Beaconshire Nursing Centre
For profit - Individual
99 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
8/100
#364 of 422 in MI
Photo by Beaconshire Nursing Center
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1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Beaconshire Nursing Centre in Detroit, Michigan, has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #364 out of 422 facilities in the state places it in the bottom half, and at #61 of 63 in Wayne County, it is among the least favorable local options. The facility has been worsening, increasing from 10 issues in 2024 to 14 in 2025, and has a troubling total of 51 issues, including one critical incident where a resident sustained second-degree burns from a fire caused by unsupervised smoking. While staffing turnover is impressively low at 0%, the overall staffing rating is poor at 1/5 stars, and there are fines totaling $42,583, indicating some compliance problems. Families should weigh the facility's low staffing ratings and serious incidents against its low turnover, but the overall picture raises significant concerns.
- Trust Score
- F
- In Michigan
- #364/422
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ○ Average
- $42,583 in fines. Higher than 57% of Michigan facilities. Some compliance issues.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 51 deficiencies on record. Higher than average. Multiple issues found across inspections.
8/100
Bottom 14%
Review needed
10 → 14 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 14 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Michigan average (3.1)
Significant quality concerns identified by CMS
Federal Fines: $42,583
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 51 deficiencies on record
1 life-threatening 3 actual harm
Sept 2025
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficient practice pertains to 1232811.Based on observation, interview, and record review the facility failed to don approp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficient practice pertains to 1232811.Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R407) of three resident reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms.Findings include:On 9/16/2025 at 10:50 AM, Licensed Practical Nurse (LPN) A was observed to perform wound care and peri care on R407. LPN A was assisted by Certified Nurse Assistant (CNA) B. LPN A and CNA B did not put on a gown during patient care despite there being an Enhanced Barrier Precaution (EBP) sign on the door indicating R407 was on (EBP).During this time LPN C (unit manage) enter R407 room while wound care was being performed.On 9/16/2025 at 11:15 AM, CNA B was interviewed about (EBP) and said a gown should be worn when a resident has a foley catheter, wound and doing personal care.On 9/16/2025 at 11:17 AM, LPN A was interviewed and queried about the care they had performed on R407. LPN A said she should have worn a gown because R407 had an open wound and a foley catheter.On 9/16/2025 at 11:49, AM LPN C was interviewed and acknowledged when they entered the room during patient care they did not see LPN A nor CNA B wearing a gown. LPN C said they should have been wearing a gown because R407 was on EBP.On 9/16/2025 at 1:00 PM, the Director of Nursing (DON) was interviewed and said they had the signs posted on door R407. The DON also acknowledged there were orders in R407 chart indicating they were on EBP, but staff did not follow the orders or signs. The DON said they would expect staff to follow the orders.Record review revealed R407 was initially admitted on [DATE] and readmitted on [DATE]. R407 had the following diagnosis: urinary tract infection, osteomyelitis (bone infection), pressure ulcer stage IV, unspecified injury at C4 and neurogenic bowel.Review of Minimum Data Set (MDS) for R407 from the Quarterly Review dated 7/19/2025 noted R407 Brief Interview for Mental Status was a 15 out of 15 indicating R407 was cognitively intact.Review of facility policy titled, Enhanced Barrier Precautions with a review date of 9/16/2025 noted, It is the policy of this facility to implement enhanced barrier precautions for the prevention transmission of multidrug-resistant organisms. Documented under implementation of enhanced barrier precautions indicated Personnel Protection Equipment (PPE), is for EBP is only necessary when performing high- contact care activities. High contact care activities included providing hygiene, changing linen device care which included urinary catheter and wound care.
Jun 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
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 in intake: MI00153399 and MI00153424.
Based on observation, interview, and record review the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains in intake: MI00153399 and MI00153424.
Based on observation, interview, and record review the facility failed to ensure staff reported a bruise of unknown origin for one (R503) of five residents reviewed for abuse, resulting in an unreported incident of potential abuse.
Findings include:
The State Agency (SA) received a complaint on 6/1/2025 that the resident had a bruises of unknown origin to the body and left breast.
On 6/4/25 at 1:00 PM R503 was observed seated in the dining room eating lunch and interacting with other residents. R503 had bruises to both lateral upper arms at the same area where the resident's arms were touching and resting on the wheelchair's armrests. Upon interview the resident denied anyone hitting her or having pain to either upper arm area. The resident declined to go to her room for further skin assessment.
On 6/4/25 at 1:15 PM Licensed Practical Nurse (LPN) B reported they were unaware of any bruising to R503's upper arms. LPN B said the resident was on blood thinners and a skin assessment would be completed when the resident completed her lunch.
A review of R503's Electronic Health Record (EHR) revealed that R503 had initially admitted to the facility on [DATE] with multiple diagnoses that included bipolar disorder, psychotic disorder with delusions and schizophrenia. The resident was identified to have moderately impaired cognition with a Brief Interview for Mental Status Score of 8/15. The Medication administration record indicated that R503 was receiving Eliquis, a blood thinner twice a day. A skin assessment dated [DATE] did not identify any bruises to the resident's body.
On 6/5/25 at 10:00 AM R503 was observed in the day room interacting with other staff and residents during an activity. R503 was agreeable to a skin assessment in their room. Certified Nursing Assistant (CNA) E assisted R503 to her room and was present for the observation of the resident's left breast. A purplish red bruise that was approximately the size of a soft ball was observed underneath and on the resident's left breast. R503 denied anyone hitting or hurting them at this time. R503 denied any abuse or pain at the site. CNA E was asked if the bruise was present at the time of AM care and replied, Yes, I told the nurse about it.
At this time LPN F interviewed and said, I have no idea about the resident having a bruise to her left breast.
Nurse unit manager, LPN C was interviewed about R503's bruising. LPN C reported that they were unaware of the resident's multiple bruises until now. LPN C completed a skin assessment at this time and confirmed that the bruises were of unknown origin and initiated an investigation. LPN C could not explain why the skin assessment dated [DATE] did not identify any bruising.
On 6/5/25 at 12:45 PM R503 was observed in the day room eating lunch and interacting with other residents. Upon interview R503 continued to deny abuse or concerns about the bruise to their left breast area or bilateral arms.
On 6/5/25 at approximately 1:00 PM during an interview with the Director of Nursing (DON) they said an investigation was being conducted and an incident was reported to the State Agency at this time. The DON could not explain the delay in initiating an investigation for bruises of unknown origin. They confirmed it was the facility's policy to report and investigate any bruises in potential areas of abuse such as the breast. The DON said R503 had been to the emergency room (ER) on 6/2/25 and the bruises could have resulted during transportation or while in the ER. The DON could not explain why a skin assessment on 6/4/25 did not identify any bruises or why the State Agency received a complaint on 6/1/25 regarding the bruising of the left breast.
According to the facility's policy for Abuse, Neglect and Exploitation last reviewed 6/5/2025 in part reads:
IV. Identification of Abuse, Neglect and Exploitation.
B. Possible indicators of abuse include, but are not limited to:
2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident ' s body
3. Physical injury of a resident, of unknown source
V. Investigation of Alleged Abuse, Neglect and Exploitation
A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.
VI. Protection of Resident
The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:
VI. Reporting/Response
A. The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:
a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or
b.
Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
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 F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
This citation pertains to intake MI00152716.
Based on observation, interview and record review, the facility failed to ensure a call light was available and in place for 6 residents (R503, R508, R509,...
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This citation pertains to intake MI00152716.
Based on observation, interview and record review, the facility failed to ensure a call light was available and in place for 6 residents (R503, R508, R509, R510, R511, and R512) of 91 residing in the facility resulting in the potential for unmet needs, harm or serious injury.
Findings include:
The State Agency received a complaint that R503 did not have a call light or a way to notify staff that assistance was needed.
On 6/4/25 at 11:50 AM R503's private room was observed to not have a call light cord plugged into the call light outlet. There was no desk bell or any other way to notify staff that assistance may be needed. R503 was not in the room at this time. Certified Nursing Assistant (CNA) B entered the room and was asked where the call light was. CNA B could not find the call light cord or a bell.
At this time Licensed Practical Nurse (LPN) A was asked where the call light was for R503. The room was searched and no call light or bell was found in the room.
On 6/4/25 at approximately 12:00 PM nurse unit manager, LPN C was asked about the lack of a call light for R503 and replied, Some of the call lights were not functioning properly and we are getting that repaired. In the meantime we have provided desk bells for the residents whose call lights are not functioning. LPN C confirmed that R503 did not have a call light or desk bell.
At 12:06 PM R503 was observed and in the day-room and did not voice any concerns regarding the lack of the call light in their room.
An inspection of the facility determined that in addition to R503, the following residents did not have call lights or any additional way to notify staff that assistance was needed; R508, R509, R510, R511, and R512. During the time of the observations all of the residents were not in their room. The residents were in common areas or dining rooms and did not report any concern with the lack of the call light or desk bell in their room.
On 6/4/25 at approximately 2:00 PM the Nursing Home Administrator (NHA) said the facility was in the process of repairing the call light system and all residents that were identified to have malfunctioning call lights should have had a desk bell or cow bell to alert staff that assistance was needed. The NHA was unable to provide a list of malfunctioning call lights at this time but provided an undated invoice for repair of the facility's call light system. The NHA said there was no policy for call lights.
Jan 2025
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/27/25 at 11:50 AM, a computer on a medication cart was observed opened to R28's Electronic Medical Record, (EMR). Social Wo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/27/25 at 11:50 AM, a computer on a medication cart was observed opened to R28's Electronic Medical Record, (EMR). Social Worker, (SW) Q was coming down the hall and stopped when directed to look at the resident's information on the computer screen. SW Q alerted the nurse that was coming down the hall that the computer was left opened. SW Q was then queried about R28's EMR being opened in the hallway so anyone walking by could see it and said it was a violation of the resident's privacy.
On 1/27/25 at 11:55 AM, License Practical Nurse, (LPN) I was interviewed about leaving R28's EMR open and said that was not the normal computer they use. LPN I said they understand R28's EMR should not have been left open and they know it is a violation of R28's privacy.
On 1/29/25 at 12:00 PM, the DON was interviewed about R28's EMR left opened. The DON said it was a violation of HIPPA.
R28 was initially admitted on [DATE] with a pertinent diagnosis of Psychosis, Muscle Weakness, Schizophrenia, Vascular Dementia and Cerebral Infarction (stroke). The quarterly assessment dated [DATE] for Brief Interview for Mental Status, (BIMS) revealed R28 had severe cognitive impairment.
Based on observation, interview, and record review, the facility failed to properly secure protected health information for two residents (R198 and R28) resulting in the potential for unauthorized disclosure and access.
Findings include:
On 1/29/25 at 12:47 PM, the laptop computer on a 1st floor nursing medication cart, located in the unit's commonly accessible hallway, was observed unlocked, and the electronic health record (EHR) for R198 was opened. R198's order for haloperidol deconoate (an injectable antipsychotic medication used for schizophrenia) was visible on the computer screen. There was no nurse visible near the 1st floor nursing medication cart. On 1/29/25 at 12:49 PM, Licensed Practical Nurse (LPN) D approached the cart. When queried about the opened EHR, LPN D said it was a HIPPA (Health Insurance Portability and Accountability Act) violation to expose resident information.
A review of R198's medical record documented an initial admission date of 11/14/24 and readmission date of 1/28/25. R198's diagnoses included schizophrenia. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment.
On 1/29/25 at 2:06 PM, the Director of Nursing (DON) was interviewed and stated, We follow HIPPA protocol (meaning) that no patient health information is left exposed.
On 1/29/25 at 4:40 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to make timely repairs for the residents residing in rooms [ROOM NUMBER] ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to make timely repairs for the residents residing in rooms [ROOM NUMBER] resulting in unsafe, unhomelike, and dysfunctional paper towel dispenser.
Findings include:
On 1/27/25 at 11:30 a.m. room [ROOM NUMBER] was observed with the heating vent cover propped against the vent. The vent was observed with thick dust and dirt. The resident in bed one said the cover was taken off when maintenance was repairing the heat some time ago, I don't know why they haven't put it back on. The resident in bed two said when using the wheelchair, the cover gets knocked over. When that occurs, the resident propped it back against the vent. The residents also complained the temperature in the room gets cold. There was plastic on the windows, but maintenance took it off and didn't put it back up. There was a small heating unit (approximately the size of a personal space heater) mounted on the wall next to the window. There was some heat coming from it, but not blowing out strong.
On 1/29/25 at 11:47 a.m. Maintenance Director E was interviewed about the environment conditions in room [ROOM NUMBER] at stated, I didn't know the room was still cold. The residents haven't said anything to me. I think one of the residents may have knocked the cover off with the wheelchair. Maintenance Director E was queried about being notified of when repairs are needed. Maintenance Director E said the staff are supposed to log repairs in the Maintenance Log located on each unit but most times is made aware when walking by the resident or staff, then put in the Maintenance Director's personal note pad.
On 1/29/25 at 11:52 a.m. the CEO of Operations was interviewed and said they were aware of the many environment concerns and currently trying to address them.
Review of the facility's policy titled Safe and Homelike Environment dated 9/3/24 documented in part: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
Review of the facility's policy titled Maintenance Inspection dated 11/24 documented in part: It is the policy of this facility to utilize a maintenance inspection checklist to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public . The Director of Maintenance Services will perform routine inspections of the physical plant using the Maintenance Checklist . The Administrator, or designee, will perform random inspections of the physical plant using the Maintenance Checklist . All opportunities will be corrected immediately by maintenance personnel.
On 1/27/2025 at 9:55 a.m., the shared bathroom of rooms [ROOM NUMBERS] were observed with a broken paper towel dispenser and an orange construction cone supporting the bathroom sink. CNA O entered room [ROOM NUMBER] and was interviewed. CNA O said that the orange cone wrapped around the bathroom sink pole was to keep the pole from dislodging from the sink. CNA O added the resident in room [ROOM NUMBER] used the bathroom independently.
On 1/29/2025 at 2:13 p.m. Housekeeper P was interviewed regarding the bathroom of rooms [ROOM NUMBERS]. Housekeeper P demonstrated not being able to pull down the paper towel from the dispenser said the residents would not be able to pull the paper towels down either. Housekeeper P said the dispenser had been broken for a long time. Housekeeper P confirmed the orange construction cone in the bathroom of rooms [ROOM NUMBERS] was to hold up the bathroom sink.
On 1/29/2025 at 3:09 p.m., the Director of Nursing said during an interview that residents should have access to paper towel. and the housekeepers should check every day to may sure it's available.
On 1/29/2025 at 4:15 PM, Maintenance Director (MD) E was asked about the condition of the shared bathroom of rooms [ROOM NUMBERS] and stated, I will look into it (the bathroom sink). It should have been fixed. It's not secure for the residents.
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 (1) ensure desserts delivered to three unidentified residents were properly covered and (2) failed to maintain the ice machin...
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Based on observation, interview, and record review, the facility failed to (1) ensure desserts delivered to three unidentified residents were properly covered and (2) failed to maintain the ice machine in a clean and sanitary condition.
Findings include:
During lunch observations on 1/28/25 at 12:16 PM, a meal cart was delivered to the far end of the 1st floor residential unit. Certified Nurse Aide (CNA) B and CNA C delivered meal trays to the residents eating in their rooms at the far end of the hall. Beginning at 12:18 PM, CNA B and CNA C carried meal trays from the meal cart at the end of the hallway to the residents' dining room which was located half-way down the hall and down a shorter hall around a corner. Three meals trays were observed delivered to the dining room each with the dessert, cheese cake, uncovered.
On 1/29/25 at 11:40 AM, Dietary Manager (DM) F said that all food should be covered on the tray. The CNAs should have brought the cart closer to the dining room prior to passing the trays to the residents eating in the dining room. DM F said food should be covered to prevent possible contamination.
On 1/29/25 at 2:04 PM, the Nursing Home Administrator (NHA) said all the food was supposed to be covered. The NHA stated, Why didn't they take the cart to the dining room?
On 1/29/25 at 4:40 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.
On 1/27/25 at 4:54 p.m. the ice machine located on the first floor of the facility was observed with LPN L. An unknown substance (rust colored) was on the inside hinge of the ice machine's door. The unknown substance was shown to LPN L. On the inside of the ice machine, the ice dispenser's hood (which was white in color), was observed with numerous black speckles. The outside of the machine was observed with drip stains of an unidentified substance on both sides. LPN L was queried about the unsanitary conditions of the ice machine. LPN L could not identify the unknown substances and did not know the department responsible for maintaining the cleanliness of the ice machine. LPN L confirmed the ice machine supplies ice for the entire facility.
On 1/29/25 at 2:05 p.m. Housekeeping Supervisor M was queried about maintaining the cleanliness of the ice machine. Housekeeping Supervisor M stated, Housekeeping is not responsible for cleaning the ice machine. The dietary department is supposed to keep it clean.
On 1/29/25 at 2:40 p.m. DM F was interviewed about the ice machine and said the ice machine is cleaned every six months by an outside company. The dietary department is responsible for keeping the outside of the ice machine clean, and the maintenance department is responsible for cleaning the inside in between the six-month cleanings as needed.
On 1/29/25 at 2:54 p.m. Maintenance Supervisor E was queried about the ice machine and stated, I didn't know it needed to be cleaned. It's a company that comes in to clean it.
According to the 2013 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.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to properly dispose of refuse and maintain cleanliness of garbage and refuse areas resulting in the potential harborage of pests....
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Based on observation, interview, and record review the facility failed to properly dispose of refuse and maintain cleanliness of garbage and refuse areas resulting in the potential harborage of pests. This deficient practice has the potential to affect all 92 residents in the facility.
Findings include:
On 1/28/25 at 5:29 p.m. during an observation of the environment, the following observations at the rear of the facility were made:
Plastic cups, paper, used gloves, and cigarette butts were on the ground.
1. A wooden palette, electric fan cover, and a red storage container were propped against the building. The red storage bin was not covered, and revealed used gloves, soiled linen, and trash.
2. A large broken bed frame, used gloves, plastic soda bottles, and trash was near a back door.
3. Eight plastic storage bins, some were right side up and some were turned down stacked against the wall near the rear door. There was trash, used gloves and other debris around them on the ground 4. A container that was covered in a yellow tarp had frozen standing water in it with trash in it. There was a plastic lid sitting on top of the container. There was a rusted shovel on the ground and trash on the ground around it.
5. There were used gloves and straws in a pile, frozen to the ground.
6. There was a large grey bin with empty plastic bottles, empty milk cartons, plastic cups, pieces of plaster, and other trash in it. The bin was not covered.
On 1/29/25 at 1:50 p.m. Maintenance Supervisor E was queried about the trash and debris at the rear of the facility. Maintenance Supervisor E stated, I walk and clean the grounds every day. I couldn't get the trash on the ground because it was frozen. You know it's been snowing. Trash shouldn't be put on the ground by anyone in the first place. All palettes are put in the back to be picked up at the end of shift. Some of the other stuff you saw was just put out there.
Review of the facility's policy titled Disposal of Garbage and Refuse dated 11/4/24 documented in part: The facility shall properly dispose of kitchen garbage and refuse . Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized . Dumpsters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside the dumpster . The schedule for garbage pick-up should be revised, as needed, based on the volume of refuse . Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.
According to the 2017 FDA Food Code Section 5-501.110 Storing Refuse, Recyclables, and Returnable. REFUSE, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.
According to the 2017 FDA Food Code 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE, recyclables, or returnable. shall be maintained free of unnecessary items, and clean.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program.
Findings include:
On 1/29/25 at 1:00 PM, the Nursing H...
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Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program.
Findings include:
On 1/29/25 at 1:00 PM, the Nursing Home Administrator (NHA) was interviewed about the facility's QAPI program and process. The NHA identified having enough linen available was an area of concern and opportunity for improvement. The NHA said the QA committee developed a plan to have enough linen in the building and have enough staff to process it. The NHA stated, the QAPI effort involving linen included consistent monitoring and establishing a par level (a minimum amount of inventory that should be on hand to meet resident needs) to maintain.
A facility document titled QAPI Action Plan documented in part the following as an area of improvement:
Action Plan: Order linen and supplies once a week
Responsible Person(s): Housekeeping supervisor
Target Date: 6/30/24
Outcome: On going
A facility document titled, QA Agenda - Housekeeping - June, dated 7/25/24, documented in part, Make (sure [sic]) my weekly orders are placed.
A facility document titled, QA Agenda - Housekeeping - July, dated 8/30/24, documented in part, Make (sure [sic]) my monthly and weekly orders are placed.
The NHA indicated QA monitoring of the availability of adequate linen supplies consisted of speaking with nurses and Certified Nurse Aides about the linen and going to check herself. When asked about the data gathered and presented to the QA committee, the NHA provided a linen inventory dated 8/30/24. The NHA was unable to provide data gathered and presented to the QA committee for subsequent months. The NHA was unable to provide documentation that the linen concern was discussed during the September 2024 QA committee meeting or subsequent QA committee meetings. When the NHA was informed that having adequate linen was identified as an area of non-compliance by the current survey team, the NHA had no explanation.
When queried about QAPI efforts related to nursing, the NHA indicated that lab draws were not occurring as ordered. The NHA provided documentation that for October 2024, lab draws were not occurring as ordered. Seven out of 15 lab orders were not completed as ordered, while two were due to refusals. The NHA was unable to provide documentation that this nursing concern was discussed and evaluated in the November 2024 QA meeting or subsequent QA committee meetings.
The NHA stated, We need to recap everything that was achieved or if it wasn't achieved what else can we do. That is what we're trying to do now. The NHA indicated that a report recapping QAPI activities was not available for review and there was no tracking of data.
A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), dated 8/1/24, documented in part the following:
- The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include but is not limited to:
-- Systems and reports demonstrating systemic identification, reporting, investigation, analysis, and prevention of adverse events.
-- Data collection and analysis at regular intervals.
-- Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.
A review of the facility policy titled, QAPI Monitoring, dated 12/27/24, documented in part the following:
- It is the policy of this facility to systematically monitor performance indicators as part of the QAPI program.
- The facility QA Committee analyzes data collected through planned and routine data collection activities.
On 1/29/25 at 4:40 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.
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
Based on observation, interview, and record review the facility failed to provide a safe and sanitary laundry room and clean linen closet resulting in the potential for the spread of infection and dis...
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Based on observation, interview, and record review the facility failed to provide a safe and sanitary laundry room and clean linen closet resulting in the potential for the spread of infection and disease transmission to residents and staff.
Findings include:
On 1/27/25 at 4:08 p.m. the clean linen closet located on the first floor had the following observations:
1. A folded gown and sheet were on the floor that was dusty and dirty.
2. A clean linen cart with clean linen was not covered. The cover was observed jumbled in a corner on the floor.
3. A heavily soiled sheet was on the floor next to the folded linen that was on the floor.
4. Employee's personal items (a jacket and purse) was on the floor behind the clean linen cart.
On 1/28/25 at 4:58 p.m. the clean linen closet on the first floor was observed for the second time with the following observations:
1. Used gloves, straws, plastic wrapping, and dust was on the floor in various places in the closet.
2. The clean linen cart with clean linen was not covered.
3. A clean linen cart cover was jumbled in the corner on the floor.
On 1/28/25 at 5:07 p.m. Housekeeping Supervisor M was queried about the unsanitary condition of the clean linen closet observations. Housekeeping Supervisor M said housekeeping staff are to ensure all linen closets are cleaned daily, it is part of their daily task. Housekeeping Supervisor M was not able to explain why the clean linen cart cover was on the floor.
Review of the facility's policy titled Infection Prevention and Control Program dated 8/15/24 documented in part the following: Linens: Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . Clean linen shall be stored on all resident care units on covered carts, shelves . linen closets .
On 1/28/25 at 2:20 PM an environmental tour of the facility's Laundry Service was conducted with Housekeeping Supervisor (HS) M.
