in the Activities room.
A review of R7's Other Events- Non Fall Resident Event report, dated 1/20/23, revealed on 1/19/23 at 2:45 PM, R7 spilled hot coffee on her lap while in the recreation room. R7 sustained burn injuries to her anterior (back side of thigh) right thigh (redness), anterior left thigh (redness), and left outer knee (superficial blister). However, there were not any measurements of the burn areas noted on the report. In addition, the report failed to reveal that follow-up assessments were conducted to monitor R7 for continued/worsening injuries related to the hot coffee burn (physical damage from a burn can take time to develop and burns should be monitored and assessed over time to determine the true extent of the damage).
A review of the facility's Burn Investigation Report, undated, revealed on 1/19/23 at the request of the resident (R7) the Activity Assistant provided a cup of coffee to her in the Activity Room. The coffee was drawn directly form (from) the coffee machine in a Styrofoam cup that had a lid on it. The resident removed the lid to add creamer/sweetener to it and spilt the coffee on her lap. Actions: Activity Assistant notified nurse. Resident (Activity Assistant/nurse?) immediately returned resident to room for privacy. Resident returned to room. Clothing removed immediately. Noted general redness on left thigh, right thigh with superficial broken blister side of right knee. Cool immediately applied .
A review of R7's Nursing note, dated 1/19/23, revealed, Called to see resident after spilling hot coffee on lap. Resident returned to room. Clothing removed immediately. Noted generalized redness on left thigh, right thigh with supeficial (superficial) broken blister side of right knee. Cool immediately applied .
A further review of R7's progress notes, dated 1/19/23 to 1/25/23, failed to reveal any measurements of R7's burn injury areas prior to 1/26/23.
A review of Activities Assistant (AA) H's typed and signed statement, undated, revealed R7 asked AA H for a cup of coffee. AA H put the coffee in a Styrofoam cup with a lid on it and handed it to R7. R7 asked for more cream and sugar and AA H went to get them. When AA H was getting the cream and sugar, he heard her shout out and saw she had spilled coffee on her thighs. AA H rushed her (R7) back over to her room, and told an aide what happened and she got the nurse.
A review of R7's Wound Grids, dated 1/19/23 to 2/15/23, revealed the following:
- Left Medial Thigh Superior Aspect (top inside area of the thigh) partial thickness burn (second degree burn)- original wound onset- 1/19/23
- 1/26/23= Measurement= 4.7 cm (centimeters) x 5.4 cm x 0.1 cm (length x width x depth).
- 2/2/23= Measurement= 4.5 cm x 5.5 cm x 0.1 cm.
- 2/9/23= Measurement= 2 cm x 3.9 cm x 0.1 cm.
* There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area.
- Left Medial Thigh (inside area of thigh) full thickness burn (third degree burn)- original wound onset- 1/19/23.
- 1/26/23= Measurement= 6 cm x 6.5 cm x 0.1 cm.
- 2/2/23= Measurement= 4.1 cm x 6.3 cm x 0.1 cm.
- 2/9/23= Measurement= 4.3 cm x 3.6 cm x 0.1 cm.
* There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area.
- Left Posterior Thigh (area of the thigh on the back side of the thigh) partial thickness burn- original wound onset- 1/19/23
- 1/26/23= Measurement= 1.6 cm x 1.5 cm x 0.1 cm.
- 2/2/23= Measurement= 1.1 cm x 1 cm x 0.1 cm.
- 2/9/23= Measurement= wound healed.
* There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area.
- Right Anterior Thigh (area of thigh on the front side) full thickness burn- original wound onset- 1/19/23.
- 1/26/23= Measurement= 3.3 cm x 4.2.cm x 0.2 cm.
- 2/2/23= Measurement= 5.8 cm x 4.9 cm x 0.1 cm.
- 2/9/23= Measurement= 2.3 cm x 5.6 cm x 0.1 cm.
* There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area.
- Right Lateral Thigh (area along the outside thigh) full thickness burn- original wound onset- 1/19/23.
- 1/26/23= Measurement= 6.7 cm x 6.4 cm x 0.1 cm.
- 2/2/23= Measurement= 14 cm x 9.5 cm x 0.1 cm.
- 2/9/23= Measurement= 1 cm x 1 cm x 0.1 cm.
* There was not a measurement of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained a week after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area.
- Right Medial Thigh full thickness burn- original wound onset- 1/19/23.
- 2/2/23= Measurement= 4 cm x 15.2 cm x 0.1 cm.
- 2/9/23= Measurement= 14.5 cm x 8.4 cm x 0.1 cm.
* There were not any measurements of the burn for this area on the day of the injury recorded in this document. The first recorded measurement on this document was obtained two weeks after the burn occurred. Therefore, there was no way to know the measured extent of the original burn area and/or within the first two weeks following the event.
During an interview on 02/10/23 at 9:10 AM, the Director of Nursing (DON) stated, We don't measure bruises, red areas, and not always skin tears found on skin checks. As a result of the facility not measuring red areas, there was no way to know the measured extent of R7's original burn areas.
A review of the University of Rochester Medical Center's Classification of Burns Encyclopedia reference, dated 2023, revealed, It may be impossible to classify a burn immediately when it occurs. It can progress over time so you may not know the full extent for a day or two (https://www.urmc.rochester.edu/encyclopedia).
A review of the University of Rochester Medical Center's Classification of Burns Encyclopedia reference, dated 2023, revealed, First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the epidermis. The burn site is red, painful, dry, and has no blisters. Mild sunburn is an example. Long-term tissue damage is rare and often consists of an increase or decrease in the skin color. Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful. Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred (https://www.urmc.rochester.edu/encyclopedia).
During an interview on 2/14/23 at 4:15 PM, Dietary Aide (DA) J revealed that for coffee, we get a red cup (plastic) and put ice in it because it comes out at 170-175 degrees. The red cups are stored on shelving approximately 15-20 feet away and the 16oz Styrofoam cups are to the right of the coffee machine in white plastic bins. DA J was asked to prepare a resident's coffee. DA J grabbed a red cup, filled it ¾ full an adds approximately 8 ice cubes. The coffees temperature was 118 degrees within a minute using surveyor's thermometer.
On 2/14/23 at 4:17 PM, Activity Aide (AA) M revealed, I get the residents coffee from the kitchen all the time. AAM stated, the coffee is now served in a red cup and ice is now added. Prior to the resident being burned it went in a Styrofoam cup.
On 2/14/23 at 4:30 PM, a sign on the top of the on-demand coffee machine reflected the following information, Coffee Temp should not be 150F - 180F degrees
Add ice if serving directly from machine. Please only use the cups above (picture of the facilities red plastic cup and the blue cups with lids) do NOT use Styrofoam cups for hot liquids. Dietary Manager (DM) K stated, she was not sure when the sign was put up (on the coffee machine), she stated the Nursing Home Administrator had put it up. A cup of coffee was currently unobtainable at this time. A message was flashing on the coffee machine and coffee was unable to be dispensed. DA J revealed this surveyor would have to wait due to it being overused. Approximately 12 large carafes were observed on carts waiting to be served with dinner.
During the kitchen observation on 2/14/23 at 4:35 PM, DA J revealed what happened on the day the resident was burned. We were busy, we didn't really see them (activity staff) come in and they helped themselves to the coffee. We are always supposed to put ice in it, I don't think they did. After that happened (points to the coffee machine) that big sign went on.
On 2/14/23 at 4:36 PM, the coffee machine quit flashing and the first coffee temped at 148F degrees. Approximately a minute later, a second cup tempted out at 167.7F. No thermometers were located near the vicinity of the coffee or ice machines. The closest thermometers were next to the microwave on the other side of the kitchen.
On 2/15/23 at 8:40 AM an observation and interview were conducted at the coffee machine in the facility kitchen. Review of the coffee machine revealed a sign near the front top of the machine that read, Coffee temp should not be 150 to 180F (Fahrenheit) Add ice if serving directly from machine. Review of the area surrounding the coffee machine did not reveal any thermometers to determine the temperature of the coffee before or after ice had been added. Using a red handled coffee mug the vessel was filled with coffee directly from the coffee machine. This cup of coffee revealed a temperature of 179.2 degrees F. A second red handled coffee mug was filled with coffee directly from the facility coffee machine and revealed a temperature of 181.4 degrees F. [NAME] N reported that the temperature of the coffee is not checked or recorded. [NAME] N reported that if a resident requests coffee staff can call the kitchen or come directly into the kitchen and pour the cup. [NAME] N reported that any staff member can come into the kitchen if they are wearing a hair net.
On 2/15/23 at 11:05 AM the NHA and DON were informed of an Immediate Jeopardy (IJ)identified on 2/15/23, that started on 1/19/23 when R7 was served coffee in the activity room, and she spilled coffee on her lap and sustained full thickness (third degree) burns. The coffee was not temped by staff. Coffee is still not temped by staff before serving and staff are instructed by a sign to add ice to coffee. On 2/15/23 at 8:40 AM, 2 cups of coffee were temped at 179.2 and 181.4 degrees Fahrenheit. Kitchen staff stated they add 2-3 cubes of ice to coffee, but do not temp the coffee. Any staff member is able to come to the kitchen and obtain a cup of coffee for a resident. R7 does not have a hot liquid assessment, and per her diagnosis she has dementia, has a BIMS of 9/15 (moderately impaired cognition), has muscle weakness and muscle spasms. Per interview with facility staff they do not have a policy or procedure for completing hot liquid assessments on residents. The identified risk of serious injury, serious harm, serious impairment or death was evidenced by: R7 having full thickness (third degree) burns, per the wound notes. The initial wound measurements were: wound 1, left posterior thigh 1.1cm x 1cm x 0.1cm; wound 2 left proximal medial thigh 4.5cm x 5.5cm x 0.1cm; wound 3 left distal medial thigh 4.1cm x 6.3cm x 0.1cm; wound 4 right lateral thigh 5.8cm x 4.9 cm x 0.1cm; wound 5 right proximal thigh 14cm x 9.5cm x 0.1cm; wound 6 right medial thigh 4cm x 15.2cm x 0.1cm. A third degree burn can be sustained by contact with hot liquid at 155 degrees for one second. The need for immediate action was: The facility must take temperatures of any hot food or liquids prior to serving to directly to residents. All residents must be assessed for safety with hot liquids.
During the immediate jeopardy discussion on 2/15/23 at 11:05 AM, the DON again confirmed the facility does not do a hot liquid assessment and they do not even have a standard assessment for hot liquid safety. Occupational therapy does sometimes assess residents for the need for adaptive equipment. The NHA stated they had started a QA(Quality Assurance) Plan related to the burn and the NHA had been temping coffee weekly and determined 2-3 ice cubes will get coffee below 150 degrees Fahrenheit, which was the goal. The NHA confirmed this procedure was not written anywhere and the coffee was not being temped regularly. The NHA stated that 3-5 staff were also being quizzed weekly on new policy. The policy was their Pull/Pour policy which stated clothing would be removed from a resident immediately and cool liquid applied in the event of future hot liquid spills. The NHA and the DON were informed assessing their residents for safety with hot liquids as well as creating a policy and procedure for appropriate serving temperatures for hot liquids and taking temperature of those liquids prior to every service to residents would be key to removing the immediacy of the Immediate Jeopardy.
On 2/15/23 at 4:00 PM, the NHA confirmed they did not yet have a removal plan. It was discussed the survey team could not verify the removal of immediacy until their plan was received. The NHA stated a plan would be completed and provided to the team lead and survey manager that evening or by the next morning. The Corporate Consultant L and DON were also present during this discussion.
On 2/16/23 at approximately 8:10 AM, Telephone contact was made with the administrator and the need for a removal plan was discussed and questions answered regarding what was expected in a removal plan. The NHA stated they wanted to provide a past non compliance, but were informed this would not be acceptable and a removal plan needed to be completed.
On 2/16/23 at 9:36 AM, the NHA sent an email which stated an Abatement Plan was attached. However, the NHA had attached an alleged past noncompliance related to the concern with R7 and not any steps to remove immediacy after they were informed of the IJ. The document was titled [Facility] Coffee Spill with Burn Timeline and revealed:
On 01/19/2023, Nurse was notified of coffee spill and responded immediately. Clothing was removed immediately. Noted generalized redness on left thigh, right thigh with superficial broken blister side of right knee. Cool compress immediately applied. Pharmacy notified to send Silvadene stat. Son called and updated.
PA, DON and Wound PA notified of coffee spill with bilateral thigh redness and superficial area of peeling to lateral right thigh. N.O. for Silvadene 1% cream to affected areas BID until resolved.
The facility has one coffee machine that is located in dietary kitchen. Administrator reviewed last six months of monthly hot liquids temperature log. All data is within range of 150F to 180F degrees. During off times when coffee is not readily available at resident's requests, single cups of coffee will have 3 ice cubes added to cup.
Resident had been assessed 12/17/2022, and working with OT. The functional skills assessment ADL for eating was documented as Independent. Resident was not assessed to require any adaptive devices or special cups or lids when eating or drinking. On 02/08/2023, resident was screened by OT which again revealed the resident did not require any adaptive devices or special cups or lids when eating or drinking.
On 1/23/2023, Medical Director [name of medical director] examined the resident. Intact blisters noted over several locations. Consult for Avanti wound to follow the resident.
Care Plans Updated:
On 01/19/2023 a plan of care to address the wounds was implemented.
On 02/03/2023, the resident's care plan was revised to include Resident prefers to receive black coffee from the kitchen and to put her own creamer/sweetener in it and to drink her coffee at times without a lid.
