What is Optalis Health and Rehabilitation of Canton's CMS rating?

Optalis Health and Rehabilitation of Canton has a three-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does Optalis Health and Rehabilitation of Canton have?

Optalis Health and Rehabilitation of Canton has 52 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at Optalis Health and Rehabilitation of Canton?

Optalis Health and Rehabilitation of Canton has a two-star staffing rating from CMS with 0.85 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Optalis Health and Rehabilitation of Canton located?

Optalis Health and Rehabilitation of Canton is located in Canton, MI. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Optalis Health and Rehabilitation of Canton have?

Optalis Health and Rehabilitation of Canton has 150 certified beds.

Who owns Optalis Health and Rehabilitation of Canton?

Optalis Health and Rehabilitation of Canton is a for profit - limited liability company facility and is part of the OPTALIS HEALTH & REHABILITATION chain.

Is Optalis Health and Rehabilitation of Canton safe?

Optalis Health and Rehabilitation of Canton has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at Optalis Health and Rehabilitation of Canton stick around?

Optalis Health and Rehabilitation of Canton has high staff turnover at 75%. High turnover can mean less continuity of care as staff change frequently.

Was Optalis Health and Rehabilitation of Canton ever fined?

No, Optalis Health and Rehabilitation of Canton has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is Optalis Health and Rehabilitation of Canton on any federal watch list?

No, Optalis Health and Rehabilitation of Canton is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at Optalis Health and Rehabilitation of Canton?

Medicare inspectors have found 52 deficiencies at Optalis Health and Rehabilitation of Canton: 1 serious, 51 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Optalis Health and Rehabilitation of Canton?

Families visiting Optalis Health and Rehabilitation of Canton should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Optalis Health and Rehabilitation of Canton compare to other nursing homes?

Optalis Health and Rehabilitation of Canton has a 3-star overall rating, which is average compared to other nursing homes in MI. Consider visiting multiple facilities before making a decision.

Optalis Health and Rehabilitation of Canton | 45/100 (Grade D)

Aug 2025 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

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # 1221139 Based on interview and record review the facility failed to ensure security and accou...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # 1221139 Based on interview and record review the facility failed to ensure security and accountability for 30 oxycodone-acetaminophen 10-325 mg (milligram) tablets for one resident (R1) of three reviewed for drug diversion of controlled substances, resulting in 30 missing oxycodone-acetaminophen without resolution and a delay in pain relief.A review of the facility's incident report was received by the State Agency via online submission on: 6/23/25 revealed the following: Incident Summary On 6/22/25, the facility's routine narcotic count revealed a discrepancy involving (drug name, Oxycodone 10-325mg prescribed to resident R1. A total of 30 tablets were unaccounted for during the beginning of the day shift count.Upon further review of the narcotic sign-out sheet along with the blister pack of medication noted missing. Investigation initiated immediately by the Director of Nursing.Misappropriation of Controlled Substance (Narcotics) Time of Incident: 11:00a.m.The nurse notified the pharmacy to get a refill the pharmacy notified the nurse that the resident received a quantity of 60 pills on 6/16/25 which was too soon for a refill. The facility's routine narcotic count revealed a discrepancy involving (Drug name Oxycodone 10-325mg) prescribed to resident (R1). A total of (30) tablets were unaccounted for during the narcotic count.along with the controlled drug receipt record disposition form for the resident (R1). The alleged misappropriation involves Nurse V (Agency Nurse), a licensed nurse who had access to the medication cart during the shift prior to the discovery.On 08/11/2025 at 10:57 AM, R1 was observed in bed, wearing a hospital gown. R1 had a Tracheostomy (a surgical procedure where an incision is made in the neck to create an opening into the trachea/windpipe, allowing for a tube to be inserted to assist with breathing) that was clean and intact. A tracheostomy supply cart was next to R1's bed. R1 was interviewed and asked about the delay on June 22, 2025 of their prescribed Oxycodone 10-325mg. R1 stated after placing a speaking valve over their tracheostomy (used to help a person with a tracheostomy speak) in a soft voice , I was told that someone took my pain medication and the nurse had to call the pharmacy for more medication.my pain medication was due at 10 (A.M.).I call the DON (Director of Nursing) because I have her phone number and told her that my pain medication was missing.I had to wait a long time for my medication.my pain was horrible because I have cancer.It (pain) was horrible.I was in so much pain.A review of R1's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Malignant Neoplasm of the Hypopharynx (a type of cancer that develops in the lower throat), Chronic Obstructive Pulmonary Disease, Respiratory Failure, Tracheostomy, and Chronic Pain related to Cancer. A review of R1's Minimum Data Set (MDS) dated [DATE] revealed a score of 15/15 (cognitively intact). A review of R1's care plan revealed the following: Focus-At risk for pain and has pain related to Cancer, Malnutrition, radiation Dated Initiated 12/20/2024.Intervention/Task-Administer pain medication per physician orders.A review of R1's medication order dated 4/25/25, revealed the following: Oxycodone-Acetaminophen tablet 10-325 Give one tablet via pet-tube six times a day for pain.On 08/12/2025 at 11:18 AM, the DON was interviewed about the missing Oxycodone. The DON stated that the medication was initially received from the pharmacy on 6/16/2025. The DON was unable to determine the time that the medication was delivered by pharmacy. The DON added that Nurse Manager E signed the Controlled Substance document from the pharmacy for a total of three controlled substances cards: one card had 30 Clonazepam tablets and two cards with 30 tablets of Oxycodone that totaled 60 tablets on 6/16/2025. The DON was asked when the one card containing 30 Oxycodone tablets went missing. The DON said, I'm not sure when the Oxycodone went missing.I'm not sure who took the narcotic (Oxycodone). The DON was then asked about her documentation on the investigative report revealed that Agency Nurse V was the alleged nurse staff who had access to the medication cart during the shift and removed the Oxycodone. The DON said, I'm not sure who took the Oxycodone.It could be anyone at this point.I don't know, I don't know, I don't know. The DON stated that the narcotic sheet was also removed from the narcotic book. The DON added that Nurse AA called around 10A.M. on 6/21/2025 and stated that they called pharmacy due to R1 was out of Oxycodone. The DON said that pharmacy indicated that they delivered 60 Oxycodone on 6/16/2025 and R1 should have enough Oxycodone in the cart. The DON then said she called the pharmacy and ordered Oxycodone to be taken from the Pyxis machine (an automated medication dispensing system used to streamline medication management and enhance patient safety.) At this time the DON revealed a report showing Oxycodone 10-325mg was removed from the Pyxis timed stamped at 12:02PM on 6/22/2025 and administered to R1.A review of R1's Medication Administration Record noted documentation on 6/22/2025 that the Oxycodone 10-325mg was administered at 10am; however, the Oxycodone 10-325mg was not available at that time according to Nurse AA and the DON.On 08/12/2025 at 1:45 PM, the Nursing Home Administrator (NHA) was interviewed and queried about their expectation of Controlled Substance compliance. The NHA said, The Nurse staff must adhere to policies and procedures around controlled substance.A review of the facility's Abuse policy updated 5/24/2023 revealed the following: Residents have the right to be free from abuse, neglect, exportation, mistreatment, and misappropriation of resident property.The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.

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 pertains to intake # 1221139 Based on interview and record review the facility failed to report to law enforcement...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # 1221139 Based on interview and record review the facility failed to report to law enforcement drug diversion of 30 Oxycodone tablets (controlled substances) for one resident (R1) of three residents reviewed for missing medications. Findings include: A review of the facility's incident report was received by the State Agency via online submission on: 6/23/25 revealed the following: Incident Summary On 6/22/25, the facility's routine narcotic count revealed a discrepancy involving (drug name, Oxycodone 10-325mg (milligram) prescribed to resident R1. A total of 30 tablets were unaccounted for during the beginning of the day shift count.Upon further review of the narcotic sign-out sheet along with the blister pack of medication noted missing. Investigation initiated immediately by the Director of Nursing (DON).Misappropriation of Controlled Substance (Narcotics) Time of Incident: 11:00a.m.The nurse notified the pharmacy to get a refill the pharmacy notified the nurse that the resident received a quantity of 60 pills on 6/16/25 which was too soon for a refill. The facility's routine narcotic count revealed a discrepancy involving (Drug name Oxycodone 10-325mg) prescribed to resident (R1). A total of (30) tablets were unaccounted for during the narcotic count.along with the controlled drug receipt record disposition form for the resident (R1). The alleged misappropriation involves Nurse V (Agency Nurse), a licensed nurse who had access to the medication cart during the shift prior to the discovery.On 08/11/2025 at 10:57 AM, R1 was observed in bed, wearing a hospital gown. R1 had a Tracheostomy (a surgical procedure where an incision is made in the neck to create an opening into the trachea/windpipe, allowing for a tube to be inserted to assist with breathing) that was clean and intact. A tracheostomy supply cart was next to R1's bed. R1 was interviewed and asked about the delay on June 22, 2025 of their prescribed Oxycodone 10-325mg. R1 stated after placing a speaking valve over their tracheostomy (used to help a person with a tracheostomy speak) in a soft voice , I was told that someone took my pain medication and the nurse had to call the pharmacy for more medication.my pain medication was due at 10 (A.M.).I call the Director of Nursing because I have her phone number and told her that my pain medication was missing.I had to wait a long time for my medication.my pain was horrible because I have cancer.It (pain) was horrible.I was in so much pain.A review of R1's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Malignant Neoplasm of the Hypopharynx (a type of cancer that develops in the lower throat), Chronic Obstructive Pulmonary Disease, Respiratory Failure, Tracheostomy, and Chronic Pain related to Cancer. A review of R1's Minimum Data Set (MDS) dated [DATE] revealed a score of 15/15 (cognitively intact). A review of R1's care plan revealed the following: Focus-At risk for pain and has pain related to Cancer, Malnutrition, radiation Dated Initiated 12/20/2024.Intervention/Task-Administer pain medication per physician orders. A review of R1's medication order dated 4/25/25, revealed the following: Oxycodone-Acetaminophen tablet 10-325 Give one tablet via pet-tube six times a day for pain.On 08/12/2025 at 11:18 AM, the DON was interviewed about the missing Oxycodone. The DON stated that the medication was initially received from the pharmacy on 6/16/2025. The DON was unable to determine the time that the medication was delivered by pharmacy. The DON added that Nurse Manager E signed the Controlled Substance document from the pharmacy for a total of three controlled substances cards: one card had 30 Clonazepam tablets and two cards with 30 tablets of Oxycodone that totaled 60 tablets on 6/16/2025. The DON was asked when the one card containing 30 Oxycodone tablets went missing. The DON said, I'm not sure when the Oxycodone went missing.I'm not sure who took the narcotic (Oxycodone). The DON was then asked about her documentation on the investigative report revealed that Agency Nurse V was the alleged nurse staff who had access to the medication cart during the shift and removed the Oxycodone. The DON said, I'm not sure who took the Oxycodone.It could be anyone at this point.I don't know I don't know I don't know. The DON stated that the narcotic sheet was also removed from the narcotic book. The DON added that Nurse AA called around 10A.M. on 6/21/2025 and stated that they called pharmacy due to R1 was out of Oxycodone. The DON said that pharmacy indicated that they delivered 60 Oxycodone on 6/16/2025 and R1 should have enough Oxycodone in the cart. The DON then said she called the pharmacy and ordered Oxycodone to be taken from the Pyxis machine (an automated medication dispensing system used to streamline medication management and enhance patient safety). At this time the DON revealed a report showing Oxycodone 10-325mg was removed from the Pyxis timed stamped at 12:02PM on 6/22/2025 and administered to R1.A review of R1's Medication Administration Record noted documentation on 6/22/2025 that the Oxycodone 10-325mg was administered at 10am; however, the Oxycodone 10-325mg was not available at that time according to Nurse AA and the DON.On 08/12/2025 at 1:45 PM, the Nursing Home Administrator (NHA) was interviewed and queried about their expectation of Controlled Substance compliance. The NHA said, The Nurse staff must adhere to policies and procedures around controlled substance.A review of the facility's Abuse policy updated 5/24/2023 revealed the following: Residents have the right to be free from abuse, neglect, exportation, mistreatment, and misappropriation of resident property.The facility will attempt to coordinate with State and Local law enforcement annually and as needed to determine which crimes are reportable. The facility will ensure that all allegations involving abuse, neglect, exportation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator and: Report to State Survey Agency immediately .and law enforcement .

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 pertains to intake # 1221139 Based on interview and record review the facility failed to ensure the misappropriati...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # 1221139 Based on interview and record review the facility failed to ensure the misappropriation of 30 oxycodone-acetaminophen 10-325 mg (milligram) tablets was thoroughly investigated for one resident (R1) of three reviewed for drug diversion of controlled substances, resulting in 30 missing oxycodone-acetaminophen without resolution and a delay in pain relief. The review of the incident report revealed the following: Incident Summary On 6/22/25, the facility's routine narcotic count revealed a discrepancy involving (drug name, Oxycodone 10-325mg prescribed) to resident (R1). A total of 30 tablets were unaccounted for during the beginning of the day shift count.Upon further review of the narcotic sign-out sheet along with the blister pack of medication noted missing. Investigation initiated immediately by the Director of Nursing.Misappropriation of Controlled Substance (Narcotics) Time of Incident: 11:00a.m.The nurse notified the pharmacy to get a refill the pharmacy notified the nurse that the resident received a quantity of 60 pills on 6/16/25 which was too soon for a refill. The facility's routine narcotic count revealed a discrepancy involving (Drug name Oxycodone 10-325mg) prescribed to resident (R1). A total of (30) tablets were unaccounted for during the narcotic count.along with the controlled drug receipt record disposition form for the resident (R1). The alleged misappropriation involves Nurse V (Agency Nurse), a licensed nurse who had access to the medication cart during the shift prior to the discovery.On 08/11/2025 at 10:57 AM, R1 was observed in bed, wearing a hospital gown. R1 had a Tracheostomy (a surgical procedure where an incision is made in the neck to create an opening into the trachea/windpipe, allowing for a tube to be inserted to assist with breathing) that was clean and intact. A tracheostomy supply cart was next to R1's bed. R1 was interviewed and asked about the delay on June 22, 2025 of their prescribed Oxycodone 10-325mg. R1 stated after placing a speaking valve over their tracheostomy (used to help a person with a tracheostomy speak) in a soft voice , I was told that someone took my pain medication and the nurse had to call the pharmacy for more medication.my pain medication was due at 10 (A.M.).I call the Director of Nursing (DON) because I have her phone number and told her that my pain medication was missing.I had to wait a long time for my medication.my pain was horrible because I have cancer.It (pain) was horrible.I was in so much pain.A review of R1's electronic medical record revealed an admission to the facility on [DATE] with the diagnoses of Malignant Neoplasm of the Hypopharynx (a type of cancer that develops in the lower throat), Chronic Obstructive Pulmonary Disease, Respiratory Failure, Tracheostomy, and Chronic Pain related to Cancer. A review of R1's Minimum Data Set (MDS) dated [DATE] revealed a score of 15/15 (cognitively intact). A review of R1's care plan revealed the following: Focus-At risk for pain and has pain related to Cancer, Malnutrition, radiation Dated Initiated 12/20/2024.Intervention/Task-Administer pain medication per physician orders. A review of R1's medication order dated 4/25/25, revealed the following: Oxycodone-Acetaminophen tablet 10-325 Give one tablet via pet-tube six times a day for pain.On 08/12/2025 at 11:18 AM, the DON was interviewed about the missing Oxycodone. The DON stated that the medication was initially received from the pharmacy on 6/16/2025. The DON was unable to determine the time that the medication was delivered by pharmacy. The DON added that Nurse Manager E signed the Controlled Substance document from the pharmacy for a total of three controlled substances cards: one card had 30 Clonazepam tablets and two cards with 30 tablets of Oxycodone that totaled 60 tablets on 6/16/2025. The DON was asked if nurses count narcotics at the beginning of each shift. The DON said, They are supposed to check the narcotics at the beginning of each shift. The DON was asked about the time and date the medication card containing 30 Oxycodone tablets went missing. The DON said, I'm not sure when the Oxycodone went missing.I'm not sure who took the narcotic (Oxycodone). The DON was then asked about her documentation on the investigative report revealed that Agency Nurse V was the alleged nurse staff who had access to the medication cart during the shift and removed the Oxycodone. The DON said, I'm not sure who took the Oxycodone.It could be anyone at this point.I don't know I don't know I don't know. The DON stated that the narcotic sheet was also removed from the narcotic book. The DON added that Nurse AA called around 10A.M. on 6/21/2025 and stated that they called pharmacy due to R1 was out of Oxycodone. The DON said that pharmacy indicated that they delivered 60 Oxycodone on 6/16/2025 and R1 should have enough Oxycodone in the cart. The DON then said she called the pharmacy and ordered Oxycodone to be taken from the Pyxis machine (an automated medication dispensing system used to streamline medication management and enhance patient safety.) At this time the DON revealed a report showing Oxycodone 10-325mg was removed from the Pyxis timed stamped at 12:02PM on 6/22/2025 and administered to R1. The DON was asked if Agency Nurse V was interviewed and the DON stated she could not reach the nurse. The DON was asked if they notified the staffing agency that Agency Nurse V was being investigated for 30 tablets of Oxycodone 10-325mg. the DON said, No, we told (the staffing agency) that (Agency Nurse V) could not work at their facility anymore.A review of R1's Medication Administration Record noted documentation on 6/22/2025 that the Oxycodone 10-325mg was administered at 10am; however, the Oxycodone 10-325mg was not available at that time according to Nurse AA and the DON.On 08/12/2025 at 2:31 PM, the DON, Nurse Manager Q, and Nurse Manager E were interviewed and queried about the process of receiving medication from their pharmacy and signing narcotics into medication carts once received. The DON stated that on June 16, 2025, Nurse Manager E received three controlled substances cards: one card had 30 Clonazepam tablets and two cards with 30 tablets of Oxycodone that totaled 60 tablets on 6/16/2025 for resident R1. Nurse Manager E stated that two cards with 30 tablets of Oxycodone that totaled 60 tablets and one card had 30 Clonazepam tablets was received from pharmacy and she checked the medication and gave it to Nurse Manager Q. Nurse Manager Q stated that she received one card of 30 Clonazepam tablets and two cards with 30 tablets of Oxycodone that totaled 60 tablets and signed the medication into the medication cart. A review of the medication sheet did not indicate the medication name. Nurse Manager E stated that she did not verify the medication count sign-in on the narcotic sheet because it was not her cart. The DON stated that Nurse Manager E should have counted the controlled substance with Nurse Manager Q. A review of the narcotic medication sheet revealed illegible signatures. Nurse Manager Q was asked if the signature on the narcotic medication sheet was her signature. Nurse Manager Q stated several times that she was unsure if the signature was hers. Then Nurse Manager Q said after questioning, Well, yes it's my signature. The DON was asked when they identified that the medication was missing. The DON stated they were unsure. The DON stated that she did not notify law enforcement. A request for documentation of all staff investigated for the missing Oxycodone 10-325mg tablets was requested on 08/12/2025 at 2:31 PM. During the exit of this survey, the DON had not submit any requested additional information.On 08/13/2025 at 10:50 AM, Staffing Agency CC was interviewed by phone and asked if they were aware of the allegation against Agency Nurse V for 30 missing Oxycodone 10-325mg tablets. Staffing Agency CC said, No. We were only told that they (the facility) did not want (Agency Nurse V) working at their facility. Staffing Agency CC said they did not know anything about allegations of missing medications. Staffing Agency CC was asked when the last date Agency Nurse V worked at the facility. Staffing Agency CC indicated that that Agency Nurse V last date worked at the facility was on 6/16/25 on the midnight shift 7PM-7AM.On 08/13/2025 at 12:38 AM, Nurse AA was called and asked about when they became aware of the missing Oxycodone 10-325mg tablets. Nurse AA stated that R1 asked for their pain medication at 10AM and after checking the medication cart, there was not any Oxycodone 10-325mg available. Nurse AA said they called the pharmacy for a refill. The pharmacy told Nurse AA that the resident received a quantity of 60 Oxycodone 10-325mg tablets on 6/16/25, which was too soon for a refill. Nurse AA stated they called the DON related to the missing Oxycodone. Nurse AA was asked if 30 Oxycodone 10-325mg tablets was counted at the beginning of their shift on 6/22/25. Nurse AA stated that they counted the cart, it was accurate according to the narcotic sheet, and it did not appear to be missing Oxycodone.On 08/13/2025 at 1:45 PM, the Nursing Home Administrator (NHA) was interviewed and queried about their expectation of Controlled Substance compliance. The NHA said, The Nurse staff must adhere to policies and procedures around controlled substances.Sometimes nurses will leave before counting the cart if the incoming nurse is late.that is not how it should beA review of the facility's Abuse policy updated 5/24/2023 revealed the following: Residents have the right to be free from abuse, neglect, exportation, mistreatment, and misappropriation of resident property.Key to investigations is an environment that facilitates the reporting of such allegations. Once reported, the center conducts a timely, thorough, and objective investigation of any allegation of abuse.Identify and interview all involved persons, including the alleged victim, alleged perpetrator, witness an others who might have knowledge of the allegations.

Jul 2025 4 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

Deficiency F0557 (Tag F0557)

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 the dignity of one (R402) of three residents...

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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 the dignity of one (R402) of three residents reviewed for dignity and respect. Findings include: On 7/2/25 at 9:55 AM, R402 was observed sleeping at the [NAME] nurse's station. R402 was observed seated in a wheelchair with her head resting directly on the desk. Nurse Practitioner (NP) F was observed sitting in a different part of the nurse's station actively typing in a computer facing 90 degrees away from R402. No other staff were observed in the area. When NP F was queried regarding R402's positioning NP F said R402 was not her patient, but she had been helping keep her calm. On 7/2/25 at 10:00 AM, Registered Nurse (RN) G was observed passing medications down the 300 hallway. RN G confirmed R402 was under his care for the shift. R402 was not visible from RN G s location. On 7/2/25 at 10:05 AM, R402 was observed with RN G sleeping at the [NAME] nurses' station with her head resting directly on the desktop. When queried about R402's positioning RN G said R402's positioning wasn't optimal and agreed leaving her sleep at the nurses' station did not maintain her dignity. RN G said R402 should have been returned to her room when she fell asleep, to sleep in her bed. Record review of R402's Electronic Health Record (EHR) revealed R402 was admitted to the facility on [DATE] with diagnoses which included Acute Lymphoblastic Leukemia, Secondary Malignant Neoplasm of Cerebral Meninges, Altered Mental Status, and Restlessness and Agitation. Review of the Minimum Data Set (MDS) dated [DATE] for R402 revealed severely impaired cognition and required supervision for transfers and ambulation. Record review of R402's care plan revealed, Focus At risk for falls due to dementia, unsteady gait and muscle weakness, encephalopathy, AMS (altered mental status), anxiety, potential s/e (side effects). Date initiated: 4/23/2025. Goal Minimize risk for falls. Date initiated 4/23/25. Minimize risk for injury r/t (related to) falls Date initiated 4/23/25. Intervention/tasks -encourage resident to be on common areas when awake. Date initiated 4/30/25. Increase frequency of Client Checks. Date initiated 5/27/25. Staff to encourage resident to be up in wheelchair in visible fields when rambling is active. Date initiated 6/4/25. On 7/3/25 at 10:30 AM the Director of Nursing (DON) was interviewed and said the facility should have more supervision for R402. The nurse should not have left her at the nurse's station to sleep with her head on the table that is not maintaining a resident's dignity. We have a special room on that unit that is in line of site where she could lay on a bed. When she gets too confused/unsafe the nurse should call me so we could assign another Certified Nursing Aide to help. Review of the facility policy titled Dignity issued 9/21/25 revealed in part: It is the policy of this facility that each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem. Residents will be treated with dignity and respect at all times.