The following items were noted:
Washer/Dryer Room: Five housekeeping carts were stored in the laundry room. The housekeeping carts were observed to have soiled (dirty) mop water and there was garbage observed inside the cart's trash can. The washing machines and drying machines were in use.
When queried regarding storing the soiled housekeeping carts in the washer/dryer room HS M replied, We store the carts in here because there isn't anywhere else to store them.
When queried how clean laundry is transported to the clean linen room for folding and storage HS M said clean linens are removed from the dryer and placed into a cart and then taken to a separate clean linen room for processing. HS M pointed to a laundry cart on wheels next to a soiled housekeeping cart. HS M stated, This is what we use to transport clean linens to across the hall.
Clean Linen Room observations:
1. Bed sheets on a storage rack were not covered.
2. Clean linen cart containing resident blanket were uncovered.
3. Clean socks were uncovered.
4. Observed resident clothes uncovered hanging on a barrel.
On 1/28/25 at approximately 2:30 PM, HS M was interviewed and agreed clean linens should be covered when transported and stored. There were no other staff present in the clean linen room. HS M also agreed dirty housekeeping carts should not be stored in the laundry room when the laundry room is in use due to possible cross contamination.
On 1/29/25 at 10:15 AM the Nursing Home Administrator (NHA) was interviewed and agreed dirty housekeeping carts should not be kept in the washer/dryer room and that clean linens should be covered when stored.
A policy related to housekeeping carts was requested but not provided by the end of the survey.
Review of the facility policy titled Laundry reviewed/revised 11/4/2024 revealed in part: The facility launders linens and clothing in accordance with current CDC (Center for Disease Control) guidelines to prevent transmission of pathogens. Soiled laundry shall be kept separate from clean laundry at all times.
Review of the facility policy titled Handling Clean Linen reviewed/revised 11/4/2024 revealed in part: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. Linen can become contaminated with pathogens from environmental contaminants. Clean linen shall be delivered to resident care units on covered linen carts with covers down.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure the three-compartment sink was properly air gapped, resulting in this food equipment not being protected against conta...
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Based on observation, interview, and record review, the facility failed to ensure the three-compartment sink was properly air gapped, resulting in this food equipment not being protected against contamination from sewage or other sources of contamination.
Findings include:
On 1/27/25 at 8:58 a.m. during a kitchen observation, a pipe underneath the three-compartment sink was observed. The pipe led to a drain in the floor that appeared to have three inches of space between them. However, a black cover was observed that was approximately 4-5 inches from the floor over the drain. The three inch air gap was surrounded by the black floor drain cover.
On 1/28/25 at 2:10 p.m. the Dietary Manager (DM) F and Registered Dietician (RD) U were queried about the sink having the proper air gap. DM F stated, There hasn't been a sewage backup since I been here, so I'm not sure. RD U acknowledged the sink should have the proper air gap to prevent sewage from backing up into the pipe that could go into (contaminate) the sink.
On 1/29/25 at 8:00 AM, Maintenance Director E acknowledged that the kitchen's three-compartment sink was not properly air-gapped.
On 1/29/25 at 4:40 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.
The 2013 FDA Food Code was reviewed and revealed the following in Section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide at least 80 square feet per resident for five rooms (#'s ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide at least 80 square feet per resident for five rooms (#'s 111, 115, 119, 219, and 231) resulting in the potential for resident dissatisfaction with their living space and not having adequate space available for care.
Findings include:
Rooms 111, 115, 119, and 219 were each 157 square feet. Two residents resided in each room which yielded 78.5 square feet per resident.
room [ROOM NUMBER] was 159 square feet. Two residents resided in this room which yielded 79.5 square feet per resident.
Resident interviews and observations did not reveal any overt concerns related to the room size.
On 1/29/25 at 4:40 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information when asked.
Jan 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149479.
Based on observation, interview, and record review, the facility failed to provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149479.
Based on observation, interview, and record review, the facility failed to provide adequate supervision for one resident (R401) on oxygen with a known history of unsupervised smoking and noncompliance with smoking policy out of four residents reviewed for safety with smoking, which led to a fire resulting in a 2nd degree facial burns((an injury that damages the outer layer of skin (epidermis) and part of the underlying layer(dermis)) and hospitalization in the burn unit.
The Immediate Jeopardy began on 1/10/25 when an untrained facility staff (sitter) failed to properly supervise R401during a smoke break leading to the R401 obtaining a lighter and cigarette. Later, R401 (while inhaling oxygen through a nasal canula) attempted to smoke in his bathroom unsupervised and lit his face on fire. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) on 1/22/25 at 3:50 PM. The IJ was removed on 1/22/25, but noncompliance remains at a potential for harm due to sustained compliance that has not been verified by the State Agency.
Findings include:
On 1/13/2025 at 11:34 AM the State Agency received a complaint that on 11/10/2025 R401 lit a cigarette while on oxygen and lit his face on fire.
Record review of R401's Electronic Health Record (EHR) revealed the resident admitted to facility on 3/6/2024 with a most recent readmission on [DATE] with diagnoses which included subdural hemorrhage, chronic obstructive pulmonary disease (COPD), schizophrenia, adjustment disorder with mixed anxiety and depressed mood.
Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed a Brief Interview for Mental Status (BIMS) of 10/15 which indicated moderate cognitive impairment and partial/moderate assistance for transfers.
On 1/15/2025 at 10:50 AM R401's guardian A was interviewed and said a staff member from the facility called to notify him on 1/11/25 or 1/12/25 that R401 lit his face on fire smoking again in his bathroom and was at hospital C. R401 had previously
Review of the facility progress note dated 1/10/2025 at 10:30 PM revealed, writer observed injury when rounding on resident. Resident stated he fell in the bathroom. Writer assessed resident vital signs as follow 148/74 pulse 98, respirations 18, oxygen saturation 96% via nasal cannula. Temperature 97.8. Wound care provided resident tolerated well.
Review of the facility progress note dated 1/11/2025 at 13:33 revealed, new order for stat x-ray of the optic and nasal bone to rule out a fracture 2 views per doctor.
Review of the facility progress note dated 1/11/25 at 15:08 revealed, resident requested to transfer to the hospital physician and guardian notified.
Review of the facility progress note dated 1/11/25 20:42 revealed, resident is transferred to (Hospital B) at 7:15PM as per instructions provided by outgoing nurse and doctor, writer received recent xray result, xray report stated the orbit demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues.
Record review of the hospital B emergency Treatment note dated 1/11/2025 at 21:10 revealed, (R401) with a history of COPD on home oxygen presents emergency department facial burn. Patient states last night (1/10/25) he was on his nasal canula oxygen and attempted to smoke a cigarette causing the nasal cannula to light on fire burning his face. Second degree burns to upper and lower lip, right face, nose. Periorbitol (around eye) swelling and edema of the lips. Patient will require transfer to a burn center. Disposition transferred to Hospital C.
Record review of the hospital C progress note dated 1/13/25 revealed R401 presents to the emergency department as a transfer after a facial burn sustained while smoking on home oxygen. Sustained ~1.5% partial thickness burns to right side of face. admitted to burn service. Integumentary: warm, dry ~1.5 % partial thickness burns to right side of face. Lips swollen with some partial thickness burns.
On 1/15/25 at 2:55 PM Licensed Practical Nurse (LPN) D was interviewed and said she was called to R401's room on 1/10/25 by Sitter E. LPN D stated, R401 said he fell in the bathroom. His face appeared red. He was wearing his oxygen when I arrived, the oxygen tubing was intact.
On 1/15/25 at 3:45 PM LPN F was interviewed and said that on 1/11/15 R401 requested to go to the hospital. R401 told me he fell the night before (1/10/25), I saw that his face was swollen.
On 1/15/25 at 4:00 PM the facility's Chief Operating Officer (COO) I provided hospital C progress notes and acknowledged R401 was treated in the hospital for facial burns.
On 1/15/25 at 4:50 PM Sitter E was interviewed by phone and said that she worked with R401 on 1/10/24 from 3PM to 11PM. Around 10:30 PM R401 went to the bathroom by himself and yelled. He was wearing his oxygen. He said he fell. Sitter E said she did not smell smoke, nor did she see any burns on R401's face. Sitter E said she took R401 out to smoke on 1/10/25 around 8:00 PM by herself. Sitter E interrupted the interview and did not respond to further attempts for an interview.
On 1/16/25 at 2:15 PM and 3:33 PM Sitter E was called for an interview. Left messages with no return call.
On 1/16/25 at 10:54 AM LPN G was interviewed and said she was the was the nurse supervisor on 1/10/25 and on 1/11/25. On 1/11/25 she put in a stat (immediate) order for an xray of R401's face due to his complaints of pain. LPN G said when she saw R401 on 1/11/25 R401 had swelling to his right eye and He had grease on his face like Vaseline. LPN G further said that R401 had a sitter for behavioral issues but could not specifically state the reason why R401 had a sitter.
On 1/16/25 at 12:07 PM LPN H was interviewed and said that he observed emergency medical services pick up R401 on 1/11/25 to take him to the hospital. LPN H said R401 did not have any open wounds on his face when he was transported to the hospital but R401's face was swollen.
On 1/16/25 at 2:50 PM Certified Nursing Assistant (CNA) J was interviewed and said that she worked with R401 on 1/11/25 day shift from 7AM to 3PM. CNA J said she saw R401at approximately 1:30 PM on 1/11/25. CNA J stated, I thought R401 went to the hospital because his face it looked bad. He was drooling, he couldn't close his mouth. His face was pink including his lips. Everything was pink around his oxygen canula.
On 1/16/25 at 3:49 PM the Director of Nursing (DON) was interviewed and said R401 was sent to the hospital following his fall per the resident request. The DON said R401 experienced combustion in August 2024, smoking while on oxygen and set his face on fire. When asked what was put in place to prevent further smoking incidents with R401 the DON said a 24-hour sitter was added. When asked were the sitters made aware for what to watch for with R401 the DON replied, The sitter is aware that there is some type of safety concerns, but I'm not sure of the specific reason why they are there is shared with them. The DON agreed the specific reason why the sitter is needed should be shared with the sitters to provide resident safety.
On 1/16/25 at 3:55 PM the NHA was interviewed and said sitters should be told the specific reason why they are there to monitor residents so that it is clear why the resident needs supervision.
Review of R401's care plan revealed Focus: I am a smoker, and I am aware that I need to follow the smoking policy. I have violated the smoking policy, and it resulted in me being injured. Date initiated 8/30/24. Goal: I will follow the smoking policy. Thru next review date. Date initiated 8/30/24. Target date 3/3/25. Interventions: I am aware that a lighter nor cigarettes can be keep on my person or in my room or possession. Date initiated 10/3/24. I am aware that I can only smoke at smoking times with supervision. Date initiated 10/10/24. I am aware that I will be offered a smoking patch or smoking gum if I violated the policy. Date initiated 10/3/24. I require a sitter at my bedside for safety date initiated 11/27/24. I understand if I violated the smoking policy that I will lose my smoking privileges for 7 days or I maybe involuntary discharge from the facility. Date initiated 10/3/24.
Further review of R401's care plan revealed Focus: The resident has oxygen therapy related to a diagnosis of COPD as evidenced by low oxygen saturation and shortness of breath. Date initiated 8/21/24. Goal I will be complaint with oxygen therapy. My oxygen saturation will be between 95 and 100 percent. Date initiated 8/21/24 Target date 3/3/25. Intervention: I was educated about the importance of not using flammables around oxygen therapy. Date initiated 8/30/24.
On 1/16/25 at 4:45 PM the facility's COO I was interviewed and R401's care plan was reviewed. The COO I said that the DON created the I require a sitter at my bedside for safety date initiated 11/27/24 on 1/15/25. The COO I agreed R401's care plan was not revised to have a sitter until 1/15/25.
Review of R401's orders revealed:
Cleanse face with normal saline, apply tiple antibiotic ointment and leave open to air created on 1/11/25 at 12:17 AM.
STAT (immediate) x-ray of the optic and nasal bone to rule out a fracture 2 views per MD (medical doctor) created on 1/11/25 at 1:53 PM.
Cleanse face with normal saline, apply tiple antibiotic ointment and leave open to air created on 1/11/25 at 2:07 PM.
Transfer to hospital Created 1/11/25 at 3:07 PM.
Transfer to Receiving Hospital created on 1/11/25 at 3:07 PM.
Review of R401's most recent smoke assessment dated [DATE] revealed, safe to smoke with supervision.
On 1/21/25 at 12:30 PM Medical Doctor (MD) K was interviewed and said R401 had been hospitalized for facial burns. When asked how he was informed of R401's hospitalization MD K replied I was told by a nurse from the facility that R401 was in the hospital with facial burns. MD K stated I assume R401 smoked in his bathroom just like he did last time he got a burn because residents don't wear oxygen outside when they smoke.
On 1/21/24 at 2:00 PM R401 was interviewed at Hospital L. R401 was observed as an African American male with dark colored skin. R401's tip of nose was pink in color missing skin, top lip pink in color missing skin, bottom lip was scabbed. Both lips appeared swollen. R401's right cheek appeared pink in color missing skin. R401 knew he was at hospital L, his name and the date. When asked what happened on 1/10/25 R401 replied I lit a cigarette in my bathroom while wearing my oxygen and lit my face on fire. I told everyone that I fell and injured my face, but they knew what happened. I didn't fall. I didn't want the staff to get in trouble for what I did. I had my own cigarette and lighter from earlier in the day. The sitter didn't take back my cigarette and lighter from the earlier smoke break.
On 1/22/25 at 9:45 AM Activities Director (AD) M was interviewed and said that she completes a resident assessment before a resident is allowed to smoke to make sure residents are safe. AD M said activities staff keep residents' cigarettes and lighters locked up when not in use and smoke breaks occur daily at 9:45 AM, 1:15 PM and 6:30 PM. Only staff handles the lighter, residents do not get to use the lighter. AD M said security monitors the evening smoke break at 6:30 pm. AD M stated, The only staff authorized and trained to take residents out to smoke are nurses, activities staff and security staff. When asked did you train Sitter E on how to monitor residents for smoking AD M replied No I did not train her (Sitter E).
On 1/22/25 at 10:41 AM Activities assistant N was interviewed and said she worked and monitored the morning and afternoon smoke breaks on 1/10/25 and that R401 did not participate in either smoke break.
On 1/22/25 at 12:01PM Security Staff (SS) O was interviewed and said he worked the evening shift on 1/10/25 and that R401 did not go out for the 6:30 PM scheduled smoke break. SS O stated I have seen sitters go out with R401 to supervise him smoke by themselves not during a scheduled smoke break. He (R401) was the only guy I know with a sitter who smokes. I have given cigarettes and a lighter to the sitter to go out with R401to smoke. SS O said R401 was not allowed to go on leaves of absence and that he expected the sitters to monitor the resident during smoke breaks for safety.
On 1/22/25 at 1:20 PM the NHA was interviewed and said nursing, activities staff and security are the only employees trained and authorized to take residents out to smoke. The NHA said the staff educator and activities director are the only staff allowed to train employees to supervise residents who smoke.
On 1/22/25 at 1:35 PM the Staff Educator (SE) P said that sitters are not trained and/or authorized to take out residents to supervise smoking. When asked if Sitter E was trained to independently take a resident out to smoke SE P replied, Sitter E was not specifically trained to supervise smokers.
On 1/22/25 at 1:38 PM the NHA said the only staff authorized and trained to supervise residents who smoke are nurses, activities staff and security personnel. No one else.
A review of the facility policy titled Smoking Policy, revised 8/30/24 revealed in part: The policy of this facility is to provide a safe smoking environment for residents who can smoke and are deemed a safe smoker based on a comprehensive smoking safety assessment. All cigarettes and lighters will be labelled with resident's name and kept in a box at the security station and the staff member assigned to supervise smoking will be responsible for obtaining the box and distributing cigarettes and lighters to residents as well as collecting them an (sic) returning the box to the security office. If you do not make it out to smoke break on time you will have to wait for the next smoke break! No exception!
The Immediate Jeopardy that began on 1/10/25 was removed on 1/22/25 when the facility took the following actions to remove the immediacy:
-Beginning 1/22/25- The Director of Nursing/designee began an in-service with licensed nursing staff on independent smoker and dependent smokers, including resident choice of time smoking.
-Beginning 1/22/25- All residents who smoke will be in-serviced by the Director of Nursing/designee on the smoking policy during a special resident council meeting to include the nonadherence to the policy that may result in revoking privileges and/or initiating a discharge plan care (sic).
-Beginning 1/22/25 - Smoking signs were implemented asking families and visitors to not give residents smoking materials for the safety of our residents and turn in all smoking materials to be used only during scheduled smoking times.
-Beginning 1/22/25 Staff was in-service on the updated smoking policy; to report any residents with smoking material immediately, staff includes security and sitters, and the updated policy includes reporting immediately to the charge nurse and management if any resident have any smoking materials and residents will be searched immediately.
-Beginning 1/22/25 unscheduled smoking times will not be permit (sic) without approval from administration. Residents that smoke will be offered a nicotine patch or offered to be taking (sic) out to smoke with a nurse or Cena.
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 MI00149479.
Based on observation, interview, and record review, the facility failed to ensure s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149479.
Based on observation, interview, and record review, the facility failed to ensure staff reported an injury related to fire to the abuse coordinator for one resident (R401) out of four residents reviewed for accidents, resulting in an unreported incident of potential neglect.
Findings include:
On 1/13/2025 at 11:34 AM the State Agency received a complaint that on 11/10/2025 R401 lit a cigarette while on oxygen and lit his face on fire.
On 1/15/2025 at 10:50 AM R401's guardian A was interviewed and said a staff member from the facility called to notify him on 1/11/25 or 1/12/25 that R401 lit his face on fire smoking again in is bathroom and was at hospital C.
On 1/21/24 at 2:00 PM R401 was interviewed at Hospital L. R401 was observed as an African American male with dark colored skin. R401's tip of nose was pink in color missing skin, top lip pink in color missing skin, bottom lip was scabbed. Both lips appeared swollen. R401's right cheek appeared pink in color missing skin. R401 knew he was at hospital L, his name and the date. When asked what happened on 1/10/25 R401 replied I lit a cigarette in my bathroom while wearing my oxygen and lit my face on fire. I told everyone that I fell and injured my face, but they knew what happened. I didn't fall. I didn't want the staff to get in trouble for what I did. I had my own cigarette and lighter from earlier in the day. The sitter didn't take back my cigarette and lighter from the earlier smoke break. The facility called EMS the next day after I kept asking them to send me to the hospital because my face hurt from the burns, and I couldn't breathe good.
Record review of R401's Electronic Health Record (EHR) revealed the resident admitted to the facility on [DATE], with most recent readmission on [DATE], with diagnoses which included subdural hemorrhage, chronic obstructive pulmonary disease (COPD), schizophrenia, adjustment disorder with mixed anxiety, and depressed mood.
Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed a Brief Interview for Mental Status (BIMS) of 10/15 which indicated moderate cognitive impairment and partial/moderate assistance for transfers.
Review of the facility progress note dated 1/10/2025 at 10:30 PM revealed, Writer observed injury when rounding on resident. Resident stated he fell in the bathroom. Writer assessed resident vital signs as follow 148/74 pulse 98, respirations 18, oxygen saturation 96% via nasal cannula. Temperature 97.8. Wound care provided resident tolerated well.
Review of the facility progress note dated 1/11/2025 at 13:33 (1:33 PM) revealed, new order for stat x-ray of the optic and nasal bone to rule out a fracture 2 views per doctor.
Review of the facility progress note dated 1/11/25 at 15:08 (3:08 PM) revealed, resident requested to transfer to the hospital physician and guardian notified.
Review of the facility progress note dated 1/11/25 at 20:42 revealed, resident is transferred to (hospital B) at 7:15PM as per instructions provided by outgoing nurse and doctor, writer received recent Xray result, xray report stated the orbit demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues, medical doctor and Guardian A are notified.
Review of the Prehospital Care Report by Emergency Medical Services (EMS) dated 1/11/25 revealed, EMS responded to priority 2 to facility for difficulty breathing. EMS arrived on location with no incident. EMS entered the building and located the patient room. EMS received report from the nursing. EMS entered the room and made patient contact. Patient was found standing using an oxygen concentrator as a brace. Patient was hooked up on oxygen flowing at 8LPM via nasal cannula. Patient presented baseline with no current complaints of pain. Patient had burn marks on his face from the prior night, nursing home staff informed EMS that the burns were from a cigarette from the prior night. EMS began transport to [NAME] Grace Hospital emergency room (ER) priority 1 for facial burns. EMS swapped the patients nasal cannula for a non-rebreather mask due to patient complaint of difficulty breathing. EMS arrived at [NAME] Grace ER with no incident. Patient arrived at Destination Date/Time 2025-01-11 20:28:24.
Record review of the Hospital B emergency Treatment note dated 1/11/2025 at 21:10 revealed, R401 with a history of COPD on home oxygen presents emergency department facial burn. Patient states last night (1/10/25) he was on his nasal canula oxygen and attempted to smoke a cigarette causing the nasal cannula to light on fire burning his face. Second degree burns to upper and lower lip, right face, nose. Periorbitol (around eye) swelling and edema of the lips. Patient will require transfer to a burn center. Disposition transferred to (Hospital C.)
Record review of the Hospital C progress note dated 1/13/25 revealed, R401 presents to the emergency department as a transfer after a facial burn sustained while smoking on home oxygen. Sustained ~1.5% partial thickness burns to right side of face. admitted to burn service. Integumentary: warm, dry ~1.5 % partial thickness burns to right side of face. Lips swollen with some partial thickness burns.
On 1/15/25 at 2:55 PM Licensed Practical Nurse (LPN) D was interviewed and said she was called to R401's room on 1/10/25 by Sitter E. LPN D stated, R401 said he fell in the bathroom. His face appeared red. He was wearing his oxygen when I arrived, the oxygen tubing was intact. When asked did R401 have facial burns LPN D replied The only thing I saw was redness to his face.
On 1/15/25 at 3:45 PM LPN F was interviewed and said that on 1/11/15 R401 requested to go to the hospital. When asked did R401 have facial burns LPN F replied, R401 told me he fell the night before (1/10/25) I saw that his face was swollen.
On 1/15/25 at 4:00 PM the facility's Chief Operating Officer (COO) I provided Hospital C progress notes and acknowledged R401 was hospitalized for facial burns. When queried, COO I reported being unaware of R401 setting his face on fire while on oxygen, in the bathroom.
On 1/15/25 at 4:50 PM Sitter E was interviewed by phone and said that she worked with R401 on 1/10/24 from 3PM to 11PM. Around 10:30 PM R401 went to the bathroom by himself and yelled. He was wearing his oxygen. He said he fell. I called for nurse LPN D. Sitter E said she did not smell smoke, nor did she see any burns on R401's face. Sitter E said she took R401 out to smoke on 1/10/25 around 8:00 PM by herself. Sitter E abruptly ended the interview and did not respond to further attempts for an interview.
On 1/16/25 at 2:15 PM and 3:33 PM Sitter E was called for an interview. Left messages with no return call.
On 1/16/25 at 10:00 AM the Nursing Home Administrator/Abuse Coordinator (NHA) was interviewed and said she was told R401 fell and injured his face which is the reason R401 was sent to the hospital on 1/11/25.
On 1/16/25 at 10:54 AM LPN G was interviewed and said she was the was the nurse supervisor on 1/10/25 and on 1/11/25. On 1/11/25 she put in a stat (immediate) order for an Xray of R401's face due to his complaints of pain. LPN G said when she saw R401 on 1/11/25 R401 had swelling to his right eye and He had grease on his face like Vaseline.
On 1/16/25 at 12:07 PM LPN H was interviewed and said that he observed EMS pick up R401 on 1/11/25 to take him to the hospital. LPN H said he assisted EMS for the hospital transfer. LPN H stated, R401 did not have any open wounds on his face when he was transported to the hospital but R401's face was swollen.