Wound grids Completed:
On 01/19/2023, wound grids started.
Interventions to Address Similarly Situated Residents:
On 01/20/2023, Sign was placed on the coffee machine to add 3 ice cubes to the cup of coffee when pouring it straight from the machine.
On 02/03/2023, IDT team met to review incident, hot liquids pull/pour policy, and what would be the best method for resident to receive coffee safely while attending an activity. IDT team agreed with implementing a courtesy cart with a carafe of coffee, cups, lids, condiments, and a pitcher of cold water. Dietary manager educated dietary staff of the new protocol to provide the courtesy cart daily at 10AM and 2PM for the Activity department to utilize for residents in the Activity Room. This will enable facility to limit single cups of coffee during none meal times.
Facility will continue to follow the current policy of having admissions screened by OT for adaptive equipment if applicable.
All residents will be screened by OT at least quarterly and as identified with a change in condition for need for adaptive equipment.
Hot liquids; (coffee, tea, soup, water, milk) will continue to be served in the proper dinnerware/serve ware with a lid or covering, depending on the type of hot liquid being provided unless OT has determined that a resident requires adaptive equipment on the completion of the resident's assessment.
Education:
On 02/03/2023 Staff education was completed on the Hot Liquids Pull/Pour policy and completed competency quiz.
ED provided 1:1 education with the Activity Assistant on the Pull/Pour policy and on utilizing the red handled coffee cups and not Styrofoam cups for hot beverages.
Coffee Temperature Audit:
ED and Regional Nurse Consultant tested multiple cups of coffee, in various cups to ensure temperature of the coffee was within the facility policy for hot liquids range (150F to 180F degrees).
Styrofoam Cup:
Coffee Temperature straight from the Machine: 173F degrees
Coffee Temperature after 3 ice cubes added to the cup: 139F degrees
Red Coffee Cup:
Coffee Temperature straight from the machine: 172F degrees
Coffee Temperature after 3 ice cubes from the machine: 138F degrees
QAPI/Audits:
Administrator and/or designee will complete 4 random staff interviews on hot liquids policy weekly times 3 weeks, then monthly there after times 3 months to ensure hot liquids pull/pour policy is being followed.
Administrator and/or designee will complete 1 coffee temp audit weekly times 3 weeks, then monthly there after times 3 months to ensure coffee temp is within range.
On 2/16/23 at approximately 9:50 AM Telephone contact was made with the NHA confirming what was received was not a removal plan as discussed. The NHA was again informed about what was expected in a removal plan.
On 2/16/23 at 1:22 PM an email was sent to the NHA informing them the survey would have to be exited without a removal plan since one had yet to be received.
On 2/16/23 at 1:35 PM telephone contact was made with the NHA and they stated they would provide a removal plan immediately.
On 2/16/23 at 1:37 PM, the facility plan to remove the Immediate Jeopardy was received. It was reviewed and accepted:
02/16/2023 Director of Nursing, and Corporate Clinical team created a hot liquid assessment, and implemented new hot liquid assessment protocol. All residents residing within the facility have been assessed per the hot liquid assessment.
Director of Nursing and/or designee will educate all nurses on hot liquids assessment, and nurses will be required to complete assessment upon admission, readmission, quarterly, and significant change.
On 02/16/2023, Administrator and/ or designee educated all dietary staff that coffee temperature will be obtained and logged on updated food temperature log with each meal. Dietary staff will temp and log individual requests of coffee from staff, or residents on coffee temp log that will be available in dietary department.
On 02/16/2023, Administrator and/ or designee educated all staff that dietary department is responsible for providing and temping individual requests for coffee/ hot liquids. Non- Dietary staff are not permitted to enter kitchen to obtain hot liquids for resident safety.
Director of Nursing and/ or designee will audit new admissions hot liquid assessment twice weekly for 4 weeks, then monthly thereafter times 3 months. To ensure staff are completing new protocol to minimize residents risk to hot liquids.
Administrator and/ or designee will audit coffee temperature logs in kitchen twice weekly for 4 weeks, then monthly thereafter times 3 months. To ensure staff are temping all coffee for resident safety.
On 2/17/23, the state agency began to validate the removal plan. Upon review of kitchen temperature logs for coffee and review of the kitchen with the NHA on 2/17/23 at 10:35 AM, it was revealed that although kitchen staff were taking a temperature of the coffee, they were not informed of nor had the facility identified what the target temperature of coffee should be. The NHA stated they were unsure but thought an acceptable range would not be from 150 to 180 degrees Fahrenheit and staff were no longer supposed to use ice to cool coffee. A sign was still placed on the coffee maker stating Coffee temp should not be 150F-180F degrees. Add ice if serving directly from machine. (photos of two different cups were pictured) Please use only cups above do NOT use Styrofoam cups for hot liquids. The coffee temperature log indicated 3 different temperatures logged and each indicated ice was added. The NHA was informed the sign in the kitchen conflicted with the direction staff had been given and NHA stated multiple times the sign would be taken down but did not take the sign down. Further discussion was completed with the NHA at 10:50 AM on 2/17/23 and she provided policy about acceptable food and drink temperature and confirmed coffee would be served at 150-180 degrees Fahrenheit. The NHA was informed the temperature range needed to be added to the temperature log and education started with dietary staff in order to remove immediacy. Proof of education being provided to dietary staff was provided at 11:05 AM, removing the immediacy.
The NHA provided information regarding the dietary staff education: Effective 02/17/2023, coffee temperature will be obtained and logged on updated food temperature log with each meal. Dietary staff will temp and log individual requests of coffee from staff, or residents on coffee temp log that will be available in dietary department. Temperature range for hot liquids is 150F-180F. If temperature is within range, no ice is needed.
Although the Immediate Jeopardy was removed on 2/17/23, the facility remained out of compliance with a scope of isolated and severity of actual harm that is not immediate jeopardy due to sustained compliance not being verified by the state agency and additional identified concerns related to accidents and hazards being identified through the survey.
DPS #2
Based on observations, interview and record review the facility failed to implement and identify meaningful interventions to prevent falls for two residents (R12 and R51) reviewed for falls resulting in ongoing falls resulting in pain, facial bruising, head laceration, skin tears, and body bruising due to falls for R51, ongoing falls resulting in pain, a skin tear and hip fracture for R12, and the potential for further falls with serious injury for all residents at risk for falls.
Findings include:
R12
Review of R12's face sheet dated 2/14/23 revealed she was a [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: dementia, unsteadiness on feet, restlessness and agitation, difficulty in walking, and fracture of the right femur. R12 was not their own responsible party for financial or medical decisions.
A review of R12's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/24/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 4 which revealed R12 was significantly cognitively impaired. In addition, R12's MDS revealed she had two or more falls without injury her previous MDS assessment on 10/26/22. R12's 10/26/22 MDS assessment revealed she had a fall with major injury.
R12's fall risk assessments completed on 5/10/22, 8/4/22 and 9/15/22 revealed she was at high risk for falls.
On 2/8/23 at 9:53 AM, R12 was viewed in her room, an interview was attempted, but the resident presented with some confusion and could not recall any information about the care she receives in the facility.
R12's falls for the last 9 months were requested and 6 fall incident reports were received. R12 fell on 8/27/22, 10/19/22, 10/31/22, 11/04/22, 12/26/22, and 2/1/23. All of these falls were unwitnessed. The fall incidents were compared to review of the resident's care plan printed 2/14/23. R12's care plan showed a problem area of Falls with a start date of 9/01/2016. [R12] is at risk for fall and or injuries due to a history of falls, cognitive deficits making her lack of safety awareness (not able to be educated, she does not remember things consistently), and the use of a diuretic medication. [R12] has a diagnosis of dementia, she has forgetfulness and reported while at home .she was also noted to be outside of the house during the nighttime hours confused. She uses a walker for ambulation .[R12] does not consistently remember to lock the brakes when required. Also scoots in seated wheeled walker and does not always use properly. The potential for fatigue and pain are present with the dx (diagnosis) of osteoarthritis and hypothyroidism.
Review of R12's fall incident dated 8/27/22 revealed she had an unwitnessed fall without injury at 6:09 AM when the resident made unassisted attempt to get out of bed, slid to the floor. Additional interventions included encourage resident to utilize call light for transfer assistance, ensure proper positioning in (sic) while in bed. The only other intervention noted was to complete neurological checks on the resident. Review of R12's care plan revealed an intervention for falls on 8/27/22: Remind/encourage [R12] to use call light for assistance if needed despite the notation in problem area that she is not able to be educated.
Review of R12's fall incident dated 10/19/22 revealed she had an unwitnessed fall at 1:20 AM resulting in pain the right lower extremity in her room. R12 was found sitting on her buttocks in front of her bed. Body audit shows extreme pain with movement to Right lower extremity .send to ED (emergency department) for eval. They were noted to be in Excruciating Pain- Worst possible at a 10 out of 10. No other intervention was noted other to send to the emergency department. Review of the resident's care plan revealed no intervention added. There is no intervention on R12's care plan that is on or around the date of this fall. Review of R12's progress notes revealed she sustained a fracture of her right hip as a result of this fall. A contact with R12's responsible party on 10/19/22 at 8:30 AM revealed it was decided to start R12 on hospice care as a result of her fall with hip fracture.
Review of R12's fall incident dated 10/31/22 revealed she had an unwitnessed fall at 4:00 AM and was found laying on the floor between her bed and wheelchair, no injuries were noted. The added intervention was grippy socks. Review of the resident's care plan revealed the intervention use not skid socks to prevent slipping with transfers added to fall approaches on 10/31/22. The intervention encourage use of non skid footwear was also noted on 9/4/17.
Review of R12's fall incident dated 11/04/22 revealed she had an unwitnessed fall with no injuries at 7:26 PM and was found sitting on her butt next to her wheel chair in her room next to bed. The noted intervention was again grippy socks. No other intervention was listed on the care plan matching on or around this date.
Review of R12's fall incident dated 12/26/22 revealed the resident had an unwitnessed fall at 9:30 PM. They were found to be laying on the floor next to her bed with feet near head of bed and wheelchair next to her .resident yelled and would not move LLE (left lower extremity) . verbal order for L hip xray. R12 was noted to be in severe pain-horrible intense at a 7 out of 10. The added intervention was noted to be order for grippy strips to be placed on the floor in front of resident's bed.
Review of R12's fall incident dated 2/1/23 revealed the resident had an
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-center c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-center care plans for 3 residents (R12, R51 and R26) resulting ineffective and unimplemented care plans leading to ongoing falls, injury and pain for R12 and R51 and prolonged use of a feeding tube, anxiety and weight gain for R26 and the potential for all facility residents to not receive care and services to reach their highest potential.
Findings include:
R12
Review of R12's face sheet dated 2/14/23 revealed she was a [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: dementia, unsteadiness on feet, restlessness and agitation, difficulty in walking, and fracture of the right femur. R12 was not their own responsible party for financial or medical decisions.
A review of R12's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/24/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 4 which revealed R12 was significantly cognitively impaired. In addition, R12's MDS revealed she had two or more falls without injury her previous MDS assessment on 10/26/22. R12's 10/26/22 MDS assessment revealed she had a fall with major injury.
R12's fall risk assessments completed on 5/10/22, 8/4/22 and 9/15/22 revealed she was at high risk for falls.
On 2/8/23 at 9:53 AM, R12 was viewed in her room, an interview was attempted, but the resident presented with some confusion and could not recall any information about the care she receives in the facility.
R12's falls for the last 9 months were requested and 6 fall incident reports were received. R12 fell on 8/27/22, 10/19/22, 10/31/22, 11/04/22, 12/26/22, and 2/1/23. All of these falls were unwitnessed. The fall incidents were compared to review of the resident's care plan printed 2/14/23. R12's care plan showed a problem area of Falls with a start date of 9/01/2016. [R12] is at risk for fall and or injuries due to a history of falls, cognitive deficits making her lack of safety awareness (not able to be educated, she does not remember things consistently), and the use of a diuretic medication. [R12] has a diagnosis of dementia, she has forgetfulness and reported while at home .she was also noted to be outside of the house during the nighttime hours confused. She uses a walker for ambulation .[R12] does not consistently remember to lock the brakes when required. Also scoots in seated wheeled walker and does not always use properly. The potential for fatigue and pain are present with the dx (diagnosis) of osteoarthritis and hypothyroidism.
Review of R12's fall incident dated 8/27/22 revealed she had an unwitnessed fall without injury at 6:09 AM when the resident made unassisted attempt to get out of bed, slid to the floor. Additional interventions included encourage resident to utilize call light for transfer assistance, ensure proper positioning in (sic) while in bed. The only other intervention noted was to complete neurological checks on the resident. Review of R12's care plan revealed an intervention for falls on 8/27/22: Remind/encourage [R12] to use call light for assistance if needed despite the notation in problem area that she is not able to be educated.
Review of R12's fall incident dated 10/19/22 revealed she had an unwitnessed fall at 1:20 AM resulting in pain the right lower extremity in her room. R12 was found sitting on her buttocks in front of her bed. Body audit shows extreme pain with movement to Right lower extremity .send to ED (emergency department) for eval. They were noted to be in Excruciating Pain- Worst possible at a 10 out of 10. No other intervention was noted other to send to the emergency department. Review of the resident's care plan revealed no intervention added. There is no intervention on R12's care plan that is on or around the date of this fall. Review of R12's progress notes revealed she sustained a fracture of her right hip as a result of this fall. A contact with R12's responsible party on 10/19/22 at 8:30 AM revealed it was decided to start R12 on hospice care as a result of her fall with hip fracture.