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

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 ensure that medications were administered in accordan...

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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 ensure that medications were administered in accordance with professional standards of practice for one (R403) of four residents reviewed for medication administration resulting in inaccurate medication administration. Findings include: On 7/2/25 at 10:15 AM, R403 was observed walking out of his room holding a medication cup to his mouth with approximately four pills. R403 was observed alone without staff supervising medication administration. When asked what R403 was doing, R403 stated, I'm taking my pills. R403 dropped one pill on the floor, bent over picked up the pill, placed the pill back in the medication cup. R403 returned to his room where he swallowed the remaining pills from the medication cup. R403 was observed to have a PEG Tube (percutaneous endoscopic gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach, used for patients to take in nutrients. On 7/2/25 at 10:30 AM, Licensed Practical Nurse (LPN) A was interviewed and identified the following pills were given to R403 in a medication cup: - aspirin 81 mg - Cholecalciferol 1000 units - Loratadine 10 MG - Senna Oral Tablet 8.6 MG -Omeprazole Oral Capsule 20 MG When queried regarding R403's ability to take medications independently LPN A stated, I should have stayed and watched him take his pills. When asked, can R403 take pills? LPN A stated, Yes, he has progressed to taking pills now. Speech assessed him and he progressed to taking pills. Record review of R403's Electronic Health Record (EHR) revealed R403 was admitted to the facility on [DATE] with diagnoses which included Cerebral Ischemia (lack of blood flow to brain), Dysphagia following cerebral infarction (difficulty swallowing following stroke), Gastrostomy Status (hole placed in abdominal wall for tube feeding). Review of the Minimum Data Set (MDS) dated [DATE] for R403 revealed intact cognition. Review of the EHR did not reveal an assessment for R403 self-administer medications, a care plan for self-administration of medications or an order to self-administer medications. Review of the physician orders revealed the following: - Aspirin oral tablet 81 mg-Give 1 tablet via PEG tube. - Cholecalciferol 1000 units- Give 6 tablet via PEG Tube. - Loratadine 10 MG-Give 1 tablet via PEG Tube. - Senna Oral Tablet 8.6 MG-Give 2 tablet via PEG Tube. -Omeprazole Oral Capsule 20 MG-Give 1 capsule via PEG tube. On 7/2/25 at 1:45 AM the Director of Nursing (DON) was interviewed and said R403 was not assessed for self-medication administration and that he should be supervised during medication administration. Review of the facility policy titled Medication and Treatment storage issued 8/7/2023 revealed in part: During medication pass, medications must be under the direct observation of the person administering medications.

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

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, interview, and record review, the facility failed to ensure that medications were administered via the cor...

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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 ensure that medications were administered via the correct route via PEG Tube (percutaneous endoscopic gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach, used for patients who cannot eat normally) for one (R403) of four residents reviewed for medication administration resulting in the potential for silent aspiration (when food, liquid, or other materials are inhaled into the airway without the individual realizing it, potentially leading to serious health issues like aspiration pneumonia and even death). Findings include: On 7/2/25 at 10:15 AM, R403 was observed walking out of his room holding a medication cup to his mouth with approximately four whole pills. R403 was observed alone without staff supervising medication administration. When asked what R403 was doing, R403 stated, I'm taking my pills. R403 dropped one pill on the floor, bent over picked up the pill, placed the pill back in the medication cup. R403 returned to his room where he swallowed the remaining pills from the medication cup. R403 was observed to have a PEG Tube. On 7/2/25 at 10:30 AM, Licensed Practical Nurse (LPN) A was interviewed and identified the following pills were given to R403 in a medication cup: - aspirin 81 mg - Cholecalciferol 1000 units - Loratadine 10 MG - Senna Oral Tablet 8.6 MG -Omeprazole Oral Capsule 20 MG When queried regarding R403's ability to take medications independently LPN A stated, I should have stayed and watched him take his pills. When asked, can R403 take pills? LPN A stated, Yes, he has progressed to taking pills now. Speech (speech therapy) assessed him, and he progressed to taking pills. Record review of R403's Electronic Health Record (EHR) revealed R403 was admitted to the facility on [DATE] with diagnoses which included Cerebral Ischemia (lack of blood flow to brain), Dysphagia following cerebral infarction (difficulty swallowing following stroke), Gastrostomy Status (hole placed in abdominal wall for tube feeding). Review of the Minimum Data Set (MDS) dated [DATE] for R403 revealed intact cognition. Review of the EHR did not reveal an assessment for R403 self-administer medications, a care plan for self-administration of medications or an order to self-administer medications. Review of the physician orders revealed the following: - Aspirin oral tablet 81 mg-Give 1 tablet via PEG tube. Start date 3/14/2025. - Cholecalciferol 1000 units- Give 6 tablet via PEG Tube. Start date 6/11/2025. - Loratadine 10 MG-Give 1 tablet via PEG Tube. Start date 3/14/2025. - Senna Oral Tablet 8.6 MG-Give 2 tablet via PEG Tube. Start date 3/14/2025. -Omeprazole Oral Capsule 20 MG-Give 1 capsule via PEG tube. Start date 3/14/2025. Review of the admission assessment dated [DATE] from Facility B revealed, Respiratory: recurrent aspiration with recent pneumonia. MBS (Modified Barium Swallow) on 1/13/2025 showed aspiration without sensation of thin liquid barium. Review of the Modified Barium Swallow Study (MBSS) dated 5/14/25 revealed the following, Pt presents with moderate oral and moderate -severe pharyngeal dysphagia in the setting of CVA (cerebral vascular accident), failure to thrive affecting both swallow and efficiency (appears worsened as compared to previous MBSS-3/26/25. There was silent aspiration during and after the swallow with thin liquids and during the swallow with moderately thick liquids. Pt is judged to be at high risk for aspiration regardless of texture consumed. Review of the Speech Therapy Discharge summary dated [DATE] revealed in part: Given high risk for aspiration-oral intake is recommended as pleasure feedings and tube feeding should be primary source for nutrition/hydration. Use of safe swallow guidelines does not eliminate aspiration risk. On 7/2/25 at 12:20 PM Speech Language Pathologist (SLP) C was interviewed and said R403 was at risk for aspiration and the recommended route for medication was via PEG tube due to the high risk for aspiration if R403 takes pills. On 7/2/25 at 1:20 PM a voicemail was left for Medical Doctor D to discuss R403's medication administration with no return call by survey exit. On 7/3/25 at 11:00 AM, SLP C was interviewed and said that she evaluated R403's ability to swallow pills earlier today (7/3/25) with LPN E. SLP C said R403 coughed when took pills with water and that R403 was at risk for silent aspiration. On 7/3/25 at 11:30 AM the Director of Nursing (DON) was interviewed and said R403 was at risk for choking/aspiration and that his medications should be given as ordered-via PEG tube. Review of the facility's policy titled Tube Feeding-Formula Administration, Flushing and Unclogging issued date 8/8/2023 revealed in part: Tube feeding via pump -Verify Physician's Order. -Monitor the resident for signs and symptoms of aspiration and/or feeding intolerance. -Document procedure in resident's medical record.

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

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 ensure medical records were accurate for one (R403) o...

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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 ensure medical records were accurate for one (R403) of six residents reviewed for accurate medical records. Findings include: On 7/2/25 at 10:15 AM, R403 was observed walking out of his room holding a medication cup to his mouth with approximately four whole pills. R403 was observed alone without staff supervising medication administration. When asked what R403 was doing, R403 stated, I'm taking my pills. R403 dropped one pill on the floor, bent over picked up the pill placed the pill back in the medication cup. R403 returned to his room where he swallowed the remaining pills from the medication cup. R403 was observed to have a PEG Tube (percutaneous endoscopic gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach, used for patients who cannot eat normally). On 7/2/25 at 10:30 AM, Licensed Practical Nurse (LPN) A was interviewed and identified the following pills were given to R403 in a medication cup to take orally: - Aspirin 81 mg - Cholecalciferol 1000 units - Loratadine 10 MG - Senna Oral Tablet 8.6 MG -Omeprazole Oral Capsule 20 MG When queried regarding R403's ability to take medications independently LPN A stated, I should have stayed and watch him take his pills. When asked, can R403 take pills? LPN A stated, Yes, he has progressed to taking pills now. Speech assessed him and he progressed to taking pills. Record review of R403's Electronic Health Record (EHR) revealed R403 was admitted to the facility on [DATE] with diagnoses which included Cerebral Ischemia (lack of blood flow to brain), Dysphagia following cerebral infarction (difficulty swallowing following stroke), Gastrostomy Status (hole placed in abdominal wall for tube feeding). Review of the Minimum Data Set (MDS) dated [DATE] for R403 revealed intact cognition. Review of the EHR did not reveal an assessment for R403 self-administer medications, a care plan for self-administration of medications or an order to self-administer medications. Review of R403's Medication Administration Record (MAR) for 7/2/2025 revealed LPN A documented the following medications given at 9:00 AM: - Aspirin oral tablet 81 mg-Give 1 tablet via PEG tube. - Loratadine 10 MG-Give 1 tablet via PEG Tube. - Senna Oral Tablet 8.6 MG-Give 2 tablet via PEG Tube. -Omeprazole Oral Capsule 20 MG-Give 1 capsule via PEG tube. Review of R403's Medication Administration Record (MAR) for 7/2/2025 revealed LPN A documented the following medication given at 8:00 AM: - Cholecalciferol 1000 units- Give 6 tablet via PEG Tube. On 7/2/25 at 1:45 AM the Director of Nursing (DON) was interviewed and said R403's MAR dated for 7/2/25 was not accurate since LPN A administered R403's morning medication orally in pill form and not via PEG tube as ordered. The DON said the expectation is that medical records are accurate and that clinicians document the actual treatment provided. Review of the facility policy titled Documentation in the Medical Record issued 1/8/2025 revealed in part: Principles of documentation include: Documentation should be factual, objective, and resident centered. False information will not be documented. Record descriptive and objective information based on knowledge of the assessment, observation, or service provided. Documentation should be accurate, relevant and complete.

Feb 2025 2 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

Deficiency F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149294. Based on interview and record review, the facility failed to ensure that private pr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149294. Based on interview and record review, the facility failed to ensure that private property was protected from theft by an employee for one resident (R102) of five reviewed for misappropriation of property, resulting in an employee's deliberate removal of R102's earbuds from possession. Findings include: A facility reported incident revealed the following, Facility investigation report received via online submission on: 12/27/24, 10:21 AM Incident Summary Resident [R102] who is with us [Facility]for short-term Rehab care reported to the DON [Director of Nursing] that [R102] left [their] room to go to activities and left [their] apple air pods [wireless earbuds] in [their] room. Upon resident [R102] return to [their] room they were nowhere to be found, and [R102] then activated an app to help [R102] locate them in switch they started to make a tracking noise. Where [R102] tracked to a housekeepers cleaning cart. Investigation Summary Date of Event: 12/23/2024 Resident Name: [R102]. Staff Name: [Housekeeper A] Housekeeping department Investigation: Misappropriation Time of incident: 3:00 PM [R102] is [AGE] year-old who admitted to [Facility] on 12/21/2024 and is currently a resident .is alert and oriented x4 with a BIMs of 15. [R102] has a primary diagnosis of Kidney Transplant. 12/23/2024 On December 23, 2024, the facility DON was notified by the resident [R102] that [their] Apple I pods had gone missing out of [their] room patient gave [Facility] a timeline of when Apple I pods went missing. [R102] left her room at 2:00 PM to go to activities and returned to [their] room at 3:02 PM. However, upon return resident [R102] noticed [their] Apple I pods were missing [R102] used an app on [their] phone to . find [their] missing Apple I pods which were located on the housekeeping cart. The DON then called the administrator at 4:15 PM to inform [the administrator] of the incident [the administrator] intern spoke with both DON and resident [R102] on the phone and apologized and informed [R102] that we [the Facility] would do a thorough investigation into this incident. On December 24, 2024, the administrator came into the building and started the investigation by speaking with the housekeeper employee [Housekeeper A] employee has been employed with [the Facility] since 12/4/2024. [Housekeeper A] who had that housekeeping cart that day and was cleaning that hall. Employee [Housekeeper A] housekeeper was called into the Administrator office along with Human Resources before the start of her shift. During the interview employee [Housekeeper A] was asked about [their] workday on 12/23/2024, in response [Housekeeper A] reported that [they] had a normal day. [Housekeeper A] was then asked if the resident [R102] asked about [R102's] missing Apple I pods. [Housekeeper A] then responded that a resident [R102] did ask about the ear pods and [R102] also informed that the ear pods where (sic) ping (an application used to track/locate a missing electronic device) from [the] housekeeping cart. [R102] reported that [they] looked around on the housekeeping cart and found the ear pods at the bottom of [Housekeeper A] housekeeping cart and returned them to the resident [R102]. The resident also informed [Housekeeper A] to report this to [the] supervisor. [Housekeeper A] also stated that the housekeeping cart [they] was using was not [theirs] but another colleague who was not working the day of the incident. [Housekeeper A] was then explained to by Administrator that [they] would be suspended pending investigation. After a thorough investigation by Administrator and Human resources the allegation of misappropriation is substantiated. Employee [Housekeeper A] was terminated on 12/26/2024 by phone call from Human Resources . Further review of the investigation revealed: On 2/11/2025 at 2:30 PM, an attempt was made to contact R102 for an interview and a voicemail was left for callback without a call back. On 2/11/2025 at 3:15 PM, the Administrator was asked to elaborate on what happened on 12/24/2024 involving R102's ear pods. The Administrator stated the following, The resident (R102) came to my office and informed me that their ear pods were missing from their room and (R102) used the app (Application to locate electronic device) and it pinged to the (Housekeeper A) cleaning cart. The Administrator said that they looked on the facility cameras (Housekeeper A) was seen going into (R102's) room, walked to their cart and placed something at the bottom of the cleaning cart. A review of the facility's policy titled Abuse, updated 5/24/2023, revealed the following: Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.

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 pertains to intake MI000149346. Based on observation, interview, and record review the facility to provide shower ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI000149346. Based on observation, interview, and record review the facility to provide shower linens (towels and washcloths) for two residents (R112 and R113) resulting in an unclean, uncomfortable environmental where residents went without shower linens and had to purchase and share personal items. This deficient practice affected all 107 residents residing in the facility. Review of an anonymous intake, dated 1/6/25, noted the following on 1/24/25, Complainant states for at least the past 2 weeks the facility has been without towels and washcloths for the residents. The complainant states staff have been instructed to cut up gowns to use to wash and dry residents. Complainant states they have a loved one at the facility and staff left feces on the resident after attempting to clean them up with a gown. On 2/11/2025 at 09:15 am, an observation of the linen closets on each unit revealed the following: -Cherry Hill- zero towels and zero washcloths -Medbridge- three towels and zero washcloths -[NAME]- zero towels and zero washcloths The facility is certified for 150 beds. The census at the time of survey was 107. There were not enough linens to provide any care at the time of observation. On 2/12/2025 at 9:25 am, the Housekeeping Director, who was in the laundry room, was interviewed and queried about the availability of towels and washcloths for the residents. The Housekeeping Director pointed to the linen cart that revealed three towels and zero washcloths. The Housekeeping Director was asked if there was additional linen and he stated, We had staff that quit so we are trying to wash as much (shower linen) as we can. The Housekeeping Director was asked if there was an extra supply of linen and stated, This is what I have right now. We are washing now. I have some new ones under the desk. The Housekeeping Director retrieved approximately 50 new towels from an already opened clear package. The Housekeeping Director said that they were also in the process of washing linen. The Housekeeping Director was asked if they had any additional storage of linen and stated, Not at this time. On 2/12/2025 at 09:49 am, a Certified Nurse Aide (CNA), who requested to remain anonymous, was interviewed. The CNA was queried about the availability of towels and washcloths and stated, I have to save and hide linen because we never have enough to bathe or clean the residents .We tell the (Administrator/NHA) but she might give us one washcloth and one towel. On 2/12/2025 at 09:55 am, a second anonymous CNA was interviewed and queried about the availability of towels and washcloths and stated, I don't want to get fired, but we never have enough towels and washcloths. Sometimes we have to use pillowcases for wash cloths. On 2/12/2025 at 09:59 am, a third anonymous CNA was interviewed and queried about the availability of towels and washcloths and stated, We have to cut sheets and pillowcases to wash residents. On 2/12/2025 at 10:25 am, the Nursing Home Administrator (NHA) was observed carrying a pack of washcloths. The NHA was queried and said that she was putting out towels and washcloths. The NHA was asked how many washcloths were available and she held up the package that noted 60 washcloths came in the package. On 2/12/2025 at 11:17 am, R112 was observed in bed watching TV. R112 had dressings on both lower legs. R112 stated that they buy their own supplies because there was never enough. It was observed R112 had 11 packs of wet wipes and blue chucks (absorbent pads) they reported they ordered from a (known delivery service.) A review or R112's electronic medical record revealed an admission to the facility on 6/05/2024 with the diagnosis of Pressure Ulcers to the Lower Legs, Anxiety, Muscle Weakness. R112's Brief Interview for Mental Status (BIMS) test indicated 15/15, cognition is intact. A review of the R112's Care Plan dated 6/6/2024 revealed the following: Assist to bathe/shower as needed Assist with daily hygiene, grooming, dressing, oral care and eating as needed . On 2/12/2025 at 11:28 am, R113 was observed sitting in their room in a wheelchair. R113 was asked if they had clean towels and washcloths and stated, I was only given one washcloth and that's from yesterday . They never have enough towels or wash cloths. I have to use the same washcloth for several days. A review or R113's electronic medical record revealed an admission to the facility on 1/23/2025 with the diagnosis of Joint Replacement, Difficulty Walking, and Edema. A review of R113's Brief Interview for Mental Status (BIMS) indicated 14/15, intact cognition. A review of the R113's Care Plan dated 1/23/2025 revealed the following: ADL Assist of x1 for toileting/self-care for safety Assist with daily hygiene, grooming, dressing, oral care and eating as needed On 2/12/2025 at 3:30 PM the NHA was interviewed and queried about the lack of towels and washcloths needed for each resident's hygiene and personal care. The NHA stated, I was unaware of any linen issues. However, the NHA explained, It's hard to gauge off what is in the linen rooms, they may have to go back to the laundry room to get linens as needed. The NHA said that the CNAs are throwing washcloths in the trash and cutting-up towels. The NHA said she keeps some supplies in her office, but staff did not tell her that they needed linen supplies. The NHA was asked to explain how the linen supply is inventoried to ensure staff and residents had enough shower linen for personal care needs. The NHA explained that when they are low on linen, she will place an order for more. However, the NHA was unable to explain why there was a shortage of shower linens when the shower linens are inventoried. A review of the facility's Linen Supply Guidelines, noted the following: Closets will be replenished DAILY at 6 AM - 10 AM - 2 PM - 6 PM - 11 PM CHERRY HILL (Unit) Provide at least 65 sets of Bed linens a day Provide at least 65 sets of Shower linens every shift MEDBRIDGE (Unit) Provide at least 60 sets of Bed linens a day Provide at least 60 sets of Shower linens every shift [NAME] (Unit) Provide at least 30 sets of Bed linens a day Provide at least 30 sets of Shower linens every shift A review of the facility's policy, Homelike Environment, dated 9.21.2023 documented in part: The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment .clean bed and bath linens that are in good condition.

Jan 2025 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00149008 and MI00148990. Based on interview and record review, the facility failed to ensure...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00149008 and MI00148990. Based on interview and record review, the facility failed to ensure proper transfer assistance for two residents (R102 and R103) out of four residents reviewed for accidents. Findings include: R102 - It was reported to the State Agency that the facility failed to ensure proper transfer assistance. The complainant indicated that the resident fell to the floor while being transferred back into the bed and a nurse assistant and nurse were rough with the resident during the transfer from the floor into the bed. A review of the clinical record for R102 documented an admission into the facility on [DATE] and discharge on [DATE]. R102's diagnoses included ovarian cancer and severe protein-calorie malnutrition. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. Record review of R102's ADL (activity of daily living) self care deficit as evidence by weakness related to metastatic CA (cancer) care plan documented transfer with one-person assistance using two wheeled-walker and gait belt, initiated 12/6/24. R102's care plan also indicated R102 was at risk for falls due to weakness. A review of an incident report dated 12/7/24 and corresponding investigation for R102 revealed the following: CNA G documented that she previously assisted R102 out the bed to take her to the bathroom and R102 transferred easy. CNA G reported that when she was transferring R102 back into her bed, R102's knees buckled and R102 dropped to the floor and R102 landed on both of her knees. CNA G indicated it was hard to get R102 in the bed. R102 appeared light, but R102 was heavy. R102 was positioned on her knees facing the bed. CNA G called RN F who was right outside the door. RN F grabbed R102's upper body as if she was hugging R102 from the left side. CNA G indicated she grabbed R102's legs near her thighs. CNA G and RN F maneuvered R102 onto the bed where she was lying crossway. CNA G and RN F were able to get R102 in the bed. R102 was lying on her stomach with her face towards the head of the bed. Registered Nurse (RN) F reported Certified Nurse Aide (CNA) G called her into R102's room. Upon arrival to the room, RN F observed R102 on the floor in what appeared to be a knee position. CNA G informed RN F that she didn't know that R102 was heavy. CNA G asked RN F to assist with getting R102 up. RN F assisted R102 by her left armpit and the back of her brief with the CNA's help. They were able to get R102 halfway on the bed and at that time, R102 was lying on her left arm. When RN F and CNA F tried to rearrange R102, she rolled on to her stomach. A review of education provided to the facility clinical staff, dated 12/8/24, on falls and appropriate transfer when getting resident from the floor documented in part the following: 1. Employees are to utilize mechanical lifts when transferring residents from the floor to ensure no injuries are sustained. 2. Employees should never lift residents by their arms or legs when transferring them. 3. Employees should always ensure the safest transfers possible when assisting residents. R103 - It was reported to the State Agency that the facility failed to prevent a fall. A review of the clinical record for R103 documented an admission into the facility on 9/19/24 and discharge on [DATE]. R103's diagnoses included brain cancer and repeated falls. A MDS assessment dated [DATE] documented moderate cognitive impairment. Record review of R103's ADL self-care and mobility deficit related to COVID, weakness, recurrent falls, brain cancer, documented to transfer with full mechanical lift, initiated 9/20/24. R103's care plan also indicated R103 was at risk for falls due to generalized weakness, status post hospitalization for COVID. A review of a facility document titled, Functional Abilities and Goals, for R103 dated 9/19/24 documented the following: - Lower extremity: impairment on one side - Toileting hygiene: substantial/maximal assistance - Sit to stand: dependent Review of incident note of 9/23/24 regarding R103 revealed, IDT (interdisciplinary team) met to review resident's recent incident accident. Resident was attempting to use the bathroom with staff and fell to the floor. Intervention: Staff to refer to [NAME] when transferring patient. On 1/2/25 beginning at 2:00 PM, the Director of Nursing (DON) was interviewed regarding the falls for R102 and R103. The DON confirmed that staff should have used a mechanical lift when transferring R102 from the floor to the bed. The DON confirmed that staff attempted to walk R103 to the bathroom. R103 was not a one-person assist. R103 was interviewed and said he told staff that he needed more assistance. R103 should have been transferred with two-persons and a mechanical lift. A review of the facility policy titled, Fall Management Guidelines, dated 12/13/23, documented in part that a post-fall evaluation included: If after evaluation it is deemed safe, use the full mechanical lift to assist the resident off the floor. On 1/2/25 at 5:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information regarding this citation when asked.