On 1/16/25 at 2:50 PM Certified Nursing Assistant (CNA) J was interviewed and said that she worked with R401 on 1/11/25 day shift from 7AM to 3PM. CNA J said she saw R401at approximately 1:30 PM on 1/11/25. CNA J stated, I thought R401 went to the hospital because his face it looked bad. He was drooling, he couldn't close his mouth. His face was pink including his lips. Everything was pink around his oxygen canula.
On 1/16/25 at 3:49 PM the Director of Nursing (DON) and the NHA/Abuse Coordinator were interviewed. The DON said R401 was sent to the hospital following his fall per the resident request. The DON said R401 experienced combustion in August 2024, smoking while on oxygen and set his face on fire. The DON acknowledged R401 was admitted to the hospital with facial burns. During the interview the DON and the NHA/Abuse Coordinator reported not being aware of any incidents of fire prior to R401 being admitted to the hospital for facial burns.
Review of R401's EHR for January 2025 did not reveal any documentation of a facial burn or an acute care transfer sheet (to be completed by facility nursing staff) completed for 1/11/25.
Review of R401's care plan revealed Focus: I am a smoker, and I am aware that I need to follow the smoking policy. I have violated the smoking policy, and it resulted in me being injured. Date initiated 8/30/24. Goal: I will follow the smoking policy. Thru next review date. Date initiated 8/30/24. Target date 3/3/25. Interventions: I am aware that a lighter nor cigarettes can be keep on my person or in my room or possession. Date initiated 10/3/24. I am aware that I can only smoke at smoking times with supervision. Date initiated 10/10/24. I am aware that I will be offered a smoking patch or smoking gum if I violated the policy. Date initiated 10/3/24. I require a sitter at my bedside for safety date initiated 11/27/24. I understand if I violated the smoking policy that I will lose my smoking privileges for 7 days or I maybe involuntary discharge from the facility. Date initiated 10/3/24.
Further review of R401's care plan revealed Focus: The resident has oxygen therapy related to a diagnosis of COPD as evidenced by low oxygen saturation and shortness of breath. Date initiated 8/21/24. Goal I will be complaint with oxygen therapy. My oxygen saturation will be between 95 and 100 percent. Date initiated 8/21/24 Target date 3/3/25. Intervention: I was educated about the importance of not using flammables around oxygen therapy. Date initiated 8/30/24.
On 1/21/25 at 12:30 PM Medical Doctor (MD) K was interviewed and said R401 had been hospitalized for facial burns. When asked how he was informed of R401's hospitalization MD K replied I was told by a nurse from the facility that R401 was in the hospital with facial burns.
Review of the facility policy titled Abuse, Neglect and Exploitation date reviewed/revised revealed in part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies(e.g. law enforcement when applicable) within specified timeframes: a Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2 Assuring that reporters are free from retaliation or reprisal; 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to the following: a. Analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property of exploitation occurred, and what changes are needed to prevent further occurrences.
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** This citation pertains to intake MI00149479.
Based on observation, interview, and record review the facility failed to maintain ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149479.
Based on observation, interview, and record review the facility failed to maintain complete and accurate medical records for one resident (R401) out of three residents reviewed for accidents, resulting in the absence of accurate documentation of R401's facial burns.
Findings Include:
On 1/13/2025 at 11:34 AM the State Agency received a complaint that on 11/10/2025 R401 lit a cigarette while on oxygen and lit his face on fire.
On 1/15/2025 at 10:50 AM R401's guardian A was interviewed and said a staff member from the facility called to notify him on 1/11/25 or 1/12/25 that R401 lit his face on fire smoking again in is bathroom and was at hospital C for the treatment of facial burns.
On 1/21/24 at 2:00 PM R401 was interviewed at Hospital L. R401 was observed as an African American male with dark colored skin. R401's tip of nose was pink in color missing skin, top lip pink in color missing skin, bottom lip was scabbed. Both lips appeared swollen. R401's right cheek appeared pink in color missing skin. R401 knew he was at Hospital L, his name and the date. When asked what happened on 1/10/25, R401 replied I lit a cigarette in my bathroom while wearing my oxygen and lit my face on fire. I told everyone that I fell and injured my face, but they knew what happened. I didn't fall. I didn't want the staff to get in trouble for what I did. I had my own cigarette and lighter from earlier in the day. The sitter didn't take back my cigarette and lighter from the earlier smoke break. The facility called EMS the next day after I kept asking them to send me to the hospital because my face hurt from the burns, and I couldn't breathe good.
Record review of R401's Electronic Health Record (EHR) revealed admitted to facility on 3/6/2024 with most recent readmission on [DATE] with diagnoses which included subdural hemorrhage, chronic obstructive pulmonary disease (COPD), schizophrenia, adjustment disorder with mixed anxiety and depressed mood.
Review of the Minimum Data Set (MDS) dated [DATE] for R401 revealed a Brief Interview for Mental Status (BIMS) of 10/15 which indicated moderate cognitive impairment and partial/moderate assistance for transfers.
Review of the facility progress note dated 1/10/2025 at 10:30 PM revealed, Writer observed injury when rounding on resident. Resident stated he fell in the bathroom. Writer assessed resident vital signs as follow 148/74 pulse 98, respirations 18, oxygen saturation 96% via nasal cannula. Temperature 97.8. Wound care provided resident tolerated well. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
Review of Skin Observation Tool dated 1/10/2025 at 10:57 PM revealed, Skin Tear to nose, upper lip and forehead, site Face type skin tear. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
Review of the facility progress note dated 1/11/2025 at 13:33 (1:33 PM) revealed, New order for stat x-ray of the optic and nasal bone to rule out a fracture 2 views per doctor. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
Review of the facility progress note dated 1/11/25 at 15:08 (3:08 PM) revealed, Resident requested to transfer to the hospital physician and guardian notified. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
Review of R401's EHR revealed neurological checks were documented on 1/10/25 and 1/11/25. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
Review of the facility progress note dated 1/11/25 at 20:42 revealed, Resident is transferred to hospital B at 7:15PM as per instructions provided by outgoing nurse and doctor, writer received recent Xray result, xray report stated the orbit demonstrate no acute fracture. No joint dislocation. Unremarkable soft tissues, medical doctor and Guardian A are notified. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
Review of the Prehospital Care Report by Emergency Medical Services (EMS) dated 1/11/25 revealed, EMS responded to priority 2 to facility for difficulty breathing. EMS arrived on location with no incident. EMS entered the building and located the patient room. EMS received report from the nursing. EMS entered the room and made patient contact. Patient was found standing using an oxygen concentrator as a brace. Patient was hooked up on oxygen flowing at 8LPM via nasal cannula. Patient presented baseline with no current complaints of pain. Patient had burn marks on his face from the prior night, nursing home staff informed EMS that the burns were from a cigarette from the prior night. EMS began transport to [NAME] Grace Hospital emergency room (ER) priority 1 for facial burns. EMS swapped the patients nasal cannula for a non-rebreather mask due to patient complaint of difficulty breathing. EMS arrived at [NAME] Grace ER with no incident. Patient arrived at Destination Date/Time 2025-01-11 20:28:24.
Record review of the Hospital B emergency Treatment note dated 1/11/2025 at 21:10 revealed, (R401) with a history of COPD on home oxygen presents emergency department facial burn. Patient states last night (1/10/25) he was on his nasal canula oxygen and attempted to smoke a cigarette causing the nasal cannula to light on fire burning his face.
Second degree burns to upper and lower lip, right face, nose. Periorbitol (around eye) swelling and edema of the lips. Patient will require transfer to a burn center. Disposition transferred to (Hospital C.)
Record review of the Hospital C progress note dated 1/13/25 revealed, (R401) presents to the emergency department as a transfer after a facial burn sustained while smoking on home oxygen. Sustained ~1.5% partial thickness burns to right side of face. admitted to burn service. Integumentary: warm, dry ~1.5 % partial thickness burns to right side of face. Lips swollen with some partial thickness burns.
On 1/15/25 at 2:55 PM Licensed Practical Nurse (LPN) D was interviewed and said she was called to R401's room on 1/10/25 by Sitter E. LPN D stated, R401 said he fell in the bathroom. His face appeared red. He was wearing his oxygen when I arrived, the oxygen tubing was intact. When asked did R401 have facial burns LPN D replied, The only thing I saw was redness to his face. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
On 1/15/25 at 3:45 PM LPN F was interviewed and said that on 1/11/15 R401 requested to go to the hospital. When asked did R401 have facial burns LPN F replied, (R401) told me he fell the night before (1/10/25) I saw an abrasion on his face and his face was swollen. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
On 1/15/25 at 4:00 PM the facility's Chief Operating Officer (COO) I provided Hospital C progress notes and acknowledged R401 was hospitalized for facial burns.
On 1/15/25 at 4:50 PM Sitter E was interviewed by phone and said that she worked with R401 on 1/10/24 from 3PM to 11PM. Around 10:30 PM R401 went to the bathroom by himself and yelled. He was wearing his oxygen. He said he fell. I called for nurse LPN D. Sitter E said she did not smell smoke, nor did she see any burns on R401's face. Sitter E said she took R401 out to smoke on 1/10/25 around 8:00 PM by herself. Sitter E abbruptly ended the interview and did not respond to further attempts for an interview. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
On 1/16/25 at 2:15 PM and 3:33 PM Sitter E was called for an interview. Left messages with no return call.
On 1/16/25 at 10:00 AM the Nursing Home Administrator (NHA) was interviewed and said she was told R401 fell and injured his face.
On 1/16/25 at 10:54 AM LPN G was interviewed and said she was the was the nurse supervisor on 1/10/25 and on 1/11/25. On 1/11/25 she put in a stat (immediate) order for an Xray of R401's face due to his complaints of pain. LPN G said when she saw R401 on 1/11/25 R401 had swelling to his right eye and He had grease on his face like Vaseline. LPN G further said that R401 had a sitter for behavioral issues but could not specifically state the reason why R401 had a sitter. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
On 1/16/25 at 12:07 PM LPN H was interviewed and said that he observed EMS pick up R401 on 1/11/25 to take him to the hospital. LPN H said he assisted EMS for the hospital transfer. LPN H stated, R401 did not have any open wounds on his face when he was transported to the hospital but R401's face was swollen. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
On 1/16/25 at 2:50 PM Certified Nursing Assistant (CNA) J was interviewed and said that she worked with R401 on 1/11/25 day shift from 7AM to 3PM. CNA J said she saw R401at approximately 1:30 PM on 1/11/25. CNA J stated, I thought R401 went to the hospital because his face it looked bad. He was drooling, he couldn't close his mouth. His face was pink including his lips. Everything was pink around his oxygen canula. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
On 1/16/25 at 3:49 PM the Director of Nursing (DON) was interviewed and said R401 was sent to the hospital following his fall per the resident request. The DON said R401 experienced combustion in August 2024, smoking while on oxygen and set his face on fire. The DON agreed R401 was admitted to the hospital with facial burns. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
Review of R401's EHR for January 2025 did not reveal any documentation related to facial burns. In addition, an acute care transfer sheet (provided by the facility) was not completed or available for review as requested, for the hospital transfer on 1/11/25. The acute care transfer sheet would have documented the reason for R401's transfer to an acute care facility. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
On 1/21/25 at 12:30 PM Medical Doctor (MD) K was interviewed and said R401 had been hospitalized for facial burns. When asked how he was informed of R401's
hospitalization MD K replied, I was told by a nurse from the facility that R401 was in the hospital with facial burns. R401 admitted during interview he lit his face on fire on 1/10/25, and staff were aware of the incident.
Review of the facility policy titled, Documentation in Medical Record date reviewed/revised 1/16/25 revealed in part: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy . 4. Principles of documentation include, but are not limited to: a. Documentation shall be factual, objective, and resident centered. i. False information shall not be documented. B. Documentation shall be accurate, relevant, and complete, containing sufficient details about resident's care/or responses to care.
Aug 2024
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 MI00146029.
Based on interview, and record review, the facility failed to prevent misappropriat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00146029.
Based on interview, and record review, the facility failed to prevent misappropriation of resident medication for one resident (R101) of three reviewed for misappropriation, resulting in resident experiencing pain and the potential for misappropriation to continue.
Findings include:
Review of an admission Record revealed, R101 admitted to the facility on [DATE] with pertinent diagnosis which included quadriplegia and muscle wasting and atrophy.
Review of a Minimum Data Set (MDS) assessment dated 7/824 revealed R101 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and had a scheduled pain medication regimen.
Review of Physician orders revealed R101 had an order for, Oxycodone 30 mg (milligrams) give 1 tablet by mouth every 6 hours for pain with a start date of 3/28/24.
Review of a Medication Administration Record (MAR) for July 2024 revealed Oxycodone 30 mg not given on 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/10, 7/11, 7/12, 7/20, 7/28, 7/29, and 7/30/24.
Review of a Packing Slip dated 7/18/24 revealed, Oxycodone 30 mg was delivered for R101 signed by Licensed Practical Nurse (LPN) F.
Review of a Physician progress note with a date of 7/31/24 at 3:04 p.m. revealed, Reason for Visit: I am seeing and treating the patient (pt) today for pain, as (Unit Manager H) told me the pt needed his pain meds re-ordered again. Chief Complaint: My neck and back hurt . I also am checking on the pt, as the Staff called me yesterday (7/30/2024) to tell me they think some of the pt's Oxycodone meds were missing. I called the Pharmacy today and they said they delivered 30 Oxycodone pills on 7/18 and 30 pills on 7/20/2024. The concern is what happened to the 30 Oxycodone pills from 7/18 that were delivered and signed for . There should have been no need to send an additional 30 pills on 7/20, as the 7/18 pills would have lasted 7-8 days .
In an interview on 8/8/24 at 10:14 a.m., R101 reported informing the Director of Nursing (DON) and Physician about the missing pain medication. R101 reported the pharmacy sent a seven-day supply but they had to wait for another order after that. R101 reported experiencing increased pain and with mild withdrawal symptoms during the time the pain medication was missing.
In an interview on 8/8/24 at 10:21a.m., the DON reported on 7/18/24 a 30 count of Oxycodone 30 mg was reported missing for R101. The DON then reported the nurse could not find the pain medication that was delivered for R101. The DON reported being made aware of the situation by the nurse and R101.
In an interview on 8/8/24 at 1:29 p.m., Pharmacy Manager G reported the Oxycodone 30 mg was delivered on 7/18/24. Pharmacy Manager G then reported there is a signed delivery sheet from the driver and nurse.
In an interview on 8/8/24 at 1:43p.m. Unit Manager H confirmed the pharmacy delivered medications multiple time on 7/18/24. Unit Manager H reported on 7/19/24 they noticed R101did not have any Oxycodone and the pharmacy was called about the medication.
In an interview on 8/8/24 at 2:06 p.m., Pharmacy Driver I confirmed delivering medications on 7/18/14 for R101 and a nurse signed for the medications.
In an interview on 8/8/24 at 2:26 p.m. the Nursing Home Administrator (NHA) reported being made aware of the missing pain medication by the DON.
In an interview on 8/8/24 at 3:41 p.m., the Director of Nursing (DON) reported the Oxycodone for R101 was confirmed as missing.
Review of a Abuse, Neglect and Exploitation policy revised 7/23/34 documented, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .
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 MI00146029.
Based on interview and record review, the facility failed to report allegations of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00146029.
Based on interview and record review, the facility failed to report allegations of misappropriation for one (R101) of three residents reviewed for misappropriation.
Findings include:
Review of an admission Record revealed, R101 admitted to the facility on [DATE] with pertinent diagnosis which included quadriplegia and muscle wasting and atrophy.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R101 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and had a scheduled pain medication regimen.
Review of Physician orders revealed R101had an order, Oxycodone 30 mg (milligrams) give 1 tablet by mouth every 6 hours for pain with a start date of 3/28/24.
Review of a Packing Slip dated 7/18/24 revealed, Oxycodone 30 mg was delivered for R101signed by Licensed Practical Nurse (LPN) F.
Review of a Physician progress note with a date of 7/31/24 at 3:04 p.m. revealed, Reason for Visit: I am seeing and treating the patient (pt) today for pain, as (Unit Manager H) told me the pt needed his pain meds re-ordered again. Chief Complaint: My neck and back hurt .
I also am checking on the pt, as the Staff called me yesterday (7/30/2024) to tell me they think some of the pt's Oxycodone meds were missing. I called the Pharmacy today and they said they delivered 30 Oxycodone pills on 7/18 and 30 pills on 7/20/2024. The concern is what happened to the 30 Oxycodone pills from 7/18 that were delivered and signed for . There should have been no need to send an additional 30 pills on 7/20, as the 7/18 pills would have lasted 7-8 days .
In an interview on 8/8/24 at 10:14 a.m., R101 reported informing the Director of Nursing (DON) and Physician about the missing pain medication.
In an interview on 8/8/24 at 10:21a.m., the DON reported on 7/18/24 a 30 count of Oxycodone 30 mg was reported missing for R101. The DON then reported the nurse could not find the pain medication that was delivered for R101. DON acknowledged the incident was not reported to the state agency.
In an interview on 8/8/24 at 1:43p.m. Unit Manager H confirmed the pharmacy delivered medications multiple time on 7/18/24. Unit Manager H reported on 7/19/24 they noticed R101did not have any Oxycodone and the pharmacy was called about the medication.
In an interview on 8/8/24 at 2:06 p.m., Pharmacy Driver I confirmed delivering medications on 7/18/14 for R101 and a nurse on 1 South signed for the medications.
In an interview on 8/8/24 at 2:26 p.m. the Nursing Home Administrator (NHA) reported the missing narcotics was not reported to the state agency. NHA reported abuse including misappropriation should be reported when there is an allegation or suspicion. NHA reported abuse should be reported to the state agency immediately before the investigation begins.
Review of a Abuse, Neglect and Exploitation policy revised 7/23/34 documented, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other agencies within specific timeframes: a. Immediately but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake MI00146029.
Based on observation, interview and record review the facility failed to follow the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation Pertains to Intake MI00146029.
Based on observation, interview and record review the facility failed to follow the procedure for reconciling controlled substances (drugs that have high potential for abuse and misappropriation) for one (R102) resident from one of four medication carts reviewed for medication storage, resulting in the potential for drug diversion to go undetected.
Findings include:
In an observation and interview on 8/8/24 at 11:23 a.m. R102 had seven APAP Codeine 300-30mg (controlled substance, pain medication) tablets in the medication cart. The medication was counted on a Authorization For Controlled Substance Dispensing document. R101 did not have a proof of use record that included the dates, times or signature of medication removal. Licensed Practical Nurse (LPN) B reported they are counting the medication when they remove it but not signing it out.
Review of an admission Record revealed, R102 admitted to the facility on [DATE] with pertinent diagnosis which included dementia and fracture of skull and facial bones.
Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R102 had cognitive impairment with a Brief interview for Mental Status (BIMS) score of 1 out of 15.
Review of Physician orders revealed R102 had an order, Acetaminophen-Codeine Tablet 300-30mg give 1 tablet by mouth every 6 hours as needed for pain with a start date of 10/30/23.
In an interview on 8/8/24 at 3:14 p.m. LPN A reported nurses should sign out narcotics on a form and include date, time, signature and count.
In an interview on 8/8/24 at 3:19 p.m. LPN B reported narcotics should be signed out on the narcotic sheet with date, time, count, and signature.
In an interview on 8/8/24 at 3:41 p.m., the Director of Nursing (DON) reported the nurses should sign out narcotics when they are removed from the medication cart.
Review of a Pharmacy Services policy with a revised date of 8/8/24 documented, It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice . The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. The facility will employ or obtain the services of a licensed pharmacist (in accordance with state requirements) who:
o
Provides consultation on all aspects of the provision of pharmacy services in the facility;
o
Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and
o
Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled .
Jul 2024
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI001444419, MI00145071, and MI00145216.
Based on interview and record review the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI001444419, MI00145071, and MI00145216.
Based on interview and record review the facility failed to provide adequate supervision for one resident (R402) of three residents reviewed for elopements, resulting in a moderately cognitively impaired resident with behavior issues exiting a second-floor window and falling to the ground causing a left tension pneumothorax (collapsed lung), multiple acute rib fractures, left clavicle and scapulae fractures, and thoracic vertebrae fractures.
Findings include:
Review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 4/26/24, revealed that it was reported R402 exited the facility to the outside through his second-floor bedroom window between 10:30 PM and 10:45 PM. R402 was brought back into the facility by Licensed Practical Nurse (LPN) C and transported to the hospital at 11:02 PM.
Review of the clinical record documented R402 was admitted into the facility on 4/17/24 to a first floor standard room (not located on a lockdown unit) with diagnoses that included left calcaneus fracture (non-weight bearing), schizophrenia, and convulsions. According to the Minimum Data Set assessment dated [DATE], R402 had moderate cognitive impairment, and required substantial/maximal assistance for sit to stand. The clinical record also revealed R402 had a guardian with the correct working phone number listed on the face sheet.
Review of the care plan date initiated 4/17/24, documented: Focus: I am at risk for injury due to behaviors and impaired cognition. Interventions: I will have a sitter with me when my nurse identify I am at risk for injury or appear to be anxious/restless. Resident has impaired ability to complete activities of daily living care and needs assistance related to behavioral concerns, impaired cognition, impaired coordination, impaired mobility. Resident is at risk for falls and injury related to behavioral concerns, impaired cognition, impaired mobility, noncompliance with safety measure I had a fall on 4/18/24, 4/21/24 and 4/26/24. Interventions Nursing staff will provide me supervision and cueing as needed to maintain safety.
Review of the following progress notes documented:
4/17/24 at 18:55 Resident observed in the bed at the beginning of shift. ½ hour later resident on both knees at the bedside.
4/18/24 at 19:34 Observed patient sliding on butt next to bedside bed sitting upright. Patient has feces on finger and nails. Gown on with soiled brief. Patient asked where was the gold.
4/21/24 at 14:43 It was reported to the writer that resident was observed on the ground outside.
4/21/24 at 14:46 resident is A&Ox2 continues to stand and walk with unsteady gait. Resident has sudden episodes of unwanted anger. Writer unable to redirect resident physician notified order for Xanax every 8 hrs as needed.
4/21/24 at 14:50 Late Entry Resident had fall when outside on smoke break with staff and other residents.
Review of LPN C written statement dated 4/26/24 revealed in part . patient arrived on unit (lockdown unit requiring passcode to enter/leave) placed in room (on the second floor212 from a first floor standard room). Resident placed in bed at 10:30. Bedroom checked at 10:45. Window noted in up position. Resident not in bed. Writer proceeded to outside of building. Resident noted resting on knees, both hands touching the ground. Abrasions noted treatment implement. Resident placed into wheelchair and taken inside of building. Resident transported to hospital at 11:02 PM. Doctor, Guardian, Director of Nursing (DON) Administrator called at 11:00 PM and notified.
On 7/23/24 at 2:05 PM the Nursing Home Administrator (NHA) stated LPN D had the (R402) moved to the second-floor lockdown unit because the resident needed more supervision.
On 7/23/24 at 2:06 PM the DON said that the only remaining employee from the incident was LPN D. When asked the reason for moving R402 form the first floor to the second-floor lockdown unit the DON replied, I don't recall.
On 7/25/24 at 3:14 PM an attempt to interview LPN D via telephone was made. A message was left on the voicemail for a return call.
On 7/25/24 at 3:15 PM Guardian E was interviewed and stated I don't have a record of anyone from the nursing home requesting permission to move my resident to the lockdown unit or to change rooms. I did not receive a phone call from the nursing home telling me my resident went to the hospital. I got a call from the hospital on 4/27/24 to inform me that the R402 was in the hospital with injuries due to fall out the window. We get calls after business hours, and they are recorded and transcribed.