Review of R12's fall incident dated 10/31/22 revealed she had an unwitnessed fall at 4:00 AM and was found laying on the floor between her bed and wheelchair, no injuries were noted. The added intervention was grippy socks. Review of the resident's care plan revealed the intervention use not skid socks to prevent slipping with transfers added to fall approaches on 10/31/22. The intervention encourage use of non skid footwear was also noted on 9/4/17.
Review of R12's fall incident dated 11/04/22 revealed she had an unwitnessed fall with no injuries at 7:26 PM and was found sitting on her butt next to her wheel chair in her room next to bed. The noted intervention was again grippy socks. No other intervention was listed on the care plan matching on or around this date.
Review of R12's fall incident dated 12/26/22 revealed the resident had an unwitnessed fall at 9:30 PM. They were found to be laying on the floor next to her bed with feet near head of bed and wheelchair next to her .resident yelled and would not move LLE (left lower extremity) . verbal order for L hip xray. R12 was noted to be in severe pain-horrible intense at a 7 out of 10. The added intervention was noted to be order for grippy strips to be placed on the floor in front of resident's bed.
Review of R12's fall incident dated 2/1/23 revealed the resident had an unwitnessed fall at 11:00 PM when they were observed sitting on floor next to bed and wheelchair on opposite side. Residents black personal plastic bin tipped over next to resident. Resident unable to explain fall. Resident combative to staff. There were no noted injuries. An intervention of floor mat was indicated and later determined to be not appropriate and half assist rail was to be added to the open side of the bed to assist with self transfers. An intervention was added to R12's care plan on 2/9/23: 1/2 rail assist bar to open side of bed to assist with ADL (activities of daily life)/mobility.
Review of R12's progress notes on 2/14/23 revealed she had an additional fall on 2/13/23. A request was made to the Nursing Home Administrator at 10:17 AM on 2/14/23 for the additional fall incident.
Review of R12's fall incident dated 2/13/23 revealed the resident had an unwitnessed fall at 8:00 PM and was lying in the middle of bedroom on floor facing bathroom .abrasion noted to R elbow area . The listed intervention was request medication review to be implemented by Hospice and request orthostatic BP (Blood pressure) for 3 days. A similar intervention was also listed on R12's care plan on 3/16/22: medication review by Pharmacy consultant and orthostatic vs.
On 02/14/23 at 10:30 AM, R12 was viewed laying in the middle of her bed and sleeping, her head toward the foot of her bed and feet on the floor. Grip strips viewed at the mid bed area to the head of bed. The resident's tray table and wheelchair were entirely covering the grip strips and R12's feet were past the end of the grip strips. At approximately 10:35 AM Corporate Consultant (CC) L was viewed on the hall and was directed towards R12's room asked if they say any concerns with current visible fall interventions. CC L agreed the grip strips were not under the resident's feet in her current position.
R51
Review of R51's face sheet dated 2/14/23 revealed she was an [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: cerebrovascular disease, dementia, difficulty walking, unsteadiness on feet, and muscle spasm. R51 was not their own responsible party for financial or medical decisions.
A review of R51's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 12/28/22, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 5 which revealed R51 was significantly cognitively impaired. In addition, R51's MDS revealed she had two or more falls without injury and two or more falls with injury since her previous MDS assessment on 10/3/22.
R51's fall risk assessments completed on 9/10/22, 10/10/22 and 1/10/23 revealed she was at high risk for falls.
On initial tour of the facility, on 2/7/23 at 10:27 AM, R51 was viewed with a right eye upper cheek that was swollen with purple bruising. Certified Nursing Assistant (CNA) M stated that R51 had fallen that morning.
On 2/7/23 at 12:25 PM, R51 was viewed in the dining room and staff were attempting to assist her to dine. R51 appeared lethargic and difficult to arouse and at times was grimacing in pain.
On 2/7/23 at 1:20 PM an interview was completed in R51's room with her guardian and another visitor. R51 was viewed in her bed, grimacing and moaning softly in pain. R51's guardian stated that R51 had fallen early this morning when she tried to self-transfer. R51's guardian stated R51 was in so much pain, they are working on getting a hip x-ray due to the emergency room not completing an x-ray in that area and R51 having a concerning increase in pain in her hip area. R51's guardian stated R51 was in significant pain and they were just trying to keep her calm right now.
R51's falls for the last 9 months were requested and 9 fall incident reports were received. R51 fell on 9/15/22, 11/4/22, 11/16/22, 11/27/22, 11/28/22, 12/9/22, 1/2/23, 1/7/23, and 2/7/23. 8 of these falls were unwitnessed. The fall incidents were compared to review of the resident's care plan printed 2/14/23. R12's care plan showed a problem area of Falls with a start date of 7/19/22: [R51] is at risk for falls/injury related to and the following concerns were checked: confusion/altered mental status, poor vision, history of falls, incontinent of bowel, and incontinent of urine. R51 was noted to be on medications that put her at risk including an anxiolytic (anxiety medication), antidepressant, antihypertensive (medication for blood pressure), laxative, and narcotic. Her gait stability was noted to be impaired.
Review of R51's fall incident dated 9/15/22 revealed she had a witnessed fall in the hallway at 1:00 PM when she tripped over and IV pole. The listed intervention was to encourage resident to utilize her walker during ambulation. There was a corresponding care plan intervention with start date of 9/15/22 staff will administer IV medication while resident is in bed and will encourage resident to utilize her walker during ambulation.
Review of R51's fall incident dated 11/4/22 revealed she had an unwitnessed fall in her room and was found at 5:00 AM laying on the floor next to bed .resident did hit her head & caused small amount of bleeding .small lump noted .Resident appears to have been sticking with her usual behavior, which is if she hears something going on outside of her room .or if staff does not answer her call or question what is going on, she goes to investigate .Resident was in PJs & sock, it appears she was getting up & slipped (she did not put her shoes/slippers on prior to ambulating/transferring) falling onto the floor & hit her head on the floor. The response was noted to be medication review. R51's care plan included the intervention grippy socks and medication review with start date 11/4/22.
Review of R51's fall incident dated 11/16/22 revealed she had an unwitnessed fall at 3:35 PM and was found on the floor in her room and stated was going to bathroom. The noted intervention was to encourage to use restroom after meals. A corresponding care plan intervention was added 11/17/22: encourage to use restroom after meals.
Review of R51's fall incident dated 11/27/22 revealed she had an unwitnessed fall and was found at 9:00 AM. R51 sustained injuries including a bruise on the left buttock and hematomas on the back of her head, left shin and left buttock as well as 2 skin tears on her right forearm. The resident was observed on the floor of her bathroom this morning at approx 8 am. She was laying on her back in front of the sink with her head in the doorway. A care plan intervention was added on 11/27/22: Close observation and frequent reminders to use walker. There was no parameters noted for how frequently to check on the resident.
Review of R51's fall incident dated 11/28/22 revealed she had an unwitnessed fall in her bedroom and was found at 2:30 PM and was observed on the floor of her room, sitting with her back against the door. A care plan intervention was added on 11/28/22: Frequent reminder to use call light. R51 has dementia and is not cognitively intact. This intervention was also already on their care plan since 7/19/22 under fall interventions: encourage resident to use call light for transfer/ambulation assistance.
Review of R51's fall incident dated 12/9/22 revealed she had an unwitnessed fall in her room and was found at 6:10 PM when she was ambulating to the restroom using a walker. Socks had no grip and resident was not wearing shoes as she was laying down in bed prior to fall and did not use call light for assistance. Interventions to add included reinforce need for call light use and socks with grips at all times. There were no added care plan interventions that were on or around the date of this fall.
Review of R51's fall incident dated 1/2/23 revealed she had an unwitnessed fall in their bedroom and was found at 9:20 AM after trying to walk across the room with out her walker and fell. However, after further review, the full incident description under the section circumstances of the incident and evaluation referred entirely to another resident, R12, and appeared to have been copied and pasted from R12's fall report from 12/26/22, including her medical information and description of the fall sustained by R12 and the fall interventions completed for R12 for her 12/26/22 fall, which was to add grippy strips. The event report clearly was for R51 as her name was the heading on each page of the report and it was in her electronic medical record, however the narrative details were not about this incident. Review of R51's progress notes revealed she was going to go to the closet to get her clothes .Resident has had a recent change in narcotic and a medication review will be requested. R51's care plan had an added intervention on 1/2/23: grippy strips in front of bed there was no mention of a medication review in R51's care plan.
Review of R51's fall incident dated 1/7/23 revealed she had an unwitnessed fall and was found at 11:00 PM in her room sitting on the floor next to wc (wheelchair). R51 had a skin tear to her left upper extremity due to the incident. The added intervention after the fall was noted to be toilet resident prior to going to bed. The care plan reflected offer toileting prior to bed was added on 1/7/23.
Review of R51's fall incident dated 2/7/23 revealed she had an unwitnessed fall and was found at 1:30 AM in her room on the floor with a hematoma to the right eye and right knee and swelling in her right facial area. The resident was sent to the emergency room for evaluation following the fall and was unable to state a reason for getting out of bed. The interventions were noted to be x-rays, coordination of care with hospice completed and pain management assessment started. Medication review completed and resident pain medication was changed. An attached skin assessment for 2/8/23 also indicated multiple areas of discoloration and bruising on both legs, both arms, buttocks and back. A review of R51's care plan revealed no additional interventions were added subsequent to the 2/7/23 fall as of 2/14/23.
On 02/14/23 at 09:48 AM an interview was completed with the Director of Nursing (DON) and CC L regarding falls. The DON stated in morning meeting, they go over falls together and discuss cause, what we can do in the future. CC L stated they do root cause analysis on falls in morning meetings. The DON was asked to look for proof of this analysis and provide these. It was discussed with the DON that the incident reports provided for R12 and R51 did not have this analysis documented and the interventions were weak as the falls progressed, since interventions that were standards of care such as grippy socks, grip strips on the floor and toileting residents before bed were examples of interventions after multiple falls. The DON agreed that things like grip socks and grip strips on the floor should be implemented early on when residents are identified as being at risk for falls.
On 02/14/23 at 01:58 PM an interview was completed with the NHA (nursing home administrator) and she asked for the root cause analysis for falls that were requested from the DON. The NHA stated they have identified they had an issue with falls and it is on the agenda for Quality Assurance team to address. The NHA stated they have identified that the previous DON was not handling falls appropriately, and the new DON has only been in the role less for less than 2 weeks now. Corporate is helping them review falls and will be assisting them in addressing fall interventions.
On 02/14/23 at 02:14 PM the interview with the NHA continued in her office. The NHA reiterated that it had been determined there was in issue with fall interventions. The NHA stated the last DON didn't realize what an intervention was and thought sending someone to the hospital was an intervention. The NHA stated they had tried to educate the DON regarding appropriate fall interventions and instructed her to bring falls to be reviewed by the IDT (inter-departmental team), but they were resistant to bringing incidents to the team to review. The NHA stated they identified the problem and the former DON and former ADON (assistant director of nursing) had been educated in November regarding expectations that included fall interventions.
Corporate staff had been in the building and added a tool for morning meeting, but the former DON was resistant to using the discussion tool. The plan for all nursing staff to be educated regarding fall interventions by 2/22/23, and education was started on 1/30/23. The interventions implemented for R12 and R51 after falls were discussed and the NHA agreed things like grippy socks and grip strips to the floor should be a standard intervention if anyone was a fall risk or had one fall, not waiting for subsequent falls. The NHA also agreed interventions such as toileting a resident before bed should also be a standard of care and not a fall intervention.
Review of facility policy Fall Investigation, undated, provided by the facility on 2/10/23 revealed: It is the Facility's Policy to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. A Fall Investigation must include: Immediate Safety Intervention and Root cause analysis with (sic) be conducted by a member of the IDT.
R26
On 2/9/23 at 7:55 AM an interview was conducted with R26 in her room. At that time a tube feeding was in progress at 52 milliliters (ml) per hour (ml/h). R26 reported that about three years ago another resident threw away her dentures and she has been waiting for new dentures ever since. R26 reported the facility keeps promising to replace them but it has not happened yet. R26 reported she takes her medication whole orally and eats some food from the facility and brought in by family. R26 indicated she would rather consume food that requires teeth or dentures to eat.
Review of the Electronic Medical Record (EMR) Care Plan for R26 reflected, Problem: Potential for Alteration in Dental Oral Status (related to) full dentures. The goal of this Care Plan concern reflected (R26) will .have proper fitting dentures in good repair .by target date. The Care Plan reflected this was initiated 8/17/2020. This Care Plan reflects that obtaining new dentures for R26 has been a known concern for approximately two and a half years.
On 2/15/23 at 10:21 AM an interview was conducted with Medical Records Staff (MRS) Q. MRS Q reported and outlined a series of appointments, cancellations, change of dental providers and attempts to get dentures for R26 over the course of 2021, 2022, and 2023. MRS Q reported that R26 has a dental appointment scheduled during this annual survey.
The Therapy Department document titled ST (Speech Therapy) Discharge Summary dated 9/16/21 was reviewed. The document reflected that (R26) prefers use of PEG tube feeding . And that (R26) is scheduled to get new dentures in several weeks and indicates she will eat more at that time. The document reflects that R26 was discharged from Speech Therapy Due to no progress toward consumption .with re-evaluation if changes occur.