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

Deficiency F0694 (Tag F0694)

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 ensure the correct amount of TPN (total parenteral nutrition used t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the correct amount of TPN (total parenteral nutrition used to provide complete nutrition directly into the bloodstream) was administered for one resident (R102), out of three residents reviewed for altered methods of receiving required nutrients. Findings include: A review of the clinical record for R102 documented an admission into the facility on [DATE]. R102's diagnoses included ovarian cancer and severe protein-calorie malnutrition. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. Record review of R102's care plans documented resident was at nutritional risk related to diet restrictions, recent hospitalization, unplanned/unexpected weight loss, recurrent ovarian cancer, abdominopelvic abscess with blockage, history of nausea/vomiting, abnormal labs, history of multiple transfusions, gastrointestinal bleed, depression, severe protein-calorie malnutrition, fragile skin with drains, pedal edema, requires TPN, history of enteral support, anemia, and history of breast cancer. Interventions included to administer TPN as ordered. Date initiated: 12/8/24. Further chart review of R102's clinical record revealed an incident note of 12/8/24 that documented R102 and family member indicated that R102's TPN was not being correctly administered. R102 and family member voiced what R102 had been receiving. They stated that R102 had not received the correct dosing of the TPN since 12/6/24. R102 and husband voiced that R102 should have been receiving two bags of TPN daily to achieve the total calories but had only been receiving one a day and missed the entire dose on 12/5/24. During an interview on 1/2/25 at 2:13 PM, Registered Dietitian (RD) H said R102's TPN order was on paper, and the order had been faxed to the pharmacy. RD H indicated the order was not in the electronic health record. A review of R102's December 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reveal documentation of the administration of R102's TPN. RD H was unsure of how nursing documented TPN administration. During an interview on 1/2/25 at 2:19 PM, the Director of Nursing (DON) said the administration of R102's was never put on the MAR. R102 received TPN but nursing never transcribed the order. Nursing should have documented the administration of R102's TPN in the progress notes. The DON said when the pharmacy was contacted to clarify R102's TPN order, the facility was informed that R102 should be receiving two bags of TPN per day. The DON also indicated that lipids were included in the TPN order twice weekly on Tuesday and Thursday. Staff were hanging the TPN bag containing lipids (which appears milky white in color) but not the clear TPN bags. The DON indicated that R102 did not receive the prescribed amount of TPN. During a review of R102's clinical record, the DON could not provide documentation of TPN administration. A review of nursing education initiated on 12/8/24 regarding the accurate prescribing of ordered medications: TPN, documented the following content: - Pharmacy to dose medication - Reading and understanding prescribed TPN orders - Clarifications of orders when orders are not clear (Pharmacy, MD) - Notification to MD and families of medication errors - Completing the risk management assessment when medication errors are observed During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: - Identification of affected and like residents to ensure pharmacy is notified promptly and verified TPN orders are transcribed in medication record timely. - Coordinate with pharmacy to clarify process in verifying TPN orders received from the hospital. - One to one education conducted with involved nurses and in-service conducted with all other nurses regarding: 1. Process in obtaining verified TPN order; 2. Transcribing TPN order from pharmacy promptly and accurately; and 3. Verifying physician order prior to administering TPN. - Nurse managers to conduct audits on all residents receiving TPN to ensure hospital TPN orders are verified by pharmacy, order transcribed timely, and TPN order verified before administering formula. - The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

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

Infection Control (Tag F0880)

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 consistently change the PICC (peripherally inserted central cathete...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently change the PICC (peripherally inserted central catheter) line tubing according to physician's order for one resident (R102) out of three residents reviewed for altered methods of feeding. (The parenteral method delivers nutrition intravenously which increases the risk of infection). Findings include: A review of the clinical record for R102 documented an admission into the facility on [DATE]. R102's diagnoses included ovarian cancer and severe protein-calorie malnutrition. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. Record review of R102's potential for complications at IV (intravenous line) insertion site. PICC inserted at upper right arm, care plan indicated to change IV tubing per physician orders, initiated 12/5/24. Physician's order documented to Change IV PICC line tubing daily every day shift for safety monitoring. Start date of 12/6/24. A review of R102's Skin assessment dated [DATE] documented in part the following: Skin assessment done. Resident has a PICC line at left arm with dressing dry and intact. On 1/2/25 at 4:33 PM, a review of R102's clinical record was conducted with the Director of Nursing (DON). According to R102's December 2024 Treatment Administration Record, nursing staff failed to document that R102's IV PICC line tubing was changed on 12/7/24 and 12/8/24. A review of progress notes from 12/7/24 and 12/8/24 did not provide documentation to support the tubing had been changed. The DON stated, It doesn't look like it got done. The protocol is to change the tubing daily. It's supposed to be done daily to monitor the site and for infection prevention. On 1/2/25 at 5:45 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information regarding this citation when asked.

Oct 2024 2 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00147516. Based on interview and record review the facility failed to inform a cognitively im...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00147516. Based on interview and record review the facility failed to inform a cognitively impaired resident's representative of a change in condition for one resident (R902) out of three residents reviewed for resident's rights, resulting in a missed opportunity for R902's representative to participate in medical decisions. Findings include: Record review of R902's electronic medical record (EMR) revealed admission into the facility on [DATE] with diagnoses of dementia, pressure ulcers, and chronic kidney disease. According to the Minimum Data Set (MDS) dated [DATE], R902 was dependent with all Activities of Daily Living (ADLS). Further review of a Brief Interview for Mental Status (BIMS) dated 10/4/24, documented that R902 had scored 3 out of 15 (severe cognitive impairment). R902's facesheet identifieda resident representative. Review of Skin and Wound Evaluation dated 10/7/24, indicated R902's pressure ulcer on coccyx had worsened and categorized to a Stage III- Full- thickness skin and tissue loss. Further review revealed it was documented, Resident/responsible party notified: patient. Interview on 10/23/24 at 12:37 PM with Licensed Practical Nurse (LPN) B, it was reported R902 had impaired cognition and family should have been made aware of the worsening of R902's pressure ulcer on coccyx. Review of Lab (laboratory) Results Report dated 10/9/24, documented R902 had multiple results that indicated abnormal levels. Review of Physician Orders documented, Initiate IV (intravenous) access for fluids, may use sub q (subcutaneous) if needed. Sodium Chloride 0.9 %. Use 1 liter intravenously one time only for labs for 1 day to run 75 ml(milliliters)/hr. for 1 liter hydration. Review of R902's Nursing Progress Notes dated 10/9/24 documented, . Placed sub q infusion to right lower back/side. Fluids up and running. Progress notes did not indicate family was made aware of abnormal lab results, initiation of IV fluids, and the worsening of pressure ulcer on coccyx. Interview on 10/23/2024 at 2:24 PM with Registered Nurse (RN) A, it was reported that R902 had impaired cognition, and the family should have been made aware of the abnormal lab results on 10/9/24, and the interventions implemented. Interview on 10/23/24 at 3:12 PM with Director of Nursing (DON), it was reported that resident representatives of cognitively impaired residents should be contacted and made aware when there is a change in their condition. Review of facility's policy Change in Condition Notification dated 8/9/23 documented, it is the policy of the facility to notify the resident, his or her attending physician/practitioner. and the residents designated representative of changes in the resident's -medical/mental condition and/or status.

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00147516. Based on interview and record review the facility failed to identify a resident wit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00147516. Based on interview and record review the facility failed to identify a resident with dentures and implement adequate oral care for one resident (R902) out of three residents reviewed for Activities of Daily Living (ADLs). Findings include: Record review of R902's electronic medical record (EMR) revealed admission into the facility on [DATE] with diagnoses of dementia, pressure ulcers, and chronic kidney disease. According to the Minimum Data Set (MDS) dated [DATE] documented that R902 was dependent with all Activities of Daily Living (ADLS). Further review of a Brief Interview for Mental Status (BIMS) dated 10/4/24, documented that R902 had scored 3 out of 15 (severe cognitive impairment). Record review of facility admission Evaluation dated 10/4/24, it was documented under oral evaluation section that R902 did not have dentures. Review of R902's care plan revealed no interventions to remove and clean dentures. Review of R902's [NAME] (Information noted to perform residents care) revealed no interventions to remove and clean resident's dentures. An interview on 10/18/24 at 2:30 PM with Licensed Master of Social Worker (LMSW) C revealed an employee of the hospital where R902 was sent for evaluation on 10/14/24, LMSW C reported they observed R902's mouth and said the top dentures were packed with dried food and had mold. Review of hospital Nursing Note dated 10/14/24 at 11:11 PM, Patients mouth found to be extremely dry/crusting and bleeding at start of shift. Found patients upper dentures and was able to remove and place at patient's bedside. Review of the hospital Physician Progress Notes dated 10/15/24, Patient has poor dentition, with mold appearing plaque buildup on tongue, hard palate and in denture. Further review revealed resident had NPO (nothing by mouth) orders in place since admission at the hospital. Interview on 10/23/2024 at 2:16 PM with Certified Nursing Assistant (CNA) D, it was reported that if a resident has dentures they should be removed and cleaned. It was further reported that I can't remember if R902 had dentures. Interview on 10/23/24 at 3:17 PM with CNA E, It was reported, This patient was a bit confused I swabbed his mouth; I was not aware that resident had dentures. Interview on 10/23/24 at 3:39 PM with Director of Nursing (DON), it was reported that the admitting nurse should verify if a resident has dentures. It was further reported, It is my expectation that dependent residents are provided with oral care on every shift and as needed. Review of facility policy, Oral Care dated 9/14/23 documented, Oral Care is provided with morning and nighttime care and as needed or ordered.

Sept 2024 1 deficiency

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00146875. Based on interview and record review the facility failed to follow a physician's or...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00146875. Based on interview and record review the facility failed to follow a physician's order in a timely manner to insert an indwelling urinary catheter for one (R805) of three residents reviewed for quality of care resulting in the potential for the resident to develop a urinary tract infection. Findings include: The State Agency received a complaint that the facility failed to assess a resident (R805) for a change in condition in a timely manner resulting in the resident being hospitalized for Urinary Tract Infection in less than 24 hours after discharge from the facility. According to R805's Electronic Health Record (EHR) the resident admitted to the facilty on 8/7/24 with multiple diagnoses that included fractured left tibia (top shin bone), fractured left fibula (lateral/outer shin bone), fractured left foot, and fractured lower end of right femur (above knee). R805 had a history of urinary retention, obstructive and reflux uropathy. According to the Minimum Data Set (MDS) dated [DATE] the resident had intact cognition and required maximum assistance for bed mobility, transferring from surface to surface, and toileting. On 8/16/24 at 8:37 AM the Physician Team progress note documented; Patient reports still not being able to void (urinate) independently. Output from intermittent cath (flexible tube inserted into the urethra to drain the bladder then remove the tube) during the night Foley (indwelling urinary catheter) ordered to be reinserted Case discussed with nursing. A review of the order summary is as follows: - 8/16/24 at 9:38 AM an order for Please place foley (indwelling urinary catheter) was created in R805's EHR. - 8/16/24 at 6:29 PM (approximately 9 hours later) the order was confirmed by Registered Nurse (RN) C. On 8/17/24 at 5:23 AM a progress note written by Licensed Practical Nurse (LPN) D reads as follows: Patient had foley placed in by writer per doctor orders at 2:30 AM on 8/17/24 (Approximately 17 hours after the order was created). Patient expressed relief and denied any pain. Output of 2100 mls. On 9/18/24 at 12:45 PM, LPN D was asked about R805's order for a foley catheter and replied, Yes, we put it (foley catheter) in on midnight shift. I don't know why it wasn't done on day shift. The order was given sometime during day shift. When we put the catheter in, the resident's urine filled up the bag almost immediately. We had to empty the collection bag. The resident said they were uncomfortable and felt relief after we placed the catheter. The resident denied having any pain. On 9/18/24 at approximately 12:55 PM, RN C was interviewed about the physician's order to insert a foley catheter for R805. RN C said he received the order late in his shift and had to pass it on to the next shift. RN C reviewed the resident's EHR and acknowledged they had processed the order for R805's foley cather on 8/16/24 at 9:38 AM. On 9/18/24 at approximately1:10 PM, the Medical Director, Physician E reviewed R805's EHR and said, I would expect the nursing staff to process and complete a doctor's orders as soon as possible after receiving them (the orders). On 9/18/24 at approximately 1:15 PM the Director of Nursing (DON) said, It is a standard of practice that nurses carry out a doctor's orders as soon as possible. I can't explain why the nurse didn't do it (insert the foley) earlier in the day. According to the facility's policy Physician and Practitioner Orders last revised on 9/21/23 in part reads: The purpose of this policy is to provide guidelines for the proper and consistent provision of physician ordered services according to professional standards of quality.

Jul 2024 9 deficiencies

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** Based on observation, interview, and record review the facility failed to ensure dignity was maintained for one resident (R21) o...

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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 ensure dignity was maintained for one resident (R21) of three residents reviewed for dignity, resulting in the resident expressing feelings of embarrassment and humiliation. Findings include: In an interview on 7/9/24 at 12:40 P.M., R21 explained that on Friday 6/21/24 he had been taken to physical therapy wet. R21 reported he told the PTA (Physical Therapy assistant) G he had an accident and his sheets and briefs needed to be changed. According to R21 PTA G did not assist or request staff assistance in changing the resident's brief, but did ask the two nurse aides at the desk to change the resident's linen on the bed before the resident returned to the unit. During the interview R21 began to cry uncontrollably stating he was taken to therapy and had to wear a wet brief for 45 minutes or more and he felt embarrassed and humiliated. The resident continued and repeatedly commented, I am a human being, well respected in my church and community, and no one should be treated like that. When I returned back to my room around 1:00 P.M., (COTA I) can tell you I was wet and the bed still had the same soiled linen that PTA G had requested the staff to changed before leaving. Witnessing how upset I was PTA G requested staff to assist me with a brief change and she changed the linen on the bed. Review of the admission Face Sheet indicated R21 was admitted to the facility on [DATE] with pertinent diagnoses of: Heart Failure, Chronic Kidney Disease, stage 4, Hypertension, Atrial fibrillation, Chronic Pulmonary Disease and Diabetes Mellitus. According to the minimum Data Set (MDS) dated [DATE], R21 had a BIMS (Brief Intellectual Mental Score) of 14/15 for cognition and required two person assist with transferring and hygiene. Review of the Physician Order's for R21 indicated Physical therapy and discharge home. On 7/10/24 at 2:26 P.M. PTA G was interviewed concerning taking R21 to therapy wet. PTA G denied R21 told her he was wet, but did confirm requesting the two nurse Aides (one being CNAB) on the unit to change the linen on the bed. PTAG reported being removed from R21's workload for therapy after returning to work on 7/8/24, but was unsure why. At 2:30 P.M. interview with CNA B concerning R21 being taken to therapy wet on 6/21/24. CNA B indicated when R21 returned from therapy (1:00 P.M.) escorted by COTA I the resident was wet and assistance was provided in changing the resident's brief. The aide indicated remembering the day very well because staffing was short on the unit on that date and R21 reported to COTA I and herself how he felt and stated, he had informed PTA G of being wet before going to physical therapy. On 7/11/24 at 2:44 P.M. UMH was interviewed concerning the incident on 6/21/24 with R21. UMH reported being made aware of the details returning to the unit on 7/7/24, stating a Concern Form was formulated and sent to the Administrator and Physical Therapy Manager. No reason was provided why there was a delay in reporting the incident and correcting the concern. In a follow up interview at 3:00 P.M. the Director of Nursing could not provide any reason there was a delay in addressing R21 concern and indicated she had no knowledge of the incident. The DON was informed of the resident's uncontrollable crying while reporting the incident on 7/9/24, even though the incident occurred 6/21/24. On 7/12/24 at 9:00 A.M. Therapy manager (PT) J was interviewed concerning the incident. The manager stated something appeared to have happened between R21 and PTA G so we changed staff. I recently received the Concerned Form (unsure of date). Review of the submitted Concern Form, indicated the incident was referred to the Administrator and PT Manager on 7/7//24 and follow up date of 7/9/24. Review of the facility's policy dated 9/21/2023, Titled: Dignity . It is the policy of this facility that each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth, and self-esteem.

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 showers for one (R21) of five residents review...

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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 showers for one (R21) of five residents reviewed for Activities of Daily Living (ADL'S), resulting in the resident not receiving scheduled showers. Findings include: In an interview on 7/9/24 at 12:40 P.M., R21 stated, he was admitted to the facility on [DATE] and for 2 and half weeks after admission had not received a shower. R21 stated he got so frustrated his wife came to the facility and gave him a shower because the staff was ignoring his requests for a shower. The resident was queried, if he told anyone about his showers, R21 responded yes, it was reported to the concierge (corporate liaison from outside who take concerns in the facility 2-3 times a week) and R21 did not receive the shower promised on that Saturday night. R21 indicated the staff continued to give me a bucket bath (meaning bed bath). Review of the admission Face Sheet indicated R21 was admitted to the facility on [DATE] with pertinent diagnoses of: Heart Failure, Chronic Kidney Disease, Stage 4, Hypertension, Atrial fibrillation, Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. According to the Minimum Data Set (MDS) dated [DATE], R21 had a BIMS (Brief Intellectual Mental Score) of 14 of 15 for cognition and required two person assist with transferring and hygiene. On 7/10/24 at 9:00 A.M., review of the Care Plan dated 5/30/24, Focused ADL Self Care and mobility deficit indicated the Nurse Aide was responsible for Assisting and bathe/showers as needed, assist with daily hygiene, grooming, dressing, oral care and eating. Review of the Nurse Aide's Task Assignment for R21 did not identify showers as a task that the Aide was to perform or identify any shower days for the resident. At 2:30 P.M. Nurse Aide (CNA) B was quired concerning documentation for resident's showers. CNA B stated, showers were documented on the Assignment Sheets and once the task was completed a shower Sheet was to be put in the shower Logbook on the unit. CNA B stated during the observation of the Shower Book, when we are short of help, or someone calls in residents don't always receive showers like they are supposed to. We are not robots; we take care of the residents the best we can, and we let them know. Review of the Shower Logbook revealed an unorganized binder with multiple loose-leaf sheets. Shower sheets found for R21 documented the resident did not receive a shower on the following days: (Tuesdays, Fridays). 5/31/24, 6/4/24, 6/7/24, 6/11/24, 6/18/24, 6/21/24, 6/25/24, 6/28/24, 7/2/24, and 7/5/24. There was documentation R21 received a shower by his family 6/14/24 and on 7/9/24 after the entry of the survey team. On 7/10/24 at 4:00 P.M. interview with R21's wife revealed R21 complained staff only gave him bucket bathes. On 6/14/24 R21's wife gave her husband a shower after the resident requested to be transferred to a different facility and his attitude changed. The resident's wife explained prior to admission R21 always showered daily and was very prideful concerning his appearance. During the interview R21's wife reported the resident lost hope in progressing especially after not receiving the promised Saturday night shower from the Concierge. We then decided to report our concern to Unit Manager (UM) H who assisted in completing a Concern Form. On 7/11/24 at 2:44 P.M. Unit Manager (UM) H was interviewed and denied knowledge of the missing showers. The manager reported he became aware of the resident's concern during interviewing R21 and his wife for another incident over the weekend and during the conversation R21 reported his concern related to not receiving scheduled showers. A request was made to review the Concern Forms for R21. At 3:00 P.M. The Director of Nursing was interviewed concerning R21 not receiving scheduled showers. The DON reported R21 had some Concern Forms, but she had not received anything related to him not receiving scheduled showers. The DON acknowledged she had reviewed the shower Book, and it was incomplete, in disarray, and missing evidence of current shower sheets for residents. The DON stated, I was not aware of that concern, R21 and all residents show receive two showers a week on their scheduled days. All showers should be documented and not providing that service for the residents was unacceptable. No reason was provided why R21 did not receive showers after reporting the concern to the Concierge.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2 Based on observation, interview, and record review the facility failed to accurately obtain and ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2 Based on observation, interview, and record review the facility failed to accurately obtain and document weights for two residents (R46 and R60) out of four residents reviewed for nutrition, resulting in R46 have a documented 127.4 lbs.(pound) weight loss in a one-month period. Findings include: R46 During an observation and interview on 7/9/24 at 12:44 PM, R46 was observed alert and oriented and sitting in bed, when asked it was reported by R46 she had lost a significant amount of weight since coming into facility. Record review of R46's electronic medical record (EMR) revealed admission into the facility on 7/27/23 with pertinent diagnoses of morbid obesity and diabetes. According to the Minimum Data Set (MDS) dated [DATE], R46 had impaired cognition and was dependent on most Activities of Daily Living (ADLS). Record review of weights revealed the following: 6/8/2024 - 240.6 lbs. (pounds) 6/6/2024 - 240.8 lbs. 5/23/2024 -244.2 lbs. 5/8/2024 -244.4 lbs. 4/3/2024 -371.8 lbs. 3/6/2024 -372.9 lbs. 2/712024 -371.8 lbs. 1/10/2024 -372.4 lbs. 12/6/2023 -371.6 lbs. 11/1/2023 -370.5 lbs. 11/1/2023 -370.5 lbs. 10/11/2023 -367.8 lbs. 9/20/2023 -365.4 lbs. 9/1/2023 -363.0 lbs. 7/27/2023 -363.0 lbs. Upon further review of weights, it was documented that R46 had a weight loss of 127.4 lbs. weight loss from 4/3/24 until 5/8/24. During a follow-up interview on 7/10/24 at1:25 PM with R46, several questions were asked, and resident answered questions appropriately. When asked if resident had lost 127 lbs. in one month, R46 responded, No. When asked if facility provided three meals a day and snacks, R46 said, Yes. Resident was asked if happy with the amount of weight loss, R46, smiled and stated, Yes. Review of Nutrition/Dietary Note dated 5/14/24, Note Text: Monthly weight obtained and shows 127# weight loss. Supervised reweight recommended. Further review Nutrition/Dietary Note dated 5/24/24 at 11:27 AM- Note Text: RD (Registered Dietician) following r/t weight change. CBW 244.2# indicating 127# (lbs.) loss x 1 month. This large of weight loss not plausible. Pt has had no change in condition. PO (oral) intake 75-100%. Labs obtained 4/22 and WNL (within normal limits) except slightly low Hgb (hemoglobin) of 10.96. No new medications. Recommend continue weekly weights until stable x 4 weeks. NP (Nurse Practitioner) aware of weight showing large change. RD to follow as needed. During an interview 7/11/24 11:26 AM with RD V, It was reported that it was not possible for the resident to lose that much weight in a month with out underlying conditions. It was further reported it was believed that weights were not obtained accurately and related to the resident's therapeutic diet, weight had reduced since admission. Record review of Emergency Department Discharge dated 1/11/24, R46 weighed 330 lbs. Further review of weights revealed on 7/11/24 at 10:24 AM, a weight was documented that R46 weighed 242.4 lbs. During an observation on 7/11/24 at 10:26 AM, a weight was conducted by Director of Nursing (DON) and R46 weighed 233.6 lbs During an interview on 7/11/24 at 12:50 PM with Physician W, it was reported that R46 had been monitored frequently by himself and the Nurse Practitioner and related to their assessments and labs that were done R46 could have not lost that significant amount of weight in a month. Physician W further commented there was no indication that it was pathological. It was further reported that it was believed that the weight of the resident was not accurately obtained by staff and related to R46's diet the weight was lost over the months since admission. R60 Record review of Weight Summary dated 7/10/24, R60 weighed 157.4 lbs. Further review of weights revealed on 7/11/24 at 10:13 AM, R60 weighed 151.6 lbs. This amounted to a 7.4 lbs. weight loss. An observed weight was conducted by staff with Surveyor present. During weight it was observed that resident was not properly positioned. RD V was made aware, and staff positioned resident properly and the resident weight was then obtained revealing a weight of 159.0 lbs., and increase of 7.4 lbs. Record review of R60's electronic medical record (EMR) revealed resident was admitted into the facility on 6/19/24 with pertinent diagnosis of gastrostomy status (insertion of a tube feeding). According the Minimum Data Set (MDS) dated [DATE], R60 had impaired cognition with a Brief Interview for Mental Status (BIMS) of 5/15. During an interview on 7/11/24 at 1:30 PM with the DON, it was reported that related to R46, it was believed that the weights were not accurately obtained, and the resident did not lose that significant weight in one month, it had been reduced since admission. When asked about the inaccuracies observed and documented for R46 and R60, DON reported that the staff needs more education on obtaining weights and proper documentation. Record review of facility policy Weights dated 5/3/22 documented, The Registered Dietician or designee is responsible for the weight management program to include compliance with weights being obtained, tracking and trending, nutritional assessments, interventions, care plans, and follow-up. This citation contains two Deficient Practice Statements. Deficient Practice Statement #1. Based on observation, interview, and record review the facility failed to effectively communicate and collaborate care with hospice staff for one resident (R28) reviewed for hospice services resulting in R28 not receiving an Alternating Pressure Relief Mattress (APM). Findings include On 7/10/24 at approximately 4:00 PM, R28's family member said the resident was supposed to receive a pressure relieving mattress (APM) from hospice for comfort care about a month ago and had not received it. R28 was observed in a bariatric sized bed (a wider bed) with a regular bariatric mattress in place, not an APM. It was noted that an APM was outside the resident's room, leaning against the wall. Review of R28's Electronic Health Record (EHR) indicated R28 had multiple diagnoses that included adult failure to thrive, dementia, and was receiving hospice services. A care plan for 'hospice' was initiated on 3/19/24 included the following intervention; Collaborate care with hospice to meet resident's needs. A progress note on 6/13/24 documented that an APM was ordered by hospice. There were no corresponding progress notes from hospice in the resident's EHR. The last hospice note was dated 5/28/24. A care conference dated 6/14/24 did not document hospice orders for the APM or include hospice reports or staff participation. A review of R28's skin assessments indicated R28 was free from pressure ulcers. On 7/11/24 at 9:47 AM the Director of Nursing (DON) said that Hospice staff documents their communications in a physical paper binder kept at the nurse's station. Review of R28's binder revealed a schedule for hospice staff's on-site visits. The sign-in sheets were blank. The notes, special instructions and supplies forms were blank. The DON said since the company had switched over to a new software application the hospice staff did not have access to resident's EHR. On 7/11/24 at 1:15 PM Maintenance Director (MD) Y was asked about the APM outside R28's room. MD Y confirmed the APM was delivered by hospice for R28 about one month ago. MD Y said, The mattress was too small for the resident's bariatric-sized bed. The resident's bed is 42 inches wide and this mattress is only 36 inches wide. It isn't going to fit properly and we didn't put it on the resident's bed. MD Y said since the mattress was not the facility's equipment and he could not move it back into facility storage. MD Y was unaware of how to communicate to the hospice company and said, I thought nursing would be communicating with them to get a new mattress. On 7/11/24 at approximately 2:00 PM, the Hospice Registered Nurse (RN) P was interviewed about the APM. RN P confirmed the APM was delivered to the facility on 6/13/24. RN P said she was unaware the APM was the wrong size and had not been placed on R28's bed. RN P said there had been difficulty communicating with the facility staff since they could not access the resident's EHR. According to the facility's policy titled: Hospice issued on 3/20/24 in part reads; In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident ' s needs. These include: . - Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. - Notifying the hospice about the following: - Clinical complications that suggest a need to alter the plan of care. - Communicating with the hospice provider and documenting such communication to ensure that the needs of the resident are addressed and met 24 hours per day . The facility has designated a member of their clinical leadership team such as their Director of Nursing or Unit Managers) to coordinate care provided to the resident by our facility staff and the hospice staff. They will be responsible for: - Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving their services. - Ensuring the facility is communicating with hospice representatives including the hospice medical director, the resident's attending physician, and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions to ensure quality of care for the resident and family, - The facility and hospice will collaborate to ensure the resident's coordinated care plans maintain the resident's highest practicable physical, mental, and psychosocial well-being while reflecting the resident's goals and wishes.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