Review of the Emergency Department Hospital Admission/Discharge record revealed in part .R402 was admitted to hospital on [DATE] and discharged to a skilled nursing facility on 5/14/24. Diagnosis listed as schizoaffective disorder, bipolar type. Overview note This patient with a history of schizoaffective disorder was brought into the hospital after jumping out of second story window. It seems that patient may have underlying psychosis and acted on delusions. It did not seem to be a suicidal attempt. Patient was evaluated in the emergency department and found have a left tension pneumothorax (collapsed lung), multiple acute and chronic left rib fractures, left clavicle and scapula fractures, and L T7 and T9 (thoracic spine) fractures.
Review of the facility policy Abuse, neglect and Exploitation reviewed/revised 7/11/24 revealed in part .III Prevention of Abuse, Neglect and Exploitation B. identifying, correcting and intervening in situations in which neglect is more likely to occur with deployment of trained and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs and behavioral symptoms.
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** Based on interview and record review, the facility failed to (1) timely notify the guardian of an acute change in condition and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to (1) timely notify the guardian of an acute change in condition and (2) obtain consent and notify the guardian for a room change to a lockdown unit for one resident (R402).
Findings include:
Review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred on 4/26/24, revealed that it was reported R402 exited the facility to the outside through his second-floor bedroom window between 10:30 PM and 10:45 PM. R402 was brought back into the facility by Licensed Practical Nurse (LPN) C and transported to the hospital at 11:02 PM.
Review of the clinical record documented R402 was admitted into the facility on 4/17/24 to a standard room (not located on a lockdown unit) with diagnoses that included left calcaneus fracture (non-weight bearing), schizophrenia, and convulsions. According to the Minimum Data Set assessment dated [DATE], R402 had moderate cognitive impairment, and required substantial/maximal assistance for sit to stand. The clinical record also revealed R402 had a guardian with the correct phone number listed on the face sheet.
Review of LPN C written statement dated 4/26/24 revealed in part .patient arrived on unit (lockdown unit requiring passcode to enter/leave) placed in room (from a standard room). Resident placed in bed at 10:30. Bedroom checked at 10:45. Window noted in up position. Resident not in bed. Writer proceeded to outside of building. Resident noted resting on knees, both hands touching the ground. Abrasions noted treatment implement. Resident placed into wheelchair and taken inside of building. Resident transported to hospital at 11:02 PM. Doctor, Guardian, Director of Nursing (DON) Administrator called at 11:00 PM and notified.
On 7/23/24 at 2:06 PM the Director of Nursing (DON) was interviewed and said that the LPN C was no longer employed by the facility and did not provide contact information.
On 7/25/24 at 3:14 PM an attempt to interview LPN D via telephone was made. A message was left on the voicemail for a return call.
On 7/25/24 at 3:15 PM Guardian E was interviewed and stated, I don't have a record of anyone from the nursing home requesting permission to move my resident to the lockdown unit or to change rooms. I did not receive a phone call from the nursing home telling me my resident went to the hospital. I got a call from the hospital on 4/27/24 to inform me that the (R402) was in the hospital with injuries due to fall out the window. We get calls after business hours, and they are recorded and transcribed.
Review of the facility policy titled Notification of Changes reviewed 7/20/2024 revealed in part .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistant with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include:
1. Accidents
a. resulting in injury
b. Potential to require physician intervention.
4. A transfer or discharge of the resident from the facility.
5. A change of room or roomate assignement.
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
This citation pertains to intake MI00144419.
Based on interview and record review, the facility failed to immediately report an elopement resulting in injury to the State Agency (SA) for one (R402) of...
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This citation pertains to intake MI00144419.
Based on interview and record review, the facility failed to immediately report an elopement resulting in injury to the State Agency (SA) for one (R402) of three residents reviewed for elopement.
Findings include:
The State Agency received a Facility Reported Incident (FRI) on 4/30/24 for an incident that occurred on 4/26/24. The FRI reported that R402 exited a second-floor window and fell to the ground. R402 was observed on the ground outside by Licensed Practical Nurse (LPN) C. LPN C noted multiple abrasions on mid back and both legs, right hand and right thigh. R402 was transferred to the hospital.
On 7/24/24 at 2:00 PM the Nursing Home Administrator (NHA) was interviewed and said the FRI was submitted on 4/30/24 but it should have been submitted on 4/27/24.
According to the facility's policy Abuse, Neglect, and Exploitation revised 7/11/24 revealed in part .
VII. Reporting/Response
A. The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:
a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or
b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
Definitions:
Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.
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 F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safely secure the second-floor dining room windows an...
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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 safely secure the second-floor dining room windows and resident room [ROOM NUMBER] bathroom window from fully opening affecting all second floor residents who utilize the dining room and R405, resulting in the potential for additional unauthorized resident egress via the windows.
On 7/23/24 at 9:05 AM in an observation with Licensed Practical Nurse/Unit Manager (LPN) B the bathroom window in room [ROOM NUMBER] top pane did not lock and was able to fully open. LPN B said the window should lock and should not open all the way. It is not safe for residents because they can get out the window.
On 7/24/24 at 10:45 AM in an observation of the second-floor dining windows with Maintenance Director (MD) A the left window top panel opened fully, middle left window top panel opened fully, the right window top panel opened fully. MD A agreed residents use the room and it would be possible for a resident to open the top panel of the window and exit the building.
On 7/24/24 at 11:00 AM the Nursing Home Administrator (NHA) was interviewed and stated, Our policy for windows are that they are not allowed to be opened more than six inches we have the rule so that residents can't get out and get injured. The NHA agreed the bathroom window in room [ROOM NUMBER] and the second-floor dining hall windows were not properly secured from fully opening.
Review of the facility policy titled Preventive Maintenance Program, revised January 2024, revealed in part .A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary and comfortable environment for residents, staff, and the public.
Jun 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
Safe Environment
(Tag F0584)
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 comfortable room temperatures for two residen...
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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 comfortable room temperatures for two residents (R302 and R303) out of three residents reviewed for increased environment temperature, resulting in residents discomfort and decrease in quality of life within the facility.
Findings include:
On 6/21/24 at 12:07 PM an observation of sample resident room temperatures was made with Maintenance Director A. Room temperatures were observed and documented as follows:
room [ROOM NUMBER]- 86 degrees Fahrenheit (F)
room [ROOM NUMBER]- 82 degrees F
room [ROOM NUMBER]- 86 degrees F
room [ROOM NUMBER]- 84 degrees F
room [ROOM NUMBER]- 82 degrees F
On 6/21/24 at 9:22 AM R303 was observed lying in bed with a fan pointed at her. R303's room felt stuffy and humid. When testing the air coming from R303's fan, there was lukewarm air coming through. R303 was asked how the temperatures have been in the facility for her in the last few days. R303 stated, It was so hot yesterday (6/20/24) it felt like I was going to pass out. R303 said that she asked for an air conditioner yesterday, but she did not receive a response yet.
R303
A review of R303's EMR revealed R303 was admitted to the facility 11/7/19 and readmitted [DATE] R303 had the following medical diagnoses: Difficulty walking, Pulmonary Edema, Acute and Chronic Respiratory Failure, and Chronic Obstructive Pulmonary Disease.
A review of R303's quarterly MDS dated [DATE] revealed R303 had a BIMS score of 14/15 (cognitively intact). R303 required maximal assistance with bed mobility and was dependent on assistance with transfers.
On 6/21/24 at 9:27 AM R302 was interviewed regarding how the temperatures had been in the facility for him in the last few days. R302 said it had been uncomfortable the past few days with the heat. R303 said that the hallways and therapy room were extremely hot.
R302
A review of R302's Electronic [NAME] Record (EMR) revealed R302 was admitted to the facility 12/15/20 and readmitted on [DATE]. R302 had the following medical diagnoses: Demyelinating Disease of the Central Nervous System, Difficulty walking, Pneumonia, Nicotine Dependence (Cigarettes), and Quadriplegia.
A review of R302's quarterly Minimum Data Set (MDS) dated [DATE] revealed R302 had a Brief Interview of Mental Status (BIMS) score of 15/15 (cognitively intact). R302 required moderate assistance with bed mobility and maximal assistance with transfers.
On 6/21/24 at 10:27 AM Maintenance Director (MD) A was interviewed regarding the temperatures in the building the past few days and the interventions taken for to decrease the temperature. MD A said at the end of May they were placing new motors into the wall-attached air conditioning units but, the air conditioning units did not push out optimal cool air. MD A said after that they began taking the old portable air conditioning units out of storage and placing those into resident rooms but those ran out. MD A said it was not until Monday (6/17/24) that they started buying brand portable air conditioners. MD A said that they are slowly put air conditioning units into resident rooms. MD A said that the facility has been doing construction on the first floor that he believes was prioritized over getting air conditioning for resident rooms in a timely manner.
On 6/21/24 at 11:36 AM the Nursing Home Administrator (NHA) was interviewed regarding the uncomfortable room temperatures in resident rooms. The NHA said that comfortability of the resident will be reported to operations, maintenance, and the Administrator. The NHA said it is the expectation that residents do not feel uncomfortable and that means making sure air conditioning units are available.
A review of the facility policy titled, Safe and Homelike Environment, with a revised date of 5/1/24 revealed, The facility will maintain comfortable and safe temperature levels .The facility should strive to keep the temperature in common resident areas between 71- and 81-degrees Fahrenheit. If a resident prefers his or her room temperature be kept below 71 degrees Fahrenheit, or above 81 degrees Fahrenheit, the facility will assess the safety of this practice on the resident and the resident's roommate.
Feb 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
Transfer Requirements
(Tag F0622)
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 reason for discharge or a discharge summary was documente...
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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 reason for discharge or a discharge summary was documented in the medical record for two of two residents (R501 and R502) reviewed for discharges/transfers.
Findings include:
The State Agency received a complaint that Residents R501 and R502 were transferred to another facility without sufficient documentation including reason for discharge that met the federal requirements for discharge.
Resident 501 (R501):
A review of R501's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 1/19/24. There was no documentation to support the basis for R501's discharge/transfer to another facility. There is no discharge summary or progress note from the physician to indicate why the resident's discharge was necessary. A progress note dated 1/17/24 indicated R501's Legal Guardian was aware of resident's transfer to another facility but no reason for discharge or transfer was documented.
Resident 502 (R502):
A review of R502's EHR revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 1/19/24. R502 was his own responsible party with intact cognition. There was no documentation to support the basis for R502's discharge/transfer to another facility. There is no discharge summary or progress note from the physician to indicate why the resident's discharge was necessary.
On 2/13/24 at approximately 9:30 AM during interview with the Nursing Home Administrator (NHA) regarding the transfer of R501 and R502 she said, I was directed to transfer those residents to our sister facility by corporate. I was told the residents had consented. The NHA reviewed the Electronic Health Records for both R501 and R502 and acknowledged there was no reason for discharge or a discharge summary documented in either resident's EHRs. The NHA said, There should have been a documented reason for transfer in a progress note, and a discharge summary documented in their medical record.
On 2/13/24 at 11:15 AM, Social Worker (SW) F said she was directed to discharge the residents (R501 and R502) from the facility and transfer them to the corporation's sister facility. SW F said she was not given a reason for the resident's discharge. SW F said that R501 was OK with the transfer because he had been there before, and the resident's Legal Guardian consented without a reason being provided. R502 also agreed to be discharged to another facility without being provided a reason. SW F reviewed both resident's EHRs and acknowledged that neither resident had a discharge summary or reason for discharge documented in their EHR.
According to the facility's policy Discharge Summary last revised on 1/5/24, documented in part: It is the policy of this facility to ensure that a discharge summary is provided upon a resident's discharge which addresses each resident's discharge goals and needs .
Compliance Guidelines:
1.
Upon discharge of a resident (other than in emergency situation, including hospital, death or event that may compromise a resident's well - being) a discharge summary will be provided to the receiving care provider at the time the resident leaves the facility. The discharge summary should include:
a.
A recapitulation of the resident's stay that includes
b.
A final summary of the resident's 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
Transfer Notice
(Tag F0623)
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 notify the Ombudsman of the reason for transfer to another facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Ombudsman of the reason for transfer to another facility for two residents (R501and R502) reviewed for discharge/transfers.
Findings include:
The State Agency received a complaint that Residents R501 and R502 were transferred to another facility without notifying the resident, their representative, or the ombudsman of the reason for discharge.
Resident 501 (R501):
A review of R501's Electronic Health Record (EHR) revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 1/19/24. There was no documentation to support a notice was sent to the Ombudsman of the resident's transfer.
Resident 502 (R502):
A review of R502's EHR revealed the resident was admitted to the facility on [DATE] and discharged to another facility on 1/19/24. R502 was his own responsible party with intact cognition. There was no documentation to support a notice was sent to the Ombudsman of the resident's transfer.
On 2/13/24 at approximately 9:30 AM during interview with the Nursing Home Administrator (NHA) regarding the transfer of R501 and R502, the NHA said, There should have been a documented reason for transfer in a progress note. The NHA said there was no documentation to indicate the ombudsman was notified of the resident's transfer to another facility.
Dec 2023
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00139177 and MI00139604.
Based on interview and record review the facility failed to prevent staff t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00139177 and MI00139604.
Based on interview and record review the facility failed to prevent staff to resident verbal abuse for two residents (R38 and R235) of 16 residents reviewed for abuse, resulting in staff members abusing residents verbally and the potential for decreased self-esteem.
Findings Include:
Record review revealed facility's Nursing Home Administrator (NHA) reported to the State Agency an allegation of abuse on 9/3/23 at 7:11 PM. Incident summary documented that facility employee Sitter I was observed by LPN J using profanity toward R38. LPN J reported that Sitter I said, Why you touch my f*&King food, and then said, You got me f*$ked up .
Record review of Abuse Investigation Statement dated on 9/5/23 by LPN J documented the following:
3. What did you see concerning the alleged incident? I was passing dinner trays I overheard Sitter I talking to the resident (R38).
4. What did you see concerning the alleged incident? I seen Sitter I flex her fist at R38.
5. What did you hear at the time of the alleged incident? I heard Sitter I sat don't touch my f&*king sh&t.
Record review of Disciplinary Notice dated 9/5/23 and signed by NHA, documented the following:
Sitter I was heard by staff members using verbally abuse language to a resident
Record review revealed R38 was admitted into the facility on 4/22/22 with a pertinent diagnosis of dementia. According the Minimum Data Set (MDS) dated [DATE], R38 had impaired cognition and needed supervision to maximum assist with Activities of Daily Living (ADLS).
During an interview on 12/6/23 at 12:30 PM with NHA, it was reported that the investigation completed by the facility found that Sitter I had verbally abused R38. It was then reported that the facility would not tolerate verbal abuse of residents.
R235
Review of the Facility Investigation Report revealed that on 7/6/2023 at 11:00 P.M., R235 reported Nurse Aide (NA) came into his room and told him he was nasty, and he needed to empty his urinal due to it being on the bedside table. R235 reportedly responded to NA F that is your job. NA F responded get off your ass and empty it because you are nasty. R235 stated he told nurse aid F she had a nasty attitude and should not talk to patients like that. R235 further reported N.A F stated, would blow your s@#t out. At that point R235 stated he felt threatened and then informed the nurse of the situation. Nurse Aid F was directed to clock out and leave the facility immediately.
Further review of the documented staff interviews indicated Nurse H (no longer employed at the facility) did not witness N.A. F making the statement but observed the nurse Aid repeatedly approaching R235 in the hallway talking to him in an intimidating manner and the nurse aid was stopped and sent home.
Witness statements from several residents on the unit stated they heard voices in the hallway arguing on the unit . R246 (No longer resides in the facility) stated he heard the aid tell R235 Who's going to believe I said that to you? R246 did not know what the Nurse aide was talking about but acknowledged the statement was made by N.A. F. R247 said she heard the nurse aide and R235 arguing in the hallway but did not know what was said.
R235 no longer resides at the facility and was not available for interview.
Review of a form titled: Disciplinary Notice signed by the employee and manager stated in part . Termination violated company policy by abuse of a resident with verbal abuse and obscene language. The termination Notice stated Nurse Aid F was terminated on 7/11/23.
Review of the facility's Abuse, Neglect and Exploitation Policy, revised November 2023 stated .Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.
At 3:30 P.M. the Director of Nursing (DON) confirmed NA F was terminated for abuse.
Review of the Abuse investigation documented R235 was cognitively intact and was admitted into the facility 7/16/2014, with diagnoses of bipolar disorder, adjustment disorder with mixed anxiety, depression mood and polyneuropathy.
On 12/6/2023 at approximately 2:30 P.M. an attempt was made to interview NA. F via the telephone. A return call was requested but not received upon exit.
_
CONCERN
(D)
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** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive, person-centered...
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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 develop and implement a comprehensive, person-centered care plans for two (R17 and R22) of 27 residents reviewed for care planning, resulting in unmet care needs.
Findings include:
R17
In an observation on 12/4/23 at 10:43 a.m., Resident #17 (R17) had oxygen at 4 l/m (liters/minute).
Review of an admission Record revealed, R17 originally admitted to the facility on [DATE] with pertinent diagnosis which included Chronic Obstructive Pulmonary Disease (COPD) and Hypoxemia.
Review of a Minimum Data Set (MDS) assessment, with a reference date of 8/23/23, revealed R17 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15. R17 required oxygen use.
Review of R17's care plans revealed R17 did not have a care plan for oxygen use.
Review of Physician orders revealed, R17 had an order, Administer oxygen therapy PRN (as needed) @ (at) 2 Liters as needed for Oxygen Saturation less than 95% with a start date of 8/18/23.
In an interview on 12/6/23 at 12:19 p.m., MDS Nurse C reported comprehensive care plans are done by MDS on admission and quarterly. MDS Nurse C then confirmed that R17 did not have a oxygen use care plan.
R22
According to the electronic medical record, R22 was admitted on [DATE] with diagnoses that included dementiaand depression. R22's significant change minimum data set (MDS) with a reference date of 10/19/2023, indicated R22's had no recorded BIMS (brief interview for mental status) score with documentation of Cognition skills severely impaired.
Review of the Physician's orders dated 11/29/23 documented, Current Medications: Seroquel tablet (Antipsychotic, it can treat mood disorder) 50 mg tablet take 1 tablet two times a day, and Ativan tablet (anxiety) 1 mg tablet by peg tube route every four hours as needed.
Review of R22's care plans revealed no behavior/mood/psychotropic medication care plans in the medical record.
On 12/6/2023 at 3:48 p.m., the Director of Nursing (DON) said during an interview that all the residents should a comprehensive care plan centered to their care needs. The DON confirmed R22 did not have a behavior/mood or a psychotropic medication care plan in the medical record.
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 F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 12/6/23 at 8:30 A.M. during an environmental tour with Maintenance Supervisor A on the first floor the following were observe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 12/6/23 at 8:30 A.M. during an environmental tour with Maintenance Supervisor A on the first floor the following were observed:
1.
All the cove bases and base boards in resident's room were observed soiled with built up old wax, dust, grime, and dirt.
2.
Hallway had chipped and missing tiles on both sides of the walls.
3.
Shower room (across from room [ROOM NUMBER]) had cracked and broken tiles on floor and walls. Debris was noted on tiles.
4.
Baseboards in hallway were observed pulled away from walls.
5.
Handrail (by clean linen room) had broken plastic pieces and sharp metal edges exposed.
6.
Tile under water fountain broken and missing.
7.
Bathtub room had missing and broken tiles.
8.
Shower room (across from room [ROOM NUMBER]) had broken floor and wall tile. Broken plastic back splash. Toilet seat not secured.
9.
All door frames on first floor hallway with chipped and missing paint.
10.
Basement men's bathroom observed to have foul odors, missing and cracked tiles, rusted privacy stall, broken lights.
During interview on 12/6/23 at 9:15 AM with Maintenance Supervisor A, it was reported that all areas of the nursing home should be kept in good repair and all areas should have clean and wipeable surfaces that can be sanitized.
Record review of policy Routine Cleaning and Disinfection dated 11/2023 documented the following:
.It is the policy of this facility to ensure the provision of deep cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.
Record review of policy Preventative Maintenance dated 11/2023 documented the following:
A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a
safe, functional, sanitary, and comfortable environment for residents, staff, and the public.
Policy Explanation and Compliance Guidelines:
1.
The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
2.
The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience.
3.
If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them.
4.
The Maintenance Director shall develop a calendar to assist with keeping track of all tasks.
5.
Documentation shall be completed for all tasks and kept in the Maintenance Director 's office for at least three years.
Based on observations, interviews, and record reviews the facility failed to effectively clean and maintain the physical plant in a sanitary manner, resulting in the increased likelihood for bacterial harborage and growth, and an unsafe, environment for residents, the public and staff. This deficient practice had the potential to affect all 82 residents who resided in the facility at the time of survey.
Findings include:
On 12/4/2023 at 11:08 A.M. and on 12/5/2023 at 3:50 P.M. the following concerns were observed:
1. 40-42 missing floor tiles (approximately 4 x 4 inches) were removed from the floor leaving an uneven floor surface exiting and entering the kitchen.
2. The hallway leading to the kitchen was heavily soiled with dust, and cement powder residue.
3. The ceiling vents above the tray line area and doorway to the kitchen vent were soiled with, lint, and fuzz strings.
4. Standing floor water was observed in the dish room under the scrape table. In front of the three compartment sink the floor drain had been sealed and the existing water drain caused water to accumulate on the uneven floor area.
5. The elevator grill plate to the ceiling fan was missing and had a collection of visible grime and fuzz strings. Entering the elevator, the floor tiles were chipped and cracked. The cracks and crevices along the entry was filled with pocketed, dirt and grime.
6.The bottoms of both door frames leading to the dish room and tray line area were rusted out, and had cracked, exposing cement residue.
7 The two window exhaust fans had opened slots that were too wide and allowed potential entry of pest.
8. Stored under the stair way was a pile of empty cardboard boxes.
9.The Entry door to the kitchen was scarred, scratched, and had chipped paint.
10.The exit back stairway from the basement to the back alley had a collection of standing water, debris and the area was soiled.
On 12/5/23 at 4:15 P.M. during Interview Maintenance Supervisor A stated that the standing water was a result of one of the floor drains being sealed. When queried concerning the missing (40-42) floor It was stated the tiles were on order and there was some question as to who was responsible for cleaning the ceiling vents. Dietary Aide B who was present stated the vents had been cleaned but additional deep cleaning was required and the equipment needed was not available.
On 12/6/23 at 9:45 A.M. during an environmental tour with Maintenance Supervisor A on the second floor the following were noted:
1. All the cove bases and base boards in resident's room were observed soiled with built up old wax, dust, grime, and dirt.
2. The entire hallway was noted with chipped, missing floor tiles.
3. room [ROOM NUMBER]-B had two missing floor tiles and the privacy curtain was detached halfway off the ceiling track. The two Drawers on the lower half of the resident's wardrobe closets was broken off.
4. room [ROOM NUMBER] B cove base behind the resident's door and entry to the bathroom was detached. Inside of the cove base crumbling cement and debris was visible.
5. Dining room heating cover was bent and detached from the heating unit.
6. room [ROOM NUMBER] A the Privacy curtain was off track and tied up in a knot.
7. 229B shared bathroom had a sink that was attached to a broken wall. There was no caulking. The sink hung 1 to 2 inches from the broken wall. The area under the sink was filled with old, wet toilet paper and debris. The toilet had no excursion around the pipe exiting the bathroom.
8. The bathroom on the South Hall had multiple, missing chipped floor tiles and the bathroom sink was held in place by a stick /piece of wood. The caulking was cracked and chipped allowing visible water to enter.
9.The bathroom on the North Hall had a standing fan that was unsecured. The bathroom floor tiles were soiled and chipped.
On the Locked Unit the handrails were loose, and the end portion of the rails were missing leaving a rough exposed, splintry edge.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide 80 square feet per resident in five of 49 rooms...
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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 80 square feet per resident in five of 49 rooms in the facility (rooms 111, 115, 119, 219 and 231) resulting in the potential for inadequate living space.