On 02/14/23 at 11:06 AM R26 reported she can take in enough calories oraly to sustain herself without the tube feeding and reported she likely could have had the feeding tube removed 6 or more months ago.
Review of the EMR Progress Notes by Registered Dietician (RD) R dated 3/29/22 at 12:20 PM reflected R26 was receiving tube feeding at 52 cc per hour continuous for 24 hours a day for 1875 calories.
The EMR Progress Note by RD R dated 8/9/22 revealed that R26 weight shows significant weight gain to 161 lbs. No changes in tube feeding orders were noted at that time.
Review of the EMR vital sign weight history for R26 reflected on 2/7/23 R26 weighed 173 lbs. Review of the EMR vital sign weight history reflects an increase from 151 lbs. on 7/7/22 to 173 lbs. on 2/1/23 indicating a gain of 22 lbs.
Review of the Doctors Orders for R26 reflected two active orders for tube feeding. One, dated 10/12/21, is for Isosource at 52ml/h continuous every 24 hours. A second order dated 2/7/23 for Isosource at 65 ml/h for 18 hours beginning at 5:00 PM and off at 11:00 AM. Also noted was an order for no straws dated 12/6/22.
Review of the EMR Progress Note entered by RD R on 2/7/23 reflected documentation that the tube feeding rate was discussed with (R26) who agreed to change tube feeding time to being off (of the tube feeding) sometimes during the day. And that the tube feeding was to be adjusted to promote weight loss.
Review of the EMR Progress Note by RD R reflected on 2/14/23 at 8:36 AM that R26 had reported to RD R that the new tube feeding schedule of a rate of 65 ml/h for 18 hours is going well.
On 2/14/23 at 8:51 AM, 15 minutes following the documentation of RD R, the tube feeding for R26 was observed to be running at 52ml per hour from a bag that had been labeled to run at that rate for 24 hours and was started on 2/13/23. This conflicted with the documentation of RD R of the encounter 15 minutes prior to this observation. R26 did not indicate she was aware of a change in the tube feeding schedule.
On 2/14/23 at 11:10 AM an interview was conducted with RD R. RD R reported R26 recently changed from a 24-hour continuous tube feeding to 18 hours on and 6 hours off. RD R was informed that the tube feeding was running at 52 ml/h and not at 65 ml/h as documented in her note of 2/14/23 at 8:36 AM today. RD R acknowledged that she did not look at the tube feeding rate in progress at the time of her encounter with R26. RD R reported that although two active orders are present the one that reflects a rate of 65 ml/h is the correct order. RD R was asked what she attributed the 22 lbs. weight gain over the course of seven months (7/7/22 to 2/7/23) without adjustment of the rate and volume of tube feeding. RD R reported that R26 will say she doesn't want to get off the tube feeding so I have to encourage her to eat more. RD R was informed that straws were present at bedside and RD R reported that the no straws order would have come from Speech Therapy. However, the order for no straws was dated 12/6/22 and Speech Therapy has not evaluated R26 since 9/16/21. RD R reported she doesn't currently have any measurable goals or timeframe's in the Care Plan for R26 because the Resident has declined to have the tube removed. RD R indicated that she is optimistic this might soon happen since R26 will be getting dentures.
The first documentation identified that the facility was going to obtain replacement dentures for R26 is on the Care Plan dated 8/17/20. R26 has indicated that dentures would help in eliminating the need for nutrition by tube feeding but after more than twenty-nine months the Resident still does not have dentures. It is unclear if the appointment currently scheduled for replacement dentures will yield this result or if this will be a continuation of what R26 had endured since 8/17/20. Additionally, R26 has experienced a significant weight gain and gradual weight gains (14.5 % from 7/7/22 to 2/1/23) without adjustment to the tube feeding order. Review of the medical record did not result in discovery of referrals or evaluations by a physician to consider an adjustment to the tube feeding volume or other opinions of a medical professional. Conflicting Doctor's Orders were found to be incorrectly implemented as reported by RD R. The Doctor Order for no straws was not implemented or revised to accommodate the Resident prior to this survey. Per RD R, the Care Plan for R26 does not have any measurable goals or timeframe's to restore oral eating skills. Through interviews and documentation of the medical record it has been reported that R26 prefers to keep the feeding tube, but the documentation and statements simultaneously include that R26 is asking for replacement dentures. Lastly, during an interview R26 reported that she could have discontinued use of feeding tube feeding six or more months ago if she had dentures. No documentation was found that the facility provided R26 with appropriate treatment and services to enable the restoration oral eating skills or ensured quality care.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two Deficient Practice Statements (DPS)
DPS #1
Based on observation, interview, and record review the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two Deficient Practice Statements (DPS)
DPS #1
Based on observation, interview, and record review the facility failed to ensure enabling care and services were provided to one Resident (Resident #26 (R26)) receiving nutrition through a feeding tube to restore oral eating skills resulting in prolonged use of a feeding tube and anxiety and the potential for all facility residents with nutrition related needs to not receive enabling care and services to reach their highest practicalable potential.
Findings:
Review of the Minimum Data Set (MDS) dated [DATE] reflected that R26 was originally admitted to the facility 8/5/20 with pertinent diagnoses that included history of stroke with impairment to one side of the body. The MDS Brief Interview for Mental Status (BIMS) reflected R26 scored 15 out of 15 which indicated the Resident was cognitively intact. Section K (Swallowing and Nutrition) of the MDS revealed R26 has a feeding tube.
On 2/9/23 at 7:55 AM an interview was conducted with R26 in her room. At that time a tube feeding was in progress at 52 milliliters (ml) per hour (ml/h). R26 reported that about three years ago another resident threw away her dentures and she has been waiting for new dentures ever since. R26 reported the facility keeps promising to replace them but it has not happened yet. R26 reported she takes her medication whole orally and eats some food from the facility and brought in by family. R26 indicated she would rather consume food that requires teeth or dentures to eat.
Review of the Electronic Medical Record (EMR) Care Plan for R26 reflected, Problem: Potential for Alteration in Dental Oral Status (related to) full dentures. The goal of this Care Plan concern reflected (R26) will .have proper fitting dentures in good repair .by target date. The Care Plan reflected this was initiated 8/17/2020. This Care Plan reflects that obtaining new dentures for R26 has been a known concern for approximately two and a half years.
On 2/15/23 at 10:21 AM an interview was conducted with Medical Records Staff (MRS) Q. MRS Q reported and outlined a series of appointments, cancellations, change of dental providers and attempts to get dentures for R26 over the course of 2021, 2022, and 2023. MRS Q reported that R26 has a dental appointment scheduled during this annual survey.
The Therapy Department document titled ST (Speech Therapy) Discharge Summary dated 9/16/21 was reviewed. The document reflected that (R26) prefers use of PEG tube feeding . And that (R26) is scheduled to get new dentures in several weeks and indicates she will eat more at that time. The document reflects that R26 was discharged from Speech Therapy Due to no progress toward consumption .with re-evaluation if changes occur.
On 02/14/23 at 11:06 AM R26 reported she can take in enough calories oraly to sustain herself without the tube feeding and reported she likely could have had the feeding tube removed 6 or more months ago.
Review of the EMR Progress Notes by Registered Dietician (RD) R dated 3/29/22 at 12:20 PM reflected R26 was receiving tube feeding at 52 cc per hour continuous for 24 hours a day for 1875 calories.
The EMR Progress Note by RD R dated 8/9/22 revealed that R26 weight shows significant weight gain to 161 lbs. No changes in tube feeding orders were noted at that time.
Review of the EMR vital sign weight history for R26 reflected on 2/7/23 R26 weighed 173 lbs. Review of the EMR vital sign weight history reflects an increase from 151 lbs. on 7/7/22 to 173 lbs. on 2/1/23 indicating a gain of 22 lbs.
Review of the Doctors Orders for R26 reflected two active orders for tube feeding. One, dated 10/12/21, is for Isosource at 52ml/h continuous every 24 hours. A second order dated 2/7/23 for Isosource at 65 ml/h for 18 hours beginning at 5:00 PM and off at 11:00 AM. Also noted was an order for no straws dated 12/6/22.
Review of the EMR Progress Note entered by RD R on 2/7/23 reflected documentation that the tube feeding rate was discussed with (R26) who agreed to change tube feeding time to being off (of the tube feeding) sometimes during the day. And that the tube feeding was to be adjusted to promote weight loss.
Review of the EMR Progress Note by RD R reflected on 2/14/23 at 8:36 AM that R26 had reported to RD R that the new tube feeding schedule of a rate of 65 ml/h for 18 hours is going well.
On 2/14/23 at 8:51 AM, 15 minutes following the documentation of RD R, the tube feeding for R26 was observed to be running at 52ml per hour from a bag that had been labeled to run at that rate for 24 hours and was started on 2/13/23. This conflicted with the documentation of RD R of the encounter 15 minutes prior to this observation. R26 did not indicate she was aware of a change in the tube feeding schedule.
On 2/14/23 at 11:10 AM an interview was conducted with RD R. RD R reported R26 recently changed from a 24-hour continuous tube feeding to 18 hours on and 6 hours off. RD R was informed that the tube feeding was running at 52 ml/h and not at 65 ml/h as documented in her note of 2/14/23 at 8:36 AM today. RD R acknowledged that she did not look at the tube feeding rate in progress at the time of her encounter with R26. RD R reported that although two active orders are present the one that reflects a rate of 65 ml/h is the correct order. RD R was asked what she attributed the 22 lbs. weight gain over the course of seven months (7/7/22 to 2/7/23) without adjustment of the rate and volume of tube feeding. RD R reported that R26 will say she doesn't want to get off the tube feeding so I have to encourage her to eat more. RD R was informed that straws were present at bedside and RD R reported that the no straws order would have come from Speech Therapy. However, the order for no straws was dated 12/6/22 and Speech Therapy has not evaluated R26 since 9/16/21. RD R reported she doesn't currently have any measurable goals or timeframes in the Care Plan for R26 because the Resident has declined to have the tube removed. RD R indicated that she is optimistic this might soon happen since R26 will be getting dentures.
The first documentation identified that the facility was going to obtain replacement dentures for R26 is on the Care Plan dated 8/17/20. R26 has indicated that dentures would help in eliminating the need for nutrition by tube feeding but after more than twenty-nine months the Resident still does not have dentures. It is unclear if the appointment currently scheduled for replacement dentures will yield this result or if this will be a continuation of what R26 had endured since 8/17/20. Additionally, R26 has experienced a significant weight gain and gradual weight gains (14.5 % from 7/7/22 to 2/1/23) without adjustment to the tube feeding order. Review of the medical record did not result in discovery of referrals or evaluations by a physician to consider an adjustment to the tube feeding volume or other opinions of a medical professional. Conflicting Doctor's Orders were found to be incorrectly implemented as reported by RD R. The Doctor Order for no straws was not implemented or revised to accommodate the Resident prior to this survey. Per RD R, the Care Plan for R26 does not have any measurable goals or timeframes to restore oral eating skills. Through interviews and documentation of the medical record it has been reported that R26 prefers to keep the feeding tube, but the documentation and statements simultaneously include that R26 is asking for replacement dentures. Lastly, during an interview R26 reported that she could have discontinued use of feeding tube feeding six or more months ago if she had dentures. No documentation was found that the facility provided R26 with appropriate treatment and services to enable the restoration oral eating skills or ensured quality care.
DPS #2
Based on observation, interview, and record review the facility failed to monitor skin, identify, prevent and treat wounds for one resident, Resident #32 (R32) reviewed for skin impairment. The deficient practice resulted in R32 developing a wound to his toe.
Findings included:
A request was made for a skin assessment policy. On 2/14/23 at 2:00 PM the Nursing Home Administrator (NHA) stated that she had double checked, and this is the only skin policy the facility had. The facility provided a copy of the Pressure Injuries: Assessment, Prevention and Treatment, undated and unsigned for review. The policy reflected, Assessment .2. Skin will be assessed routinely for the presence of developing pressure injuries and documented on the Nursing Skin Tool.
R32
Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R32 admitted to the facility on [DATE] with diagnosis that included but not limited to diabetes type 2, peripheral vascular disease and a right below the knee amputation. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represents R32 was cognitively intact.
Record review of the Treatment Administration History (TAH) record from 1/1/23 - 2/14/23 was reviewed. The TAH reflected, Weekly skin assessment, document in progress notes. Notify MD (medical doctor) & wound nurse of changes. This order was signed as completed on 1/19/23, 1/26/23, and 2/2/23. On 2/9/23 it reflected, Resident unavailable, Comment: in chair, off unit. The TAH reflected the weekly skin checks were done for 3 of the 6-week period.
Record review of the nursing progress notes from 1/1/2023 - 1/18/2023 was completed. The following progress notes related to skin were as follows:
-1/1/23 at 2:11 PM No new skin issues, continue to (name of treatment) to sacral area.
-1/8/23 at 3:10 PM Weekly skin assessment completed with no skin issues observed.
-1/18/23 at 8:49 AM Resident came to nurse stating he noticed a dark scab on his toe this morning. States he notified the floor nurse who trimmed the toenail of his big toe which was pushing into the second toe causing trauma. Area is on second toe of left foot, inner aspect, 1.0 cm x 0.5 cm x uta (unable to assess). 100% nonviable tissue. Scant serosanguinous drainage. No surrounding erythema. Resident denies pain. Referral to Avanti wound specialists, MM-PA to be notified. Resident states he called his (guardian) last night around 2 am to notify her because he is nervous about the area. See grid (wound measurement) and tx (treatment) order.