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 schedule an ophthalmologist (eye doctor) appointment f...

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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 schedule an ophthalmologist (eye doctor) appointment for one resident (R12) reviewed for vision services resulting in R12 having delayed treatment for cataracts. Findings include: On 07/09/24 at 10:20 AM, R12 was observed laying in bed watching TV. R12 had several books, magazines, word search puzzles, and an IPad on his over-bed table. Upon inquiry R12 said, I like to read and play games on my IPad, but I can't see that well because I have cataracts. I've asked them several times to make me an eye doctor appointment, but nothing gets scheduled. According to R12's Electronic Health Record (EHR), the resident admitted to the facility with multiple diagnoses that included history of a stroke and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) dated [DATE], indicated the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14/15. On 6/5/24, a progress note written by Nurse Practitioner (NP) Z documented that the resident had complained of cataracts getting worse. On 6/9/24 an order was written to make an ophthalmology appointment for R12. The Ophthalmologist's information was provided in the order. On 6/13/24 a progress note written by Social Worker (SW) K indicated that R12 would like to receive vision services for his cataracts and Social Work will continue to follow. There was no documentation to support that an ophthalmology appointment had been made for the resident. On 7/10/24 at 12:45 PM SW K was asked about the ophthalmology appointment for R12. SW K was unaware if any appointment had been made for the resident. SW K reviewed R12's EHR including the progress note written on 6/13/24 and acknowledged there had been no follow up for R12 at this time. On 7/10/24 at 2:43 PM during in interview with NP Z she stated, The resident's ophthalmologist appointment should have been made already. I even put the ophthalmologists contact information in the order. According to the facility's policy titled Hearing and Vision Services, last devices on 4/3/22 reads in part; It is the policy of this facility to ensure that residents have access to and receive proper treatment and assistive devices to maintain vision and hearting abilities. 3. Once vision or hearing services have been identified the social worker/social service designee will assist the resident by making appointments and arranging transportation. According to the facility's policy titled Consultations, last revised on 2/29/24 reads in part; The purpose of this policy is to provide guidelines for physician and practitioner ordered consultations. - Following in the receipt of a physician order for a consultation, the facility will: - Secure the appointment with the consultant, if the resident of family/responsible party does not wish to do so personally.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

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 label tube feeding (liquid nutrition provided by a tub...

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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 label tube feeding (liquid nutrition provided by a tube to stomach) container and hydration flush bag for one resident (R60) out of two residents reviewed for nutrition, resulting in the potential for receiving the incorrect product and dosage. Findings include: During an observation on 7/9/24 at 10:19 AM in R60's room, a bottle of Glucerna (Liquid nutrition) was infusing as well as a hydration bag. The bottle of Glucerna was not labeled with the date started, resident's name or the physician's order for infusing. The hydration bag was not labeled with resident's name, date, order for flush or the contents of the bag. Record review of R60's electronic medical record (EMR) revealed resident was admitted into the facility on 6/19/24 with pertinent diagnosis of gastrostomy status (insertion of a tube feeding). According the Minimum Data Set (MDS) dated [DATE], R60 had impaired cognition with a Brief Interview for Mental Status (BIMS) of 5/15. Further record review of R60's physician orders revealed Enteral (Tube feeding) Feed Order: every shift. Enteral Nutrition Formula Name: Glucerna 1.5 rate: 70 ml (milliliters): Frequency per hour: Duration: Start Time 1600 (4PM) run until 1400 ml infused . Review of flush orders revealed Flush with 50 cc (cubic centimeters) of H2O (water) ever hour via auto flush while pump is running. During an interview on 7/11/24 at 10:48 AM with Unit Manager (UM) H, it was reported that both containers should have been labeled before the administration to ensure it was given to the correct resident and that the proper dose was infused as ordered by physician. During an interview on 7/11/24 at 12:39 PM with Director of Nursing (DON), it was reported that containers should have been labeled before administering to the resident. DON was asked to provide the facility's policy on correctly labeling tube feeding and hydration before administration. A facility policy or procedure guideline was not provided by the end of survey on this proper procedure.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the facility responded to pharmacist Medication Regimen ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that the facility responded to pharmacist Medication Regimen Review (MRR) recommendations timely for one resident (R8) of five residents reviewed for a medication regimen review, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes. Findings include: On 7/11/24 at 9:57 a.m. review of the clinical record documented R8 was initially admitted into the facility on 5/26/20 and readmitted on [DATE] with diagnoses that included major depressive disorder, heart failure, generalized anxiety disorder, and morbid obesity. According to the quarterly Minimum Data Set assessment dated [DATE], R8 had intact cognition and required extensive two-person assistance with activities of daily living. Review of R8's physician orders documented the resident's current medications as follows: -Buspirone HCl Oral Tablet 15 MG (Buspirone HCl)- Give 1 tablet by mouth every 8 hours for Anxiety. Start date 4/12/24. -Escitalopram Oxalate Oral Tablet 20 MG (Escitalopram Oxalate)- Give 1 tablet by mouth one time a day for Depression. Start date 3/23/24. Review of monthly pharmacy recommendations in the electronic medical record documented the following: 6/16/24- See report for any noted irregularities and/or recommendations. 5/14/24- See report for any noted irregularities and/or recommendations. 4/18/24- See report for any noted irregularities and/or recommendations. On 7/10/24 at 3:53 p.m. the facility was asked to provide the detailed pharmacy reports and recommendations. They were not located in the electronic medical record (EMR). On 7/12/25 at 10:55 a.m. the Director of Nursing (DON) was asked to verify the monthly pharmacy reports and recommendations for R8 for April, May, and June. The DON said the pharmacy did not email any reports and/or recommendations for said months. See report for any noted irregularities and/or recommendations was checked in error in the EMR. The DON explained the pharmacy reviews are completed offsite and any reports and/or recommendations are emailed when completed. The DON presented reports that were emailed by the Consultant Pharmacist. Review of the recommendations did not include R8. On 7/16/24 at 1:28 p.m. Pharmacist U who completed monthly medication regimen reviews was interviewed and explained chart reviews are completed offsite. Pharmacist U further explained that once irregularities are identified, the reports are emailed to contact person at the facility (usually the DON). The facilities EMR document there is an irregularity, but the actual reports are emailed to the facility. Once facility reviews them and either accepts or declines the recommendations, the response should be documented somewhere in the EMR. If there is no response to the recommendation, irregularities will continue to be documented until addressed. Pharmacist U confirmed R8 had irregularities that were not addressed for the months of April (4/17/24), May (5/14/24), and June (6/16/24). They are reported as follows: Consultant Pharmacist Recommendation to Prescriber: Federal guidelines state psychopharmacological drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with 1 month between attempts, then annually thereafter, when used to manage behavior, stabilize mood, or treat psych disorder. This resident has been taking Buspar 15 mg BID since 6/2023. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? There was no response to recommendation when reviewed by pharmacy in May and June. Review of the facility's policy titled Organizational Aspects - The Consultant: Medication Regimen Review (Monthly Report), effective March 1, 2018, documented in part: The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medical director and/or the administrator.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R16 On [DATE] at 1:38 p.m. R16 was observed in room sitting on the bed watching television. The resident presented as alert, ori...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R16 On [DATE] at 1:38 p.m. R16 was observed in room sitting on the bed watching television. The resident presented as alert, oriented to person and place and able to make needs known. R16 had some knowledge of desired code status when explained what it was, All I know is I want everything done to me to keep me alive as long as possible. On [DATE] at 2:03 p.m. review of the clinical record documented the R16 was initially admitted into the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses that included major depressive disorder, vascular dementia, and cerebral infarction. According to the quarterly MDS assessment dated [DATE], R16 had moderate impaired cognition and required set-up and supervision with most ADLs. Review of the resident profile in the electronic medical record document: Advance directive: Full Cardiac Pulmonary Resuscitation. Review of the R16's face sheet documented there was a legal guardian effective as of [DATE]. Review of the physician's orders dated [DATE] documented: Adv Directive: Full Cardiopulmonary Resuscitation (CPR). Further record review did not reveal a written Advance Directive formulated by the resident/ legal guardian in the electronic medical record. R19 On [DATE] at 11:31 a.m. R19 was observed in bed asleep. The resident did not respond to name when called. Per the attending nurse, R19 was non-verbal. On [DATE] at 2:20 p.m. review of the clinical record documented R19 was initially admitted into the facility on [DATE] with diagnoses that included Alzheimer's disease, peripheral vascular disease, and dementia. According to the annual MDS assessment R19 had severe cognitive impairment and required dependent total assistance with all ADLs. Review of the resident profile in the electronic medical record document: Advance directive: Full Cardiac Pulmonary Resuscitation. Review of the R19's face sheet documented there was a DPOA (Durable Power of Attorney) for healthcare effective [DATE]. Review of the physician's orders dated [DATE] documented: Adv Directive: Full Cardiopulmonary Resuscitation (CPR). On [DATE] an email correspondence with the Nursing Home Administrator read as follows: Good morning our policy states that a form will only be required for Do-Not-Resuscitate (DNR) . This was submitted after requesting to review written Advance Directives for multiple residents that had Full Code statuses. According to the Michigan Physician's Orders for Scope of Treatment (MI-POST) and Michigan Public Health Code Act 368 of 1978: An advance directive is a written document in which you specify what type of medical care you want in the future, or who you want to make decisions for you, should you lose the ability to make decisions for yourself . MI-POST General Rules:1 Are for adults with advanced illness/frailty. 2 Should use standard form. 3 Should be retained in medical record . Based on interview and record review the facility failed to provide accurate and complete information for Advance Medical Directives (AMD), legal documents that allow a person to identify decisions about end-of-life care ahead of time, for eight residents (R12, R15, R16, R17, R19, R21, R40, and R55) of 12 residents reviewed for AMDs resulting in the resident or their Legal Guardian (LG) not being fully informed of how to formulate an AMD and their preferences for medical care not to be followed by the facility. Findings include: R12 According to R12's Electronic Health Record (EHR), the resident admitted to the facility with multiple diagnoses that included history of a stroke and chronic obstructive pulmonary disease. The EHR's header (top of page) indicated R12 was a full code. (All medical measures will be take to maintain and resuscitate life including Cardio Pulmonary Resuscitation if the resident has no heartbeat and not breathing.) R12 had a Legal Guardian (LG) with valid paperwork and contact information in the EHR. The Minimum Data Set (MDS) dated [DATE], indicated the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14/15. A care conference on [DATE] indicated that the resident's LG was not present, did not attend by phone, and the resident was 'unable to participate due to cognitive limitations'. R12's code status was marked as Full Code with no additional documentation. There was no AMD form or progress note that indicated information had been provided to R12 or the LG regarding code status or the formulation of an AMD. On [DATE] at approximately 10:30 AM during an interview with R12 he said he had no recall of anyone asking him about AMDs. A phone call to R12's LG was made and a voice message left. On [DATE] at 1:00 PM Social Worker (SW) L reviewed R12's EHR and said, The resident is a full code. That is his code status. All residents are full codes unless there is a medical directive stating otherwise and a 'Do Not Resuscitate' order (Do not attempt resuscitation efforts in the event of not heartbeat or breathing) has been written. SW L could not locate any documentation to support R12 or the LG had been provided with information regarding code status or AMD formulation. R15 According to R15's EHR the resident admitted to the facility on [DATE] with multiple diagnoses that included vascular dementia with severe agitation, psychotic disorder with delusions, and failure to thrive. The EHR header indicated R15 was afull code. R15's admission orders from the hospital indicated that R15 was a Do Not Resuscitate (DNR). There was no AMD form or progress note that indicated information had been provided to R15 or the family regarding code status or the formulation of an AMD. A MDS dated [DATE], indicated R15 had severely impaired cognition with a BIMS score of 4/15. A care conference dated [DATE] documented R15's family was present. There was no documentation to support AMD information was provided or discussed. R15 was marked as a 'Full Code'. On [DATE], a Physician's progress note documented that R15's family wants the resident to be a DNR. A psychiatric consultation was ordered for mental competency evaluation. A Psychiatric assessment was conducted on [DATE] that did not include a competency evaluation. There was no additional documentation to indicate R15 or his family had been provided with information regarding the formulation of an AMD for the resident. On [DATE] at 12:36 PM during an interview with SW K it was acknowledged that R15 did not have an AMD form or any documentation to support that AMD information had been given to the resident or the family. SW K was aware that R15's family members had requested the resident to be made a DNR and said, They were going through the process to obtain Legal Guardian status to make medical decisions for the resident. The psych consult was to determine the resident's mental capacity. I don't know why that process had not happened yet. According to the facility's policy for 'Advance Directive - Code Status' last revised [DATE] in part reads; Upon admission, the facility will inquire if the resident has executed a written advance directive related to their code status. If they have not, the facility will provide information in a manner easy to understand to the resident related to their right to formulate advanced directives related to their code status. -If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative -If the resident and/or their legal representative has chosen for the resident's code status to be Do-Not- Resuscitate: - The facility will accept a Michigan Do-Not-Resuscitate (DNR) form that has been completed prior to admission to the facility under the following circumstances: - The form is fully filled out and includes the resident signature or the resident's legal representative signature, two witness signatures, and physician signature. R17 On [DATE] at 1:37 P.M. Review of the admission Face Sheet indicated R17 was admitted to the facility on [DATE], with pertinent diagnoses of spinal stenosis, anemia, morbid obesity, and osteoarthritis. Review of the admission assessment dated [DATE] indicated the resident had (BIM'S) Brief Intellectual Mental Score of 15 for cognition. The resident was his own responsible person. Review of the resident's clinical record revealed no Advanced Directive, and no written evidence that the resident had a discussion concerning formulation of an Advanced Directive. R21 On [DATE] at 1:51 P.M. review of the admission Face Sheet indicated R21 was admitted to the facility on [DATE] with pertinent diagnoses of Heart failure, Diabetes mellitus, Hypertension, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and shortness of breath. According to the Minimum Data Set (MDS) dated [DATE] R21 had a BIM'S of 14 of 15 for cognition, required substantial/maximum assistance for toileting and ambulation. In an interview on [DATE] at 3:00 P.M. R21 was queried if the facility had discussed or provided him any information concerning and Advanced Directive. R21 responded NO. They have not talked to me about my wishes. Documented under Advanced Directive: Full Cardiopulmonary Resuscitation (CPR) from the Hospital. R40 On [DATE] at 2:24 P.M. review of the admission Face Sheet indicated R40 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of the mandible According to MDS dated [DATE], R40 had a BIM'S of 15 of 15 for cognition required supervision for most activities of daily living (ADL'S). R40 was her own responsible person. The Face Sheet documented Full code by default. There was no evidence or written discussion related to Advanced Directive. R55 On [DATE] at 2:14 P.M. review of the admission Face Sheet indicated R55 was admitted to the facility on [DATE] with diagnoses of sepsis, adjustment disorder, insomnia, peripheral vascular disease, and acute kidney failure. According to the admission MDS dated [DATE] R55 had a BIMS of 13 of 15 for cognition and his brother was his responsible party. According to the Clinical Record documented under Advanced directive indicated: Full Cardiopulmonary Resuscitation (CPR) from the hospital. There was no documentation or evidence the resident's brother had been contacted to formulate or discuss and Advanced Directive.

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 F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00144625 and MI0014484. Based on observation, interview, and record review the facility fail...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00144625 and MI0014484. Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to meet the needs of residents' dependent upon staff for care needs. This deficient practice has the potential to affect all 72 residents that reside at the facility. On 7/9/24 at 9:52 a.m. during the Entrance Conference, it was confirmed the resident census was 72 (32 residents on the second floor; 40 residents on the first floor). On 7/09/24 at 10:46 a.m. during the initial pool process, the second floor had two nurses and two nurse aides to provide care for 32 residents. On 7/9/24 at 10:50 a.m. Unit Manager H said there is usually two nurse aides for 32 long term residents. Unit Manager H was not able to confirm the number of residents that required two-person assistance with care (transfers, bed mobility, showers, toileting). LPN T said there are three nurse aides at times but there are usually just two. LPN T did not respond to the inquiry of two nurse aides being sufficient to care for 32 residents. On 7/9/24 at 12:40 p.m. it was confirmed it is usually two-day shift nurse aides assigned to care for 32 long term care residents on the first floor. On 7/10/24 at 1:10 p.m. the number of residents that required two-person assistance for care needs was reviewed. The first floor had 10 residents that requiredd a minimum of two people for care needs. The second floor had 15 residents that required a minimum of two people for care needs. On 7/11/24 at 12:17 p.m. the second floor appeared to have an increase in nurse aides on the day shift. It was confirmed there were 31 residents with 4 nurse aides. CNA S was interviewed and said there are usually only two nurse aides providing care, not four. CNA S was asked was that enough staff to care for over 30 residents. CNA S hesitantly stated, I do my best for my residents with check and changes (incontinence care), passing water, showers, bed baths. We try to help each other when we can. Some nurses will help, but most will not. I can only do so much in 8 hours. On 7/11/24 at 3:44 p.m. during QAPI/QAA the Nursing Home Administrator (NHA) was interviewed and said staffing was sufficient. It is currently not being QA'd because it had not been identified as a concern. The acuity of care versus the number of staff scheduled to meet the needs of the residents was brought to the NHAs attention. The NHA was unable to explain why staffing was not scheduled according to resident acuity/needs. On 7/12/24 at 10:32 a.m. Staffing Coordinator R was interviewed and said the facility staff according to census not acuity. More aides can be scheduled with the Director of Nursing's approval. There should be at least three aides on the units speaking as a former nurse aide. On 7/12/24 at 10:55 a.m. the Director of Nursing (DON) was interviewed and said staffing is based on census not acuity. At times staffing can be maneuvered by acuity. There is more staffing on the skilled unit because it's a difficult unit and is usually staffed first. An aide will be reassigned from another unit first to be assigned to the skilled unit. The DON confirmed there is always three aides on the first floor and two on the second floor. The DON confirmed that is not sufficient staff according to acuity. Review of the Facility Assessment, last reviewed 4/25/24, documented in part for a census of 95 (residents) there should be 1 aide per 8 residents. According to the Facility Assessment there should have been a minimum of 3 aides on the second floor and a minimum of 4 aids on the first floor, or a total of 9 aides for a census of 72 and there was not. Review of the facility's policy titled Staffing, dated 11/3/23, documented in part: The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for the residents in accordance with the resident's plan of care. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on their plan of care . R21 In an interview concerning staffing on 7/9/24 at 12:40 P.M. R21 stated, There is not enough staff to take care of the residents. Usually there are two nurse aides on the unit. When you put on the call light for assistance with transfers for example, the aide on my side of the unit may answer my light but if the aide on the other side of unit is busy, the aide that answered my call light will have to go and find assistance, because I am a two-person transfer. There are always two nurse aides on this floor. It's worse on weekends. Staff will tell you there is no staff, and they will assist you as soon as possible. The day I was taken to therapy soiled/wet was an example. There were only two aides working that day. (Review of the Floor Assignments for 6/21/24 confirmed there were two nurse Aides on the unit. On 7/10/24 at 2:30 P.M. CNA B stated when the unit is short of staff, or someone calls off. Residents don't always receive showers like they are supposed to. We are not robots. In a confidential interview with CNA A, concerning staffing CNA A stated, . staffing someday's was bad, and it did affect their ability to provide better services. Rarely do we get additional or replacement help. On 7/12/24 at 10:00 A.M., review of the first-floor assignment sheets for the [NAME] Bridge Unit for 7/9/24 revealed three Nurse Aides were assigned, with one call in leaving two Nurse Aides on the Unit for 32 residents.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to ensure a Registered Nurse (excluding the Director of Nursing) was on duty for eight consecutive hours a day, seven days a week; resulting i...