Findings include:
On 12/4/2023 during an environmental tour of the facility, the facility document (which indicated waivered rooms) was reviewed and revealed:
room [ROOM NUMBER] had 157 square feet and two residents which yielded 78.5 square feet per resident.
room [ROOM NUMBER] had 157 square feet and two residents which yielded 78.5 square feet per resident.
room [ROOM NUMBER] had 159 square feet and two residents which yielded 79.5 square feet per resident.
room [ROOM NUMBER] had 157 square feet and two residents which yielded 78.5 square feet per resident.
room [ROOM NUMBER] had 159 square feet and two residents which yielded 79.5 square feet per resident.
A query and observation of the residents did not indicate a dissatisfaction with the adequacy of the living space.
The health and safety of the residents who occupied the rooms were not affected. Resident interviews did not reveal any concerns related to the room size.
May 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0602
(Tag F0602)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00136501 and MI00136279.
Based on observation, interview and record review, the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00136501 and MI00136279.
Based on observation, interview and record review, the facility failed to ensure money was safe from misappropriation for two residents (R201 and R202) of three residents reviewed, resulting in $6,130.00 of unauthorized ATM (Automated Teller Machine) transactions for Resident #201 and theft of $10,200.00 from Resident #202's room (financial loss) and subsequent psychological distress.
Findings include:
R201
A review of a Facility Reported Incident (FRI) dated 5/1/2023 documented the following:
On 4/4/2023 at approximately 9:30 AM, Activity Aide (AA) L accompanied Resident #201 (R201) to the bank to make a withdrawal. The bank teller informed R201 that there was not enough money in the account to make a withdrawal. R201 requested a printout of her transactions. Upon review, R201 noticed multiple unauthorized ATM transactions on her account. R201 informed the bank that she never used an ATM card. R201 requested that her debit card be deactivated. The bank started an investigation into the unauthorized transactions. The bank also restored the total amount of money withdrawn from R201's bank account pending her cooperation with the investigation.
The FRI continued and documented that on 4/21/23, AA L and R201 made a return trip to the bank to followed up on the investigation. The bank shared pictures of the perpetrator. AA L telephone the Nursing Home Administrator (NHA) from the bank and indicated the pictures of the perpetrator appeared to be Business Office Manager (BOM) E (a previous BOM that no longer worked at the facility. R201 identified the perpetrator as BOM E as well.
Further review of the FRI revealed a 4/27/2023 bank print out that listed sixteen transactions:
1. 10/14/2022 - $500.00
2. 10/21/2022 - $300.00
3. 10/26/2022 - $600.00
4. 11/3/2022 - $1000.00
5. 11/14/2022 - $430.00
6. 11/16/2022 - $500.00
7. 11/22/2022 - $460.00
8. 11/28/2022 - $180.00
9. 1/9/2023 - $700.00
10. 1/10/2023 - $300.00
11. 1/13/2023 - $160.00
12. 1/17/2023 - $160.00
13. 1/26/2023 - $300.00
14. 1/30/2023 - $220.00
15. 2/1/2023 - $120.00
16. 2/6/2023 - $200.00
Unauthorized ATM withdrawals totaled $6130.00.
The facility's investigation Conclusion documented: .At this time, given the evidence from the bank and the statements taken from staff abuse of misappropriation of funds is substantiated.
An attempt to contact the local police department was made on 5/17/2023 at 10:40 AM. A message was left but no return call was received.
According to the electronic medical record, R201 was admitted to the facility on [DATE] with diagnoses of Ventricular fibrillation, fracture of ribs right side, anemia, Parkinson's disease, schizophrenia, and anxiety disorders. R201's annual Minimum Data Set (MDS) with a reference date of 2/9/2023 indicated R201 was cognitively intact with a BIMS (brief interview for mental status) score of 14/15.
During an interview on 5/16/2023 at approximately 4:20 PM R201 stated, I had an ATM card when I was in Georgia with my daughter, but I haven't had an ATM card since I been here (in the facility). R201 said she went to the bank on 10/13/2022 and made a withdrawal of $15,000 to pay the facility for her stay. R201 stated, I did not agree to other withdrawals. I am working with the head of the bank now. R201 said they paid her the money back but all of it will not be available until the investigation is concluded. R201 stated, I went back to the bank, and they showed me the camera (footage) of the business guy (Business Office Manager- BOM E) that works here. It was him. The activity person that went with me said it was him too. He had all my (financial and personal) information. R201 expressed frustration and disappointment that she was unable to fully handle her financial responsibilities. R201 explained that the facility made multiple attempts to collect money that was due to them. R201 was observed with her head down while covering her mouth and became emotionally distraught because she was unable to pay for much needed dental care. R201 described disappointment in not having money for dental work.
The Facility Nursing Home Administrator (NHA) was interviewed on 5/17/2023 at 10:59 a.m. regarding R201's missing funds. The NHA was asked if BOM E still worked in the facility. The NHA said the employee was terminated before March 2023 due to poor work performance. The NHA was asked how did BOM E get R201's ATM card. The NHA stated, I don't know how the employee got access to the resident's ATM card. I was under the impression that she didn't have an ATM card. The NHA reviewed the bank's printout sheet of withdrawals from 10/14/2022 through 2/6/2023. The NHA stated, He had to have had her information to get an ATM card. He had access to all her information.
During an interview on 5/23/2023 at 2:56 p.m., the Senior Bank Manager (SBM) D confirmed there was an investigation ongoing with R201's missing money but could not go into details due to bank policy.
R202
On 5/11/2023 the facility submitted a report of an allegation of a resident's (R202) missing money.
On 5/17/23 at 3:20 p.m. the NHA was queried regarding R202's missing money. The administrator stated, My staff called me at home and told me that R202 wanted to call the police and report somebody stole fifty-five hundred dollars from him. I believe that was on a Thursday May 11th. It was around 8 PM when the MDS (Minimum Data Set) Nurse (MDSN C) called me. I told the MDSN C to go help him (R202) to call the police to make a report. My MDS Nurse (MDSN C) said (R202) said (CNA B) stole it. (R202) said he sent (CNA B) to get him some Pepsi and she saw the one-hundred-dollar bills when he went to get a twenty to give her to pay for his Pepsi. R202 said he had ten thousand and two hundred dollars all in one-hundred-dollar bills that he kept on his bed in a pillowcase. I called (CNA B) and interviewed her. I spoke with the police over the phone when they got there. The administrator said she interviewed some staff but had not completed the full investigation at the time of the interview.
On 5/17/2023 at approximately 3:50 p.m. R202 was interviewed regarding the missing money. R202 stated, (CNA B) is a girl who works here. She took $5500.00 from me. She took it out of my pillowcase. She waited until I fell asleep and took it. (Security Guard A) took the other $4700.00 that I gave him to keep for me. All together it was $10,200.00 exactly, all one-hundred-dollar bills. I took the money out of the bank because they said the bank was closing. I've been hiding it for the last three years. I was keeping the money safe until I came here, then people started to steal from me. (Before arriving at this facility), I used the money for hotels and use some to eat with. I made a mistake when I wanted to buy me a Pepsi and pulled out the only twenty-dollar bill I had. (CNA B) saw it and stole $5500.00 of it. I called the police and made a police report. I saw (CNA B) come into my room three or four times that same night. (Security A) is head of security, I told (security A) about the missing money, (Security A) said, you should have given it to me to put it in a safe place. R202 confirmed the other nursing facilities was keeping the money and provide receipt upon discharge. R202 stated, They stole the receipt here too. During the interview R202 was observed with his head held downward. R202 spoke in a soft voice as repeatedly stated he have no money to buy sodas and cigarettes. In addition, R202 reported he had no friends or family to bring sodas and cigarettes to the facility. R202 repeatedly expressed the importance of having his own money especially since he spent most of his time on the street and slept in his truck.
According to the electronic medical record, Resident #202 (R202) was admitted on [DATE] and readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, history of repeat falls, hypertension, cervicalgia, spinal stenosis, lumbar region without neurogenic claudication, diabetes mellitus type two, peripheral vascular disease, atherosclerotic heart disease, and major depressive disorder. No available Minimum Data Set assessment was available.
Review of the admission Neurological assessment dated [DATE] documented as following:
- Temporal orientation: Able to report correct year, month and day of the week correctly.
- Recall: yes, no cue required with two of the three words.
During an interview on 5/17/2023 at 4:06 p.m., NHA M of R202's previous nursing home was contacted and said R202 stayed at that facility between 3/28/2023 and 4/26/2023. NHA M was asked did she have any knowledge of R202 having a large sum of money during his stay at the facility? NHA M stated, There was no knowledge of (R202) having a large sum of money when he was in the facility, but he did have some money. The Social Services Director (SSD) J confirmed R202 did have a large sum of money all in one-hundred-dollar bills when he was in their facility (3/28/2023 to 4/26/2023) because he was part of the facility's Stand Down meeting and made staff aware that R202 had large sums of money. SSD J explained the Activity Director reported to him about R202 large sum of money.
During an interview on 5/17/2023 at approximately 4:15 p.m. NHA N was interviewed and stated, (R202) was admitted [DATE] through 3/13/2023. NHA N was asked was there any knowledge of R202 having a large sum of money during his stay and was there ever a complaint made from R202 of missing money. NHA N stated, Yes, he did have a lot of money that we kept while he was here and gave him a receipt at the time he was discharged from the facility. It was in the thousands of dollars. He left with the money. He had a stack of rolled up one- hundred- dollar bills. I will scan a copy of the amount and the document of it tomorrow morning (5/18/2023).
On 5/19/2023 NHA N provided a copy of R202's receipt in the sum of ten-thousand-one-hundred dollars dated 3/13/2023 prior to discharge from the facility.
On 5/18/2023 at 10:35 a.m. SG A was interviewed via telephone regarding R202's missing funds. SG A was asked did he had a conversation with R202 on 5/11/2023 regarding missing money, SG A stated, Yes. SG A was asked to explain the conversation. SG A explained (MDSN C) came outside and asked to see me between 6:30 p.m. and 7:30 p.m. on that Thursday (5/11/2023). MDSN C said she found a large sum of money on R202. MDSN C had the money in her hand and counted it. MDSN MSDN C counted forty-seven hundred dollars and showed a receipt that had R202's name on it for ten-thousand-two hundred dollars. SG A stated, I asked her did she call the administrator because he (R202) was talking about some young lady had stolen some of the money already. SG A was asked what happened to the money. SG A reported that the police arrived at the facility, escorted R202 back to his room, counted R202's money, and provided R202 with a police report.
On 5/18/2023 at approximately 2:34 p.m. MDSN C was interviewed via telephone regarding R202's missing money. MDSN C explained R202 came to the MDS office and reported that someone stole fifty-one- or fifty-two-hundred-dollar bills from him and wanted to call the police. MDSN C then described R202 pulled money out of his pocket. MDSN C stated, I counted the money twice with (R202) and (SG A) and it was forty-seven hundred dollars all in one-hundred-dollar bills .
On 5/18/2023 at approximately 3:00 p.m. the first-floor hallway camera was reviewed for the date of 5/11/2023 and revealed staff entered and exited R202's room at the following times:
- CNA B and LPN H entered at 10:24 a.m. and exited at 10:32 a.m.
-CNA B and LPN H entered at 10:34 a.m. and exited at 10:40 a.m.
-Wound nurse K entered at 10:40 a.m. and exited 10:46 a.m.
-CNA B brought what appeared to be soda in a bottle at 12:28 p.m. in the front lobby door and entered R202's room at 12:41 p.m.
- Therapist F. entered at 1:00 p.m. with a wheelchair while CNA B remains in R202's room and CNA B exited out with Therapist F pushing R202 in a wheelchair at 1:18 p.m.
-R202 was observed coming back sitting in a wheelchair in front of the room at 1:35 p.m. alone.
-R202 observed at 2:07 p.m. sitting in the lobby in a wheelchair.
On 5/18/2023 at approximately 4:00 p.m., another interview was conducted with the facility and confirmed R202's room was searched, and no money was found. The facility NHA verbalized that R202 was never offered an opportunity to secure his funds. When asked, the facility NHA surmised the following, Either one of the staff members have it or he still have it. This is the only two conclusions. However, R202 continue to report missing ten-thousand-two-hundred dollars.
According to the facility's policy titled Abuse, neglect and exploitation revised on 4/1/2023:
It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation and misappropriation of resident property . Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent, use of a resident 's belongings or money without the resident's consent.
Feb 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
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 MI00133159.
Based on interview and record review, the facility failed to document a thorough i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00133159.
Based on interview and record review, the facility failed to document a thorough investigation for an allegation of abuse for one resident (R102) out of six residents reviewed for abuse, resulting in the potential for missed opportunities to implement corrective measures and for other allegations of abuse to go undocumented.
Findings include:
It was reported to the State Agency that a resident was physically abused by a facility staff.
According to the clinical record, R102 was initially admitted to the facility on [DATE] and was discharged on 12/29/22. R102's medical diagnoses included Disorders of Adult Personality and Behavior (adult behavioral problems), Anxiety Disorder, Major Depressive Disorder, and Alcohol Abuse. A progress note dated 10/25/22 at 1:30pm indicated R102 was alert and oriented to person, place, time, and situation.
Further review of R102's clinical record documented the following progress notes:
A nursing progress note written by LPN (Licensed Practical Nurse) J dated 11/25/22 at 8:30pm revealed, Resident was receiving care when writer heard yelling and resident began to become combative. Resident threatened to hit anyone who rolled him. Resident then reported to nurse that CNA (Certified Nursing Assistant) allegedly threw his meal tray at him and yelled at him. Meal tray was located on side table with food on it. Resident called 911 alleging CNA beat him up. Resident was assessed for any pain or discomfort with none being noted. MD notified and request resident to be sent to hospital for imaging.
A progress note written by the Administrator with a creation date of 11/28/22 at 9:55am and an effective date of 11/25/22 at 6:46pm revealed, Spoke with resident in his room to address some of resident's concerns. After police responded to the facility due to resident calling. Police cleared the complaint and left. When Administrator started asking follow-up questions the resident became angry and told Administrator to leave the room and stated, 'you are playing games.' Administrator responded by saying 'I am trying to get clarity'. Resident was (sic) appeared delusional and manipulative. Resident referred to psych services.
In an interview on 2/1/23 at 2:00 pm the Administrator stated, I'm sure I reported it. I have to go back into my office to see where the file is. When I report (to the State Agency), I put it in a red folder. It is reportable because (R102) said the CNA had blackened his eye or hit him. The police came. I can't imagine I didn't report it because the police came. At 2:21 pm the Administrator returned from the office and stated, I did not report it because I didn't feel it was reportable after reading the notes. I did the investigation. I talked to the staff and police. The Administrator said they did not have written documentation that a thorough investigation into resident's allegation of abuse was completed.
A review of the policy titled Abuse, Neglect, and Exploitation date reviewed 3/1/22 revealed, Written procedures for investigations include .providing complete and thorough documentation of the investigation.
On 2/1/23 at 3:45pm during the exit conference the Administrator and Director of Nursing did not offer additional documentation or information when asked.
Oct 2022
21 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
This citation pertains to MI00131177.
Based on interview and record review, the facility failed to ensure proper wheelchair transport for one resident (R537) out of two residents reviewed for accident...
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This citation pertains to MI00131177.
Based on interview and record review, the facility failed to ensure proper wheelchair transport for one resident (R537) out of two residents reviewed for accidents, resulting in an abrasion, opened wound, hematoma, and an emergency hospital encounter. Findings include:
It was reported to the State Agency that during a wheelchair transport a resident fell out of the wheelchair face forward and was then transported to the hospital.
On 10/6/2022 at 1:51 PM, Resident #537's (R537) Concerned Family Member (CFM) stated they were present when the resident fell out of the wheelchair. CFM said when staff transported R537 down a ramp face forward, the resident fell out of the wheelchair scraping his hand and fingers, the surgical wound on his amputated leg hit the ground and reopened, the resident's head hit the ground causing a bruise to form, and the resident was sent to the hospital.
A review of the Face Sheet for R537 revealed an admission date of 9/7/2022 and discharge date of 9/8/2022 with diagnoses that included end stage renal disease and peripheral vascular disease. A review of hospital discharge documents dated 9/7/2022 documented in part the following: gangrene of right foot (status/post) right above knee amputation of 8/12/2022.
A review of R537's care plans documented in part the following, Resident is at risk for falls and injury related to impaired mobility, newly admitted , new surroundings. Date initiated 9/7/2022.
Review of nursing progress notes, skin observations, incident/accident report, and post-fall assessment documented in part the following:
1. 9/7/2022 at 6:45 PM: Patient arrived via ambulance at 6:30 pm alert and oriented x4 able to make needs known .Resident is a right leg amputee above the knee and a dialysis patient.
2. 9/8/2022 at 11:35 AM: (Patient) .admitted to (Facility Name) on 9-7-2022 from the hospital where he .had a right leg AKA (above knee amputation) (Patient) sent to hospital for care after acute fall and laceration .
3. 9/8/2022 at 2:43 PM: writer assessed resident, resident has an open area on the right stump. Encounter measurements are 5.5cm (centimeter) length x 5cm width x 0.5cm depth. Wound bed is pink. There was a moderate amount of (sanguineous) drainage coming from the area. The area does have an odor. Writer contacted the wound team and obtained an order for (Dakins) to the area. Resident isn't in any pain nor discomfort at this time.
4. 9/8/2022 at 3:51 PM: Writer was made aware that resident had a fall outside while being transported to dialysis. Writer completed assessment .resident had c/o (complaint of) pain in (his right) arm. Writer noted a hematoma on resident's right side of forehead; an abrasion on residents (right) elbow and skin tear on the fingers of residents (right) hand. Resident and family who was present requested that resident be sent to the hospital for further assessment. Resident was transported to (local hospital). MD notified.
5. Skin Observation Tool, dated 9/7/2022, upon admission:
Skin intact: Yes.
Bruise: Right wrist
Left lower leg (front and rear): scaly skin
6. Skin Observation Tool, dated 9/8/2022, post fall:
Skin intact: No. Resident had a previous wound on right stump.
Face: Hematoma
Right Hand: Skin tear
Right elbow: Abrasion
7. Incident/Accident Report, dated 9/8/2022:
Incident Description - Nursing: Writer was called to the porch, writer observed resident laying on his right side on the ground.
Incident Description - Resident: Resident stated that he slid out the chair.
Immediate Action Taken: (R537) receive a skin, pain & neurological assessment. Resident was placed back in his wheelchair. Physician notified about the incident and ordered resident be sent to the hospital. Writer and staff stayed with resident until EMS arrived.
Injuries Observed at Time of Incident: Right elbow abrasion; right hand (palm) skin tear; face hematoma.
8. Interdisciplinary Post-Fall Assessment, dated 9/8/2022:
Description of fall: Resident stated that he slid out of chair
Injury description: right elbow abrasion, hematoma to face, right hand skin tear
Mental status: alert and orientated
Gait balance deficits: wheelchair bound / non-ambulatory
Activity at time of fall: Staff assisted
Consider a probable cause for this fall based on review and investigation: Resident was moving quickly in wheelchair.
Recommendations from review by IDT (interdisciplinary team) and primary/attending physician: Resident to be taken down declining ramp backwards with staff assistance.
During an interview and record review on 10/6/2022 at 4:27 PM, the Nursing Home Administrator (NHA) reviewed R537's post-fall assessment and stated, He had a fall. The NHA was unable to answer 'how' and 'why' R537 fell out of the wheelchair. The NHA said there were no interviews available for review.
During an interview on 10/6/2022 at 4:41 PM, the Director of Nursing (DON) stated R537 fell on his way to an appointment. The resident was full of energy and somehow slid out of his chair. The DON did not have written statements from the transportation driver or family member present.
During an interview on 10/6/2022 at 4:50 PM, Transportation Driver (TD) I said R537's nurse cleared the resident to go to his dialysis appointment. The resident was agitated and cursing. TD I stated, I was taking (R537) to his hemodialysis appointment and was pushing him in his wheelchair. TD I said while she was pushing R537 slowly down the ramp he stated, I'm not going. R537 then slid himself out of the wheelchair. TD I said while she was pushing him down the ramp face forward in the wheelchair, she had one hand on his shoulder to hold him in the wheelchair. TD I said she was unsure of what part of R537's body hit the ground first but reported that his leg and hand hit the ground and then his face.
During an interview on 10/6/2022 at 5:07 PM, Therapy Director, Occupational Therapist EE stated, You take a resident down the ramp backwards, so they are facing away from the decline. Therapy Director EE added the resident would be more at risk for sliding out of the chair when they are facing towards the decline.
During an interview on 10/7/2022 at 10:15 AM, the DON said that it's possible the fall could have been prevented if the resident had been turned backwards while going down the ramp. The DON stated, (TD I) was taking the resident down face forward. The resident should have been turned the opposite way.
The facility policy titled, Incidents and Accidents, dated 10/7/2022 was reviewed and revealed in part the following:
- It is the policy of this facility for staff to utilize Risk Management to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.
- Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.
- If an incident/accident was witnessed by other people, the supervisor or designee with obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or administrator.
On 10/7/2022 at 6:00 PM during the exit conference, the NHA 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
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
Based on observation, interview, and record review the facility failed to treat one resident (R68) in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to
Based on observation, interview, and record review the facility failed to treat one resident (R68) in a dignified manner that recognized his individuality from eight residents reviewed for dignity and respect when R68's roommates were observed wearing his (R68's) clothes on multiple occasions resulting in feeling of loss of self-worth and individuality. Findings include:
According to a complaint intake received 1/26/22, the resident was missing clothes.
During an interview on 10/4/22 at 1:30 PM R68's Responsible Party (RP) said during visitation she has seen other residents wearing his (R68's) clothes and has reported this to staff. The RP said R68 was in a four-bed room and that he shared one closet with three other men.
On 10/04/22 at 10:19 AM three residents R68, R2, and R32 were seated in the 2 North hall way wearing shirts that were labeled as R68's property. R68 had his name written on the sleeve of his T-shirt. Upon inquiry R68 confirmed he was wearing his own shirt and that both R2 and R32 were also wearing his clothing. R68 was asked how he felt when other resident's wore his clothing. R68 shrugged his shoulders and shook his head and said, It happens all the time. Nothing I can do.
R32 was observed wearing a red shirt with R68's name on it and R2 was observed wearing a gray shirt with R68's name on it. Neither R2 or R32 could be meaningfully interviewed due to their cognition status.
On 10/4/22 at approximately 10:30 AM Certified Nursing Assistant (CNA) H was asked why resident R2 and R32 were wearing R68's shirts. CNA H said that she would change their shirts during AM care. On 10/4/22 at approximately 2:45 PM both R2 and R32 were still wearing R68's clothing.
According to R68's Minimum Data Set (MDS) dated [DATE] he had moderately impaired cognition and with a BIMS (brief interview for mental status) score of 9/15 and was able to make his needs known. R68 was identified to require total assistance from one staff member for bed mobility and Activities of Daily Living (ADL).
On 10/06/22 at 10:40 AM, R32 had a shirt on that was labeled as R68's property. CNA H was asked why R32 was wearing R68's shirt again. CNA H said that R32 and R68 shared a closet and he (R32) was confused on which clothes were his.
According to R32's MDS dated [DATE] he had severe cognition impairment with a BIMS score of 00/15 and was independent with all ADLs.
According to R2's MDS dated [DATE] he had severe cognition impairment with a BIMS score of 00/15 and required limited assistance from one staff person for dressing and transferring.
On 10/6/22 at approximately 11:00 AM the one closet in R68's room had four different cubicle areas. One cubicle for each of the four resident's personal belongings. However none of the four cubicles were labeled to identify which closet belonged to which resident. Clothing that was labeled as R68's property was observed hanging in three separate cubicles of the closet.
On 10/06/22 at 1:10 PM the Director of Nursing (DON) confirmed that she was aware that other residents had been wearing R68's clothing. The DON said the maintenance department would label the cubicles in the closet to clearly identify which cubicle belonged to which resident.