During an interview and record review on 2/14/23 at 3:00 PM, Nurse I reviewed the nursing notes regarding the new toe wound and stated that she thought she had charted it but must have forgotten. Nurse I stated that R32 had noticed a wound on his toe and brought it to my attention first thing that day (1/18/22). Nurse I stated that R32 had complained of pain to his toe (2nd toe on left foot). Nurse I stated that he had a sharp piece of nail (from the great toe) embedded in the side of his second toe. Nurse I stated that she used a tongue depressor to lift it slightly and snipped the sharp piece off and reported it to the wound nurse.
During an interview on 2/9/23 at 3:46 PM, R32 stated he had a new wound to his second toe. R32 stated he's the toenail on the great toe caused it. R32 stated his roommate got his toenails trimmed by the podiatrist that comes to the facility and asked staff why he wasn't getting his done because they needed it.
During a telephone interview on 2/10/23 at 9:29 AM, R32's Representative stated she was a bit upset about the new sore R32 had on his toe. R32's Representative stated that R32 was supposed to be seen by the podiatrist who came to the facility. R32's Resident Representative stated, I'd like to know what happened to that. I signed a form authorizing it.
During an interview on 2/10/23 at 9:45 AM, the Director of Nursing (DON) stated staff do not trim R32's toenails, only podiatry can. A request for all podiatry notes for nail trimming from admission [DATE] - 2/10/23 was made. At 11:45 AM the DON provided the following documents for review:
-A copy of the Request for Service dated 10/5/2022. R32's Representative signed authorizing services for audiology and podiatry, upon admission.
-A Podiatry Visit Summary dated 10/13/22, 39 residents were treated and R32's name was not listed on the visit summary.
-A Podiatry Visit Summary dated 12/29/22, 32 residents were treated and R32's name was not listed on the visit summary.
When asked why R32's was not seen by podiatry since his admission, the DON stated the (name of the service) decides when residents will be seen. When asked if a staff member can recommend residents be placed on the podiatry list, the DON stated, Yes. Actually (name of R32) requested to see them. The DON stated she was unable to find any notes that R32's toenails were trimmed from admission until the wound was noted on 1/18/23 (15 weeks).
According to the physician orders dated 1/20/23, Doxycycline was ordered for a diagnosis of paronychia (infection surrounding the nail) for the new ulcer on the left foot, second toe.
According to the podiatry note dated 1/30/23 at 9:21 AM, R32 was evaluated by an offsite podiatrist. The note reflected, Pt (patient) seen with ulceration medial (side) left 2nd digit secondary to toenail digging into the skin. He noticed erythema (redness) and edema and was placed on doxycycline .Nails are elongated (long toenails) 1-5 L (all toes on left foot) there is thickening, subungual debris (accumulates under the nail) .Nails debrided L (nails trimmed to left foot) .
The facility provided the following wound specialist notes with weekly wound measurements:
-1/19/23 0.9 x 0.6 x 0.1
-1/26/23 0.7 x. 0.4 x 0.1
-2/2/23 0.4 x 0.4 x 0.1
During an interview on 2/20/23 at 2:34 PM, when asked about documenting the weekly head to toe skin assessments, the DON stated, We don't measure bruises, red areas or skin tears, only open areas.
During an interview and record review on 2/14/23 at 2:00 PM, a request to review the skin assessments documented on the Nursing Skin Tool (according to the policy) from 10/4/22 - 2/14/23 was made and the facility provided the Nursing Assistant Bathing/Skin Tool instead. The NHA stated the facility was not able to locate the Nursing Skin Tools. The NHA stated that she did not expect the nurse aides to diagnosis and document skin assessments. The NHA stated, That's the licensed nurses responsibility.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
QAPI Program
(Tag F0867)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to fully implement its established Quality Assurance Process Improvement (QAPI) plan and adequately and appropriately address known deficienci...
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Based on interview and record review, the facility failed to fully implement its established Quality Assurance Process Improvement (QAPI) plan and adequately and appropriately address known deficiencies resulting in 1.) The inability to sustain substantial compliance with federal regulations, 2.) unrecognized and incompletely evaluated systems leading to physical and psychosocial harm and diminished quality of life for residents living at the facility.
Findings:
The facility provided a copy of the policy titled, Quality Assurance Performance Improvement Plan Updated 12/2019. The policy reflected, Our QAPI Principals .Principle #2: Our organization utilizes data trends from many sources including CASPER, MY INTERVIEW and Nursing Home Compare to identify areas that may need interventions to improve outcomes .Principle #7: Our organization encourages all staff and stakeholders to identify breakdowns in service, opportunities for improvement and service gaps so that improvement can be made .
Review of the facility survey history revealed the annual recertification survey event GYJG11 dated 2/01/22 found the facility non-compliant with federal regulations including but not limited to dignity, reporting injuries of unknown origin, falls, hot water hazards, sanitary food handling and kitchen, and pest control.
On 1/19/23 at 2:45 PM, R7 sustained 6 full thickness burns to her bilateral thighs when she spilt hot coffee in her lap. The facility investigated and put interventions into place following the incident. On-going non-compliance at Accidents and Hazards for safe hot liquid handling was identified at a level of serious harm with injury. The facility was issued an Immediate Jeopardy notice by the survey team. The facility failed to identify the need to assess all residents for safe handling of hot liquids and take temperatures on hot liquids before serving. The facility developed a removal plan which was validated by the survey team on 2/17/23. Review of the survey history reflected the facility was cited for hot water hazards on 2/1/22 and did not sustain compliance.
Review of the fall histories for R12 reflected 7 falls in 9 months and R51 sustained 9 falls in 9 months. The falls resulted in injuries such as pain, facial bruising, head laceration, skin tears, and hip fracture. The facility failed to thoroughly investigate and put meaningful interventions into place after both residents exhibited patterns and trends with falls.
On 02/14/23 at 09:48 AM an interview was completed with the Director of Nursing (DON) and CC L regarding falls. The DON stated in morning meeting, they go over falls together and discuss cause, and what we can do in the future. CC L stated they do root cause analysis on falls in morning meetings. The DON was asked to look for proof of this analysis and provide these to the Surveyor.
On 02/14/23 at 01:58 PM an interview was completed with the NHA (nursing home administrator) and she asked for the root cause analysis for falls that were requested from the DON. The NHA stated they have identified they had an issue with falls, and it is on the agenda for Quality Assurance team to address. The NHA stated they have identified that the previous DON was not handling falls appropriately, and the new DON has only been in the role less for less than 2 weeks now. Corporate is helping them review falls and will be assisting them in addressing fall interventions.
On 02/14/23 at 02:14 PM the interview with the NHA continued in her office. The NHA reiterated that it had been determined there was in issue with fall interventions. The NHA stated the last DON didn't realize what an intervention was and thought sending someone to the hospital was an intervention. The NHA stated they had tried to educate the DON regarding appropriate fall interventions and instructed her to bring falls to be reviewed by the IDT (inter-departmental team), but they were resistant to bringing incidents to the team to review. The NHA stated they identified the problem and the former DON and former ADON (assistant director of nursing) had been educated in November regarding expectations that included fall interventions. Corporate staff had been in the building and added a tool for morning meeting, but the former DON was resistant to using the discussion tool. The plan for all nursing staff to be educated regarding fall interventions by 2/22/23, and education was started on 1/30/23.
Review of the pest service inspection report dated 1/18/23 at 11:14 AM reflected the following areas of concern that required action: broken floor tiles in the Dementia shower stall floor identified ants were coming and going, remove and/or clean under kitchen equipment and tables to reduce pest allure (unsanitary conditions), and the appropriate placement of mouse traps.
According to observations made by the survey team on 2/7/23 at approximately 10:00 AM, the items were not acted on by the facility and the pest issues continued.
During an interview on 02/10/23 at 12:15 PM, Maintenance Director (MD) I revealed, I was unaware of any issues on the pest report. MD I further revealed that prior to this week he had not received any pest reports since he started because they were going to the previous maintenance person's email. MD I stated the pest reports pointed to ongoing issues that should have been corrected. This deficient practice resulted in continued non-compliance in the pest control and a sanitary kitchen which were both identified in the last annual survey.
During an interview on 2/15/23 at 3:40 PM, the NHA identified issues that contributed to the QA programs effectiveness. The NHA identified staff turn over the past year for multiple positions which included by not limited to the NHA changed 3 times, the DON changed 3 times, the ADON changed 5 times, the ICP (infection control preventionist) changed 4 times. The NHA stated the staff could not stay organized to identify their deficient practices and put plans of correction into place.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers to MI00134349.
Based on interview and record review, the facility failed to report allegations of an injury...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers to MI00134349.
Based on interview and record review, the facility failed to report allegations of an injury of unknown origin and investigation results in a timely manner to the state survey agency for 1 of 7 residents (R30) reviewed for abuse, resulting in delayed reporting to the state survey agency, the potential for abuse to go undetected for extended periods of time, and the potential for residents to not be protected from abusive individuals.
Findings include:
A review of R30's Face Sheet, dated 2/14/23, revealed R30 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, the Face Sheet revealed multiple diagnoses that included dementia with behaviors, repeated falls, and generalized muscle weakness.
A review of R30's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/27/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 7 which revealed R30 was severely cognitively impaired.
A review of R30's Nursing Assistant Bathing/Skin Tool, dated 12/13/22, revealed, Bruise right flank, red legs. The Nursing Assistant Bathing/Skin Tool had a picture of a body in which both lower legs (including the feet) and the right side of the body were circled indicating the location of the bruise and red legs. There were not any measurements of the bruise noted on R30's Nursing Assistant Bathing/Skin Tool. Therefore, based on the area circled on the picture, it would be reasonable to conclude the bruise extended from R30's right side (flank) below the lower ribs to R30's right hip area.
A review of R30's Nursing note, dated 12/19/2022 (6 days after the bruising was noted on the Nursing Assistant Bathing/Skin Tool), revealed, Resident has large bruise to right lateral thigh, origin unknown. The Nursing note did not indicate that anyone was notified of the bruise of unknown origin.
A review of R30's Nursing note, dated 12/20/22, revealed, Bluish discoloration, the size of quarter to resident's lateral right upper leg due to resident's aggressive self transferring from bed and into her wheelchair .
A further review of R30's medical record failed to reveal any measurements of R30's right flank bruise (as noted on the Nursing Assistant Bathing/Skin Tool, dated 12/13/22). In addition, R30's medical record failed to reveal any other reference to R30's right lateral thigh bruise except for the Nursing notes on 12/19/22 and 12/20/22.
A review of the facility's Investigation Report for an injury of unknown origin, undated, revealed the following:
- The Administrator was notified R30 had a long skinny bruise on right outer hip on 12/23/22 at 10:00 AM (10 days after bruising was noted on R30's Nursing Assistant Bathing/Skin Tool and 4 days after a large bruise of unknown origin was noted in a Nursing note) and reported an allegation of an injury of unknown origin (long skinny bruise on right outer hip) to the state survey agency (SSA) on 12/23/23 at 11:10 AM. The bruise measured approximately 3 inches long, less than an inch wide.
- The facility started an investigation on 12/23/22 after they reported the allegation to the SSA.
- The facility concluded their investigation on 1/4/23 and concluded that R30's bruise was the result of her bumping her hip on the arm of the wheelchair when she was transferring [from and/or to] the wheelchair.
During an interview on 2/14/23 at 9:10 AM, the Director of Nursing (DON) stated the bruise that was referenced on the 12/13/22 Nursing Assistant Bathing/Skin Tool was the same bruise that was referenced in the Nursing notes on 12/19/22 and 12/20/22. The DON also stated that the bruise referenced on the Nursing Assistant Bathing/Skin Tool and in the Nursing notes was the same bruise that was reported to the SSA on 12/23/22 at 10:00 AM as an injury of unknown origin.
A review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy and Procedure, undated, revealed, E. Initial Report 1. Timing. a. Administrator. All incident and allegations of Abuse, Neglect, Exploitation, or mistreatment of a resident, or Misappropriation of Resident Property and all Injuries of Unknown Source must be reported immediately to the Administrator or designee . The Administrator or his/her designee will notify [name of State Survey Agency (SSA)] and one or more law enforcement entities of all violations involving Abuse, Neglect, Exploitation and Misappropriation of Resident Property and Injuries of Unknown Source as soon as possible, but in no event later than twenty-four (24) hours from the time the incident/allegation was made known to the staff member . R30's injury of unknown origin (bruise) was reported to the Administrator 10 days after it was first noted by the nursing assistant on R30's Nursing Assistant Bathing/Skin Tool and 4 days after a nurse documented R30 had a bruise of unknown origin in a Nursing note.
A review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy and Procedure, undated, revealed, F. Investigation Once the Administrator, [name of SSA] and law enforcement are notified, an investigation of the allegation violation will be conducted. 1. Time frame for investigation. The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days (e.g., quantifying amounts misappropriated if an accountant needs more time) . H. Final Reports 1. Timing. The results of the investigation will be reported to the Administrator, and a final report will be submitted to [name of SSA] no later than five (5) working days after discovery of the incident (excluding holidays, Saturday and Sunday). The facility concluded their investigation and reported their findings to the SSA 8 working days after the allegation was reported to the Administrator.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation refers to MI00134349.
Based on interview and record review, the facility failed to timely and thoroughly investiga...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation refers to MI00134349.