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Based on interview and record review, the facility failed to ensure a Registered Nurse (excluding the Director of Nursing) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all 72 residents in the facility. Findings include: On 7/12/24 9:46 a.m. review of the nurses' schedule for the month of June 2024, revealed there was no Registered Nurse (RN) coverage on June 1st through June 3rd (Saturday-Monday). On 7/12/24 at 10:32 a.m. during an interview with the Staffing Coordinator R who confirmed, on June 1st and 2nd there was no RN coverage, and the Director of Nursing came in to provide coverage. On June 3rd the RN that was scheduled to come in called off and the Director of Nursing had to come in to cover. On 7/12/24 at 11:05 a.m. The Director of Nursing was interviewed and confirmed there was no RN coverage for the dates of June 1st-3rd due to call offs and came in to provide coverage, I was later told that I was not able to provide RN coverage because I was the Director of Nursing.

May 2024 1 deficiency

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #144271 Based on interview and record review the facility failed to obtain blood glucose levels...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #144271 Based on interview and record review the facility failed to obtain blood glucose levels per physician orders effecting one resident (R901) out of three residents reviewed for change in condition, resulting in unmonitored blood glucose levels. Review of an admission Record revealed, R901 admitted to the facility on [DATE] and discharged on 4/30/24 with pertinent diagnosis which included Sepsis, Type 2 Diabetes, and Severe Sepsis with Septic Shock. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R901 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and required parenteral nutrition. Review of Physician orders revealed R901 had orders which included: Blood Sugar check two times a day for DM (diabetes mellitus) with a starte date of 4/14/24 and an end date of 5/3/24. TPN (Total Parenteral Nutrition) Electrolytes Intravenous Concentrate (Parenteral Electrolytes) use 75 ml/hr intravenously every 24 hours for supplement revised 4/22/24. Review of a care plan revealed R901 had focus Risk adverse outcomes from potential hypoglycemic (low blood sugar) episodes dx. (diagnosis) of DM2 (Type 2 Diabetes). Interventions included accu-check-type blood sugar testing as ordered initiated on 4/15/24. Review of an electronic health record revealed R901 had no documented blood glucose levels. Review of lab results dated 4/30/24 revealed, R901's blood glucose level was 852. Review of a progress note with a date of 5/1/24 at 12:29 p.m. revealed, (R901) was sent to the hospital due to worsening symptoms. She was started on antibiotics, fluids, and had imaging and labs ordered. (R901) was found to have elevated sugars at greater than 800, with evidence of DKA (diabetic ketoacidosis, body not producing enough insulin) . Review of a hospital record for R901's 4/30/24 admission revealed, R901 was noted to be hypotensive by EMS and received fluids on the way to the ED. On arrival, patient noted to be hypotensive with fever 100.2 and blood Glucose level was 113. In an interview on 5/14/24 at 1:55 p.m. Registered Nurse (RN) C reported blood glucose levels are checked when a resident is on TPN per physician orders and stated, sometimes four times a day. In an interview on 5/14/24 at 2:01 p.m. Unit Manager E reported a resident's blood sugar are usually monitored per physician orders while a resident is on TPN. In an interview on 5/14/24 at 2:14 p.m. the Director of Nursing (DON) reported R901 went out for high blood sugar and possible sepsis. DON reported there was an order for BS two times a day which was not prompted to document. DON reported the physician called her because R901's blood sugar was not being monitored. Review of a Parental Nutrition Administration policy issued 9/7/23 documented the following: . Routinely monitor residents receiving TPN/PPN per facility protocol for the following signs and symptoms of complications: Hypo/hyperglycemia . Include the following clinical monitoring at regular intervals (per physician or pharmacy order) . glucose levels .

Mar 2024 2 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

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 pertains to Intake MI00143275. Based on interview and record review, the facility failed to report an allegation o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143275. Based on interview and record review, the facility failed to report an allegation of abuse for one resident (R502) of four residents reviewed for abuse. Findings include: A review of a facility investigation report for R502 revealed the following: Description of the incident: R502 alleged that someone around 8:00 AM, a heavy woman, tried to wake her up. R502 said, 'It felt like a bull laid on me.' Summary of the investigation: LPN (Licensed Practical Nurse) A was providing care. Took (R502's) blood pressure and gave her two breathing treatments. Note, LPN A had to reach over to put facemask and apply breathing treatment. Timeline of Events per review of cameras. At 8:22 AM LPN A was seen with the blood pressure machine and entered resident room. At 8:25 AM LPN A came out of room and prepared medication. At 8:29 AM LPN A entered the resident room with medication and breathing treatment. A review of R502's EMR (Electronic Medical Record) revealed R502 was admitted to the facility on [DATE]. R502 had the following medical diagnoses: Encephalopathy (altered mental status and confusion due to changes in brain function), Aphasia (difficulty speaking), speech and language deficit. A review of R502's Minimum Data Set (MDS) dated [DATE] revealed R502 had a BIMS (Brief Interview of Mental Status) score of 8/15 (moderate impaired cognition). On 3/21/24 at 11:46 AM the NHA (Nursing Home Administrator) was interviewed regarding the allegation of abuse. The NHA said R502 did not say specifically say that she was abused. The NHA said she did not report the allegation because when she investigated the incident in the 2-hour window, she did not substantiate the allegation. On 3/21/24 at 11:53 AM the NHA was interviewed regarding her expectations regarding reporting allegations of abuse. The NHA said it was her expectation that all allegations of abuse should be reported to the State Agency in the time frame required. A review of the facility policy titled, Abuse, dated 4/13/22, revealed, The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator and: - Reported to the State Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials OR - Reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury to the State Survey Agency and to other officials.

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 pertains to Intake MI00143275. Based on interview and record review, the facility failed to investigate an allegat...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00143275. Based on interview and record review, the facility failed to investigate an allegation of abuse for one resident (R502) of four residents reviewed for abuse. Findings include: A review of a facility investigation report for R502 revealed the following: Description of the incident: R502 alleged that someone around 8:00 AM, a heavy woman, tried to wake her up. R502 said, 'It felt like a bull laid on me.' Summary of the investigation: LPN (Licensed Practical Nurse) A was providing care. Took (R502's) blood pressure and gave her two breathing treatments. Note, LPN A had to reach over to put facemask and apply breathing treatment. Timeline of Event per review of cameras. At 8:22 AM LPN A was seen with the blood pressure machine and entered resident room. At 8:25 AM LPN A came out of room and prepared medication. At 8:29 AM LPN A entered the resident room with medication and breathing treatment. A review of R502's EMR (Electronic Medical Record) revealed R502 was admitted to the facility on [DATE]. R502 had the following medical diagnoses: Encephalopathy (altered mental status and confusion due to changes in brain function), Aphasia (difficulty speaking), speech and language deficit. A review of R502's Minimum Data Set (MDS) dated [DATE] revealed R502 had a BIMS (Brief Interview of Mental Status) score of 8/15 (moderate impaired cognition). A review of the facility investigation report revealed no documented interview of LPN A's account of the incident. On 3/21/24 at 11:28 AM the NHA (Nursing Home Administrator) was interviewed regarding the investigation regarding the allegation of abuse. The NHA said she only got a verbal interview of the incident and did not document an interview with the perpetrator.

Jan 2024 1 deficiency

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00141653. Based on interview and record review the facility failed to administer intravenous ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00141653. Based on interview and record review the facility failed to administer intravenous fluids ordered by physician for one resident (R303) out of three residents reviewed for medication administration, resulting in R303 not receiving intravenous fluids as ordered by the physician. Findings include: Record review of electronic medical records (EMR) revealed R303 was admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy and aftercare following digestive surgery. According to the Minimum Data Set (MDS) dated [DATE], R901 had intact cognition and was provided with partial to moderate assist with Activities of Daily Living (ADLS). Review of Progress Notes dated 11/13/23 at 7:38 PM noted: MD (Medical Doctor) in order IV (intravenous) access initiated for fluids. Sodium chloride to run at 100 cc (cubic centimeters) /hr. for 2 days. Orders processed waiting IV placement. Electronically signed by Register Nurse (RN) B. Review of Progress Notes dated 11/14/23 at 6:00 AM, documented the following: MD called at this time to notify pt (patient) is hypotensive (low blood pressure). No answer, message left on voicemail. Oncoming nurse aware for follow up. Pt is receiving sub (sub cutaneous - hydration given in fatty tissues) fluids at this time. 0.9% sodium chloride at 75cc/hour. During an interview on 1/18/24 at 10:30 AM Physician D reported that he was not informed that R303's IV was not started and that subcutaneous hydration was started. When asked if he should have been notified, Physician D said, Yes. During interview on 1/18/24 at 1:47 PM, RN B stated, It was the end of my shift, I did not start the IV. When asked if an IV access company was called to place the IV, RN B said, I would have written a note if I placed the IV or called the access company. Review found no notes written. When asked if the order was passed onto the on coming nurse, RN B said, I must have passed it onto the oncoming nurse. During an interview on 1/19/24 at 12:20 PM with Licensed Practical Nurse (LPN) C, it was reported that R303 was her resident that night. When asked if the IV was started as ordered by the physician, LPN C said, No. When asked if the physician was made aware that the IV was not started, LPN C responded, I cannot recall if I called the physician. When asked who started the subcutaneous hydration on R303, LPN C said, I don't know if I started it or another nurse. Further review revealed LPN C pulled the subcutaneous hydration kit from the back up system. During an interview on 1/19/24 at 12:36 PM with Director of Nursing (DON), it was reported that the physician should always be made aware when an IV can not be started. Nurse should have obtained an order before starting the subcutaneous hydration.

Dec 2023 5 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00139751. Based on interview and record review, the facility failed to develop a skin alterat...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00139751. Based on interview and record review, the facility failed to develop a skin alteration care plan for one resident (R420) of five residents reviewed for pressure ulcers, resulting in the potential for the resident to not receive the proper interventions/treatment. Findings include: A review of R420's EMR (Electronic Medical Record) revealed R420 was admitted to the facility on [DATE] and discharged from the facility on 9/26/23. R40 had medical diagnoses that included: disorder of muscle, type 2 diabetes, and encephalopathy (disease that disrupts brain function causing confusion and altered mental status). A review of R420's MDS (Minimum Data Set) dated 9/18/23 revealed R420 had a BIMS (Brief Interview of Mental Status) score of 15/15 (cognitively intact). According to the MDS, R420 had the possibility of developing pressures but at the time of the MDS, R420 did not have any pressure ulcers. A review of R420's orders revealed the following orders: - Wound consult- right buttock (order date 9/16/23) - Cleanse right buttock with normal saline apply with dry dressing (order date 9/16/23) A review of R420's care plan dated 9/14/23 revealed, Diagnosis: At risk for alteration in skin integrity related to: COVID, pneumonia, generalized weakness, hyperlipidemia (elevated lipid levels in the body), chronic obstructive pulmonary disease (chronic lung inflammation that obstructs air flow), lung cancer with metastasis to brain (lung cancer that spreads to the brain), pulmonary embolism (blockage of a lung artery), and chronic back pain. A review of the comprehensive care plan did not reveal an updated, resident specific care plan for the developed skin alteration once the orders for a wound consult and wound care treatment were placed on 9/16/23. On 12/13/23 at 11:50 AM, during an interview, the DON (Director of Nursing) verified that she did not see a care plan related to R420's pressure ulcer wound. The DON said she expected the nurses to put in a general skin alteration care plan with a focus that is specific to the resident.

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00136584, MI00138968, MI00140212, and MI00140483. Based on interview and record review, the facility...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00136584, MI00138968, MI00140212, and MI00140483. Based on interview and record review, the facility failed to provide showers according to resident's preference and/or on their scheduled shower days for three (R403, R416, and R426) of fifteen residents reviewed who were dependent on staff for performance of activities of daily living (ADLs), resulting in untimely and unmet care needs regarding personal hygiene. Findings include: It was reported to the State Agency that residents were not receiving regular showers. Resident #416 On 12/11/23 at 10:00 AM, a review of complaint intake related to Resident #416 (R416) documented resident was not showered in a timely manner. Record review of R416's face sheet revealed admitted to facility on 6/29/23 diagnoses included Covid-19, fall, diabetes mellitus type 2, Atrial fibrillation, hypertension, high cholesterol, psychotic disorder, congestive heart failure, and disorder of muscle. Review of the Minimum Data Set (MDS) dated [DATE] for R416 revealed a Brief interview for Mental Status BIMS of 8/15 moderate cognitive impairment and physical help in part of bathing activity, one-person physical assist. On 12/12/23 at 10:13 AM the director of Nursing (DON) was queried about the frequency of showers for R416. Shower sheets were requested. Record review of the ADL care plan-created date of 6/30/2023 documented, Will receive the assistance necessary to meet ADL needs .Interventions: Assist to bathe/shower as needed. In an interview with the DON on 12/12/23 at 1:45 PM the DON stated there are no records of a shower log or showers/baths given for R416, It looks like the task was never triggered by nursing. When the DON was queried about the expected frequency of showers, she said, Showers are to be given twice a week and should be documented. Resident #403 On 12/11/23 at 12:45 PM, Unit Manager/Licensed Practical Nurse (UM/LPN) D was interviewed and stated, We are still trying to get showers in order. Staff complete shower sheets when showers are given and shower refusals should be documented. UM/LPN D was able to produce one shower sheet for Resident #403 (R403) which was dated 11/2/23. UM/LPN D stated, I don't see any more shower sheets (for R403). UM/LPN D said she had been told that R403's family prefers R403 to receive showers. Resident's preferences and/or family's preferences for showers should be honored. CNA documentation of showers/baths given to R403 during the last 30 days were reviewed with UM/LPN D and revealed that bed baths were given on 11/13/23, 11/16/23, 11/20/23, 11/23/23, 11/27/23, 11/30/23, 12/4/23, and 12/7/23. There were no documented showers given to R403 during the last 30 days. A review of nursing notes did not reveal documentation of shower refusals during the last 30 days. A review of the admission Record for R403 documented an admission date of 12/31/22. R403's diagnoses included Alzheimer's disease, major depressive disorder, and legal blindness. A MDS assessment dated [DATE] documented severe cognitive impairment. A MDS assessment dated [DATE] documented dependence upon staff for showers/baths. Record review of R403's ADL self-care deficit care plan revised on 11/27/23 documented, Assist to bathe/shower as needed. Resident #426 A review of the admission Record for Resident #426 (R426) documented an admission date of 9/16/23. R426 discharged from the facility on 10/31/23. R426's diagnoses included cancer of the vulva (external female genitals), lungs, bladder, and bone, moderate protein-calorie malnutrition, congestive heart failure, type 2 diabetes mellitus, and dementia. A MDS assessment dated [DATE] documented severe cognitive impairment. A MDS assessment dated [DATE] documented dependence upon staff for showers/baths. Record review of R426's ADL self-care deficit care plan created on 9/18/23 documented, Assist to bathe/shower as needed. A review of shower documentation for R426 during October 2023 provided by the DON revealed R426 was to receive a shower/bath on Tuesdays and Fridays. R426 received a bed bath on 10/3/23 and 10/20/23. There was no documentation regarding why R426 did not receive a shower/bath as scheduled on 10/6/23, 10/17/23, 10/24/23, and 10/27/23. On 12/12/23 at 10:50 AM, the DON stated, It's the patient's right to have their preferences honored. The DON said when a resident cannot speak for themselves, we should have a voice for the resident. Regarding R403's family, the DON said the family member wants what was best for R403 and it is my expectation that (R403) gets a shower. Record review of the facility policy titled Activities of Daily Living (ADL) issued 8/21/23 revised 12/7/23 revealed in part Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care).

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00140212. Based on interview and record review, the facility failed to consistently document the pro...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00140212. Based on interview and record review, the facility failed to consistently document the provision of meal assistance for one resident (R426), deemed to be at nutrition risk, out of eleven residents reviewed for food intake/feeding assistance, resulting in the potential for additional nutrition concerns to go undetected and compromise in nutritional status. Findings include: It was reported to the State Agency that facility staff failed to provide meal assistance for a resident. A review of the admission Record for Resident #426 (R426) documented an admission date of 9/16/23. R426 discharged from the facility on 10/31/23. R426's diagnoses included cancer of the vulva (external female genitals), lungs, bladder, and bone, moderate protein-calorie malnutrition, congestive heart failure, type 2 diabetes mellitus, and dementia. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A MDS assessment dated [DATE] documented extensive one-person physical assistance for eating. Record review of R426's Resident is at nutrition risk (related to) cancer with mets (metastasis - cancer that has spread), mod PCM (moderate protein calorie malnutrition), impaired skin integrity, dementia, CHF (congestive heart failure), poor appetite, dependent for feeding, weight loss PTA (prior to admission) care plan created on 9/18/23 documented in part, Assistance with meals as needed, Red napkin - (patient) needs to be fed, and Monitor intake and record q (every) meal. A review of September 2023 and October 2023 documentation of meal assistance provided to R426 by CNAs (Certified Nurse Aides) documented no evidence of eating support provided for the following meals: Breakfast: 9/22/23, 9/25/23, 9/28/23, 9/30/23, 10/1/23, 10/2,23, 10/9/23, 10/22/23 to 10/25/23, 10/27/23, 10/28/23, 10/30/23 Lunch: 9/20/23, 9/22/23, 9/25/23, 9/27/23 9/28/23, 9/30/23, 10/1/23, 10/2/23, 10/9/23, 10/22/23 to 10/28/23, 10/30/23, 10/31/23 Dinner: 9/21/23, 9/22/23, 9/26/23, 9/28/23, 9/30/23, 10/2/23, 10/5/23, 10/8/23, 10/9/23, 10/13/23 to 10/15/23, 10/20/23, 10/23/23, 10/28/23 to 10/31/23 A review of nutrition notes documented in part the following: 1. Nutrition assessment dated [DATE]: .(R426) also has vulvular cancer with mets. Not currently receiving treatment .(past medical history) includes mod PCM .Recommend liberalize to diabetic diet. Her appetite is poor. Food prefs (preferences) obtained. Provided with menu to make meal selections. Per daughter she needs to be fed and requires encouragement to initiate feeding .She has been losing weight for several months .Skin - open area to sacrum and groin . 2. Nutrition progress note dated 10/6/23: RD (Registered Dietitian) following r/t (related to) weight change .She needs to be fed . On 12/12/23 at 10:18 AM, the Director of Nursing (DON) was queried and said the red napkin designation means the resident requires meal assistance. The dietitian assesses the patient and determines who needs the red napkin. The DON added that Nurses can do it, but usually it is the dietitian. The CNA's should see it in the plan of care for the resident because that is how they know what type of care the resident needs. R426's care plans were reviewed with the DON. The DON acknowledged that R426 needed to be fed by staff and there was missing documentation that R426 was receiving meal assistance according to her plan of care. On 12/12/23 at 1:20 PM, RD F stated R426 was considered at nutrition risk because she came into the facility with diagnosis of moderate protein calorie malnutrition. RD F said R426 had dementia and was very weak.

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

This citation pertains to MI00140483. Based on observation, interview, and record review, the facility failed to ensure the Cherry Hill shower room was maintained in a clean and sanitary manner, resul...

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This citation pertains to MI00140483. Based on observation, interview, and record review, the facility failed to ensure the Cherry Hill shower room was maintained in a clean and sanitary manner, resulting in the potential to spread harmful pathogens and residents' environment not being clean and homelike. Findings include: It was reported to the Stage Agency that resident shower rooms were not clean. During an interview and observation of the Cherry Hill shower room on 12/11/23 at 12:31 PM with Certified Nurse Aide (CNA) H, used tissue paper, that appeared somewhat dry, was observed on top of a shower chair seat/commode, wedged underneath the seat/commode, and lying on the bottom front frame of the shower chair. CNA H said the tissue paper looked like it was stained with urine. CNA H stated, The shower chair should have been cleaned after use. On 12/12/23 at 12:52 PM, the Director of Nursing said that shower rooms should be cleaned up after use. A review of a facility policy titled, Showering, dated 2/1/03, revealed in part, Clean the shower room, leaving it in order and ready for use.

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

This citation pertains to MI00140483. Based on observation, interview, and record review, the facility failed to properly clean resident refrigerators, date-label opened food, and remove expired/undat...