According to the facility's policy 'Resident Personal Belongings' revised on 3/2/22;
It is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident, or to the resident's representative in the event of the resident's death or discharge from the facility.
Policy Explanation and Compliance Guidelines:
1.
All resident possessions, regardless of their apparent value to others, will be treated with respect.
2.
The facility will support the resident's right to retain and use personal possessions to promote a homelike environment and maintain their independence.
3.
All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record.
6.
The facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each resident's room.
7.
The facility will exercise reasonable care for the protection of the resident's property from loss or theft.
8.
The social services designee, or another designated staff member, will encourage residents and their families to bring in personal belongings (within space constraints).
CONCERN
(D)
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** This citation pertains to intakes MI00123918 and MI00126680.
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 MI00123918 and MI00126680.
Based on interview and record review, the facility failed to ensure resident's personal belongings were inventoried and accounted for, affecting two residents (R532, R539) of four residents reviewed for personal property, resulting in the potential for missing/unaccounted items and resident dissatisfaction.
Findings include:
Complainants reported to the State Agency that residents' belongings were not returned upon discharge from the facility.
During an interview beginning on 10/6/2022 at 11:57 AM, the Director of Nursing (DON) indicated that the last time the facility used paper to document a resident's personal property upon admission to the facility was in 2020. The facility uses an electronic health record (EHR) document titled, Personal Effects Inventory Checklist to document a resident's personal belongings. A review of Resident #532's (R532) EHR with the DON revealed an inventory sheet had not been completed for the resident.
During an interview and record review with the DON, a document titled, Personal Effects Inventory Checklist, dated 1/20/2022, had been generated for Resident #539 (R539). However, this document was blank with the exception of the following notation, Copy uploaded. This document failed to inventory resident's property or that the resident arrived with no personal belongings. A further review of R539's EHR with the DON did not reveal an uploaded inventory of the resident's personal belongings.
A review of the Face Sheet for R532 documented an initial admission to the facility on 7/16/2021, readmission on [DATE], and discharge on [DATE]. R532's diagnoses included Alzheimer's disease and depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition.
A review of the Face Sheet for R539 documented an admission to the facility on 1/28/2022 and discharge on [DATE]. R539's diagnoses included dementia and diabetes mellitus - type 2. A MDS assessment dated [DATE] documented severe cognitive impairment.
According to the DON, an inventory of a resident's personal belongings is important in order to identify what is the patient's property. If they are alleging that property is missing, we can confirm they actually had the property in the facility.
During an interview on 10/7/2022 at 2:49 PM, the Nursing Home Administrator (NHA) stated her expectations were for a resident's inventory to be obtained upon admission to the facility to make sure everything they said they have is here.
A review of the facility policy titled, Resident Personal Belongings, dated 3/2/2022, documented in part the following:
- It is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the residents, or the resident's representative in the event of the resident's death or discharge from the facility.
- All resident personal items will be inventoried at the time of admission .and documentation shall be retained in the medical record.
On 10/7/2022 at 6:00 PM during the exit conference, the NHA 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
Deficiency F0578
(Tag F0578)
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 obtain a completed Advance Medical Directive (AMD) for one resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a completed Advance Medical Directive (AMD) for one resident (R43) out of 14 residents reviewed for advanced medical directives, resulting in the potential for the resident's emergency care wishes to not be carried out.
Findings include:
A review of Resident 43's (R43) Face Sheet revealed an admission date of 7/28/2022 with diagnoses that included seizure disorder, cerebral infarction, and hypertensive emergency. A Minimum Data Set assessment dated [DATE] documented intact cognition.
On 10/5/2022 at 9:24 AM, a review of R43's electronic health record (EHR) revealed that an AMD was not available for the resident. On 10/5/2022 at 11:29 AM, the Nursing Home Administrator (NHA) was requested to provide a copy of R43's AMD.
On 10/6/2022 at 7:55 AM, a paper copy of a document titled, Consent to Advance Directive/Care Planning, dated 7/28/2022, was reviewed and revealed the following:
- Name of Signer: self
- In the event of an illness or change in the resident medical condition, normal care may not be enough to sustain life. Resident would want the best possible care to alleviate pain and suffering and to maintain the highest practicable well-being for health and comfort. In the event of the illness, I wish the following directive to be followed:
- A list of medical designations, including but not limited to cardiopulmonary resuscitation, mechanical ventilation, blood transfusion, organ donation, were to be checked with either a Yes or a No. None of the life sustaining items had been checked with a Yes or No.
- The signatory areas for the Resident or Legal Representative and Attending Physician were blank.
- A handwritten notation on the form documented, Resident unable to sign due to being partially blind.
During an interview and record review on 10/7/2022 at 2:35 PM, the NHA reviewed R43's AMD. The NHA stated, Nothing is marked. Did they ask him to sign it?
The following policy titled, Communication of Code Status, dated 10/7/2022, was reviewed and revealed in part the following: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information.
On 10/7/2022 at 6:00 PM during the exit conference, the NHA 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
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide evidence that residents were issued a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice - Form 10055) for three resident...
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Based on interview and record review, the facility failed to provide evidence that residents were issued a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice - Form 10055) for three residents (R31, R70, R71) of three residents who were reviewed for notices of Medicare non-coverage and appeal rights, resulting in the resident not being fully informed of the estimated cost in order to make a decision to continue therapy treatments. Findings include:
During an interview and record review on 10/7/2022 at 10:43 AM with the Minimum Data Set (MDS) Coordinator, BB the following was revealed:
- Resident #31 (R31) was discharged from Medicare covered Part A on 6/10/2022, had Medicare benefit days remaining, and continued to reside in the facility past the last covered day for their Medicare services.
- Resident #70 (R70) was discharged from Medicare covered Part A on 6/17/2022, had Medicare benefit days remaining, and continued to reside in the facility past the last covered day for their Medicare services.
- Resident #71 (R71) was discharged from Medicare covered Part A on 9/29/2022, had Medicare benefit days remaining, and was discharged from the facility on 9/30/2022.
- The facility completed a document titled, SNF Beneficiary Protection Notification Review, for each resident, R31, R70, and R71. A review of these documents revealed, and MDS Coordinator BB confirmed, that these three residents did not receive the SNF ABN.
During an interview on 10/7/2022 at 2:40 PM, the Nursing Home Administrator (NHA) said the SNF ABN notice was used to inform the resident of the cost of therapy should they want to continue. The NHA agreed that it's important for residents to be informed about the cost of therapy should they want to continue.
The facility policy titled, Advance Beneficiary Notices, dated 5/24/2022, was reviewed and revealed in part the following: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.
On 10/7/2022 at 6:00 PM during the exit conference, the NHA and Director of Nursing 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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00123692.
Based on interview and record review, the facility failed to obtain a physic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00123692.
Based on interview and record review, the facility failed to obtain a physician's order for discharge to the community for one resident (R534) out of 3 closed records reviewed for discharge orders, resulting in the lack of physician collaboration and unmet discharge needs. Findings include:
During an phone interview on 10/5/22 at 112:34 PM with R534's sister and RR, it was reported that the facility had my sister was sitting in a wheelchair on the front porch of the facility at 5:30 PM when I arrived to pick her up .They didn't give us enough time to make financial arrangements .There was no discharge instructions, bandages for the wound, or home care ordered.
A review of the Face Sheet for R534 documented an initial admission to the facility on 9/8/2021, readmission on [DATE], and discharge on [DATE]. R534's diagnoses included a diabetic foot ulcer and visual loss (legal blindness). An admission Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. The Face Sheet indicated R534's sister was the emergency contact.
A physician's progress note dated 9/10/21 revealed R534 had a Left Lower Extremity (LLE) heel ulcer (skin wound treated with debridement (removal of damages tissue from a wound).
A physiologist noted for evaluate capacity for medical decision-making and capacity to handle personal/financial affairs dated 10/12/21 documented, I agree with facility staff that resident does show some cognitive deficits in her insight, particularly related to how much assistance she needs due to her blindness .However, the deficits do not appear severe enough at this time to warrant stating that she lacks capacity. She performed well on cognitive testing and she is familiar with her medical and financial situation. At this time, she appears to retain capacity for medical decision-making and retains capacity to handle personal/financial affairs. However, I do agree that she needs some form of accommodations to assist her due to her blindness .
Review of the physician's orders from 10/2021 revealed no order for discharge, medical, nursing, equipment, educational, psychosocial needs, or referrals to local contact agencies.
A nurses note dated 10/20/2021 documented, Resident (R534) left at 5:30 PM. Sister was mode of transportation.
During an interview and medical record review on 10/06/22 at 12:30 PM, with the Director of Nursing (DON) and Social Service staff E the DON indicated a physician's order is to be obtained for discharge.
SS staff E said she was new to the facility and was not aware of the 30 involuntary discharge process at that time. SS E could not explain why local healthcare agencies were not contacted to coordinate medical care for R534.
Review of the policy titled, Discharge Planning Process dated 10/6/22 documented, .6. An active individualized discharge care plan will address, at a minimum:
a. Discharge destination, with assurances the destination meets the resident ' s health/safety needs and preferences.
b. Identified needs, such as medical, nursing, equipment, educational, or psychosocial needs.
c. Caregiver/support person availability and the resident ' s or caregiver ' s/support person ' s capacity and capability to perform required care.
d. Resident ' s goals of care and treatment preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00123692.
Based on interview and record review, the facility failed to notify, in writ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00123692.
Based on interview and record review, the facility failed to notify, in writing, the reason for a facility-initiated transfer to the resident representative (RR) and to the State Ombudsman for one (R534) of three residents reviewed for discharges, resulting in the potential for the resident to be misinformed, an inappropriate discharge, and/or not to have an advocate the ensure their rights.
Findings include:
During an phone interview on 10/5/22 at 12:34 PM with R534's RR/sister, it was reported that the facility gave a couple hours discharge notice to come pick the resident up from the facility. R534's sister reported the facility called her around 2:30 PM and my sister was sitting in a wheelchair with her belongings on the front porch of the facility at 5:30 PM when I arrived to pick her up.
A review of the Face Sheet for R534 documented an initial admission to the facility on 9/8/2021, readmission on [DATE], and discharge on [DATE]. R534's diagnoses included a diabetic foot ulcer and visual loss (legal blindness). An admission Minimum Data Set (MDS) assessment dated [DATE] document intact cognition. The Face Sheet indicated R534's sister was the emergency contact.
A physiologist noted for evaluate capacity for medical decision-making and capacity to handle personal/financial affairs dated 10/12/21 documented, I agree with facility staff that resident does show some cognitive deficits in her insight, particularly related to how much assistance she needs due to her blindness .However, the deficits do not appear severe enough at this time to warrant stating that she lacks capacity. She performed well on cognitive testing and she is familiar with her medical and financial situation. At this time, she appears to retain capacity for medical decision-making and retains capacity to handle personal/financial affairs. However, I do agree that she needs some form of accommodations to assist her due to her blindness .
A Social Service (SS) progress note dated 10/20/2021 at 3:56 PM documented, Resident (R534), Business Office Manager (BOM), and MDS Nurse to meet. BOM to explain that resident Medicaid application has been accepted, and her Medicaid status is active. BOM to explain percentage that Medicaid pays for facility stay and that resident is to pay. Resident reports her Social Security Income (SSI) will not be used for facility payment because . her facility stay will be covered for 90 days by her insurance .Resident has refused to pay for facility stay. BOM inform resident that she has to discharge from facility due to refusal to pay; Social Service to inquire whom should be contacted for discharge. Resident's sister has been notified of discharge and reports she will transport resident around 5 PM when she is off of work.
A nurses note dated 10/20/2021 documented, Resident (R534) left at 5:30 PM. Sister was mode of transportation.
During an interview and medical record review on 10/06/22 at 12:30 PM, with the Director of Nursing (DON) and Social Service staff E the DON indicated he was not the DON of the facility at that time. SS staff E said she was new to the facility and was not aware of the 30 involuntary discharge process at that time. SS E said the BOM issued the involuntary discharge and no longer works at the facility.
The Administrator was interviewed at 12:59 PM and reported she was aware that with a facility-intiated discharge a resident be given a 30 day notice. The Administrator added that she was on a leave of absence at the time of the event.
During a phone interview on 10/11/22 at 9:42 AM, Long Term Care Ombudsman II stated, I did'nt know R534 had been discharged . I never received any notification of the facility-initiated discharge. They are suposed to notify me. A resident like that needed to have services in place before discharge.
Review of the State of Michigan, Department of Licensing and Regulatory Affairs, Bureau of Community and Health System document ITD-100 titled, Notice of Involuntary Transfer or Discharge and Facility-Intiated Discharge for Nursing Homes dated 1/7/20 documented, As defined in 42 CFR 483.15 (c)(1), this form is to be used when there is a discharge of a resident from the nursing home to any location with the expectation that the resident will not return to the nursing home. The form lists date of notice, resident name, guardian/RR name, Nursing home name, transfer destination, reason for discharge, right to an Appeal Hearing, notification of Michigan Long Term Care Ombudsman and appeal request.
CONCERN
(D)
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 MI00119974.
Based on observation, interview, and record review, the facility failed to develop an indi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00119974.
Based on observation, interview, and record review, the facility failed to develop an individualized comprehensive skin care plan for one resident (R9) and an individualized comprehensive nutrition and hemodialysis care plans for one resident (R80) of 32 reviewed for comprehensive care plans, resulting in the potential for unmet medical and nutritional care needs. Findings include:
Resident #9 -
During an observation and interview on 10/4/2022 at 12:20 PM, Resident #9 (R9) was awake, lying in her bed, and was covered by a sheet. R9 stated, I have marks all over my body. I itch and scratch myself at night. R9 proceeded to pull back the sheet and red marks approximately the size of a small nail head were observed scattered all over her torso and arms. R9 stated, They put something on my body, but it is not working.
A review of R9's Face Sheet documented an initial admission date of 6/17/2021 and readmission date of 8/26/2021. R9's diagnoses included hemiplegia/hemiparesis following cerebral infarction and disorder of the autonomic nervous system. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. A review of physician's orders documented the following orders for topical skin care:
- Ammonium Lactate Cream 10 %. Apply to apply to (bilateral upper extremities), (abdomen) topically two times a day for re: dry skin.
- Hydrocortisone Cream 2.5 %. Apply to irritated skin topically every 6 hours as needed for itching.
An observation of the nursing treatment cart revealed both skin treatments were available.
A review of nursing progress notes documented the following:
- 9/5/2022: Bed bath given, skin assessment complete, resident has self inflicted scratches over upper torso.
- 7/19/2022: Resident skin issues. Previously identified area. Treatment in place.
Resident #80 -
The complainant reported to the State Agency that the resident's health may be declining in the facility.
A review of the Face Sheet for Resident #80 (R80) revealed an initial admission date of 4/14/2021, readmission date of 4/18/2021, and discharge date of 6/27/2021. R80's diagnoses included dependence on renal dialysis, diabetes mellitus - type 2, hyperlipidemia, hypertension, cerebral infarction, and peripheral vascular disease. An MDS assessment dated [DATE] documented intact cognition. The clinical record documented R80 received hemodialysis three times weekly on Tuesday, Thursday, and Saturday.
During an interview and record review on 10/6/2022 at 11:12 AM, Registered Dietitian (RD) T confirmed R80 was receiving hemodialysis treatments. RD T said she would consider R80 at high nutrition risk because of hemodialysis, renal failure, and diabetes. RD T said she was not familiar with (R80) and after a review of R80's clinical record did not see any nutrition notes, assessments, or care plans.
During an interview and record review on 10/6/2022 at 11:42 AM, the Director of Nursing (DON) confirmed R80 received hemodialysis treatments and was diagnosed with diabetes mellitus. A review of R80's clinical record with the DON did not reveal a renal or nutrition related care plan. The DON said this was a concern because R80 was at risk for infection because of the dialysis site and a nutrition care plan is pertinent to make sure the resident has an appropriate diet. The DON further considered if (R80) even had orders for hemodialysis or for nursing to check the hemodialysis site. The DON stated, There are no supportive orders for dialysis. No orders to check for bruit and thrill. (Nursing should) monitor the infusing site for skin integrity and signs and symptoms of infection. These would be in the orders and care plan. The DON confirmed R80 did not have renal or nutrition related care plans.
During an interview and record review beginning on 10/7/2022 at 1:10 PM, the DON said he was not familiar with the condition of R9's skin. Following an observation of R9's skin, the DON reported that R9 had redness which appeared to be a rash and there was scattered redness, most were scabbed over. R9 reported that they itch and that she scratches them at night while she sleeps. The DON confirmed R9 had been on a cream since at least May 2022. The areas covered with the scattered redness were her front torso and upper and lower extremities. When queried if R9's skin issues should be care planned, the DON stated, Yes it should be included in her care plan. I do not see one.
A review of the facility policy titled, Comprehensive Care Plan, dated 10/6/2022, was reviewed and revealed in part the following: The comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
On 10/7/2022 at 6:00 PM during the exit conference, the NHA (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
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 administer a Respiratory inhaler as prescribed for one...
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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 administer a Respiratory inhaler as prescribed for one Resident (#9) of 8 residents reviewed for medication administration, resulting in the potential for respiratory complications.
Findings include.
On 10/6/2022 at 11:34 a.m., Licensed Practical Nurse (LPN) FF was observed administering medication to R9 during an afternoon medication administration (Med Pass). After LPN FF administered the afternoon medications, R9 asked if she can get her inhalers. LPN FF stated, Oh, you didn't get your inhalers today? R9 stated, No, I didn't, and I need them. I always take my morning inhalers because this is when I become congested, in the morning. I refuse my noon nebulizer but not my morning inhalers. LPN FF went to the computer to reviewed R9 's morning medication administration records (MARs) and said, They were signed out as given for today at 0800. I wasn't here this morning. Another nurse had this cart when I got here. LPN FF opened the medication cart and said, Both inhalers are here.
On 10/6/2022 at 11:56 a.m., Unit Manager /LPN GG during an interview, UM/LPN GG stated, I was on this cart this morning, but I had someone assisting me passing medications. UM/LPN GG stated, I did not give (R9) her inhalers and I did not sign them out. UM/LPN GG said, Registered Nurse (RN) HH was helping me, and she is up on the second floor now. I will go ask her did she give R9 her inhalers. UM/LPN was informed that the surveyor would query RN HH regarding the inhalers. UM/LPN stated, I will call the Doctor to get a one-time order to give the inhalers now.
RN HH was interviewed on 10/6/2022 at 12:15 p.m. on the second floor and confirmed she did not administer R9's inhalers and signed the MAR, indicating the inhaler was given. RN HH stated, I wasn't assigned to her, the other nurse was (Referring to UM/LPN GG) The Unit manager came after me, she was supposed to give it.
Review of the electronic medication administration record revealed the initial of UM/LPN GG signed the inhalers out being administered on 10/6/2022 at 0800.
According to the electronic medical record (EMR), R9 was admitted to the facility on [DATE] with diagnoses of chronic obstruction pulmonary disease (A group of lung disease that block airflow and make it difficult to breathe), emphysema, and morbid (severe) obesity. R9's annual Minimum Data Set (MDS) with a reference date of 6/25/2022 indicated R9 was cognitive intact with a BIMS (brief interview for mental status) score of 15.
Review of the Physician's orders revealed as following:
- Incruse Ellipta Aerosol powder breathe activated 62.5 MCG/INH give one puff inhale orally one time daily active date of 8/9/2022.
-Fluticasone Furoate vilanterol Aerosol powder breath activated 100-2.5 (3) MG/3 ML give 3 ML inhale orally four time daily active date of 8/27/2021.
Further review of the physician's orders later that day revealed new orders as following:
-Incruse Ellipta Aerosol Powder Breath Activated 62.5 MCG/INH one puff inhale orally one time now dated 10/6/2022.
-Fluticasone Propionate HFA Aerosol one puff inhale orally one time now date 10/6/2022.
On 10/6/2022 at 2:15 p.m., the Director of Nursing (DON) was interviewed regarding R9's inhalers. The DON stated, The nurses are to follow the physician's orders and give the medication as the physician prescribed.
According to the facility's Documentation in Medical Record Policy revision date 10/7/2022 documented, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident .Policy explanation and Compliance Guidelines: 3. Principles of documentation include .False information shall not be documented.
In review of the Medication Administration policy revision date 10/7/2022 documented, Policy explanation and compliance Guidelines: 17. Sign MAR after administered .
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** Based on observation, interview, and record review the facility failed to administer eye drops per the ophthalmologist recommend...
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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 administer eye drops per the ophthalmologist recommendations for one resident (R36) of a total sample of two residents reviewed for vision; and failed to follow dental recommendations from an oral surgeon for teeth extractions for one resident (36) of a total sample of four residents reviewed for dental, resulting in discomfort, pain, and other unmet dental and vision needs.
Findings include:
On 10/4/22 at 12:15 p.m. during the initial pool tour, R#36 was observed resting in bed watching television. R#36 presented as alert, oriented to person, place, and situation as well as make all needs known. R#36 was observed wearing glasses and stated, I can't see out of them. I had them for about a month. I'm blind (experienced blurred vision) wearing them.
On 10/05/22 at 9:11 a.m. review of the clinical record documented R#36 was admitted into the facility on 1/24/22 with diagnoses that included cataract and Parkinson's disease. According to the quarterly MDS assessment dated [DATE], R#36 was cognitively intact with a BIMS score of 15 and required extensive one person assistance with most activities of daily living.
Review of the eye care group consultation dated 7/14/22 documented: Assessment: Cataract, nuclear, both eyes; Dry eye, both eyes; and Myopia and Presbyopia, both eyes . Plan: .Continue present eye medications; Monitor; Medication Order: Artificial tears oph. Solution, apply 1 drop, both eyes, at bedtime for 90 days .
The physician orders were reviewed and there was no evidence of eye drops ordered. The July 2022 to October 2022 medication administration record was reviewed and there was no evidence eye drops were administered.
On 10/6/22 at 12:33 p.m. R#36 was interviewed again and stated, I never got eye drops since being here. I didn't even know I was supposed to get them.
On 10/6/22 at 12:40 p.m. Nurse (FF) was interviewed and confirmed the was no physician's order for the eye drops in the electronic medical record. Nurse (FF) also confirmed eye drops had not been administered according to medication administration record. Nurse (FF) stated, She doesn't have any (eye drops).
On 10/4/22 at 12:15 p.m. during the initial pool tour, R#36 was observed resting in bed watching television. R#36 presented as alert, oriented to person, place, and situation as well as make all needs known verbally. R#36 expressed frustration of not seeing the dentist. R#36 opened her mouth and missing teeth can be seen on the lower and upper with the exception of two on the upper left and right sides. R#36 also expressed frequently having toothaches. R#36 stated, This tooth is loose, and it hurts. The resident was moving the tooth on the upper left side. I want dentures, but I need these taken out. I saw the dentist a couple of months ago, but they didn't do anything but exam them.
On 10/05/22 at 9:11 a.m. review of the clinical record documented R#36 was admitted into the facility on 1/24/22 with diagnoses that included Parkinson's disease, chronic obstructive pulmonary disease, congestive heart failure, kidney failure, ventricular fibrillation, and hypertension. According to the quarterly MDS assessment dated [DATE], R#36 was cognitively intact with a BIMS score of 15 and required extensive one person assistance with most activities of daily living.
There was no evidence of a dental care plan to address dental needs. Review of the pain care plan dated 1/24/22 did not address tooth pain. There was no evidence of an antibiotic care plan to address multiple tooth infections.
Review of the dental group consultation dated 7/28/22 documented the following:
Condition: Poor; Gingivitis, Inflammation/ Swollen, Bleeding Gums: Severe; Periodontal Condition: Poor. Treatment Notes: . Patient having discomfort to #11 (upper left tooth). One periapical film (x-ray) to #11. Film shows periapical lesion (abscess). Tooth #11 needs to be extracted .