Based on interview and record review, the facility failed to timely and thoroughly investigate an allegation of an injury of unknown origin for 1 of 7 residents (R30) reviewed for abuse, resulting in the potential for abuse to go undetected and residents not being protected from an abusive individual.
Findings include:
A review of R30's Face Sheet, dated 2/14/23, revealed R30 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, the Face Sheet revealed multiple diagnoses that included dementia with behaviors, repeated falls, and generalized muscle weakness.
A review of R30's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 1/27/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 7 which revealed R30 was severely cognitively impaired.
A review of R30's Nursing Assistant Bathing/Skin Tool, dated 12/13/22, revealed, Bruise right flank, red legs. The Nursing Assistant Bathing/Skin Tool had a picture of a body in which both lower legs (including the feet) and the right side of the body were circled indicating the location of the bruise and red legs. There were not any measurements of the bruise noted on R30's Nursing Assistant Bathing/Skin Tool. Therefore, based on the area circled on the picture, it would be reasonable to conclude the bruise extended from R30's right side (flank) below the lower ribs to R30's right hip area.
A review of R30's Nursing note, dated 12/19/2022 (6 days after the bruising was noted on the Nursing Assistant Bathing/Skin Tool), revealed, Resident has large bruise to right lateral thigh, origin unknown.
A review of R30's Nursing note, dated 12/20/22, revealed, Bluish discoloration, the size of quarter to resident's lateral right upper leg due to resident's aggressive self transferring from bed and into her wheelchair . If this note is also referring to the bruised area that was noted on the Nursing Assistant Bathing/Skin Tool, dated 12/13/22, then the measurement was made one week after the bruise first appeared and would reflect healing with a diminution in size. Therefore, the original size of the bruised area was unknown, except as depicted in the circled portion of the picture on the Tool.
A further review of R30's medical record failed to reveal any actual measurements of R30's right flank bruise (as noted on the Nursing Assistant Bathing/Skin Tool, dated 12/13/22) around the time the bruise was first noted or any mention of the right flank bruise (unless the Nursing notes on 12/19/22 and 12/20/22 are referring to it after it has had a week to heal). In addition, R30's medical record failed to reveal any other reference to R30's right lateral thigh bruise except for the Nursing notes on 12/19/22 and 12/20/22.
A review of the facility's Investigation Report for an injury of unknown origin, undated, revealed the following:
- The Administrator was notified R30 had a long skinny bruise on right outer hip on 12/23/22 at 10:00 AM (10 days after bruising was noted on R30's Nursing Assistant Bathing/Skin Tool and 4 days after a large bruise of unknown origin was noted in a Nursing note resulting in a significant delay in initiating an investigation) and reported an allegation of an injury of unknown origin (long skinny bruise on right outer hip) to the state survey agency (SSA) on 12/23/23 at 11:10 AM. The bruise measured approximately 3 inches long, less than an inch wide.
- The facility started an investigation on 12/23/22 after they reported the allegation to the SSA.
- The facility indicated they did not notify law enforcement that there was an allegation of an injury of unknown origin.
- Admissions Coordinator (AC) C's typed and signed statement, dated 12/27/22, revealed, I have noticed [name of R30] aggressively propelling herself forward in her wheelchair by using a consistent back and forth motion with her upper body and legs. Resident is also noted trying to push her walker by holding it in front of her as she propels in her wheelchair. This statement was taken 4 days after the incident was reported to the Administrator, 8 days after the nurse noted R30 had a bruise of unknown origin in the Nurses note, and 14 days after the nurse aide noted R30 had a bruise to the right flank on the Nursing Assistant Bathing/Skin Tool.
- Registered Nurse (RN) G's written and signed statement, dated 12/27/22, revealed, I have noted [name of R30] on several occasions including today ambulate in her wheelchair with her walker. She rocks back and forth in the wheelchair with doing this. She will often refuses care and/or redirection stating No. Leave me alone. This statement was taken 4 days after the incident was reported to the Administrator, 8 days after the nurse noted R30 had a bruise of unknown origin in the Nurses note, and 14 days after the nurse aide noted R30 had a bruise to the right flank on the Nursing Assistant Bathing/Skin Tool.
- Nursing Assistant (NA) D's written and signed statement, undated, revealed, Resident likes to self transfer from bed to wheelchair as well as self transfer from chair to toilet. She refuses help when we offer. There are times that have self transfers a little to [sic] hard and her hips hit the sides of the wheelchair. This statement was undated. Therefore, it was unknown if the statement was taken on 12/23/22 or on an earlier/ later date.
- Licensed Practical Nurse (LPN) E's written and signed statement, undated, revealed, Notified by staff that resident self transfers to bed and toilets self. Resident had hx of falls. This statement was undated. Therefore, it was unknown if the statement was taken on 12/23/22 or on an earlier/ later date.
- LPN F's written statement, undated, revealed, Since I have been working at [name of facility] and have been the East Hall nurse I have witnessed [name of R30] refuse care on a regular basis. Even in passing when I was not the assigned nurse, there have been numerous occasions when staff attempted to her transfer in and out of bed and in and out of her chair and she screamed for them to go away. [Name of R30] will self transfer from bed to chair and back and also on and off toilet without using call light for assistance. [Name of R30] requests her meds be sat down and for staff to leave. Staff will watch [name of R30] take medications from the hallway to honor her wishes. When [name of R30] transfers from bed/toilet to chair she flops her body in the chair very roughly. This statement was undated. Therefore, it was unknown if the statement was taken on 12/23/22 or on an earlier/ later date.
- There was not an interview in the investigation file for R30 or any documentation that R30 had been interviewed or an interview had been attempted.
- The facility concluded their investigation on 1/4/23 and concluded that R30's bruise was the result of her bumping her hip on the arm of the wheelchair when she was transferring [from and/or to] the wheelchair. Even though there was not a documented interview of R30 (except in the 5-Day Summary), the facility came to their conclusion based on an undocumented statement by R30 that the bruising was because I bumped it or something, even though R30 allegedly stated she did not know what caused her bruise when initially asked about it. This undocumented statement was allegedly taken from R30, even though the facility indicated in the report that R30 was severely cognitively impaired.
During an interview on 02/10/23, the Director of Nursing (DON) stated, We don't measure bruises, red areas, and not always skin tears found on skin checks. As a result of the facility not measuring bruises, there is no way to know how large the bruises are initially, if the bruises are getting larger or smaller, how many bruises are in one area, and/or have an idea what they look like (e.g., rounded shape, irregular shape, long/skinny, multiple rounded bruises that appear consistent with finger marks).
During a second interview on 2/14/23 at 9:10 AM, the DON stated the bruise that was referenced on the 12/13/22 Nursing Assistant Bathing/Skin Tool was the same bruise that was referenced in the Nursing notes on 12/19/22 and 12/20/22. The DON also stated that the bruise referenced on the Nursing Assistant Bathing/Skin Tool and in the Nursing notes was the same bruise that was reported to the SSA on 12/23/22 at 10:00 AM as an injury of unknown origin. Therefore, R30's bruise that was referenced on the 12/13/22 Nursing Assistant Bathing/Skin Tool was not investigated until 12/23/22 for a possible cause.
A review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy and Procedure, undated, revealed, F. Investigation Once the Administrator, [name of SSA] and law enforcement are notified, an investigation of the allegation violation will be conducted. 1. Time frame for investigation. The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days (e.g., quantifying amounts misappropriated if an accountant needs more time). 2. Investigation protocol. The person investigating the incident should generally take the following actions: . Obtain a statement from the resident, if possible the accused, and each witness . At a minimum, staff taking the interview statements should date and sign that these statements were taken . 3. Documentation. Evidence of the investigation should be documented. The facility concluded their investigation 8 working days after the allegation was reported to the Administrator. In addition, the investigation was missing key documentation that the facility alluded to in their summary of the investigation (e.g., measurements of the bruise(s), interview of the resident) that would contribute to a complete and thorough investigation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent for one Resident (Resident #58 (R58)) resulting in the implementat...
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Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent for one Resident (Resident #58 (R58)) resulting in the implementation of an insulin delivery device inconsistent with the manufacturer's recommendation and the potential for inaccurate administration of insulin to all facility residents prescribed insulin through a delivery device.
Findings:
Review of the manufacturer's package insert for the Humalog Kwik Pen reflected: Prime before each injection . If you do not prime before each injection you may get too much or too little insulin. And Step 6 To prime your pen turn the dose knob to select 2 units. Steps 7 and 8 continue to describe the priming process to ensure the proper dose will be administered. Step 11 of the manufacturer's package insert directs the administration of insulin once a site is selected and cleansed with an alcohol swab as follows, Insert the needle into (the) skin. Push the knob (plunger) all the way in. Then Continue to hold the dose knob in and slowly count to 5 before removing the needle.
Review of the Doctor's Orders for R58 reflected a current order for use of a Humalog Kwik Pen with the dose determined by a sliding scale based on the blood sugar result taken before meals and at bedtime
On 2/8/23 at 8:05 AM a medication observation was conducted with Licensed Practical Nurse (LPN) B for R58. During the task LPN B was observed confirming the dose of insulin to be administered and setting the Humalog Kwik Pen to the prescribed dose. During the administration of the insulin the site selected, cleansed, and administered with immediate withdrawal of the needle from the skin following administration. LPN B was not observed to have primed the needle of the Humalog Kwik Pen prior to setting the dose or to have held the device at the site of administration as directed by the manufacturer. On return to the medication cart LPN B was asked to describe the steps in the use of the Humalog Kwik Pen. LPN B reported and demonstrated that the dial on the insulin pen is set to the prescribed dose. LPN B reported no priming of the needle was needed and that once the device plunger is pushed to the bottom of travel to withdraw from the administration site. No holding of the device to the injection site was needed. The description of use of the Humalog Kwik Pen provided by LPN B was inconsistent with the manufacturer's recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure safe and proper storage of medications for three Residents (Resident #4 (R4) and Resident #121 (R121) and Resident #20 ...
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Based on observation, interview and record review, the facility failed to ensure safe and proper storage of medications for three Residents (Resident #4 (R4) and Resident #121 (R121) and Resident #20 (R20)) that had not been evaluated for self-administration of medication, resulting in the potential for misuse and overuse of medication and the potential for medication diversion.
Findings include:
During the initial resident screening process of the annual survey medications were observed in the possession of three facility Residents: R121, R4, and R20.
On 2/7/23 at 9:40 AM in the room of R121 a Symbicort inhaler attached to an aero chamber spacer and an albuterol multi-doses inhaler were observed on the over-the-bed table at the Resident's bedside.
On 2/7/23 at 10:09 AM in the room of R4 a fluticasone propionate 16-gram net weight bottle containing 120 metered doses was observed on the over-the bed table at bedside.
During an interview conducted 2/7/23 at 11:33 AM, R20 displayed an albuterol inhaler he reported he kept on his person to use when he felt he needed to.
Review of the Electronic Medical Record (EMR) reflected that the three residents had current Doctors Orders for the medications. However, further review of the EMR did not reveal that the residents had been evaluated and Care Planned for self-administration of these medications.
On 2/14/23 at 1:51 PM an email was submitted to the Nursing Home Administrator (NHA) requesting documentation of the assessments for self-administration of medications for R121, R4, and R20.
On 2/15/23 at 9:56 AM, an interview was conducted with the Director of Nursing (DON) and the NHA in the office of the DON. The NHA reported that approval for self-administration of medications is a lengthy process and no residents at the facility have this approval. The DON and the NHA were informed of the findings. The NHA reported that the Residents should not have the medications in their possession.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 residents (R12...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for 2 residents (R12 and R51) reviewed, resulting in inaccurate and incomplete medical records and protected health information related to R12 being documented in R51's medical record and the potential for providers not having an accurate picture of the resident condition.
Findings include:
Review of R12's face sheet dated 2/14/23 revealed she was a [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: dementia, unsteadiness on feet, restlessness and agitation, difficulty in walking, and fracture of the right femur. R12 was not their own responsible party for financial or medical decisions.
Review of R51's face sheet dated 2/14/23 revealed she was an [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: cerebrovascular disease, dementia, difficulty walking, unsteadiness on feet, and muscle spasm. R51 was not their own responsible party for financial or medical decisions.
Fall incident reports were reviewed for both R12 and R51.
Review of R51's fall incident dated 1/2/23 revealed she had an unwitnessed fall in her bedroom and was found at 9:20 AM after trying to walk across the room with out her walker and fell. However, after further review, the full incident description under the section circumstances of the incident and evaluation referred entirely to another resident, R12, and appeared to have been copied and pasted from R12's fall report from 12/26/22, including her name, demographic information, medical diagnosis information and description of the fall sustained by R12 and the fall interventions completed for R12 for her 12/26/22 fall, which was to add grippy strips. The event report clearly was for R51 as her name was the heading on each page of the report and it was in her electronic medical record, however the narrative details were not about this incident. Review of R51's progress notes revealed she was going to go to the closet to get her clothes .Resident has had a recent change in narcotic and a medication review will be requested. R51's care plan had an added intervention on 1/2/23: grippy strips in front of bed there was no mention of a medication review in R51's care plan.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers in part to MI00133328 and MI00133125:
Based on observation, interview, and record review the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers in part to MI00133328 and MI00133125:
Based on observation, interview, and record review the facility failed to ensure trained staff in sufficient numbers to ensure identified individualized care needs are addressed timely for three Residents (Resident #30 (R30) Resident #26 (R26), Resident #48 (R48), and supervision for Resident #12 (R12) and Resident #51 (R51) resulting in unmet care needs, actual and reasonable-person feelings of worthlessness, lack of dignified care, neglect, unwitnessed falls and the potential for all facility residents to not receive timely, necessary competent care and services.