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This citation pertains to MI00140483. Based on observation, interview, and record review, the facility failed to properly clean resident refrigerators, date-label opened food, and remove expired/undated food from two resident refrigerators, resulting in the potential for food borne illness. Findings include: It was reported to the State Agency that the nourishment rooms were not cleaned. On 12/11/23 at 8:48 AM the Medbridge Nourishment Room was observed with Unit Manager Nurse (UM) C. The following was noted: - The rug in front of the ice machine was soiled and dirty. UM C stated, The rug needs to be vacuumed. - The soap dispenser near the handwashing sink was empty. - The outside of the resident refrigerator was soiled. UM C stated, It's very dirty. The inside of the refrigerator was soiled with a dried red fluid. UM C stated, It needs to be cleaned. - A 48 oz. container of cranberry juice cocktail was opened and undated in the resident refrigerator. - The following food items stored in the resident refrigerator were identified as belonging to a resident by UM C: 1. Two bags of an identified resident's food was undated. 2. One container of food with no resident identification or date. 3. Two containers of an identified resident's food was undated 4. One bag of food with no resident identification or date. 5. One disposable container with no resident identification or date. 6. Opened container of a sports drink with no resident identification or date. - The contents of the resident refrigerator freezer included: 1. A fast food chocolate shake with no resident identification or date. 2. A frozen pot pie with no resident identification. UM C stated the freezer was very dirty. On 12/11/23 at 9:00 AM the Cherry Hill Nourishment Room was observed with Unit Manager Licensed Practical Nurse (UM/LPN) D. The following was noted: - The soap dispenser near the handwashing sink was empty. - The following food items stored in the resident refrigerator were identified as belonging to a resident by UM/LPN D: 1. Two bags of opened shredded cheese were undated. 2. One package of sliced cheese was undated. 3. 12 oz. container of mayonnaise was undated. 4. One round container of food was undated 5. One box of pizza with four slices that remained was undated. 6. Four-pack of cheesecake with no resident identification. 7. Three containers of food in a bag with no resident identification or date. - The following food items were opened and undated in the resident refrigerator: 1. 46 oz. container of cranberry juice cocktail 2. 46 oz container of tomato juice 3. 89 oz. container of ice tea with a use-by-date of 10/24/23 4. 89 oz. container of orange juice with a use-by-date of 11/10/23 On 12/12/23 at 12:52 PM, the Director of Nursing stated, Everyone should be monitoring the resident refrigerators. Housekeeping is supposed to clean the resident refrigerators. A review of the facility policy titled, Safe Storage of Food Provided by Families No. 5014 Department of Dietary, dated 3/8/21 documented in part the following: - When families bring in food for our residents, the facility will provide safe storage as defined by the US Food Code. All food items provided by families will be labeled and dated, stored properly, and used within an acceptable timeframe. - Each item will be clearly labeled with resident's name and room number, and the current date before being refrigerated. - All refrigerated food is to be used within 72 hours or discarded. - If food items are not labeled, they will be discarded. - Once daily, Housekeeping is responsible for cleaning of the refrigerator and for review of dated items stored in the refrigerator. According to the 2013 FDA Food Code: - Section 3-101.11, Safe, Unadulterated, and Honestly Presented: Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented. - Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. - 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.

Jul 2023 1 deficiency

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

This citation pertains to intake MI00138406. Based on interview and record review, the facility failed to provide accurate resident identifying documents and medical records upon emergent transfer to ...

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This citation pertains to intake MI00138406. Based on interview and record review, the facility failed to provide accurate resident identifying documents and medical records upon emergent transfer to the hospital for one resident (R401) of four residents reviewed for emergency transfer resulting in incorrect resident identification and medical information being sent with EMS (Emergency Medical Service) personnel to the hospital, incorrect family involvement with R401's hospitalization, and the potential for unmet care needs upon transfer. Findings include: On 7/16/23 at 9:19 PM R401 was transferred to the hospital by EMS, at which time an inaccurate face sheet (document that give a patient's information that includes contact details and brief medical history) and medical information was passed on to the EMS personnel. The facility became aware of the incorrect medical information being sent to the hospital on 7/17/23 at 7:15 PM when R401's Family Member A called the facility. A review of the facility investigation report revealed R401 was transferred to the hospital by EMS on 7/16/23 at 9:19 PM for pain and shortness of breath. During the transfer, Licensed Practical Nurse (LPN) B gave EMS the wrong resident's face sheet. A review of the EMS run sheet (form that includes resident's demographics, vital signs, assessments, and medical information) revealed R404's name and date of birth . The face sheet and medication list of R404 was given to EMS. A review of R401's Electronic Medical Record (EMR) revealed R401 was admitted to the facility 7/11/23 and discharged on 7/16/23. R401 had medical diagnoses of acute and chronic respiratory failure with hypercapnia (increased carbon dioxide in the blood). R401 was their own responsible party but had an emergency contact (Family Member C). A review of R401's EMR revealed she had 'full code' status (all resuscitation procedures will be provided). A review of R404's EMR revealed R404 was admitted to the facility 9/7/21. R404 had medical diagnoses of Dementia, Hypothyroidism, and Parkinson's Disease. R404 had a Legal Guardian, who was their responsible party and first emergency contact. A review of R404's EMR revealed she had 'full code' status. On 7/31/23 at 9:44 AM in an interview with LPN B, she said on the evening of 7/16/23 at 9:30 PM Certified Nurse Assistant (CNA) E told her R401 was complaining of pain. She said when she went to check on R401 she noticed immediately R401 was having difficulty breathing. R401's Sp02 (oxygen saturation in the blood) and found out it was 45% (normal range is 90% or above). When rechecked the Sp02 went up to 73%. LPN B said Nurse Manager D told her to send R401 to the hospital right away. She said she called 911 and EMS said she need to collect the admission sheet (face sheet) and medication list for R401. When asked about giving the wrong paperwork to EMS she stated, I pulled up the wrong paperwork. I gave EMS the wrong face sheet and medication list. On 7/16/23 at 9:15 PM R401 was transferred to the hospital for emergency care. At the time of transfer when LPN B giving report and documents to EMS she gave R404's medical documents (medication list and face sheet) with R401. The documents sent with R401 would reveal to the hospital that she had a Legal Guardian, no known allergies, and a medication list that contained R404's medications. Whereas R401's face sheet and medication list would have provided the hospital with accurate information to inform them she was her own responsible party and prompted them to call her emergency contact (Family Member C), and made them aware of her allergies to certain antibiotics. On 7/31/23 at 10:21 AM, Family Member F (R404's family member) was queried regarding the incident. Family Member F recalled he received a call on the night of 7/16/23 by the local hospital saying R404 was in the Intensive Care Unit (ICU). Family Member F said on 7/17/23 he came to the local hospital to check on R404, at which time he realized the patient in the hospital room was not R404. That evening he saw R401's family member and discovered that it was R401 who was in the hospital, not R404. On 7/26/23 at 2:12 PM, during an interview with the Director of Nursing (DON) she was asked about the wrong information being sent with R40. The DON said there was no check list regarding the documents needed to be sent out during transfer to the hospital. The DON added there was no policy that outlined what to do or to ensure that accurate documents are being given to EMS during a transfer of a resident to the hospital. On 7/26/23 at 3:07 PM, the DON was asked about the possible harm that could have occurred to R401 when inaccurate medical documents were sent to the hospital with R401, the DON said R401 could have had a possible allergic reaction to medication and had the wrong medical care (code status action in an emergency). The DON said R401 was transferred to the hospital on a Sunday and the facility did not become aware of the incorrect medical information being sent with R401 until the next day, Monday.

May 2023 11 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practices. Deficient Practice #1: Based on interview and record review, the facility failed to i...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practices. Deficient Practice #1: Based on interview and record review, the facility failed to implement appropriate safety interventions for one resident (R71) out of eight residents reviewed for accidents, resulting in a fall with injury (femoral fracture), and an emergency hospital encounter. Findings include: During an interview on 5/3/2023 at 9:31 AM, a concerned family member of Resident #71 (R71) stated, R71 fell in his room right in front of me. He fell hard and went to the hospital for surgery. A review of the admission Record for R71 revealed an admission date of 10/10/2022 and readmission date of 1/23/2023 with diagnoses that included right femur (thigh bone) fracture. A Minimum Data Set assessment dated [DATE] and 5/1/2023 documented severe cognitive impairment. The MDS of 1/13/2023 documented no impairment of lower extremity and supervision with one-person physical assistance for transfer. The MDS of 5/1/2023 documented lower extremity impairment on one side and very limited bed transfers documented during the seven-day look back period. Further review of R71's clinical record and post-fall documents revealed in part the following: 1. Progress note date/time: 1/16/2023 at 5:55 AM: Writer found patient on floor at 2:45am, patient was assessed physically and there is no known injuries. Patient denies hitting his head or being in any pain. Patient states he was trying to stand up to put his pants back on. Teaching was reinforced to use call lights when he feels he is in need or has wants, the bed light was put on, and bed is put in lowest position. Neuro-checks was (in place) and there is no change in mental status. Physician and patient's son has been notified of incident. 2. Radiology Report date/time of 1/16/2023 at 12:12 PM: Femur 1 View: Conclusion: Acute intertrochanteric right femoral fracture as noted. 3. Progress note date/time of 1/16/23 at 3:48 PM: Acute intertrochanteric right femoral fracture as noted. (Physician) updated. New order for patient to be sent to emergency room. 4. Staff Statement dated 1/16/23: Certified Nurse Aide (CNA) R changed R71's brief at 2:00 AM. 5. Post-Fall Assessment, dated 1/16/2023. Observations included: poor lighting, improper bed height, water spills, patient reaching for items. Comments: Patient was trying to put on their pants. 6. Investigation Report dated 1/16/2023. Summary of alleged incident: Patient got himself out of bed attempting to put his pants on and fell while holding onto the bed side table. 7. Progress note date/time of 1/17/2023 at 1:23 PM (created on 1/23/2023 at 1:24 PM): IDT (interdisciplinary team) reviewed fall from 1/16/23. Patient fell attempting to get self dressed at (3:00 AM). Patient initially denied all pain. During the next shift patient began to complain of hip pain. X rays obtained and fx (fracture) noted. Patient sent out for treatment of fracture. Fall interventions in place at time of fall. Patient is cognitively impaired and unable to be educated on call light use . 8. Incident Report dated 1/17/23. Corrective Action: Bed is back into lowest position, reinforced teaching on using the call light, and bed light is turned on. 9. Review of at risk for falls care plan documented the following intervention: Bed in low position. Date initiated 10/11/2022. During an interview on 5/8/23 at 2:22 PM, CNA Q said she had been a CNA for approximately two years. CNA Q said that when she changes a resident's brief, she brings the bed up to a decent height so she doesn't strain her back. After the brief is changed, she puts the resident's pants back on and lowers the bed back down just in case the resident rolls out of the bed, or they try to get out of the bed. During an interview and record review on 5/8/2023 at 2:57 PM, the Director of Nursing (DON) said R71's fall was avoidable. The DON stated, If we had the bed at the right level, better lighting, and water off the floor. (We need) to make sure spills are wiped up and have items within reach. The DON listed the following as contributing to R71's fall: poor lighting, water spill, and improper bed height. The facility document titled, Fall Management Guidelines, dated April 2022, was reviewed and revealed in part the following: Fall reduction and injury prevention strategies that can be implemented upon admission may include, but are not limited to the following .Provide environmental modifications as indicated (use of appropriate height bed, removal of trip hazards, bedside commode) . Deficient practice #2. Based on observation, interview, and record review, the facility failed to ensure assessments for the use of electronic cigarettes were adequately completed for two residents (R128 and R230) observed using electronic cigarettes on the grounds of a non-smoking facility, resulting in the potential for harm from the use of electronic cigarettes. Findings include: During observations on 5/2/2023 at 8:30 AM, wall signage on the front entrance to the facility and on the front patio indicated: THIS IS A SMOKE FREE CAMPUS. During an observation on 5/4/2023 at 1:00 PM with Unit Manager (UM) F, Resident #128 (R128) and Resident #230 (R230) were observed on the facility's front patio using electronic cigarettes. R128 A review of the admission Record for R128 documented an admission date of 4/13/2023 with diagnoses that included right fibula (calf bone) fracture, chronic pulmonary embolism, chronic obstructive pulmonary disease, and syncope (fainting) and collapse. A MDS assessment dated [DATE] documented intact cognition and no upper extremity impairment. A Non-Smoking Facility Smoking Evaluation was initiated and completed on 5/4/2023 at 1:59 PM and 2:00 PM respectively. The smoking evaluation completed on R128 did not specifically address the use of electronic cigarettes. R230 A review of the admission record for R230 documented an admission date of 4/14/2023 with diagnoses that included peripheral vascular disease, chronic obstructive pulmonary disease and stage 3 chronic kidney disease. A MDS assessment dated [DATE] documented intact cognition and no upper extremity impairment. Review of clinical record revealed R230 was offered education on risk of smoking and vaping. Patient offered smoking cessation and declined. Patient able to show safe vaping technique. Patient verbalized understanding to the sign out policy and that she needs to sign out and go outside independently. Progress note of 5/4/22 at 1:22 PM documented: Resident signed out for LOA with the understanding that she is her own responsible person and responsible for herself when leaving the building. She states that she wants to vape and her vape were provided to her. She was able to navigate the hallway to the outside sitting area and safely vaped while at the table. She was approached by the unit manager who informed her that we are a non-smoking facility and smoking must be 150' from the building to which the resident explained that she was not smoking and she was in fact vaping. The resident then stated that she would move to the city sidewalk. She was able to navigate the parking lot onto the city sidewalk off of (the facility's) property and safely vape. The resident understands the potential negative effects of smoking and vaping and declines smoking/nicotine cessation. During an interview and record review on 5/8/2023 at 2:48 PM with the DON, the Non-Smoking Facility Smoking Evaluation completed for R230 on 5/1/2023 was reviewed. The DON stated, A care plan has been done. Everything else is blank. (R230) does not have a completed smoking assessment. The areas left blank on the smoking evaluation were cognitive function, visual function, communication function, physical function, non-smoking facility, and patient observation. The DON said the purpose of the smoking assessment was to ensure the resident's safety when they go out to smoke and acknowledged the potential for harm is there with vaping. On 5/10/2023 at 1:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135738. Based on interview and record review, the facility failed to conduct an initial car...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135738. Based on interview and record review, the facility failed to conduct an initial care conference for one resident (R248) of two residents reviewed for choices, resulting in the missed opportunity for the resident and/or resident representative to participate in the care planning process and make choices about the resident's daily life. Findings include: It was reported to the State Agency that the resident representative was not contacted to discuss plans and goals of care for the resident. A review of the clinical record for Resident #248 (R248) revealed an initial admission date of 2/24/2023 and readmission date of 3/22/2023 with diagnoses that included unspecified disease of the digestive system, depressive disorder, and anxiety disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of clinical progress notes for R248 revealed in part the following: - 2/24/2023 nursing: .Pt. is A&Ox3 (patient is alert and oriented to person, place, and time) and is able to make his needs known . - 2/24/2023 at 2:07 PM nursing: .spoke with family who are at bedside Patient has not communicated or answered any questions, just stares at you. Patient did shake his head no when asked about pain. Sister states this is patient's baseline. He answers in one or two words and hasn't been self in over 3 years . - 2/28/2023 social service: Social Services 5 day Assessment completed with Patient and Chart review. Patient presents as A & O x 1-2 and able to make some needs known .The BIMS (Brief Interview for Mental Status) Assessment was administered with score of 01, indicating patient has a potential for severe cognitive impairments. Patient has periods of confusion . - 3/2/2023 physician note: .Chief Complaint(s): Follow up visit He is not talking much, and does not (eat) much. Per family, he has been severely depressed . - 3/8/2023 care conference note: .Care conference held. Those in attendance include Rehab Social Services Other Case Manager .The discharge planning process is active at this time. Plans to discharge to private home/apartment with live in support. Was living home alone . The care plan was developed and reviewed with the attending physician, registered nurse, nurse aide, and dietary staff prior to the care plan conference. An interview was conducted on 5/9/2023 at 12:23 PM, with the Director of Nursing (DON) and Unit Manager (UM) G. UM G stated, Residents are always invited to attend their 72-hour care conference if they are their own responsible party and capable of making their own medical decisions. (These residents) can determine if they want family there. UM G said if the resident is not capable of making medical decisions the resident representative/first emergency contact is always invited to the 72-hour care conference. During an interview on 5/9/2023 at 12:37 PM with Social Worker (SW) D and Therapy Director (TD) E, SW D said it was standard for residents to have a 72-hour care conference. If residents are their own responsible party, we would like for them to attend their care conference, and we would document if the resident refused to attend. The emergency contact should be contacted if the resident had a BIMS score of 01 but no responsible party was designated. TD E said the purpose of a 72-hour care conference was to have an introductory meeting with the resident (and resident representative if in attendance) and facility disciplines, to make sure the resident's and facility's goals are aligned, to confirm discharge plans, equipment needs, and review any questions and concerns that may have occurred since admission. SW D and TD E confirmed R248 did not have a 72-hour care conference. The care conference conducted on 3/8/23 was a managed care meeting update held with the liaison for the building staff and the resident's insurance carrier. The residents do not attend the managed care meetings. During an interview on 5/10/2023 at 11:22 AM the DON said she was aware that R248 did not have a 72-hour care conference and that these conferences were important to touch base with the resident and first emergency contact and explain everything to them, get resident history, and start preparing for goals of discharge planning. On 5/10/2023 at 1:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

This citation pertains to Intake MI00133152. Based on observation, interview, and record review, the facility failed to administer medications timely and per physician's orders for one resident (R59) ...

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This citation pertains to Intake MI00133152. Based on observation, interview, and record review, the facility failed to administer medications timely and per physician's orders for one resident (R59) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken properly. Findings include: In an observation and interview on 5/9/23 at 11:05 a.m., Licensed Practical Nurse (LPN) O prepared medication for Resident #59 (R59). The medication administration screen had red boxes on each medication. LPN O placed Amlodipine (treats high blood pressure), Aspirin, Plavix (prevents blood clots), Levetiracetam (anticonvulsant), Multivitamin-Minerals, and Senexon-S (prevents constipation) in a medication cup and poured MiraLAX (prevents constipation) in a cup. LPN O entered R59's room and administered the medication and exited the room. LPN O documented the medication administration. When asked if the medication was administered late, LPN O stated Yes. I got behind this morning. In an interview on 5/10/23 at 8:21 a.m., LPN P reported medication should be administered one hour before or after the scheduled time. In an interview on 5/10/23 at 8:31 a.m., The Director of Nursing (DON) reported one hour before or one hour after is the acceptable timeframe to pass medications before they are considered late. The DON then reported, if the nurse is late, the Physician should be notified to see if it is ok to administer the medication and a progress note should be made in the medical record. Review of a Medication Administration Hours policy with an issue date of 9/29/17 revealed, Policy: Routine medication administration hours have been formulated to ensure appropriate and timely administration of medications in accordance with the physician's orders. The physician may specifically order certain medications to be administered at different hours then noted below . Procedures: 1. Medications will be administered within one hour of the prescribed time for administration (60 minutes before or 60 minutes after the assigned time) 2. If a nurse determines during her medication pass that the residents will not receive their medications according to this policy, he or she should contact the Nurse Manager and/or Supervisor for their assistance in medication administration .