Review of the physician's orders documented the following:
Schedule ASAP dental appt for tooth extraction. Start date 8/25/22.
Dental consult dx: pain, requesting extraction. Start date 4/5/22.
Review of the nurse progress notes documented the following:
7/5/2022 23:23 Nurses Progress Notes Resident remains on ABT for tooth infection no adverse reaction noted afebrile.
7/3/2022 13:20 Nurses Progress Notes Resident remains on ABT for tooth infection no adverse reaction noted afebrile.
7/2/2022 13:35 Nurses Progress Notes Resident remains on ABT for tooth infection afebrile no adverse reaction noted.
6/30/2022 06:41 Nurses Progress Notes Resident on continuing ABT therapy for tooth abscess .
6/27/2022 13:55 Nurses Progress Notes Resident continues penicillin ABT therapy for tooth abscess .
6/27/2022 07:24 Nurses Progress Notes ABT in progress for tooth abscess. McGeer's criteria met. MD notified. ABT to continue as prescribed.
6/26/2022 13:38 Nurses Progress Notes Resident has antibiotic ordered for tooth infection waiting for antibiotics to arrive .
6/24/2022 08:41 Nurses Progress Notes Resident c/o pain to tooth with an abscess. Resident states she spoke to someone previously about the pain . NP notified .
4/19/2022 23:19 Nurses Progress Notes Resident remains in oral ABT . administered all pm meds including oral ABT for tooth abscess .
On 10/6/22 at 11:51 a.m. the Social Service Director (SSD) was interviewed about the unmet dental and vision recommendations. The SSD stated, Once I get the consults from dental and/or vision, I give them to the Director of Nursing (DON). I was unaware the resident was having problems with her vision or dental.
On 10/7/22 at 2:35 p.m. the DON was interviewed about the unmet vision and dental recommendations. The DON stated, I do not recall this consultation for eye drops. I do not recall receiving this consultation from the SSD. Dental extractions are done outside of the facility and nursing arranges transportation and/or set up appointments. I facilitate once I receive them. Sometimes it can take a few days to a week to receive the consultations. A list of all patients with recommendations are then given to the unit manager to implement.
On 10/7/22 at 3:37 p.m. the facility's policy titled Dental Services dated 10/6/22 documented: It is the policy of this facility to assist residents in obtaining routine and emergency dental care . The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location
The facility's policy titled Hearing and Vision Services dated 10/6/22 did not document the process or procedure for addressing recommendations.
CONCERN
(D)
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 intake pertains to MI00119974.
Based on interview and record review, the facility failed to properly assess and implement n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This intake pertains to MI00119974.
Based on interview and record review, the facility failed to properly assess and implement nutrition interventions for two residents (R18, R80) of eight residents reviewed for maintenance or improvement in nutritional status, resulting in the potential for compromise in nutritional status. Findings include:
It was reported to the State Agency that the facility failed to provide a resident with proper food.
A review of the Face Sheet for Resident #80 (R80) revealed an initial admission date of 4/14/2021, readmission date of 4/18/2021, and discharge date of 6/27/2021. R80's diagnoses included dependence on renal dialysis, diabetes mellitus - type 2, hyperlipidemia, and hypertension. A Minimum Data Set assessment dated [DATE] documented intact cognition. The clinical record documented R80 received hemodialysis three times weekly on Tuesday, Thursday, and Saturday. Review of physician orders documented R80 was prescribed a Regular Diet on 4/29/2021.
A review of R80's hospital discharge documents dated 4/14/2021 revealed the following diet instructions: Diabetic diet. This is a carbohydrate controlled diet, with balanced meals. Cardiac diet with 2 gram sodium restriction. Renal diet. 1500 milliliter fluid restriction daily.
During an interview and record review on 10/6/2022 at 11:12 AM, Registered Dietitian (RD) T confirmed R80 was receiving hemodialysis treatments. RD T said for residents on hemodialysis she would normally complete a nutrition assessment and recommend a renal diet which is low in potassium and sodium. RD T stated, A regular diet would not be appropriate unless the renal center dietitian recommended it. RD T also confirmed that R80 was not on a fluid restriction. RD T said she would consider R80 at high nutrition risk because of renal failure and diabetes. RD T said she was not familiar with (R80) and after a review of R80's clinical record did not see any nutrition notes, nutrition assessments, nutrition care plans, or communication with the renal center dietitian.
During an interview and record review on 10/6/2022 at 11:42 AM, the Director of Nursing (DON) confirmed R80 was diagnosed with end stage renal disease and received hemodialysis treatments. The DON said it was his expectation for a resident on hemodialysis to be followed by the registered dietitian to monitor the resident's weight, to make sure there is no fluid overload, to monitor labs, and make changes to the diet as necessary.
The facility policy titled, Nutritional Management, dated 9/23/2022, was reviewed and revealed in part the following:
A systematic approach is used to optimize each resident's nutrition status:
- Identifying and assessing each resident's nutritional status and risk factors
- Evaluating/analyzing the assessment information
- Developing and consistently implementing pertinent approaches
- Monitoring the effectiveness of interventions and revising them as necessary.
On 10/7/2022 at 6:00 PM during the exit conference, the NHA 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.
Resident #18 (R18):
On 10/05/22 at 9:31 AM, R18 was observed seated in the 2 North hallway. R18 appeared very thin with dried lips, sunken eyes and cheeks. R18 was nonverbal and had severe cognition impairment. Certified Nursing Assistant (CNA) S was present and asked if R18 ate breakfast. CNA S said, He hasn't been eating well. He just came back from the hospital.
According to the Electronic Medical Record (EMR) R18 re-admitted to the facility from the hospital on [DATE] with new orders for a pureed diet and a documented weight of 145 pounds (lbs.). A Nutritional assessment dated [DATE] identified R18 had a significant weight loss of 12.8% in 30 days, a 12.3% weight loss in 60 days and weighed 117 lbs. The assessment indicated R18 was on a regular diet and received 4 ounces of Med Pass 2.0 (fortified health shake to supplement calories and protein) three times a day and one can of Ensure (nutrition shake) with each meal. A review of R18's orders and Medication Administration Records (MAR)for September 2022 revealed no documentation to support R18 had been ordered or received the 4 ounces of Med Pass 2.0 or the one can of Ensure three times a day.
A review of the previous Nutritional assessment dated [DATE] revealed R18 weighed 125 lbs., had a 3-5% weight change in 90 days, and a 7.5-10% weight change in180 days. On 6/23/22 the Registered Dietitian (RD) noted that R18 was not on any supplementation and recommended to give R18 Med Pass 2.0 three times a day. There is no mention of the one can of Ensure.
A review of R18's orders and Medication Administration Records (MAR) for June, July, and August of 2022 revealed no documentation to support R18 had received 4 ounces of Med Pass 2.0 three times a day or one can of Ensure with each meal.
A care plan for nutrition initiated on 12/28/21 had interventions that included monitor resident for oral intake and weights. There is no documentation regarding Med Pass 2.0 or can of Ensure.
On 10/5/22 at approximately 10:00AM during an interview with Registered Nurse (RN) B she said R18 had been sent out to the hospital by the physician on 9/30/22 for changed mental status and pocketing his food. RN B said the hospital sent the resident back with a pureed diet and no other change of orders. RN B requested nursing staff to obtain an admission weight on R18. RN B confirmed there was no documentation to support R18 had received any type of nutritional supplement or increased intake or weight monitoring since identified to have weight loss in June 2022. It was reported to RN B that R18's current weight was 106 lbs.
.
On 10/6/22 at 1:10 PM during an interview with the Director of Nursing (DON) he could not explain why R18 had not received any nutritional supplements that was recommended in the Nutritional Assessments from 6/23/22 or 9/27/22. The DON said, the resident should have been on increased oral intake and weight monitoring. I will review the hospital orders and recommendations with the doctor.
On 10/06/22 at 2:31 PM during an interview with Registered Dietitian (RD) T she said she had completed R18's nutritional assessment on 6/23/22 and recommended that he be put on Med Pass 2.0 three times a day. RD T said she placed her recommendation on the communication board and nursing should follow through with the recommendation and get an order from the physician. RD T said R18 was receiving one can of Ensure with every meal but could not produce any documentation to support that occurred. The Certified Dietary Manager (CDM) U reviewed R18's EMR including the dietary ticket from the kitchen and could not provide any documentation to support R18 had received Med Pass 2.0 or one can of Ensure with meals. RD T confirmed she had completed R18's Nutritional Assessment on 9/27/22 and thought he was receiving Med Pass 2.0 and the Ensure.
According to the facility's Weight Monitoring Policy last revised on 9/23/22:
Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.
Compliance Guidelines:
Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional
problem.
3.
Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible:
a.
Identified causes of impaired nutritional status
b.
Reflect the resident's personal goals and preferences
c.
Identify resident-specific interventions
d.
Time frame and parameters for monitoring
e.
Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or new causes of nutrition-related problems are identified.
f.
If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate.
g.
The resident and/or resident representative will be involved in the development of the care plan to ensure it is individualized and meets personal goals and preferences.
4.
Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status.
5.
A weight monitoring schedule will be developed upon admission for all residents:
c. Residents with weight loss - monitor weight weekly
d. If clinically indicated - monitor weight daily
e. All others - monitor weight monthly
6.
Weight Analysis: The newly recorded resident weight should be compared to the
or designee.
7. Documentation:
a. The physician should be informed of a significant change in weight and may order nutritional interventionsOn 10/05/22 at 9:31 AM R18 was observed seated in the 2 North hallway and appears very thin with
dried mouth, sunken eye and cheeks. Certified Nursing Assistant (CNA) S was asked if R18 was assisted with breakfast. CNA S said, He hasnt been eating well. He just came back from the hospital.
According to the Electronic Health Record (EHR) R18 re-admitted to the facility from the hospital on [DATE]. The last documented weight after hospitalization for
res did not eat breakfast, seated in hallway RR = res is pocketing food and declining care he was sent out to hospital 9/30 for further eval and nothing was done except iv fluids. and urinary catheter. res has LG and returned to facility on 10/4/22 without any change to orders/diet/meds. Weigth is documented in the EMR as 145 . physically looking at the resident he is exceptionally thin and emaciated with sunken eyes and cheeks. He last weight from facility on 9/12/22 indicated he weight 116.
I with Dreena 2N Unit manager Rn was interviewed she agreed resident would be reweighed. newly admitted last evening. according tot eh re-weigh he weighs 106 pounds!!!
MDs on 7/1/22 qrtly indicated weight of 125 no eating issue or dental issue. care plan indicated verbal cues needed to eating assistance in 6/22. the resident did not eat any breakfast today.
10/06/22 12:18 PM per CNA [NAME] said, resident is shaky and weak, he wasnt like this before he went to the hospital. resident was fed and ate 50% of his pureed diet.
RR: after return from the hospital the physician did downgrade the resident's diet to pureed and ordered for speech evaluation.
10/06/22 01:09 PM I with DON regarding weight loss for R#18 and why he didn't have any supplements ordered as recommended by the RD.DON said he would review the EMR
10/06/22 02:31 PM I with [NAME] and CDM, asked about june dietary assessment indicating that he lost weight and med pass a was recommended and not put on mar/tar or dietary tickeyt res did nt have ensure She said, (RD) CDM put on communication board for recommendation and talks wi nurse also both CDMa nd RD confirms that med pass was not given nor was ensure
10/07/22 012:31 PM laying in bed, had not eaten lunch
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R56
During a tour of the facility on 10/4/2022 at 10:47 a.m., R56 was observed sitting in his wheelchair alert and able to be in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R56
During a tour of the facility on 10/4/2022 at 10:47 a.m., R56 was observed sitting in his wheelchair alert and able to be interviewed. R56' s room had a feces-like smell upon entering. R56's bed linen was observed dirty with dark brown smears which appeared to be feces. R56 was asked when was the last time his bed was changed with clean linen? R56 stated, My bed have not been changed at least a week. I can't even remember the last time it was changed. I got a shower about two days ago and they didn't change my sheets then. You give a shower but don't change my bed sheets, Ha! (Shaking his head) that's not right.
On 10/6/2022 at 3:10 p.m., observed R56's bed linen dirty with dark brown smears which appeared to be feces. R56' s room had a feces like smell.
On 10/6/2022 at 3:40 p.m., Certified Nursing assistance (CNA) F was interviewed in R56's room regarding the facility's procedures when to change resident's bed linen. While observing R56' dirty bed linen, CNA F stated, Oh, Lord, I will change his sheet now. I gave him a shower yesterday, but I didn't know his sheets was like this. CNA F was asked, should she have change R56's bed linen at the time of his shower yesterday? CNA F said, Yes, you should change his sheets and pillowcases then and as needed.
According to the EHR, R56 was admitted to the facility on [DATE] with diagnoses of Multiple sclerosis, dementia, anxiety, and major depressive disorder. R56's quarterly Minimum Data Set (MDS) with a reference date of 8/20/2022 indicated R56 was cognitively intact with a BIMS (brief interview for mental status) score of 13. Required limited assistance of one person with Activity Daily Living (ADLs). A care plan initiated on 2/8/2019 for ADLs documented, Resident has impaired ability to complete ADL care and needs assistance related to diagnose multiple sclerosis, behavioral concerns, impaired cognition, impaired mobility.
Review of the facility's policy titled, Resident Environmental Quality dated 10/6/22 documented, It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public
R53
During an interview on 10/4/22 at 10:20 AM, R53 was asked about the cleanliness of the facility, R53 said, They (Facility) need to do some cleaning around here. R53 pointed to the overbed side table, it was observed to have several areas of dried brown areas related to liquid spills. R53 then pointed at the wall between the two wardrobe closets, the floor trim was observed to be separated from the wall and there was staining on the wall. When the door to room was moved, it was observed that there was dark sticky debris behind the door. In the corners of the room dust and debris could be seen.
Record review revealed R53 was admitted into the facility on 7/19/22 with a diagnosis of generalized muscle weakness. According to the Minimum Data Set (MDS) dated [DATE], R53 had intact cognition.
Resident #43 -
During an interview on 10/6/2022 at 1:55 PM, Resident #43's (R43) Concerned Family Member said she visited R43 last week and his bed looked like a gurney or a cot. It did not look comfortable.
During an observation and interview on 10/6/2022 at 5:00 PM, R43 was observed dressed, awake, and sitting on his bed. When asked if his bed was comfortable, R43 stated, I feel like I'm sleeping on a box spring. It's been uncomfortable for a while, at least a week. The mattress on R43's bed was a deflated low air loss mattress.
During an observation and interview on 10/6/2022 at 5:03 PM with Certified Nurse Aide (CNA) CC, R43's bed was observed. CNA CC stated, There is no cushion. I felt the spring underneath. I would not want to lie in that bed. It feels uncomfortable.
During an observation and interview on 10/6/2022 at 5:04 PM with CNA DD, R43's bed was observed. CNA DD stated, I felt no cushion. I felt the metal that the mat is on. It feels very uncomfortable.
During an interview on 10/6/2022 at 5:12 PM, Maintenance Supervisor D said the mattresses lie on a frame/spring which was made from metal.
During an interview on 10/7/2022 at 10:37 AM, R43's roommate, Resident #86 who was alert and fully oriented said R43's mattress had been deflated since he's been in that room.
A review of R43's Face Sheet revealed an admission date of 7/28/2022 with diagnoses that included seizure disorder, cerebral infarction, and hypertensive emergency. A MDS assessment dated [DATE] documented intact cognition.
During an interview on 10/7/2022 at 10:01 AM, the Director of Nursing (DON) stated, There could be many reasons for the mattress to be deflated. The DON said R43's mattress was inflated when he spoke with him in his room on 10/5/2022.
On 10/7/2022 at 6:00 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.
This citation pertains to Intake number MI000129720 and MI00130963.
Based on observation, interview, and record review, the facility failed to: 1. Ensure toilets were functioning for rooms 231, 233, 235, and 237; 2. Provide adequate housekeeping services to ensure the 2North common area, resident rooms (Room numbers 223, 225, 227, 229, 231, 233,235, 237) and hallways on the first and second floors were free from debris, odors and stains on walls; 3. Ensure adequate lighting, repair broken slats on window blinds, repair chair cushions, close gaps in air conditioning unit, paint over plaster wall repair, paint over scrapes on walls, provide clean linen, repair closet doors and dresser drawers, and ensure resident's bed had an appropriate mattress, affecting 6 residents (R42, R43, R53, R56, R70, R86) of 32 residents reviewed for environmental concerns, resulting in the potential for dissatisfaction in living conditions.
Findings Include:
During an observation on the second floor nursing unit on 10/06/22 at 9:06 AM with Housekeeping Supervisor A, dust, debris and a build up of dark black residue was noted around the tile floor baseboards. Housekeeping Supervisor A confirmed the observation reporting the black residue on the floor was old wax build up saying, I have been trying to hire a floor tech (dedicated staff that stripped old wax off the tile floor and applied new) since I took over the position in June (2022), but staff hire in and quickly quit.
During an observation on the second floor nursing unit on 10/06/22 at 9:38 AM with Maintenance Director (MD) D the following was observed:
-room [ROOM NUMBER] (R22); a build up of dark black residue was around the floor baseboards, one drawer of 3 drawer dresser noted missing, door handle to closet missing, chipped paint on walls, no paint noted over wall repair patch, over bed light not working;
-room [ROOM NUMBER] (R38); broken blind slats, a build up of black residue was around floor baseboards, food debris on floor, chipped pain on walls;
-room [ROOM NUMBER] (R37); a build up of black residue was around floor baseboards, no blinds on windows, scratches on walls, dried spilled dark brown substance on door frame of bathroom, missing drywall on inner window frame, broken wood molding on wall;
-room [ROOM NUMBER] (R45); food spills noted on walls, curtains on windows missing hooks;
-Dining/day room at end of hallway; 2 chairs with torn seat cushions with foam exposed; and
- an air conditioner in window with gaps noted to the outside.
MD D reported starting painting couple of weeks ago on the first floor, but had not been able to complete the job. MD D confirmed that other than himself, there was one other staff member in the Maintenance Department, saying With all the other work that needs to be done, I get to the repairs when I have time.
MD D did not confirm if regular room inspections were performed.
Review of the second floor Maintenance Log book revealed the last entry in the log was 6/2022 (4 months prior).
On 10/4/22 at 1:00 PM during a tour of the 2 North secured unit a strong smell of excrement and urine permeated the hallway. Resident 86 (R86) said, My toilet has been plugged up since I got here and the smell is unbearable. Go in there and take a look. The light doesn't work either. I went next door but that toilet is plugged up too. I have to go across the hall to use the bathroom.
On 10/4/22 at 1:00 PM the bathroom floor between rooms [ROOM NUMBERS] was covered with brownish yellow liquid that strongly smelled of excrement and urine with the presence of three flies swarming around the toilet. The toilet was full of toilet paper and overflowing brown liquid. The overhead light did not work and there was no light from an outside window.
On 10/04/22 at 1:08 PM the bathroom floor between rooms [ROOM NUMBERS] had brownish yellow liquid on the floor that strongly smelled of excrement and urine with the presence of a fly swarming around the toilet. The toilet was full of toilet paper and overflowing brown liquid. Maintenance Director (MD) D was present and said they would snake out the toilets.
On 10/4/22 at approximately 1:30 PM the 2 North activity room had a puddle of yellow liquid on the floor that smelled like urine and the presence or several flies hovering around it.
On 10/4/22 at approximately 1:45 PM Certified Nursing Assistant (CNA) H said that the toilets had been plugged up for about two days and maintenance had been made aware of the issue. CNA H said that there were four residents (R42, R43, R70, and R86) that were independent or continent with toileting that had to use the toilet in room [ROOM NUMBER] for the last two days.
According to R86's Electronic Health Record (EHR) he admitted to the facility on [DATE]. R86 had no cognition impairment and was independent with all Activities of Daily Living.
On 10/05/22 at 8:52 AM the 2 North unit had a strong odor of excrement and urine throughout the hallway. The bathroom light between room [ROOM NUMBER] and 233 did not work. The 2 North activity room had a puddle of yellow liquid that smells like urine and several flies around it on a table and a chair. At this time the Director of Nursing (DON) was asked about the puddle of yellow liquid on the floor and said he would notify housekeeping staff immediately.
On 10/06/22 at 9:54 AM the 2 North activity room had a puddle of yellow liquid on a chair and the floor. Environmental Staff (ES) Z was present and asked about the daily puddles of yellow liquid on the 2 North activity room floor. ES Z said, Yeah this happens almost everyday We just plan to come up here and clean it everyday.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 7
According to R7's Electronic medical record, he was admitted to the facility on [DATE] with diagnoses of hemiplegia a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 7
According to R7's Electronic medical record, he was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, adjustment disorder with mixed anxiety and depressed mood, major depressive disorder recurrent severe with psychotic symptoms, and dementia. R7's quarterly Minimum Data Set (MDS) with a reference date of 6/22/22 indicated R7 is cognitive intact with a BIMS (brief interview for mental status) score of 14. A care plan start date on 9/22/22 for Cognition documented, I have moderately impaired cognitive function related to my diagnoses of schizophrenia, anxiety and depression. I make poor decisions.
Review of the medication administration record (MAR) revealed, Quetiapine Fumarate tablet 25 mg give one tablet by mouth at bedtime for major depression order date 12/17/2021 was administered on 10/1/2022 through 10/5/2022.
Review of R7's 10/5/2022 Level I preadmission screening annual resident review (PASARR-form 3877) a form used to screen mental illness/intellectual developmental disability /related conditions identification of Michigan Department of Health and Human Services on 8/31/2022 revealed, Section II, Numbers 1, 2 and 3 on the form were checked Yes with the diagnoses of Mental Illness circled. The section reflected the preparer was to explain any Yes and Major Depressive Disorder, dementia, schizophrenia and 1 anti-depression medication that R#7 was prescribed.
According to the Level I preadmission screening annual resident review (PASARR-form 3877) a form used to screen mental illness/intellectual developmental disability /related conditions identification of Michigan Department of Health and Human Services Notes: The person screened shall be determined to require a comprehensive level II OBRA evaluation if any of the above items are Yes Unless a physician, nurse PR actioner or physician's assistant certifies on form DCJ-3877 that the person meets at least one of the exemption criteria.
section II:
#1) The person has a current diagnosis of mental illness (Yes).
#2) The person has received treatment for mental illness (Yes).
#3 The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days (Yes).
Explain any Yes
schizophrenia, dementia, and adjustment disorder with mixed anxiety and depressed mood. RX: Quetiapine 25 mg, (antidepression medications).
Being that Section II (Numbers 1, 2 and 3) were checked Yes, the Level II OBRA 3878 was searched for in the EMR but could not be located.
The EHR revealed no written request Facility Intake Referral for the Level II (3878).
On 10/6/2022 at 10:13 AM during an interview with the Director of Social Services (DSS) E a hard copy of R7's Level II (3878) was requested. On 10/6/2022 at 2:30 p.m. a copy of the Level I (3877) was presented in the conference with no Level II (3878). DSS E was asked when should a Level II of the PASSAR screening be completed? DSS E stated, I don't know when you are supposed to request a Level II on this resident. I just got out of training in June.
Resident #36
On 10/4/22 at 12:15 p.m. during the initial pool tour, R#36 was observed resting in bed watching television. R#36 presented as alert, oriented to person, place, and situation as well as make all needs known. The resident stated, I'm ok, but I get very nervous about everything, especially being here.
On 10/05/22 at 9:11 a.m. review of the clinical record documented R#36 was admitted into the facility on 1/24/22 with diagnoses that included personal history of other mental and behavioral disorders, undifferentiated schizophrenia, anxiety disorder, and Parkinson's disease. According to the quarterly MDS assessment dated [DATE], R#36 was cognitively intact with a BIMS score of 15 and required extensive one person assistance with most activities of daily living. Section A1500 of Preadmission Screening and Resident Review (PASRR) of the MDS also documented: Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition? No.