Findings:
2/7/23 at 9:38 AM, Licensed Practical Nurse (LPN) B refused to talk about staffing.
2/7/23 at 10:05 AM, CNA O reported that the facility does not have enough staff to meet the needs of the residents. CNA O reported that she is the only CNA for 21 residents on the East Hall.
R30
Review of the Minimum Data Set (MDS) dated [DATE] reflected that R30 was originally admitted to the facility 5/11/19 with pertinent diagnoses that included non-traumatic brain dysfunction, dementia, and psychotic disorder. The MDS Brief Interview for Mental Status (BIMS) reflected a score 2 out of 15 which indicated the Resident was severely cognitively impaired. Section G (Functional Status) of the MDS reflected that R30 was non-ambulatory.
On 2/7/23 at 10:15 AM on the East Hall R30 was observed self-propelling her wheelchair out of her room wearing a blouse but appeared to be naked from the waist down initially. It was determined she was clad in a brief which was difficult to see in the position she was sitting. Staff, dressed in street clothes (not in scrubs), who arrived shortly after the survey screening process began on the East Hall, attempted to attend to R30. No efforts were observed to protect the dignity of R30. These staff members did not appear to know how to assist the Resident.
Continued from above on 2/7/23 at 10:23 AM, R30 remains in the hall clad in a blouse and a brief. The staff in street clothes, gathered farther down the hall, were overheard saying that R 30 won't let them do anything.
On 2/10/23 at 7:50 AM, Registered Nurse (RN) G reported that staffing is the worst it ever has been, even during COVID. RN G reported in the past staff worked together but that numerous changes in management and supervision have resulted in staff turn-over. RN G reported that usually it is just her and one aide on the East Hall. RN G described a recent incident when residents were returning from dining, a meal cart was on the hall, and it was just her and one aide. RN G described the scene as chaos. RN G reported that three management and supervision staff were standing in the hall talking and laughing when all this chaos was going on, RN G stated I went off . RN G indicated that her outburst earned her a gesture of disgust from the Nursing Home Administrator (NHA), and I'm like, can't you see what is going on here, like what's the matter with you. RN G indicated that it was evident that the few staff on the floor and the residents needed help but that her comments did not prompt the help that was hoped for. RN G stated, the last six or seven months . it's just been terrible. RN G reported that staffing has been increased since the start of this state survey.
On 2/10/23 at 7:53 AM, R30 was observed in her room asleep uncovered in a low bed wearing only a wet brief. R30 did not have any clothing on her upper body and was laying on a bare mattress stripped of all bedding. A pillow lay on the floor near the foot of the bed. A wheelchair was close to the bed with an empty strawberry shake drink box on the seat. No water was in reach. No call light was in reach and the drapes to the outside were fully open. Besides RN G, no other staff were observed on the hall. At 8:11 AM the presentation of R30 was unchanged.
On 2/10/23 at 1:36 PM an interview was conducted with the Director of Nursing (DON) and Corporate Nurse (CN) P. During this interview the two observations of R30 on 2/7/23 and the two observations of 2/10/23 were reviewed. The DON reported that she was one of the staff members present during the observations of 2/7/23. The DON reported that R30 is Care Planned for refusal of care.
The MDS dated [DATE] for R30 was reviewed. The MDS Section E for Behavior, on line E0800 Rejection of Care, was documented, behavior not exhibited.
Review of the Care Plan for R30 reflected an Active Problem that R30 is Non-adherent with care/services. (R30) is resistant to hands on care and assistance with (Activities of Daily Living) weights, skin checks, and bathing. The start date of this active problem is documented as 2/10/23 and Last Reviewed/Revised on 2/10/23 at 10:09 AM; two hours after the last Resident observation at 8:11 AM this day. No interventions were found that instructed staff on how to maintain the Resident's dignity either in or outside of her room with alleged known behaviors.
The undated policy provided by the facility titled Abuse, Neglect, Exploitation, and Misappropriation of Resident Property was reviewed. The facility policy revealed on page 3, section C, The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and ensure that staff assigned have knowledge of the individual residents' care needs.
R26
Review of the MDS dated [DATE] reflected that R26 was originally admitted to the facility 8/5/20 with pertinent diagnoses that included history of stroke with impairment to one side of the body. The MDS Section C for Cognitive Patterns reflected R26 had a BIMS score 15 out of 15 which indicated the Resident was cognitively intact. Section K of the MDS revealed R26 has a feeding tube. The MDS section for Functional Status (Section G) reflected that R26 required extensive assistance of two staff with bed mobility, transfers, and toileting.
On 2/9/23 at 7:55 AM the call light for the room of R26 was observed to be visible in the hall. An interview was conducted and R26 reported that she is wet, needs changing, and that her call light has been on for about ten minutes. R26 reported that she doesn't get out of bed very often because she requires a lift and two staff members. R26 reported that it takes a lot of time to get her out of bed and staff, don't have time to get me up but they sure have the time to get everyone else up.
On 2/9/23 at 8:09 AM the call light for R26 remained unanswered. R26 reported that she experiences long response times, and this makes her feel like crap. R26 reported if the call light doesn't get their attention she must holler. R26 stated, They respond to me hollering, I know they're short-staffed, I'm not stupid.
On 2/9/23 at 8:26 AM, 31 minutes after the initial interview, the call light for R26 remained visible in the hall. R26 reported no staff have been in to inform that she is wet and needs to be changed. During this conversation a nurse from another hall was observed walking past the door without looking into the room. Stepping to the door of the hall, a visible call light above to door of the room was confirmed and three staff members were observed down the hall talking in group around a meal cart.
On 2/14/23 at 8:51 AM R26 reported that the facility was short staffed the night of Friday 2/10/23. R26 reported she turned on her call light at 10:50 pm but did not received assistance until 12:00 AM when she started yelling out. R26 reported that the CNA came in to tell her she was waking up the other residents on the hall. R26 reported that the CNA told her she was sorry for the long wait but that she was the only staff on the hall as the nurse was also covering the locked unit.
R48
Review of the MDS dated [DATE] reflected that R48 was originally admitted to the facility 2/2/22. The MDS reflected R48 had medically complex conditions, and had an indwelling catheter. The MDS Brief Interview for Mental Status (BIMS) reflected R26 scored 12 out of 15 which indicated the Resident had mild cognitive impairment. Section G (Functional Status) of the MDS reflected that R26 required extensive assistance of two staff with transfers, toileting, and hygiene.
On 2/7/23 at 9:48 AM R48 was observed sitting in a wheelchair next to his bed. R48 reported he is disgusted as he has been waiting a long time to get back into bed. R48 reported staff are aware he wants to get back into bed. R48 reported that he knows he must wait his turn but then repeated it's been a long time. R48 did not give a measure of the time he had been waiting. R48 indicated that extended wait times are common because the facility doesn't have enough staff.
On 2/8/23 at 3:07 PM R48 was in bed in his room. Certified Nurse Aide (CNA) P was in the room emptying the catheter drainage bag of R48. CNA P was observed to fill and emptied a 1-liter container three times to complete the task. CNA P was interviewed in the hall after leaving the room of R48 and reported that she had just started her shift. CNA P indicated that the day shift reported all catheter bags had been emptied, but she found the catheter bag of R48 was not. CNA P reported that she was a new CNA, was afraid of losing her job for speaking, but stated that staffing could be better because it was difficult to meet the needs of the residents due to low staffing. CNA P reported that she does not have a mentor and that the new CNA's do not get the support they need. CNA P indicated that the nurses will sometimes help but that no other staff will show me the ropes, that she felt she is on my own, and that she just tries to keep my head down.
On 2/8/23 at 3:41 PM after the interview with CNA P a follow up interview was conducted with R48 in his room. R48 reported that staff are not real good about emptying his catheter bag, and Day shift is the worst. R48 indicated that the facility doesn't have enough staff to keep up with his needs and the needs of other residents. R48 reported he felt the staff needed better training. R48 reported this is because sometimes he can hear staff laughing and joking out in the hall when they should be emptying my bag instead of walking past his room. R48 reported that the clip that holds his catheter bag broke once. R48 reported he was told that the clip was defective from the manufacturer then stated, but really they just let the bag get too heavy.
Falls
Review of a large white board in the Speret hallway (a locked dementia unit) on 2/7/23 at 12:20 PM showed only one nurse and one CNA assigned to the hall. Review of the facility provided schedule showed two CNAs scheduled from 6:30 PM-2:30 PM and only one CNA scheduled from 2:30 PM-10:00 PM.
R12 resides on the Speret hall unit and in the last 9 months has sustained 7 unwitnessed falls.
R51 resides on the Speret hall unit and in the last 9 months has sustained 8 unwitnessed falls.
The facility Matrix (CMS form 802) provided by the facility on 2/7/23 was reviewed. The facility Matrix reflected a recent history of 13 falls and 6 falls with injury.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers in part to MI00133328 and MI00133121:
Based on observation and interview, the facility failed to maintain ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers in part to MI00133328 and MI00133121:
Based on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment, as evidenced by soiled resident rooms/flooring in rooms 140, 129, 121,and 165, and odors, soiled/damaged shower rooms, soiled shower chairs, damaged toilet seat and soiled bedside table in room [ROOM NUMBER], and patched walls throughout the building. This deficient practice had the potential to affect all 63 residents in the facility.
Findings include:
Facility
On 2/7/23 at 11:50 AM, the South Hallway clean linen and medical supply storage area were found to be cluttered, and dirty. The hand sink is inaccessible due to boxes, garbage and several IV stands blocking the hand sink. Causing possible missed opportunities to provide good hand washing/hygienic practices by staff.
On 2/7/23 at 11:55 AM, the Central Hallway Shower Hallway findings include:
1. Broken tiles in the shower stalls.
2. Walls that are patched but not sealed or painted.
3. Shower stalls along the floor/wall junctures are soiled.
On 2/7/23 at 12:18 PM during lunch service, the main dining room was found not in use. Rafters, insulation, water and drain lines are exposed due to a very large hole in the ceiling.
During the initial environment tour on 2/7/23 between 10:30 AM -12:40 PM, the walls throughout the resident living areas were observed to have numerous white patches.
During a tour on 02/07/23 between 3:45 - 4:10 PM, Maintenance Director (MD) I revealed the dining room is closed due to a large hole in the ceiling. MD I stated a pipe burst on Sunday (2/5/23) and the repairs still need to be completed.
During an environmental tour of Dementia unit on 2/7/23 between 12:20 - 12:40 PM, the following observations were made:
During a bathroom water temperature observation in room [ROOM NUMBER], the toilet seat was observed to have deep grooves, crevices and what looks to be possible teeth indentations caused by someone biting down with the right side of their mouth upon the left edge of the toilet seat. The bedside table was grimy and sticky.
The Dementia Shower Room findings include:
1. Door does not lock.
2. The flooring is wet by the walkway in front of the shower stalls.
3. A plastic bag covers the toilet bowl with wrappers other garbage observed inside the empty bowl.
4. Feces and other residues are on the shower chair seat
5. Soiled towel is on the flooring next to the shower chair.
6. The flooring is soiled, especially along the floor/wall junctures where thick layers of caulking have been
installed. The ridge from the thick caulking is providing an environment susceptible to the build-up of
grime, slime, and bacteria.
7. The flooring is dirty and needs a thorough cleaning.
8. Numerous small brown ants are on the flooring near the edge of the shower stalls wall.
During a tour of the Dementia Unit on 2/7/23 between 3:45- 4:10 PM, Maintenance Director (MD) I stated, The shower room does not lock. The toilet is repaired. A long plastic spiral looking chain with a thick wad of paper attached was found clogging the toilets drain line. Ant activity has increased by the shower stalls.
room [ROOM NUMBER]
On 2/8/23 at 11:05 AM an observation was conducted in room [ROOM NUMBER]. One bed was observed in the room. The floor below the over-the-bed table next to the bed and was soiled with what appeared to be dried coffee spills and food debris. Ants were observed to be on the food debris by the bed. Along the outside wall of the room was other debris with ants and ant traversing along the baseboard of the wall. A snap-type mouse trap was observed near the far corner of the room.
On 2/8/23 at 2:04 PM, room [ROOM NUMBER] was unchanged with the dried spills remaining next to the bed as well as the debris with ants.
On 2/9/23 at 8:31 AM in room [ROOM NUMBER] the dried spills, debris, ants, and mouse trap remain as observed and documented twice on 2/8/23. A partial bag of Fritos lay on the floor in the space between the wall and the bed.