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake number MI00135633. Based on interview and record review, the facility failed to provide transpo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake number MI00135633. Based on interview and record review, the facility failed to provide transportation for one resident (R431) scheduled for a follow up orthopedic appointment out of one resident reviewed for appointments, resulting in the potential for a delay and frustration in treatment due to multiple missed appointments by the facility. Findings include: Review of the Electronic Health Record (EHR) revealed Resident #431 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of multiple fractures of ribs from a motor-vehicle accident and pain in left and right knees. R431's admission Minimum Data Set (MDS) with a reference date of 3/7/2023 indicated R431 had intact cognition with a BIMS (brief interview for mental status) score of 15/15, required extensive assistance of two persons with transfers and bed mobility, extensive assistance of one person for toileting, dressing and hygiene. Review of the ADL care plan created on 3/3/2023 revealed, ADL self-care deficit as evidence by significant need for assist related to trauma, physical limitations to bilateral knees with no weight bearing, multiples fractures. Review of Physician Orders dated 3/10/2023 documented, Please schedule appointments ASAP (As soon as possible) .March 14th at 1:15 p.m. ortho Surgery Vascular and March 20th, 2023, at 1:30 p.m. one time only. Review of nursing progress note dated 3/14/2023 at 4:15 p.m. documented, Patient was very upset stating she receive a phone call from the orthopedic Doctor stating the facility cancelled her appointment for tomorrow (referring to 3/14/2023 appointment). Patient states this is the third appointment she has missed since coming here due to rides not being scheduled (No documentation noted in the nurses progress notes of the previous missed appointments). Patient was tearful and visibly upset. Review of nursing progress note dated 3/14/2023 at 6:50 p.m. documented, Resident express desire to transfer back to the hospital due to missed appointments after her accident. MD (Medical Doctor) made aware and order to transfer to be initiated. Ambulance to pick up this evening. Review of the nursing progress note dated 3/15/2023 at 10:13 a.m. documented, Back on unit with new orders for Bactrim DS (antibiotic) BID (Twice a day) for 10 days. On 5/4/2023 at 11:18 a.m. during an interview, the Director of Nursing (DON) reviewed R431's electronic medical record and confirmed that R431 did missed two ortho appointments but could not state the date of the first scheduled appointment. The DON stated, It looks like we cancelled her appointment for March 14th and it's not documented why. I will have to get with the administrator to see why the appointment was cancelled. I don't know why because I wasn't here in March. The DON continued to read the nurse's progress notes for 3/14/2023 and said, the appointment was cancelled because they did not make transportation three times. I will check around to see why and to see was there a follow up. The DON was asked to provide copies verifying R431 went out for the scheduled appointments. On 5/4/2023 at 12:07 p.m., the DON presented a document verifying the resident had a post- op orthopedic appointment scheduled for March 14, 2023, at 1:15 p.m. The DON said, We identified there was a transportation issue for the March 14th appointment, she needed to go to her appointment on a stretcher not wheelchair. She requested to go back to the hospital because she missed her March 14th appointment. The appointment was rescheduled for March 17th, 2023, and she still went out for that appointment after going back to the hospital. The DON was asked shouldn't the person scheduling appointments be informed about the manner of transportation needed already? The DON said, Yes, this is something she should know before, checking to see what kind of transportation the residents will be needing. According to the facility's 8/2022 .therapeutic leave & Doctor appointment/Medical Visit policy documented as following: -1.0 This Facility shall allow residents to leave the facility, as appropriate, to ensure resident choice and continuity of care. -2.0 The nurse will obtain an order from the practitioner specifying approval of a therapeutic leave or a follow up medical visit.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R485 In an observation on 5/2/23 at 11:33 a.m., Resident #485 (R485) sat in a wheelchair and had a PICC line in the right upper ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R485 In an observation on 5/2/23 at 11:33 a.m., Resident #485 (R485) sat in a wheelchair and had a PICC line in the right upper arm. Review of an admission record revealed, R485 admitted to the facility on [DATE] with pertinent diagnosis which included Infection and Inflammatory Reaction due to Internal Right Hip Prothesis. Review of a MDS assessment, with a reference date of 4/18/23 revealed R485 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15. Review of Physician orders revealed R485 did not have a current order for a PICC line or management of the PICC line. R485 had an order to receive cefTRIAXone Sodium (treats infections) Intravenous Solution Reconstituted 2 GM (Ceftriaxone Sodium) Use 2 gram intravenously at bedtime for antibiotic until 05/17/2023 with a start date of 4/19/23. In an observation on 5/8/23 at 10:45 a.m., R485 had a PICC line in right upper arm with a date of 5/8/23. In an interview on 5/08/23 at 10:47 a.m., Registered Nurse (RN) H reported everyone usually has an order for PICC line flushes. RN H then reported there are no orders pertaining to a PICC line for R485 in the EHR (Electronic Health Record). RN H reported the PICC line should be flushed before and after medication administration and the dressing should be changed weekly and as needed. In an interview on 5/8/23 at 10:50 a.m., Unit Manager G stated, Anybody with a PICC line should have maintenance orders, that's policy. Unit Manager G reviewed R485's Physician orders and stated, She has none. In an interview on 5/8/23 at 10:57 a.m., The Director of Nursing (DON) reported every resident with a PICC line should have orders to maintain it. The DON then reported Physician orders should include dressing change every seven days and flush orders. A review of the facility policy titled, IV-Dressing Changes for Central Lines, dated 9/26/2017, revealed the following: -The catheter insertion site is a potential entry for bacteria that may cause a catheter-related infection. Dressing change procedure for central line catheters and midline catheters: -1. Vigorously cleanse around catheter insertion site with antimicrobial solution, according to the manufacturer's instructions. Allow to air dry. -2. Apply securement device if not integral to the transparent dressing. -20. Label dressing with date, time of dressing change. -21. Documentation in the medical record includes, but is not limited to: (a) date and time (b) site assessment (c) reason for dressing change (d)patient response to procedure . -Transparent dressing changes: 24-hour post insertion or on admission, then every week and as needed. Based on observation, interview, and record review, the facility failed to provide timely PICC (peripheral inserted central catheter) line/dressing changes, label an IV (Intravenous, therapy that delivers liquid substances directly into a vein) bag, date an IV tubing, and obtain physician's order for PICC line maintenance for two residents (R43 and R485) reviewed for IV Parenteral fluid resulting in the potential for medication delay and error and a bacterial infection originating at the PICC line site. Findings include: R43 On 5/3/2023 at 1:10 p.m., a bag of IV solution was observed hanging at R43's bedside with no label on the bag and no date on the IV tubing. R43 was observed with a right arm PICC dressing dated 4/23/2023 which appeared soiled and not adhered to the skin. On 5/3/2023 at 4:30 p.m., the Director of Nursing (DON) was interviewed in R43's room while observing the unlabeled IV bag, undated IV tubing, and the 4/23/2023 dated PICC dressing. The DON was asked about the frequency of a PICC line dressing change, should the IV bag be labeled, and the tubing dated. The DON stated, The PICC line dressing should be change every seven days I think, for infection reasons, and afterwards they should put a date on the dressing. The IV line should be dated, and the bag should have the resident's name, date, room number, medication name, and the time it went up. The DON verified the PICC line was not changed within the seven days, and the IV bag had not been labeled and the IV tubing was not dated. During the interview, R43 stated, The dressing was wet, and it started to itch after getting it wet from a shower. We try to keep it dry with tape and a plastic bag, but it's hard. A nurse came by today about an hour ago taped it up after I asked her to change the dressing. The nurse said, since you are being discharged tomorrow (5/4/23), I will just tape it instead. A concern family member (CFM) in the room at this time verified the nurse did not change the PICC line dressing after R43 requested it to be changed. According to the electronic medical record, R43 was admitted into the facility 2/17/2023 with diagnoses of cellulitis of left lower limbs and discitis of lumbosacral region (an infection of the intervertebral disc space). R43's admission Minimum Data Set (MDS) with a reference date of 2/24/2023 indicated R43 was cognitively intact with a BIMS (brief interview for mental status) score of 14/15. Review of R43's physician's order dated 2/19/2023 revealed, Change PICC line dressing every night shift every Sunday. Review of the April 2023 and May 2023 Medication Administration Records did not reveal documentation that the PICC line dressing had been changed.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physician responded to a pharmacy recommendation for one r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a physician responded to a pharmacy recommendation for one resident (R26) out of five residents reviewed for pharmacy recommendations resulting in a missed opportunity for collaboration on a medication recommendation and the potential for unmet medical care needs. Findings include: A review of the clinical record revealed Resident #26 (R26) was admitted into the facility on 1/27/2022. R26's diagnoses included congestive heart failure, atrial fibrillation, and anxiety disorder. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of a Medication Regimen Review (MRR) for R26 dated 1/9/2023 revealed the following recommendation: The National Osteoporosis Foundation recommends an intake of 800 - 1000 units of vitamin D per day for adults age [AGE] and older. Please consider Vitamin D 1000 units daily. During an interview and record review on 5/8/2023 at 1:45 PM, Unit Manager (UM) F revealed that R26 did not receive supplemental Vitamin D and the multivitamin with mineral supplement that R26 received contained 400 units of Vitamin D. During a review of R26's medical record, UM F was unable to confirm that R26 had been prescribed supplemental Vitamin D since 1/9/2023 or that the physician addressed the pharmacist's 1/9/2023 recommendation. During an interview on 5/8/2023 at 2:42 PM, the Director of Nursing, (DON) said it was a concern that the physician had not responded to the pharmacist's recommendation. The DON stated, The pharmacists recommends something for the patient's well-being. The doctor needs to review (the recommendation) and say if it is a suggestion that needs to be followed up. A review of the facility policy titled, Medication Regimen Reviews (MRR) - Pharmacy Services, dated 10/8/2018, revealed in part the following: - Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR, and the Director of Nursing, to act upon the recommendations contained in the MRR. For those issue that require Physician/Prescriber intervention Facility should encourage Physician/Prescriber to either, accept and act upon the recommendations contained within the MRR, or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record. - The attending physician should address the consultant pharmacist's usual MRR recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. - If the attending physician has not yet responded to the resident's MRR report by their next scheduled visit, the Director of Nursing will notify the Medical Director to review and respond to the pending MMR reports. On 5/10/2023 at 1:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Smoking Policies (Tag F0926)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to develop and implement a smoking policy that addressed the use of electronic cigarettes (e-cigs) for residents of the facility...

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Based on observation, interview, and record review, the facility failed to develop and implement a smoking policy that addressed the use of electronic cigarettes (e-cigs) for residents of the facility. This deficient practice resulted in two residents (R128 and R230) using e-cigs on the property of a non-smoking facility and staff not being adequately educated about the use of e-cigs. Findings include: During an observation and interview on 5/4/2023 at 1:00 PM with Unit Manager (UM) F, Resident #128 (R128) and Resident #230 (R230) were observed on the facility's front patio using electronic cigarettes. Registered Nurse (RN) H was sitting on the front patio with the two residents. UM F stated, They are not allowed to use those within 150 feet of the building. During an interview on 5/4/2023 at 2:12 PM, RN H said when R230 wanted to vape (use her e-cigs), he got her vapor pens from the unit manager. R230, her friend (R128), and RN H went out on the front patio. According to RN H, he informed R230 that they were not allowed to smoke within 150 feet of the property. R230 told RN H that she was not smoking she was vaping. RN H said this was his first time being with R230 while she used an e-cig. RN H stated, If they are only vaping, they don't need a smoking assessment. During an interview on 5/4/2023 at 4:10 PM, the Director of Nursing (DON) said their current policy on smoking does not address the use of electronic cigarettes. The DON stated, We're treating vaping under general smoking guidelines. They did not follow the guidelines today because they were smoking on the front patio. On 5/8/2023 at 2:48 PM during an interview and review of a facility document titled, Smoking Guidelines, dated November 2013, the DON said the facility's current smoking guidelines do not address the safe use of electronic cigarettes. On 5/10/2023 at 1:30 PM during the exit conference, the Nursing Home Administrator, DON, and Regional Clinical Services Director (RCSD) I were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey. The DON said that a policy that addressed the use of e-cigs was currently undergoing the Quality Assurance process but had not been implemented in the facility. The DON added that staff are educated once new policies have been implemented.

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R487 In an observation and interview on 5/2/23 at 12:58 p.m., Resident #487 (R487) sat in a wheelchair in the room. R487 reporte...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R487 In an observation and interview on 5/2/23 at 12:58 p.m., Resident #487 (R487) sat in a wheelchair in the room. R487 reported experiencing vaginal itching for the prior three to four days. R487 reported they had one shower in the past three weeks. Review of an admission record revealed, R487 admitted to the facility on [DATE] with pertinent diagnoses which included COVID-19, Hypertension and Congestive Heart Failure. Review of a Minimum Data Set (MDS) assessment, with a reference date of 4/21/23 revealed R487 had mild cognitive impairment with a Brief interview for Mental Status (BIMS) score of 9 out of 15. Review of a shower task as documented in the POC (Point of Care) revealed, R487 had scheduled showers on Wednesday and Saturday day shift. R487 did not have a documented shower on 4/5, 4/22, 4/26, or 4/29. In an interview on 5/3/23 at 2:09 p.m., R487 reported she did not get a shower today. In an interview on 5/8/23 at 12:34 p.m., the DON reported the staff should document showers in POC and the nurse should follow up. In an interview on 5/8/23 at 2:44 p.m., Certified Nursing Assistant (CNA) K reported showers are documented in POC. This citation pertains to Intakes MI00134525, MI00134776, MI00135107, and MI00135738. Based on observation, interview, and record review, the facility failed to provide shaves, nail care, and scheduled showers for seven residents (R26, R73, R228, R248, R429, R480, and R487) out of ten residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADL needs, a feeling of frustration, and the potential for loss of dignity. Findings include: R430 On 5/2/2023 at 11:27 a.m., R430 was observed lying in bed alert and able to be interviewed. R430 was observed with long facial hairs. During an interview, R430 stated, I would love to have a shave because I do not want all the hair on my face. My roommate gets shaved and got one yesterday, but he ended up putting his own shaving cream on and did his own shave. I always had a shave, and they only gave me one shower since I been here. R430 was asked does the staff ask to assist with shaves? R430 stated, They never ask to help shave me, even when I got the one shower. My nails are long, and I never let them get this long. R430 fingernails was observed long and untrimmed. On 5/4/2023 at 3:29 p.m., R430 was observed lying in bed with long untrimmed fingernails and stated, They haven't shaved me yet. According to the electronic medical record, R430 was admitted to the facility on [DATE] with diagnoses of chronic kidney failure stage 3, major depressive disorder, anxiety, atrial fibrillation, seizure, Parkinson's disease, hypertension, and history of falls. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R430 had moderate cognitive impairment with a BIMS (brief interview for mental status) score of 12/15, required extensive assistant of one person with bed mobility, toileting, bath/showers, require extensive assistance of one person with dressing, toileting, and incontinent of bowel and bladder. Review of R430's Activity Daily Living (ADL) care plan with start date of 4/26/2023 documented, ADL self-care deficit as evidence by .chronic renal failure, mechanical fall, hypertension, Hyperlipidemia, a-fib (irregular heartbeat), MDD, (major depressive disorder), anxiety, gout, Parkinson, TIA (mini stroke), skin cancer, falls, BPH (benign hyperplasia (enlarge prostate) related to physical limitations. Interventions as following: -Assist to bathe/shower as needed. -Assist with daily hygiene, grooming, dressing . Review of the Shower/Bath/Bed Bath Task on a look back scheduled for Wednesday and Saturday evenings for the month of April revealed, R430 received a shower on 4/22/2023 and received a bed bath on 4/12/2023 and 4/19/2023. R26 During an interview on 5/2/2023 at 11:42 AM, Resident #26 (R26) expressed frustration because he had not been receiving his scheduled showers. Review of the clinical record for R26 documented an admission date of 1/27/2022. R26's diagnoses included congestive heart failure. A MDS assessment dated [DATE] documented intact cognition and independence with showers/baths with setup help only. Review of ADL self-care deficit care plan documented the following intervention: Assist to bathe/shower as needed. Dated 4/27/2020. During an interview and record review on 5/8/2023 at 3:57 PM with UM G, R26 missed receiving a shower/bath on the following scheduled dates between 3/1/2023 to 5/8/2023: 3/14/23, 4/4/23, 4/14/23, 4/18/23, 4/25/23, and 5/2/23. R73 During an interview on 5/2/2023 at 11:43 AM, Resident #73 (R73) indicated he had been missing his showers. Review of the clinical record for R73 documented an admission date of 8/14/2020. R73's diagnoses included cerebral infarction and chronic obstructive pulmonary disease. A MDS assessment dated [DATE] documented moderate cognitive impairment and that a bathing activity had not occurred during the seven-day look back period. R73 was scheduled for shower/baths twice weekly on Tuesdays and Fridays. Review of ADL self-care deficit care plan documented the following intervention: Assist to bathe/shower as needed. Dated 8/19/2020. During an interview and record review on 5/8/2023 at 3:52 PM with UM G, R73 missed receiving a shower/bath on the following scheduled dates between 3/1/2023 to 5/8/2023: 3/7/23, 4/4/23, 4/14/23, 4/18/23, 4/25/23, and 5/2/23. R228 Review of the clinical record for Resident # 228 (R228) documented an admission date of 2/7/2023 and discharged date of 3/2/2023. R228's diagnoses included fusion of spine, cervical region. A MDS assessment dated [DATE] documented intact cognition and no upper or lower extremity impairment, and one-person physical assistance for bathing. R228 was scheduled for shower/baths twice weekly on Wednesdays and Saturdays. Review of ADL self-care deficit care plan documented the following intervention: Assist to bathe/shower as needed. Dated 2/8/2023. During an interview and record review on 5/8/2023 at 4:01 PM with the DON, R228 missed receiving a shower/bath on the following scheduled dates between 2/7/2023 and 3/2/2023: 2/8/23, 2/18/23, 2/22/23, and 3/1/23. The DON stated, Showers lead to good hygiene and helps maintain good skin integrity. (Residents) might not feel very good about themselves if they don't get a shower. R248 Review of the clinical record for Resident #248 (R248) documented an initial admission date of 2/24/2023, discharge date of 3/16/23, readmission date of 3/22/2023, and final discharged date of 3/24/2023. R248's diagnoses included cerebral infarction and hemiplegia/hemiparesis affecting left dominant side. A MDS assessment dated [DATE] documented severe cognitive impairment and one-person physical assistance for part of bathing. Review of ADL self-care deficit care plan documented the following intervention: Assist to bathe/shower as needed. Dated 2/27/23. A review of shower documentation revealed R248 missed receiving a shower/bath on the following scheduled dates: 3/7/23, 3/10/23, and 3/14/23. R429 Review of the clinical record for Resident #429 (R429) documented an admission date of 1/13/2023 and discharged date of 2/27/2023. R429's diagnoses included cerebral infarction and hemiplegia/hemiparesis affecting left dominant side. A MDS assessment dated [DATE] documented severe cognitive impairment, upper extremity and lower extremity impairments on one side, and a bathing activity had not occurred during the five-day look back period. Review of ADL self-care deficit care plan documented the following intervention: Assist to bathe/shower as needed. Dated 1/16/2023. During an interview and record review on 5/8/2023 at 3:59 PM with UM G, R429 missed receiving a shower/bath on the following scheduled dates between 1/13/2023 and 2/27/2023: 1/14/23, 1/18/23, 1/25/23, 1/28/23, 2/4/23, 2/11/23, 2/15/23, 2/18/23, 2/22/23, and 2/25/23. UM G indicated refusal should be documented and there were none. On 5/10/2023 at 1:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not. According to the facility's 4/1/2022 Activity Daily Living (ADL) policy, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADLs do not deteriorate unless deterioration is unavoidable. Resident needs for ADL care will be met according to resident specific care plan. Care and services will be provided for the following activities of daily living: -1. Bathing, dressing, grooming and oral care.

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 F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

This citation pertains to Intake MI00134180. Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for multiple residents on the...

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This citation pertains to Intake MI00134180. Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for multiple residents on the Medbridge Unit, Resident #65, an unidentified resident, and four out of seven anonymous residents attending a Resident Council Meeting, resulting in resident hunger, dissatisfaction with the meal experience, and the potential for unmet nutritional needs. Findings include: A complainant reported to the State Agency that the facility failed to serve palatable food. In an interview during the resident council meeting on 5/3/2023 at 3:00 PM, four out of seven residents reported the food was not warm when trays arrived for meals. During an observation and interview on 5/4/2023 at 8:21 AM, the last tray on the Medbridge Unit meal cart was obtained and used as a test tray. The Minimum Data Set (MDS) Coordinator A was present during the testing of food temperatures on the breakfast tray. The following temperatures were obtained using a metal stem thermometer: Sausage link #1: 113 ºF (Fahrenheit) Sausage link#2: 115.8ºF Carton of milk: 55 ºF Yogurt: 52 ºF Apple juice: 55 ºF The temperature of the toast was not taken. MDS Coordinator A agreed that when a pat of soft butter/margarine was spread on the toast it did not melt. During an observation and interview on 5/4/2023 at 12:28 PM, Resident #65 (R65) was observed with her lunch tray in front of her. A dome lid covered her plate. When queried if she ate her lunch, R65 stated she was hungry but could not eat her food because it was cold. R65 granted the State Surveyor permission to remove the dome lid and R65's lunch appeared to be untouched. The plate in front of R65's roommate was observed and also appeared untouched. R65's roommate stated, I'm not going to eat it. I can't eat cold things. During an interview on 5/9/2023 at 8:16 AM, Food Service Director (FSD) B stated her expectations for point of service food temperatures were hot food should be 135 or above and cold food should be 41 or below. FSD B added. The cold temps (obtained from the test tray) for sure bother me because those are dairy products. They are coming out of the cooler and shouldn't be that high. During an interview on 5/10/2023 at 9:21 AM, Corporate Registered Dietitian (RD) C stated her expectations for point of service food temperatures was that food is served safe and without bacterial growth. RD C agreed that it was important to serve palatable food and stated, People need to eat. We need to heal them. Clinically speaking we count on (food acceptance) to avoid significant weight loss. A facility policy titled, Trayline Food Temperatures, dated April 2023, was reviewed and revealed in part the following: It is the policy of this facility to serve food at acceptable temperatures that are safe and palatable. On 5/10/2023 at 1:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

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

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, plumbing, and an accessible hand sink, resulting in the potential contamination of food and equi...

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Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, plumbing, and an accessible hand sink, resulting in the potential contamination of food and equipment, and potential for discouragement of hand hygiene, affecting all residents who consume food from the kitchen. Findings include: On 5/02/23 at 10:29 AM, a dried spill and food splatter was observed in the dry storage room at the wall/floor juncture near the can shelf. An unknown substance was observed to have a solidified drip hanging from the wire rack at the same location. 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. (B)Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. On 5/02/23 at 10:31 AM, food debris and grease were observed to be accumulating in the top and bottom drawer of the three-tier drawer near the preparation sink, where utensils were stored. 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. Pf (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. On 5/02/23 at 10:34 AM, water was observed to be accumulating under the coffee maker shelving. At this time, Food Service Director B stated that the leak may be a result of the newly installed coffee maker and juice machine. 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; P and (B) Maintained in good repair. On 5/02/23 at 10:36 AM, food debris and soil, beyond daily operational spills/messes, were observed to be accumulating on the floor near the preparation sink, cookline, hand sink, and dish machine area. At this time, Food Service Director B stated that they just hired a floor cleaner who will be starting to clean floors today. On 5/02/23 at 10:38 AM, the hand sink by the cookline was observed to be blocked by three large rolling carts. At this time, Food Service Director B moved the carts to provide access to the hand sink. 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 is accessible at all times for EMPLOYEE use. Pf (B) A HANDWASHING SINK may not be used for purposes other than handwashing. Pf (C) An automatic handwashing facility shall be used in accordance with manufacturer's instructions. Pf On 5/02/23 at 10:43 AM, a mop was observed to be left in a mop bucket, in the janitorial closet, not hung up in a position to air dry. According to the 2017 FDA Food Code Section 6-501.16Drying Mops. After use, mops shall be placed in a position that allows them to air-dry without soiling walls, EQUIPMENT, or supplies. On 5/02/23 at 11:48 AM, the nourishment refrigerator, located near the 100 hall, was observed to contain a quinoa salad with no date label to identify the discard date. According to the 2017 FDA Food Code Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Pf On 5/02/23 at 3:28 PM, three of the accessible rolling tray carts, used to distribute meal trays to residents, were observed to be soiled with dried food splatter, grease, and wrappers. At this time, Food Service Director B was queried on the frequency of cleaning the carts and stated that they are cleaned in between each meal and have been cleaned at this time. Food Service Director B commented on the condition of the rolling carts, not having been adequately cleaned.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure staff adhered to contact precautions durin...

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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: 1. Ensure staff adhered to contact precautions during meal pass; 2. Ensure a meal cart was properly cleaned and sanitized for meal distribution to the residents; and, 3. Educate residents on the risks of sharing electronic cigarettes. These deficient practices resulted in the potential for the spread of harmful pathogens among the residents in the building. Findings include: - Isolation precautions and meal cart On 5/2/2023 at 12:21 PM, a meal tray was observed removed from the room of a resident on contact precautions (transmission-based measures implemented to a resident known or suspected to be infected with a microorganism that can be transmitted by direct contact with other residents or indirect contact with environmental surfaces) for Clostridium difficile (C-diff: symptomatic infection due to the spore forming bacteria causing watery diarrhea). Certified Nurse Aide (CNA) M donned personal protection equipment (PPE) upon entering the isolation room to retrieve the tray which included a regular cup, plate, eating utensils, plate warmer, and dome lid. CNA M was wearing gloves when she opened the resident's door and handed the tray to CNA L who was not wearing gloves. CNA L placed the meal tray from the isolation room on the rolling meal cart with the rest of the used meal trays. During an interview on 5/2/23 at 12:22 PM, CNA M said she donned a gown and gloves because the resident had C-diff. When queried about passing the isolation tray to CNA L, CNA M stated, Why did I have on gloves and she didn't? CNA M offered no answer to her question/statement. During an interview on 5/2/23 at 12:25 PM, Registered Nurse (RN) N was informed about the way the isolation tray for a resident on contact precautions was handled. RN N said the resident was on contact precautions and anyone on isolation should have disposable eating containers and utensils. RN N stated the resident's tray on isolation was on the meal cart and can potentially contaminate everything else. RN N said she wondered if the kitchen was aware this resident was on isolation for C-diff. During an observation and interview on 5/2/2023 at 3:28 PM, the rolling tray carts in the kitchen were observed to be soiled with dried food splatter, wrappers, grease and crumbs on the interior surface and rails. At this time, Food Service Director (FSD) B said the carts are cleaned in between each meal and have been cleaned already post lunch. On 5/3/2023 beginning at 8:38 AM during dining observations of residents on isolation for COVID-19, resident meals were served on regular trays, using regular cups, plates, eating utensils, plate warmers, and dome lids as follows: - Isolation room [ROOM NUMBER]'s meal service included regular utensils, dome lid, plate, charger, and tray. The meal ticket for this resident was reviewed and did not specify isolation. - Registered Nurse (RN) H was observed exiting isolation room [ROOM NUMBER] with a regular cup. When queried, RN H said this resident should not have a regular cup since they were on isolation. - Isolation room [ROOM NUMBER]'s meal service included a regular tray, plate, plate warmer, dome, cup, and eating utensils. - Isolation room [ROOM NUMBER]'s meal service included disposable eating wear but was served on a regular tray. On 5/3/2023 at 8:52 AM during an observation, the used trays from the isolation rooms were placed on the same meal cart as the used trays from non-isolation rooms. On 5/8/2023 at 2:37 PM, the Director of Nursing (DON) said that the resident on isolation for C-diff should have been serve meals using disposable items which should have been disposed of in their room. The DON stated, Everything should have been disposable and discarded in the room. There must be a break in communication between the kitchen and the floor staff. This was an infection control violation and could have potentially cause the spread of C-diff spores. During an interview on 5/9/2023 at 8:12 AM, FSD B said she was unaware that some residents were on isolation and had concerns because her staff could be exposed to whatever the patient has when they were breaking the trays down in the kitchen. FSD B agreed that disposable items were to be used for residents on isolation. A review of the policy titled, Tray Pass / Food Acceptance Policy, dated February 2018, revealed in part the following: All residents on isolation precautions (all types) should have their meals served on disposable trays. All content should be disposed of within the room when the meal is completed. All trash should be removed per regulations of contaminated waste removal. Reusable products (i.e. plastic trays) should not be used in the rooms for isolated residents. - Sharing electronic cigarettes During an observation on 5/4/2023 at 1:00 PM with Unit Manager (UM) F, Resident #128 (R128) and Resident #230 (R230) were observed on the facility's front patio using electronic cigarettes. During an interview on 5/4/2023 at 2:20 PM, UM G said that R230 had four vapor pens and these vapor pens were shared with R128. During an interview on 5/4/2023 at 2:49 PM, R230 said she used her vapor pens today and on Sunday (4/30/2023) and she allowed R128 to hit it once or twice. R230 stated, We didn't think about infection control when queried about sharing vapor pens. During an interview on 5/4/2023 at 2:58 PM, R128 stated, My friend vapes. She has some different flavors, so I hit it a couple of times. I've been out twice with her. A review of the medical record for R128 revealed an admission date of 4/13/2023 with diagnoses that included fracture of right fibula, atherosclerotic heart disease, and chronic pulmonary embolism. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition and no upper extremity impairment. A review of the medical record for R230 revealed an admission date of 4/14/2023 with diagnoses that included infection of amputated stump, peripheral vascular disease, and chronic obstructive pulmonary disease. A MDS assessment dated [DATE] documented intact cognition and no upper extremity impairment. During an interview on 5/8/2023 at 1:42 PM, Unit Manager F said residents should not share electronic cigarettes because medically, depending upon what the other person has, things can be transferred via saliva and that could put the residents at risk. During an interview on 5/8/2023 at 2:48 PM, the Director of Nursing (DON) stated she had concerns with residents sharing electronic cigarettes because of germ swapping. During an interview on 5/10/2023 at 11:52 AM, UM F said she was unaware if R128 or R230 had received education regarding the potential risks of sharing electronic cigarettes. UM F stated, If they were educated, it would be documented. UM F was requested to provide documentation of this education. Proof of resident education regarding sharing electronic cigarettes was not provided by the end of the survey. A review of the facility policy titled, Smoking Guidelines, dated November 2013, revealed the following: Instruct patients, family members and visitors not to share lighted cigarettes, lighters, or other smoking accessories with other patients. On 5/10/2023 at 1:30 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was not.