Review of the hospital 3877 which was completed by the hospital on 1/13/22 documented the following: The resident had mental illness and Dementia (both checked), but diagnoses were not specified in the explanation section of the document. The Mental Illness/Intellectual Disability/ Related Exemption Criteria Certification (3878) indicated Hospital Exemption Discharge also dated on 1/13/22: . The patient under consideration 1.) is being admitted after a hospital stay, AND 2.) requires nursing facility services for the condition for which he/she received hospital care, AND 3.) is likely to require less than 30s days of nursing services.
The two documents indicated a Level II (comprehensive Level II OBRA (Omnibus Budget Reconciliation Act)) evaluation is required, however there was no evidence the evaluation was completed in the medical record.
Review of the psychiatric services progress note dated 1/31/22 (initial) documented the resident had mental illness diagnoses: Undifferentiated schizophrenia and anxiety disorder. There was no evidence, R#36 had a dementia diagnosis.
On 10/05/22 at 3:35 p.m. the Social Service Director (SSD) was interviewed and stated she did not send the referral for a Level II evaluation. The SSD also stated she thought she had up to a year to have the evaluation done.
Based on observation, interview, and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) forms for Mental Illness/ Intellectual Disability/ Related Conditions Identification (DCH-3877) documents were reviewed, revised, and sent to the local state agency for annual evaluation for a Level II determination for four (R7, R36, R69, and R70) of eight residents reviewed for PASSARs, resulting in the potential for unmet intellectual/ developmental disability care needs.
Findings include:
Resident #69 (R69):
A review of R69's electronic medical record (EMR) did not reveal any PAS/ARR forms (DCH-3877) or Level ll evaluation. There was no Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening).
According to R69's Minimum Data Set (MDS) dated [DATE] she had resided in the facility since 2002 with diagnoses that included psychosis, major depressive disorder, and dementia with behaviors. R69 was prescribed an antipsychotic medication seven days a week.
Resident #70 (R70):
A review of R70's electronic medical record (EMR) did not reveal any current PAS/ARR forms (DCH-3877) or Level ll evaluation. The last PAS/ARR form was dated 2018. There was no Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification (DCH-3878) form. (The DCH-3878 is a State of Michigan Department of Health and Human Services (MDHHS) form used to claim exemption for level ll screening).
According to R70's MDS dated [DATE] he has resided in the facility since 2018 with diagnoses that included paranoid schizophrenia and dementia with behaviors. R70 was prescribed two separate antipsychotic medications seven days a week.
On 10/4/22 at 2:50 PM during an interview with the Social Service Director (SSD) she was asked to provide the PAS/ARR (3877) and any Level ll OBRA assessments for R69 and R70.
On 10/05/22 at 3:35 p.m. the Social Service Director (SSD) was interviewed and said she could not provide any evidence that she had completed a PAS/ARR form or Level ll evaluation for R69 or R70.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide meaningful, diverse, and engaging activities 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 provide meaningful, diverse, and engaging activities for five (R41, R68, R69, R70, and R86) of seven residents reviewed for activities, resulting in feelings of boredom, decreased quality of life and potential for social isolation. Findings include:
On 10/04/22 at approximatley 10:15 AM on the 2 North secured unit one resident was in the activity/day room seated by herself in a wheelchair (R69). The TV was off and there was no music, or objects in the activity room. There were no pictures or décor on the walls or on the tables in the activity room. There was no activity calendar posted in the activity room. There was a large puddle of yellow liquid in the middle of the floor that smelled like urine and several flies were present. In the hallway across from the nurse's station 7 residents were sitting in wheelchairs or regular dining chairs not talking. There was no music or any type of engaging activity. There was no activity calendar posted at the nurse's station, or the hallways.
On 10/04/22 at 10:18 AM R68 said, I'm just sitting here. There is nothing for me to do.
On 10/04/22 at approximately 10:20 AM R86 said There is nothing to do around here. It's pitiful! Unless you are a smoker you can't even go outside.
10/04/22 10:33 AM R69 was up in the activity room in her wheelchair with the TV off. R69 was talking to herself and yelling out. Upon inquiry R69 said, I don't know what to do here.
On 10/4/22 at 10:39 AM R41 was in her room, lying in bed singing out in a child-like voice. Upon inquiry R41 complained of not having access to a TV, a phone, or music to listen to. This is terrible. I have nothing to do here.
On 10/4/22 at 10:41 R70 was wandering in and out of other resident's rooms and non-verbal when interviewed.
On 10/4/22 at 10:45 AM Certified Nursing Assistant (CNA) X was asked about activities for the 2 North secured unit residents. CNA X said she had never seen any activity in the 2 North activity room and only the residents who smoke have gone to the patio. CNA X said there was an activity calendar in room [ROOM NUMBER].
According to the activity calendar on 10/4/22:
10:00 AM Church Service
11:00 AM Reader's corner
2:00 PM Last Days patio time
2:30 PM Ice Cream Social.
On 10/4/22 at 12:46 PM there were four residents (R68, R69, R70, R86) in the 2 North activity room with no TV, no music, or any engaging activity taking place on 2 North. At 2:30 PM no resident from 2 North had been taken to the patio and no resident had been offered any ice cream. At 2:40 PM R68, R69, R70, R86 were observed seated in the activity room or ambulating up and down the 2 North hallway.
During observations of the 2 North secured unit on 10/05/22 at approximately 8:55 AM, and from approximately 12:37 PM through 2:00 PM there were no activities, the TV was off, there was no music playing for the residents. Several residents, including R68, 69, 70, and 86 were seated in the hallways across from the nurse's station not engaging in any meaningful activity.
On 10/5/22 at 1:15 PM R68 said, I'm still just sitting here. There is nothing to do here. R68 asked why he couldn't even get a TV in his room. R86 asked if they could have some Motown music on. R41 remained in her room lying in bed without any TV or music on.
On 10/5/22 at 1:40 PM CNA Y was asked if anyone had offered any activity to the residents on 2 North and she replied, No, they don't have anyone to do activities for them. I think there is only one activity person in the building right now. I'll put some music on from my phone for them. At 1: 43 PM R86 and R70 confirmed there had been no person that offered them any type of activity. R86 said he did not go outside yesterday, nor was offered any ice cream or snacks.
According to the Activity Calendar on 10/5/22:
10:00 AM Let's Chat
11:00 AM Baking time
2:00 PM Bingo
3:00 PM Table games
On 10/05/22 at approximately 2:00 PM, Registered Nurse (RN) B said every person should be included in activities that are appropriate for them and have an activity calendar in their room. RN B said that even non-smokers could be assisted to the patio during smoke breaks because they are supervised.
On 10/05/22 at 2:20 PM during an interview with the Activity Director (AD) V she said that several activities had been changed or cancelled because she was the only activity person in the building. On 10/4/22 the 'ice cream social' had been changed to a popcorn snack because the facility did not have any ice cream. On 10/5/22, Baking time was changed to a potato chip snack and Bingo had canceled. AD V confirmed she did not go to 2 North with the popcorn or potato chip snacks. Upon inquiry of 'patio time', AD V said that even non-smokers could go to the patio during smoke break but confirmed that 2 North residents had not been included on 10/4/22 or 10/5/22.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to meet the requirement for staff vaccinations, resulting in 10 out of 104 staff members not being vaccinated or receiving a medical or religio...
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Based on interview and record review the facility failed to meet the requirement for staff vaccinations, resulting in 10 out of 104 staff members not being vaccinated or receiving a medical or religious exemptions per the regulation from The Center of Medicare and Medicaid Services (CMS) and the potential for further spread of COVID-19 Virus. Findings Include:
Record review of facility's Covid-19 Vaccination Employee Tracking Log and Covid-19 Exemption Employee Tracking Log revealed the facility had 104 total employees. 89 of the employees had been vaccinated, 5 of the employees had either medical or religious exemptions, and 10 employees had received one vaccine but had not completed the second vaccine in a timely manner. Therefore, the facility was only at an 90.38 percent compliance rate.
Further review of the above logs revealed the 10 employees were due a second dose of a vaccine to be considered fully vaccinated and did not receive or return evidence of their second vaccination to facility. The following employees were reviewed:
1.
Employee B received first dose on 11/30/21.
2.
Employee G received first dose on 8/7/22.
3.
Employee J received first dose on 11/30/21.
4.
Employee K received first dose on 7/26/22.
5.
Employee L received first dose on 10/28/21.
6.
Employee N received first dose on 3/15/22.
7.
Employee O received first dose on 7/26/22.
8.
Employee P received first dose on 11/10/21.
9.
Employee Q received first dose on 3/25/22.
10.
Employee R received first dose on 5/11/22
During an interview on 10/7/22 at 12:20 PM with Nursing Home Administrator (NHA), it was confirmed that the facility was not in compliance with the CDC requirement regarding staff vaccinations and exemptions.
During an interview on 10/7/22 at 1:10PM with Director of Nursing (DON), when asked the reason for noncompliance, DON said, We were waiting for them to bring in their cards to show they had completed vaccination.
Record review of Employee Vaccination for Covid-19 (no date) documented the following:
It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines.
.Compliance Guidelines: 1. The facility will ensure that all eligible employees are fully vaccinated (CMS term) or up to date (CDC term) against COVID-19, unless religious or medical exemptions are granted as per CMS guided timeframes .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Rooms 112, 114, 121, 123, and 125
On 10/4/22 at 1:08 p.m. there were five rooms (112, 114, 121, 123, and 125) with hall call lig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Rooms 112, 114, 121, 123, and 125
On 10/4/22 at 1:08 p.m. there were five rooms (112, 114, 121, 123, and 125) with hall call light indicators on. The indicators were located above the room doors and with a luminated light.
On 10/4/22 at 1:23 p.m. the five rooms continued to have the hall call light indicators on however staff were not going into the rooms to answer the call lights.
At 1:23 p.m. the call light was on in room [ROOM NUMBER], however there were no residents in the room. The call light cord was not connected to the wall call light unit and there was a piece of black tape over the wall unit indicator.
At 1:24 p.m. the call light was on in room [ROOM NUMBER]. There was no one in the room. Although the call light cord was connected to the wall unit, there was a piece of black tape over the wall indicator unit.
At 1:26 p.m. the call light was on in 125. The resident in the room was asked did the call light worked. The resident shook his head no and stated, It's broke. The cord was not connected to the wall and there was a piece of black tape over the wall unit indicator.
At 1:29 p.m. there was a resident in room [ROOM NUMBER] sleeping. The hall call light indicator was on. The call light cord was on the floor. The call light indicator unit on the wall had a black piece of tape over it. There was a handheld bell on the bedside table beside the resident's bed.
On 10/4/22 at 2:25 p.m. the call light panel located on the wall at the nurse's station displayed 12 red luminated lights indicating the call lights were on. There were no audio indicators heard. A nurse aide walking by was asked why was did the panel display so many call lights on but not the hall call light indicators. The nurse aide stated the call light system isn't working.
On 10/7/22 at 12:35 p.m. the Maintenance Director was interviewed and stated, The call light system has been an on-going project. I got a few quotes to get a new call light system. The black tape was put on by a company that came to assess the call light system to indicate something is wrong with the call light. Residents were given a bell in place of the call light. The call lights have been a problem off and on for a couple of months.
The Maintenance Director was asked what if the bell can't be heard or residents get tired of manually ringing the bell. The Maintenance Director did not provide a response to the inquiry.
Based on observation, interview, and record review, the facility failed to provide alternate means of alerting staff when the Resident Call System was not available for one resident (R48) and failed to have a functioning Resident Call System for two resident (R23 and R53) and five rooms (112, 114, 121, 123, and 125) from a sample of 32, resulting in the potential for delayed ability to contact staff for care needs.
During observations on 10/4/22 at 1:24 PM, 10/5/22 at 8:36 AM, 12:48 PM, 2:38 PM and 10/6/22 at 8:32 AM, R48 was observed to not have a Resident Call System light (call light) in the room. At 9:03 AM, along with the Unit Manager (UM) Licensed Practical Nurse (LPN) B she reported, the resident in bed 2 (R48's roommate) rolls around on the floor and keeps pulling the call light out of the wall taking away the resident in bed 1's (R48's bed) ability to have access to a call light. UM B was unsure how long the call light had been missing.
During an interview with Maintenance Director (MD) D on 10/06/22 at 9:38 AM, he reported he was not aware that the call light was missing from R48's room.
Record review revealed that R48 was admitted into the facility on 2/3/21 with diagnoses which included Schizoaffective disorder (mental health disorder), dementia and high blood pressure. The Minimum Data Set (MDS) dated [DATE] indicated R48 had impaired cognition with a Brief Interview for Mental Status (BIMS) score of 3/15. The MDS indicated R48 required one person staff assistance for all Activities of Daily Living (ADL's).
Review of the facility's policy titled, Call Lights: Accessibility and Response reviewed 10/6/22 documented, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents bedside, toilet, and bathing facility to allow residents to call for assistance. Call Lights will directly relay to a staff member or centralized location to ensure appropriate response. In the event there a failure in the call light system an alternative (bells, whistles) will be used as an alert system.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00126680.
Based on observation and interview, the facility failed to maintain adequate ventilation o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00126680.
Based on observation and interview, the facility failed to maintain adequate ventilation on the first floor resulting in the potential for an increase of odors and possible poor air quality for all residents on the first floor. Findings include:
It was reported to the State Agency that the facility's lobby smells of smoke.
During an observation on 10/5/2022 at 2:30 PM, an intense cigarette smell was noted in the front vestibule. Both doors leading to the outside porch were closed.
During an observation on 10/7/2022 at 10:30 AM, an intense cigarette smell was noted in the front vestibule. Both doors leading to the outside porch were closed.
During an interview on 10/7/2022 at 2:46 PM, the Nursing Home Administrator (NHA) stated that the front vestibule does [NAME] of smoke. You can smell it all the way down to Unit One when the residents are out on a smoke break. The NHA said she was not sure when the ventilation system was updated. The NHA stated, It's a concern but it's out of my control. When we had air purifiers that helped a little.
During an interview and observation of the Unit One hallway on 10/07/22 at 3:30 PM, the NHA stated, I had three (air purifiers) in this hallway. The air purifiers were gone.
On 10/7/2022 at 6:00 PM during the exit conference, the NHA 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 clean food contact surface, clean cooking utensils after use, have a working and accessible hand washing station, a...
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Based on observation, interview, and record review the facility failed to maintain a clean food contact surface, clean cooking utensils after use, have a working and accessible hand washing station, and bring and maintain precooked chili to the appropriate temperature potentially affecting all residents that consumed food from the kitchen, resulting in the increased potential for food borne illness due to cross contamination. This deficient practice had the potential to affect all residents who consumed facility-prepared meals.
Findings include:
On 10/4/22 at 9:40 a.m. during the initial brief kitchen tour, it was discovered the kitchen was closed for renovations on 10/3/22 and temporarily moved to the activity's office for two weeks. Upon entering the activity's office, two large cookers were observed on the counter. The cooker's contained chili that was going to be served for lunch. The counter also contained office binders, folders, stacks of paper, a sizable box of oatmeal, face shield, and a bottle of solution. There was a plastic storage bag with a whisk inside of it. The whisk had been used to stir the chili and had residue of food on it. There were flies that landed on various areas of the counter. There was no hand washing station in the office. There was small green bucket filled with water and a cloth sitting at the end of the counter.
At 10:00 a.m. the Kitchen Manager was interviewed and asked where staff washed their hands. The Kitchen Manager stated, They use the bathroom across the hall and there is hand sanitizer near the door.
At 10:02 a.m. the bathroom across the hall from the activity's office was observed. At that time, there was someone using it. Immediately upon entering the bathroom, the sink was observed with standing water. The Kitchen Manager was asked what happens if there is always someone in the bathroom when handwashing is needed. The Kitchen Manager stated, We wait and there's hand sanitizer available too. The Kitchen Manager was asked about the standing water in the sink and stated, Maintenance had been told about the sink a couple of days ago and hadn't fixed it yet.
At 10:20 a.m. Dietary Aide (JJ) removed the chili from the cookers, placed it in a large cooking pan, and placed it on the steam table. The temperature of the chili was taken and temped at 145 degrees.
At 11:30 a.m. Dietary Aide (JJ) checked the temperature of the chili again before plating and serving. The chili tempted at 143.9 degrees. Dietary Aide (JJ) was asked what the appropriate temperature should be for serving. Dietary Aide (JJ) stated, At least 150 degrees. The aide was then asked was the steam table temperature checked. The aide stated, No. No one ever told me I should do that.
On 10/5/22 at 8:54 a.m. the Kitchen Manager was interviewed about the temperature of the chili and stated, The temperature of the chili should have reached 180-190 degrees while it was in the cooker before going on the steam table. Food should always reach the appropriate temperature.
On 10/5/22 at 1:05 p.m. the Registered Dietitian was interviewed and stated, The kitchen renovations were planned, and we knew about it weeks in advance. The handwashing in the bathroom was ok but I was not aware of a problem with the sink. Hot food should be maintained at 160 degrees. Food should be reached at the appropriate temperature to prevent cross contamination. There should not have been items on the counter while food was being cooked once again to prevent cross contamination.
According to the 2013 FDA Food Code:
Section 3-101.11, entitled, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under § 3-601.12, honestly presented.
Section 4-602.11. Equipment Food-Contact Surfaces and Utensils. Equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred.
Section 6-301.12: Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to properly dispose of refuse and maintain cleanliness of the facility grounds resulting in the potential harborage of pests. This deficient pra...
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Based on observation and interview, the facility failed to properly dispose of refuse and maintain cleanliness of the facility grounds resulting in the potential harborage of pests. This deficient practice has the potential to affect all 77 residents in the facility. Findings include:
On 10/5/22 at 3:06pm - 3:10pm, during an observation of the outside environment with the Kitchen Manager and Registered Dietitian, upon entering the receptacle area, there were numerous cigarette butts scattered on the ground. Within a few feet, two wooden platforms were leaning against the building. There was also a piece of plexiglass with it's wrapping laying on the ground.
Next to wooden platform, was a small grey plastic trash can on the ground (empty). There was a large black bin uncovered with a plastic bag with trash (contents unknown) and soiled gloves and used facial mask along with other debris.
A small metal dumpster was observed with trash overflowing out of it with plastic trash bags torn open. The clear plastic bags exposed foam containers that were torn out of the bags along with food and used facial mask. The ground in front of the dumpster had empty milk cartons, paper, foam cups, cup lids, foam containers, torn clear plastic bags, empty food cups, cigarette butts, and plastic forks and spoons. Behind the dumpster, there was a small black garbage bag, an empty food cup, and paper on the ground.
There were two large green metal dumpsters, one in which had a piece of torn plywood on the ground in front of it.
The Registered Dietitian and Kitchen Manager stated, The kitchen is supposed to use the green dumpsters not that other one (small grey dumpster). They were unable to say who is responsible for maintaining the cleanliness of the trash area.
On 10/7/22 at 9:02 a.m. review of the facility's policy titled Disposal of Garbage and Refuse dated 10/6/22 documented: The facility shall properly dispose of kitchen garbage and refuse . Garbage shall be disposed of in refuse containers with plastic liners and lids . Garbage and refuse containers shall be durable, cleanable, and free from cracks or leaks and covered when not in use . Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized . Dumpsters shall be emptied according to the facility contract. Garbage should not accumulate or be left outside the dumpster.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to maintain 1.) a clean and sanitary pantry that housed the ice machine on the first floor of the facility; 2.) ensure the ice ma...
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Based on observation, interview, and record review the facility failed to maintain 1.) a clean and sanitary pantry that housed the ice machine on the first floor of the facility; 2.) ensure the ice machine on the first floor was in good functioning condition, resulting in the potential for cross contamination. This deficient practice has the potential to affect all 77 residents in the facility. Finding include:
On 10/4/22 at 1:50 p.m. while on the first floor completing the initial environment observation of the facility, the door to the pantry was observed ajar. Upon walking into the pantry, a white sheet was observed on the floor underneath the ice machine. There were wet spots in front of the ice machine as evidenced by dirty footprints. Upon opening the ice machine door, pooled water and melted ice was observed. The inside of the ice machine door also appeared to have a brown dust like substance that coated the hinge of the door. The back of the ice machine had a pink basin filled with standing water positioned placed underneath the draining mechanism. Inside the water filled basin, was a metal spoon, empty salad dressing package, and plastic lid. The water also appeared to have collected residue that settled to the bottom of the basin. Further behind the ice machine, trash was observed on the floor. The floor had rust like stains on it. The lower part of the wall had missing tiles.
Upon leaving the pantry, the door was attempted to be closed but would not close completely. The door appeared to be stuck and further force would damage the door.
On 10/5/22 at 3:00 p.m. the Kitchen Manager stated the kitchen does not have an ice machine and gets ice from the first-floor ice machine. The Kitchen Manager was told about the conditions of the pantry and ice machine. The Kitchen Manager stated with a frowned face, I don't eat that ice. I don't use the ice from there.
On 10/7/22 at 12:42 p.m. the Maintenance Director was interviewed about the condition of the pantry's door and ice machine. The Maintenance Director stated, I put a brand-new pump on the ice machine. The other pump could not keep up with the drainage from the ice machine. The pump keeps the ice from melting and pooling water. The previous pump was not keeping up with the water. I have replaced it before but I'm not sure how long ago. Housekeeping is supposed to clean the pantry, but I cleaned it after replacing the pump. As for the door, housekeeping will place a wet floor sign in the hinge of the door which threw the door frame off.
Review of the facility's policy titled Preventative Maintenance Program dated 10/6/22 documented: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public . The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide at least 80 square feet per resident for three rooms (#'s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide at least 80 square feet per resident for three rooms (#'s 111, 119, and 231) resulting in the potential for resident dissatisfaction with their living space and not having adequate space available for care. Findings include:
On 10/6/2022 at 03/08/20 at 12:30 PM during an environmental tour of the facility and review of the facility document, which indicated waivered rooms, was reviewed and revealed:
room [ROOM NUMBER] had 157 square feet. One resident currently resided in the room which was physically set-up for two residents which for two residents would yield 78.5 square feet per resident.
room [ROOM NUMBER] had 157 square feet and two residents which yielded 78.5 square feet per resident.
room [ROOM NUMBER] had 159 square feet and two residents which yielded 79.5 square feet per resident.
Resident interviews did not reveal any overt concerns related to the room size.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 3 harm violation(s), $42,583 in fines, Payment denial on record. Review inspection reports carefully.
- • 51 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $42,583 in fines. Higher than 94% of Michigan facilities, suggesting repeated compliance issues.
- • Grade F (8/100). Below average facility with significant concerns.
Bottom line: Trust Score of 8/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Beaconshire Nursing Centre's CMS Rating?
CMS assigns Beaconshire Nursing Centre an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Beaconshire Nursing Centre Staffed?
CMS rates Beaconshire Nursing Centre's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Beaconshire Nursing Centre?
State health inspectors documented 51 deficiencies at Beaconshire Nursing Centre during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, 44 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Beaconshire Nursing Centre?
Beaconshire Nursing Centre is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 99 certified beds and approximately 95 residents (about 96% occupancy), it is a smaller facility located in Detroit, Michigan.
How Does Beaconshire Nursing Centre Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Beaconshire Nursing Centre's overall rating (1 stars) is below the state average of 3.1 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Beaconshire Nursing Centre?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Beaconshire Nursing Centre Safe?
Based on CMS inspection data, Beaconshire Nursing Centre has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Michigan. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Beaconshire Nursing Centre Stick Around?
Beaconshire Nursing Centre has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Beaconshire Nursing Centre Ever Fined?
Beaconshire Nursing Centre has been fined $42,583 across 4 penalty actions. The Michigan average is $33,505. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Beaconshire Nursing Centre on Any Federal Watch List?
Beaconshire Nursing Centre is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.