On 2/9/23 at 2:45 PM, Housekeeping staff was observed outside of room [ROOM NUMBER] about to clean the room. Housekeeping was asked to delay the cleaning until the room could be reviewed with the Assistant Director of Nurse (ADON). The ADON subsequently arrived at room [ROOM NUMBER]. The ADON was informed that the observations initially identified on the morning of the previous day remain evident at this time. The ADON was shown that these areas are unchanged to include the dried spills and food debris with ants where the room's Resident sits and eats his meals and the ants along the outside wall baseboard.
room [ROOM NUMBER]
On 2/7/23 at 10:00 AM the floor in room [ROOM NUMBER] was observed to be extensively soiled in the area next to bed 1. Dirty wheelchair tracks extended out from bed 3 to 4 feet with scattered debris. Outside of bathroom and into bathroom dark dirty spots were evident along with orange-colored drips, spots and large smears and clumps of various sizes of an orange-colored pasty substance extending across three 1 foot square floor tiles and extended out from the toilet eight 1 foot square floor tiles to the outside of the bathroom into the resident room.
room [ROOM NUMBER]
On 2/7/23 at 12:20 AM an observation was conducted in room [ROOM NUMBER]. The floor next to bed 1 of this room was notably soiled and included dirty wheelchair tracks next to the bed and debris scattered about the floor the length of the bed and across the room to the pathway of the door.
room [ROOM NUMBER]
On 2/8/23 at 10:01 AM in room [ROOM NUMBER] the floor area beside bed 1 and in front of beige recliner floor extensively soiled across gripper strips with dirt splotches and what appears to be dried coffee spills. Clutter was observed stacked between bed and recliner chair.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment, food and non-food contact areas, maintain the physical facility, effecting 63 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.
Findings include:
During the initial tour of the kitchen between on 2/7/23 between 9:55 AM to 10:28 AM the following issues were observed:
The hand sink was found blocked by a cart. The hand sink basin was observed visibly soiled with grime, scale, and what appeared to be coffee stains.
The 3-compartment located across from the hand sink, was observed to have a leak coming from around the spout on the faucet.
The 3-basins, backsplash, and drain boards were observed to be visibly soiled with scale and other debris.
The interior and exterior of dish machine was found to have scale, slime, and grime along with the drainboards, walls, and shelving. Standing water on the flooring was a result of low grout areas causing a non-easily cleanable surface. The flooring also provided the potential of harborage conditions for grime and pests.
The 2- Compartment Sink on the outside wall was observed to be visibly soiled. Beneath the 2-Compartment Sink Area a red towel has been shoved inside an abandoned drain line from a relocated hand sink. A large gap/opening was observed between the drain line and the surrounding wall.
During an interview on 2/7/22 at approximately 10:15 AM, Dietary Aide (DA) L stated, we use to have a hand sink by the 2-compartment sink, but they moved it because that wall freezes.
According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing Sink, (A) A HANDWASHING SINK shall be maintained so that it accessible at all times for EMPLOYEE use. (B) A HANDWASHING SINK may not be used for purposes other than handwashing.
According to the 2017 FDA Food Code section 6-501.18 Cleaning of Plumbing Fixtures, PLUMBING FIXTURES such as HANDWASHING SINKS, toilets, and urinals shall be cleaned as often as necessary to keep them cleaned.
According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.
According to the 2017 FDA Food Code section 4-501.14 Warewashing Equipment, Cleaning Frequency, A WAREWASHING machine; the compartments of sinks, basins, or other receptacles used for washing and rinsing EQUIPMENT, UTENSILS, or raw FOODS, or laundering wiping cloths; and drainboards or other EQUIPMENT used to substitute for drainboards as specified under 4-301.13 shall be cleaned: (A) Before use; (B) throughout the day at a frequency necessary to prevent recontamination of EQUIPMENT and to ensure that the EQUIPMENT performs its intended function; and (C) If used, at least every 24 hours.
According to the 2017 FDA Food Code section 6-501.11 Repairing, PHYSICAL FACILITIES shall be maintained in good repair.
According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.
According to the 2017 FDA Food Code section 6-201.16 Exterior Walls and Roofs, Protective Barrier. Perimeter walls and roofs of a FOOD ESTABLISHMENT shall effectively protect the establishment from the weather and the entry of insects, rodents, and other animals.
Further tour of the kitchen on 2/7/23 between 9:55 AM and 10:28 AM, revealed the juice machine had an accumulation of sticky debris inside the spout. The spout was also resting in stagnant holder filled with juice.
The coffee machine had residues and coffee grime in/on the spouts, the underside of where the coffee comes out, and the shelving.
The white storage bins/organizers for Styrofoam cups/lids located between the coffee and juice machine was visibly soiled from grime and spills.
The can opener blade, housing unit and holster had a build-up of stuck on food resides, grime on them.
The hand mixer has stuck on food residues and grime encrusted the bottom of the mixer and the cord.
The top of the [NAME] Oven was covered with greasy food residues and stuck on grime.
The inside cavity of the steamer has a build-up of lime, scale, and food residues.
The steam table has a build-up of stuck on food residues, grease, debris on the pan lids, the wells, the surface of the equipment including the handles, top and sides.
The Traulsen 2-Door Refrigerator Unit was observed to be soiled with stuck on food resides, spills and debris on the doors, walls, shelving, and bottom of the unit. Date Marking was observed to be for 3-4 days on ready to eat potentially hazardous food items. The following items were found past the date on the containers: Macaroni Salad 2/2-2/5, Egg Noodles 2/2-2/6, Turkey 2/2-2/6, Chicken Noodle Soup 2/2-2/5, Bacon found in a Gallon sized bag was undated.
According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety .
According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) .
The microwave covering the door, door opening, the entire inner cavity top, sides and bottom has stuck on food debris, greasy resides and grime.
According to the 2017 FDA Food Code section 4-602.12 Cooking and Baking Equipment, (B) The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacture's recommended cleaning procedure.
The outside wall of the kitchen located beneath the air conditioning unit has a large area of mold like substance. Repairs to the surface of the wall have been made, however, the surface is not a smooth, durable, and easily cleanable surface.
The back hallway that is used for deliveries was observed to have a wall that had been patched in numerous spots, but was not a smooth, easily cleanable surface. The white flooring was black and has layers of caked on dirt, salt, and grime.
The dirty flooring in the dry storage room is covered in dirt, food debris, wrappers, and cardboard and improperly installed pest control boxes.
The Walk-In-Cooler has food debris, dirt, and mold/mildew like substances on the shelving, storage racks, walls, and flooring.
The Walk-In-Freezer's flooring is littered with garbage and food debris.
According to the 2017 FDA Food Code section 6-101.11 Surface Characteristics, (A) Except as specified in (paragraph) (B) of this section, materials for indoor floor, wall and ceiling surfaces under conditions of normal use shall be:
(1)
SMOOTH, durable, and EASILY CLEANABLE for areas where FOOD ESTABLISHMENT operations are conducted.
According to the 2017 FDA Food Code section 6-501.11 Repairing PHYSICAL FACILITIES shall be maintained in good repair.
According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.
The black 4 wheeled carts and the 2-door resident food delivery carts were visibly soiled.
The utensil and dish storage bins and containers were found to soiled with dust, and food debris.
According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
Review of the Revised 3/2022 OPERATION AND CLEANING PROCEDURES on 2/10/23 at 1:00 PM revealed the following Policy, To promote safety and infection control, all employees shall follow standard operating and cleaning procedures. Further review revealed the following Procedures were not achieved, 2. ALL areas of the kitchen shall be cleaned on a daily basis to ensure proper sanitation in the operation. 3. Daily cleaning lists for each position shall be in place and monitored by the Director of Food and Nutrition. 7. ALL employees shall be responsible to follow the operating/cleaning procedures. 8. Director of Food and Nutrition will conduct weekly audits of all areas of the dietary department utilizing the cleaning checklist to ensure that proper sanitation is being followed.
Review of (Name of Company) Pest Report dated for 12/21/22 at 11:06 AM, reflected the following Open Conditions in the kitchen's interior,
Condition: Food residue under the equipment & tables - Food residue under equipment & Tables High Severity Created 11/20/2010.
Action: Please remove and /or clean to help reduce possible pest allure Client Responsibility Last Inspected 12/21/2022
Condition: Floor tiles need repair/grout - grout very low/needs to be replaced repaired, High Severity Created 11/8/2017
Action: Seal Cracks and Crevices Client Responsibility Last Inspected 12/21/2022
Condition: Gap around pipe going into wall- under the double sink, old waste line is now capped. Gap is all the way around it. High Severity Created 12/12/2018.
Action: Repair or replace as needed. Client Responsibility Last Inspected 12/21/2022.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers in part to MI00133328:
Based on observation, interview, and record review, the facility failed to effective...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation refers in part to MI00133328:
Based on observation, interview, and record review, the facility failed to effectively treat, monitor, and provide a pest free environment potentially effecting 63 residents, resulting in decreased environmental comfort and enjoyment.
Findings include:
Review of a [Name of Pest Control Company] article on How to Use Glue Traps and Boards, undated, reflected the following information: Mice and rats are creatures of habit - they like to take the same path to and from their nests. Mice are also very curious, so they'll check out any new thing along the way. Rats are more hesitant to explore new things, so slightly more time may be needed for them to encounter the trap. These behaviors will help you detect and control your rodent problem. [https://(name of)brand.com/en-us/product-types-tips/how-to-use-glue-traps-and-boards.html]
Review of a [Name of Pest Control Company] article on How to Use Glue Traps and Boards, undated, reflected, Position traps along active rodent runways, such as along walls, under large kitchen appliances, in cupboards, and other areas where rodents travel. Be sure to fit the glue trap flush against a wall where rodents will run over and stick to it. Avoid placing traps in corners indoors. Since glue traps hold the mouse in place to show evidence, you can utilize glue traps to track where rodents are traveling. If you don't catch a mouse within 2 days, move the trap to another spot. In addition to capturing mice, (Brand Name) Glue Traps of all varieties also trap insects such as spiders, roaches, or even scorpions. After use, dispose of the trap and captured rodent or insects in the trash.
[https://(name of )brand.com/en-us/product-types-tips/how-to-use-glue-traps-and-boards.html]
During a kitchen evaluation on 2/7/23 between 9:55-10:30 AM, of the approximate 5 traps located throughout the kitchen, storage, and dish areas. Three traps were found in positions that would not aid in catching/monitoring pest activity due to their poor locations including: being approximately a foot away from the wall, the opening in the box/trap were flipped around so that the opening was not flush with the wall, the opening of the trap was perpendicular to the wall.
During a laundry room evaluation on 2/07/23 at 10:30 AM, covered glue traps were found several feet away from the wall and the openings of the glue traps were running perpendicular to the nearest surface, making it less like to function as a mechanism to catch/monitor for activity.
On 2/7/23 at 12:30 PM, Ant activity was found in the Dementia Unit's shower room by the shower stalls. Ants were observed going in and out of some damaged floor tiles. Flooring was noted to be wet and had grimy build-up along the floor/wall junctures.
During a walk through on 2/7/23 between 3:45 - 4:10 PM, Maintenance Director (MD) I and this surveyor observed an increase in ant activity on the flooring in the Dementia Unit shower room.
On 02/08/23 at 11:30 AM, review of (Name of Pest Control Company) Service Inspection Report dated 1/18/2023 at 11:14 AM, reflected the following Open Conditions in the kitchen's interior,
Condition: Food residue under the equipment & tables - Food residue under equipment & Tables High Severity Created 11/20/2010.
Action: Please remove and /or clean to help reduce possible pest allure Client Responsibility Last Inspected 1/18/2023
Condition: Floor tiles need repair/grout - grout very low/needs to be replaced repaired, High Severity Created 11/8/2017
Action: Seal Cracks and Crevices Client Responsibility Last Inspected 1/18/2023
Condition: Gap around pipe going into wall- under the double sink, old waste line is now capped. Gap is all the way around it. High Severity Created 12/12/2018.
Action: Repair or replace as needed. Client Responsibility Last Inspected 1/18/2023. Review of the inspection report revealed, in rooms [ROOM NUMBERS] Snap traps were placed. Further review of the inspection report failed to reflect any monitoring of the resident shower rooms for pest activity.
During an interview on 02/10/23 at 12:15 PM, Maintenance Director (MD) I revealed, I was unaware of any issues on the pest report. MD I further revealed that prior to this week he had not received any pest reports since he started because they were going to the previous maintenance person's email. MD I stated the pest reports pointed to ongoing issues that should have been corrected.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 4 harm violation(s), $71,552 in fines, Payment denial on record. Review inspection reports carefully.
- • 29 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $71,552 in fines. Extremely high, among the most fined facilities in Michigan. Major compliance failures.
- • Grade F (13/100). Below average facility with significant concerns.
Bottom line: Trust Score of 13/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is The Orchards At Big Rapids's CMS Rating?
CMS assigns The Orchards at Big Rapids an overall rating of 3 out of 5 stars, which is considered average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is The Orchards At Big Rapids Staffed?
CMS rates The Orchards at Big Rapids's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Michigan average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 68%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at The Orchards At Big Rapids?
State health inspectors documented 29 deficiencies at The Orchards at Big Rapids during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 24 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Orchards At Big Rapids?
The Orchards at Big Rapids is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 100 certified beds and approximately 59 residents (about 59% occupancy), it is a mid-sized facility located in Big Rapids, Michigan.
How Does The Orchards At Big Rapids Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, The Orchards at Big Rapids's overall rating (3 stars) is below the state average of 3.1, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting The Orchards At Big Rapids?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is The Orchards At Big Rapids Safe?
Based on CMS inspection data, The Orchards at Big Rapids has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Michigan. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Orchards At Big Rapids Stick Around?
Staff turnover at The Orchards at Big Rapids is high. At 61%, the facility is 15 percentage points above the Michigan average of 46%. Registered Nurse turnover is particularly concerning at 68%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was The Orchards At Big Rapids Ever Fined?
The Orchards at Big Rapids has been fined $71,552 across 2 penalty actions. This is above the Michigan average of $33,794. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is The Orchards At Big Rapids on Any Federal Watch List?
The Orchards at Big Rapids is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.