Mar 2023 1 deficiency

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

Deficiency F0777 (Tag F0777)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI000134514. Based on interview and record review the facility failed to promptly report abnormal X-ra...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI000134514. Based on interview and record review the facility failed to promptly report abnormal X-ray results to the Physician for one (R501) of three residents reviewed for falls and radiology services resulting in the Physician being unaware the resident had a wrist fracture and delayed orders for transport to the Emergency Department (ED). Findings include: The State Agency received a complaint that the facility failed to notify the Physician of R501's wrist fracture until 25 hours later when the Complainant came into the facility and asked about the resident's X-ray results. According to the Electronic Health Record (EHR) R501 admitted to the facility with multiple diagnoses that included falls with fracture of the sacrum area and dementia. R501 was assessed to have moderately impaired cognition with a BIMS (Brief Interview for Mental Status) score of 12/15. An Incident Report report written by Licensed Practical Nurse (LPN) C on 12/28/22 at approximately 1:40 PM reported that R501 had an unwitnessed fall and was found seated on the floor next to a chair in her room. The resident was assessed and complained of left wrist pain. The Physician and R501's family were notified of the fall. The Physician ordered a STAT (immediate) X-ray of the left wrist and the resident was given pain medication. Radiology report dated 12/28/22 at 2:49 PM indicated that R501 had an acute displaced fracture of the distal radius and avulsion fracture of the ulnar styloid. (bony projection at end of ulnar near hand/ wrist). The report documented that the X-ray was taken on 12/28/22 at 2:24 PM, reported on 12/28/22 at 2:49 PM. A progress note written by Unit Manager LPN B on 12/29/22 at 9:47 AM included the following documentation; IDT (Interdisciplinary team) met to discuss pt. fall on 12/28/2022, . pt. (patient) stated she was sitting on the edge of the bed and was going to sit in her bedside chair, and slipped to the floor bedside, pt. stated hurting her wrist trying to catch herself upon falling, X-Ray ordered . There is no mention of the X-ray results. During an interview on 3/8/23 at 11:20 AM with Unit Manager LPN B he said he did not have the X-ray results for R501 at the time of the IDT meeting on 12/29/22 when the resident's fall was discussed. Upon further inquiry LPN B said it was the floor nurse's responsibility to obtain the resident's X-ray report. LPN B acknowledged that only managers have the password to access the radiology website to acquire X-ray reports. A progress note written by LPN A on 12/29/22 at 4:16 PM (25 hours after the stat X-ray) reads as follows;Daughter inquired about X-ray results, results found online. On-call clinician called regarding results. Send patient out to ED .for left wrist fracture. During an interview on 3/8/23 at 11:45 AM LPN A said the resident's daughter came in and asked about the X-ray results. There were no results in the chart so I had to get them. I don't know why we didn't get them sooner. The resident fell the day before and the results were available then. They (radiology company) usually fax the report over immediately. I don't know if we ever got the fax or if anyone else had looked for it. During an interview with R501's Physician on 3/8/23 at approximately 12:00 PM he said he was not made aware of R501's left wrist fracture until later the next day. The Physician said the resident was treated with scheduled pain medication while at the facility and did not require any surgical intervention. The resident returned to the facility with orders from the ED for a left forearm sling. On 3/8/23 at 12:53 AM during a phone interview the Radiology company's Representative (RCR) D was asked about R501's radiology report on 12/28/22. RCR D reported that R501's radiology report was faxed over to the facility on [DATE] at 2:52 PM. RCR D provided the correct the fax number to the facility and confirmation of receipt report. On 3/8/23 at approximately 2:30 PM the Nursing Home Administrator (NHA) confirmed the fax number from RCR D was accurate. The NHA could not provide any fax history reports from the time frame of R501's incident because It's too far back. The NHA said the facility's policy is for the radiology company to fax over reports and that nursing should be looking for them and report the results to the Physician immediately. The NHA said there was no specific policy regarding notification of radiology results only for changes in status. According to the facility's 'Change in Status' policy (undated) the American Medical Directors Association (AMDA) Clinical Practice Guideline - Acute Changes in Condition in the Long-Term Care Setting; immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed.

Feb 2022 6 deficiencies

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** This citation pertains to Intake number MI00012519. Based on observation, interview and record review the facility failed to ens...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00012519. Based on observation, interview and record review the facility failed to ensure one sampled resident (R#79) was treated with dignity from a total sample of 21, resulting in feelings of inconveniencing staff when using call light for staff assistance. Findings include: Resident #79 During a tour of the first floor nursing unit on 2/16/22 at 12:34 PM, R79 was observed in bed with the call light hanging on the drawer of the dresser next to the bed. R79 anxiously reported a midnight female staff member, unknown, told him that he uses the call light too much . she yelled at me .I only use it when I need to. R79 indicated he reported incident to Speech Therapist (ST) O and Certified Nurse Assistant (CNA) E. Review of an admission Record face sheet revealed R79 was admitted to the facility on [DATE], with pertinent diagnoses which included cerebral palsy (incurable abnormal movement of muscles due to abnormal brain development), cardiac disease, gastritis and high blood pressure. Review of an admission Minimum Data Set (MDS) assessment for R79, with a reference dated of 2/2/22, revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated moderately impaired cognition. The MDS indicated the resident required extensive, one person assistance with all activities of daily living (ADL's). Review of the care plan falls dated 1/30/22 had an intervention to Assist with activities as needed. Review of the care plan Cognitive loss as evidenced by BIMS Score of 12 dated 1/31/2022 had interventions of Allow adequate time to respond. Do not rush or supply words; Approach/speak in a calm, positive/reassuring manner; Explain each activity/ care procedure prior to beginning it; Explain each activity/ care procedure prior to beginning it. Review of the care plan Difficulty communicating related to slight speech impairment, difficulty expressing words at times dated 2/4/2022 had an intervention to Gain individual's attention before beginning to converse. During an interview with ST O on 2/16/22 at 3:30 PM, she reported visiting with R79 around 8:45 AM (morning of incident). ST O reported R79 mentioned an incident about the call light. He said a staff member told him he pushes (the call light) to often .staff tells him he uses the call light too much. ST O denied reporting the incident to anyone saying, I should have reported it. During an interview with Administrator A (who is also the abuse coordinator) on 2/16/22 at 3:42 PM, he reported No that (call light incident with R79) was not reported to me. During an interview with CNA E on 2/17/22 at 1:30 PM, she reported R79 told her that someone from midnight shift (2/15/22 into 2/16/22) told R79, Your on the call light too much. CNA E reported R79 seemed sad when reporting incident. CNA E reported she did not report incident to anyone saying I didn't know I needed to. During an interview with the Director of Nursing (DON B) on 2/18/22 at 11:13 AM, she indicated that on 2/16/22 at 5:48 PM the facility reported the incident (to the State Agency) and are currently doing an investigation. The DON reported the LPN N was the staff member involved in the incident. During a phone interview on 2/18/22 at 12:51 PM, LPN N reported she was in the hallway around 7 am (on 2/16/22) and R79 had the call light on several times. LPN N reported 1-2 times R79 was asking for a pain pill and one time was putting on the call light for his roommate (total of 3 times). LPN N reported she told R79 he can tell me everything he needs in one visit. LPN N reported she was familiar with R79 she had taken care of him before .I cannot remember any other time (when the resident frequently used the call light). During an interview with Administrator A on 2/23/22 at 11:48 AM, he reported, We were able to substantiate the allegation, but it was not the intention of the message, it was how it was said. Review of a facility provided document titled Resident Rights dated 11/28/16 documented, 4. Respect and dignity-The resident has the right to be treated with respect and dignity .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to provide timely incontinence care and provide showers for two resident (Resident #22, #36) of eight residents reviewed for Acti...

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Based on observation, interview and record review, the facility failed to provide timely incontinence care and provide showers for two resident (Resident #22, #36) of eight residents reviewed for Activities of Daily Living (ADL), resulting in the potential for skin breakdown and infection. Findings include: Resident #22 Review of an admission Record revealed, Resident #22 admitted to the facility with pertinent diagnosis which included Vascular Dementia and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side (weakness and paralysis). Review of a Minimum Data Set (MDS) assessment, with a reference date of 12/29/21 revealed Resident #22 had severe cognitive impairment and required extensive assistance of one with toileting. In an observation on 2/16/22 at 9:55 a.m., Resident #22's brief was heavily soiled indicated by dark blue lines in the middle of the brief. Certified Nursing Assistant (CNA) D performed incontinent care on Resident #22. In an observation and interview on 2/17/22 at 1:22 p.m., CNA H removed Resident #22's blankets to perform a bed bath. Resident #22's brief was heavily soiled indicated by dark blue lines in the middle of the brief. CNA H reported she is in the facility twice a week to perform care on Resident #22. CNA H then reported Resident #22 is always soiled when she comes. In an interview on 2/18/22 at 10:39 a.m., CNA D reported residents are checked and changed every two hours. CNA D then reported residents that are incontinent more frequently are checked every hour. In an interview on 2/18/22 at 1:49 p.m., Director of Nursing (DON) B reported residents should be checked and changed every two hours. DON B reported a dark blue line indicates there is moisture in the brief. Resident #36 Review of an admission Record revealed, Resident #36 admitted to the facility with pertinent diagnosis which included Schizoaffective Disorder and Major Depressive Disorder. Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/10/22 revealed Resident #36 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. Resident #22 required total dependence of one staff with bathing. In an interview on 2/16/22 at 9:51 a.m., Resident #36 reported they get one bed bath a week. Resident #36 then reported they would like to get in the shower every once in a while. Review of a Documentation Survey Report for the last 60 days revealed, Resident #36 had scheduled showers on Tuesday and Friday on the day shift. Resident #36 had documented showers on 1/25, 2/4, 2/8, and 2/11/22. There were no documented showers on 1/28, 2/1, 2/15, 2/18, or 2/22/22. In an interview on 2/23/22 at 11:22 a.m., Resident #36 reported not receiving a shower yesterday (2/22/22). Resident #36 stated, No, regarding if a shower or bed bath was offered. In an interview on 2/23/22 at 11:27 a.m., CNA D reported residents receive a shower or bed bath twice a week. Review of Daily Assignment Sheet with a date of 2/22/22 for day shift revealed, Resident #36 had a scheduled shower. In an interview on 2/23/22 at 12:49 p.m., DON B reported residents are scheduled two showers per week. DON B then reported showers are documented on the shower sheet and in the electronic medical record. DON B confirmed Resident # 36 did not receive a shower twice a week for the last 60 days. Review of Skin Worksheets revealed, in the last for 60 days Resident # 36 received a shower on 12/28/21, 1/7, 1/18, 1/25, 2/4, 2/8, and 2/11/22.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure medications were safely secured for one resident (Resident #15) out of a total sample of 21 residents, resulting in the...

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Based on observation, interview, and record review the facility failed to ensure medications were safely secured for one resident (Resident #15) out of a total sample of 21 residents, resulting in the potential for accidental ingestion of medication, improper administration, and infection control concerns. Findings include: In an observation on 2/16/22 at 9:28 a.m., a tray with medications sat on Resident #15's dresser. The medication included Fluticasone (nasal spray), two bottles of Timolol Maleate (eye drops), two bottles of Brimonidine Tartrate (eye drops), and unknown cream in a med cup. In an interview on 2/16/22 9:30 a.m., Licensed Practical Nurse (LPN) I reported medications are not normally left in a resident's room. LPN I then reported the medications were just brought in the room to give to Resident #15, but resident was eating breakfast. LPN I then reported the cream was left in the room last night. In an interview on 2/17/22 at 1:19 p.m., LPN J reported medications should not be left at the bedside unless there is a Physicians order. Review of an admission Record revealed, Resident #15 admitted to the facility with pertinent diagnosis which included Acute Angle Closure Glaucoma (rapid increase of pressure in eye). Review of a Minimum Data Set (MDS) assessment, with a reference date of 12/17/21 revealed Resident #15 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 3, out of a total possible score of 15. Review of Physician Orders revealed, Resident #15 did not have a self-administration of medication order. Resident #15 had medication orders which included, Timolol Maleate Solution 0.5 % Instill 1 drop in both eyes every morning and at bedtime for glaucoma with an order date of 11/22/17. Brimonidine Tartrate Solution 0.2 % Instill 1 drop in both eyes every morning and at bedtime for glaucoma with an order date of 11/22/17. Fluticasone Prop 50 mcg spray 1 spray in both nostrils one time a day for allergy relief with an order date of 4/19/19. In an interview on 2/18/22 at 11:00 a.m., Director of Nursing (DON) B reported Resident #15 does not have a medication self-administration assessment form. In an interview on 2/18/22 at 1:52 p.m., DON B reported medication should not be left at the bedside unless there is an order. Review of an Medication Administration: Self-Administration of Medications policy with a updated date of 03/2018 revealed, .Medication Storage and Security: Medications and biologicals are securely stored in a locked cabinet, cart, or medication room, accessible to only licensed nursing staff and pharmacist or authorized pharmacy staff, and maintained under a lock system when not actively utilized and attended to by nursing staff for medication administration, receipting, or disposal .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

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 correctly administer physician's ordered insulin for on...

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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 correctly administer physician's ordered insulin for one sampled resident (R#6) of 6 residents reviewed during medication pass resulting in the potential for a sub therapeutic amount of insulin. Findings include: FACILITY Medication Administration During an observation on 2/23/22 at 10:48 AM, a Novolog (rapid acting) insulin Flexpen was prepared by LPN J for administration to R6. Review of a Physician order dated 10/20/20: NovoLOG FlexPen Solution Pen-injector 100 UNIT/ML (Insulin Aspart). Inject subcutaneously before meals and at bedtime for Diabetes Mellitus (DM-high blood sugar) Inject as per sliding scale: (R6's Random Blood Sugar= RBS-298); 251 - 300 = 4 units. LPN J dialed the flex pen to the order amount of insulin (4 units) with out first priming the pen with 2 units of insulin. LPN J injected the Novolog insulin into R6's left upper arm. LPN J inserted the needle, pressed and held the dose button until the dose counter reached 0 then removed the needle, without slowly counting to 6 to ensure complete dosing. At 11:15 AM, LPN J was queried about the insulin administration and said, No we don't have to prime prior to administering insulin. Review of an admission Record face sheet revealed R6 was admitted to the facility on [DATE], with pertinent diagnoses which included Type 2 Diabetes Mellitus (high blood sugars). Review of the quarterly Minimum Data Set (MDS) assessment for R6, with a reference dated of 2/17/22, revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated severely impaired cognition. Review of a DIABETES care plan dated 5/13/20 documented an intervention of, Administer medication per physician orders. During an interview on 2/23/22 at 1:54 PM, during in interview with the facility's Director of Nursing (DON) she said that she was aware of Nurse J not priming the insulin pen and was providing 1:1 inservice for Nurse J and inservicing the rest of the nursing staff. Review of the 2019 manufactures guidelines documented, .Prime your pen Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears .Please note that if the needle is removed before the 6 second count is completed after the dose counter returns to 0, then under dosing may occur by as much as 20%, resulting in the need for increasing the frequency of checking blood sugar and possible additional insulin administration. Review of the facility's undated policy titled Using your Flexpen documented, Get your pen ready to use: 1. Wash and dry your hands well. 2. Remove the pen cap 4. Wipe the rubber end of the pen with an alcohol swab. 5. Remove the seal from the new pen needle and screw it onto the end of the pen. 6. Remove the outer needle cap and set it aside. Remove the inner needle cap and throw it away. 7. Turn the knob on the pen to a dose of 2 units.

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** Resident #60 Review of an admission Record revealed, Resident #60 admitted to the facility with pertinent diagnosis which includ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #60 Review of an admission Record revealed, Resident #60 admitted to the facility with pertinent diagnosis which included Dementia and Senile Degeneration of Brain (mental decline). Review of a Minimum Data Set (MDS) assessment, with a reference date of 1/21/22 revealed Resident #60 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 3, out of a total possible score of 15. Resident #60 required extensive assistance of two staff with ADL (Activities of Daily Living) care. Review of a Documentation Survey Report revealed Resident #60 had scheduled showers on Tuesday and Friday evenings. Resident #60 had a one documented shower on 1/25/22 in the last 60 days. Resident #60 refused the shower on 1/4/22 and 1/28/22. There were no other showers documented for January or February 2022. In an interview on 2/23/22 at 11:32 a.m., Certified Nursing Assistant (CNA) E reported hospice completed Resident #60's weekly showers. CNA E then reported documentation for showers are completed on a shower sheet. In an interview on 2/23/22 at 12:49 p.m., Director of Nursing (DON) B confirmed Resident # 60's shower documentation revealed showers were not given twice a week for the last 60 days. Review of Skin Worksheets revealed, in the last for 60 days Resident # 60 received or refused a shower on 12/21/21, 12/28/21, 1/5/22, 1/14/22, and 1/25/22 . In an interview on 2/23/22 at 1:04 p.m., DON B reported hospice provides showers for Resident #60. DON B then reported she had to figure out where hospice documented showers for Resident #60. In an interview 2/23/22 1:58 p.m., DON B provided documentation from hospice which revealed Resident #60 received scheduled showers in the past 60 days. DON B then reported the documentation for Resident #60's showers were not in the EHR (Electronic Health Record) or hard chart. According to the facility's policy for Requirements and Guidelines for Clinical Record Content dated 1/31/2017; Progress notes are electronically documented in the EHR to reflect the patient's condition, significant care issues, response to treatment and changes in condition and treatment. Final Progress Notes: For each discharged patient, a final progress notes is entered into the EHR by each discipline at the time of the discharge or discontinuation of therapy. The final progress notes acknowledges the patient's discharge and documents the progress, or lack of progress made by the patient since the previous comprehensive progress notes. Based on interview and record review the facility failed to maintain complete and accurate records for two of 21 sampled residents (R198, R60) , resulting in the potential for miscoordination of care and incomplete medical records. Findings include: Resident 198: A review of R198's EHR (Electronic Health Record) revealed the resident admitted to the facility on [DATE] at approximately 6:00 PM for rehabiliation after a laminectomy (surgical procedure of the spine) and was out of the facility by 12/16/21 at 9:35 AM. A progress note on 12/16/21 at 9:35 AM written by Physical Therapy reads as follows; The resident is no longer in the facility. There is no additional documentation to indicate why R198 is no longer in the facility, or where she was discharged to. On 12/16/21 the physician wrote an order for R198 to go on a LOA (leave of absence) with family members. On 2/17/22 at 1:15 PM, Administrator A was interviewed regarding R198's EHR and confirmed there was no documentation to indicate the reason or type for discharge of R198. Admininistrator Asaid R198 insisted on going to the hospital for pain management because a nurse had pulled on her right leg too hard. R198 called '911' herself because the physician did not agree to transfer her to the hospital. The physician wrote an order for LOA with family. An investigation was initiated immediately and the incident was reported to the State Agency. Administrator A confirmed that no documentation was in the EHR. A review of the 'investigation file' for R198 revealed details of the discharge but were not included in EHR. According to the facility's policy for Requirements and Guidelines for Clinical Record Content dated 1/31/2017; Progress notes are electronically documented in the EHR to reflect the patient's condition, significant care issues, response to treatment and changes in condition and treatment. Final Progress Notes: For each discharged patient, a final progress notes is entered into the EHR by each discipline at the time of the discharge or discontinuation of therapy. The final progress notes acknowledges the patient's discharge and documents the progress, or lack of progress made by the patient since the previous comprehensive progress notes.

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 observation, interview and record review, the facility failed to properly thaw food products, resulting in an increased risk for food borne illness that had the potential to affect 99 of 103 ...

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Based on observation, interview and record review, the facility failed to properly thaw food products, resulting in an increased risk for food borne illness that had the potential to affect 99 of 103 resident's that ate meals from the kitchen. Findings include: During an initial tour of the kitchen on 2/16/22 at 8:37 AM with Dietary Manger (DM) K , it was observed that six partially thawed 5# (pound) roast beef packages were sitting in a compartment of the sink. DM K reported that the roast beef was thawing (at room temperature) for lunch the following day. DM K said, It (the roast beef packages) should be thawing under cold running water as she turned on the cold water so that it was running onto the roast beef in the sink. According to the 2013 FDA food code section 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less; or (B) Completely submerged under running water; (1) At a water temperature of 21oC (70oF) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41oF). Review of the facility's Thawing Foods policy dated 11/20 documented, 1. Foods are removed from the freezer and placed in the refrigerator for defrosting .8. While it is not recommended, foods can be defrosted fully submerged under running water at 70oF or lower. The force of the water needs to be great enough to wash any loose food particles in to an overflow drain. Ready-to-eat foods should not exceed 41oF during the thawing process .

Optalis Health and Rehabilitation of Canton

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