Medilodge of Farmington
For profit - Corporation
117 Beds
MEDILODGE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#384 of 422 in MI
Photo by Medilodge of Farmington
Photo by Medilodge of Farmington
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1 / 5 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Medilodge of Farmington has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. They rank #384 out of 422 nursing homes in Michigan, placing them in the bottom half of all facilities in the state and #30 out of 43 in Oakland County, suggesting limited better local options. While the facility is improving, with issues decreasing from 28 in 2024 to 19 in 2025, it still reported concerning deficiencies. Staffing is a mixed bag, with a below-average rating of 2/5 stars but a relatively low turnover rate of 37%, which is better than the state average. However, the facility has incurred $296,114 in fines, which is higher than 96% of nursing homes in Michigan, indicating repeated compliance problems. Specific incidents include a long-term resident who was on a ventilator without any recent evaluations by a pulmonologist, and another resident developed serious skin wounds due to inadequate care and staffing shortages. Additionally, there was a serious incident of alleged sexual abuse involving a resident with dementia, raising significant concerns about resident safety. Overall, while there are some strengths in staffing retention, the facility faces serious weaknesses that families should consider carefully.
- Trust Score
- F
- In Michigan
- #384/422
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 37% turnover. Near Michigan's 48% average. Typical for the industry.
- Penalties ✓ Good
- $296,114 in fines. Lower than most Michigan facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 54 minutes of Registered Nurse (RN) attention daily — more than average for Michigan. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 97 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 10%
Review needed
28 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 28 issues
2025: 19 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Michigan average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Michigan average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 37%
Near Michigan avg (46%)
Typical for the industry
Federal Fines: $296,114
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: MEDILODGE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 97 deficiencies on record
2 life-threatening 4 actual harm
Sept 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #2595964 and #2579668.Based on interview and record review, the facility failed to ensure wound...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #2595964 and #2579668.Based on interview and record review, the facility failed to ensure wound treatments were provided for two residents (R905 and R906) of three residents reviewed for pressure uclers. Findings include: R906
On 9/3/25 at 8:00 AM, a review of R906's closed clinical record revealed they originally admitted to the facility on [DATE] with diagnoses that included: traumatic brain hemorrhage, skull fracture, and diffuse traumatic brain injury due to a pedestrian motor vehicle accident. R906 was non-verbal, and displayed severely impaired cognition. A review of R906's weekly skin assessments revealed an assessment dated [DATE] that documented a scar to their neck and a blister to their toe. It was noted the next weekly skin assessment was conducted on 6/6/25 and documented an “Other” skin impairment to their left lateral malleolus (ankle bone). The next skin assessment dated [DATE] only documented a right upper leg skin tear, and the assessment dated [DATE] indicated an “Other” skin impairment to the left ankle with a treatment in place. It was noted the next weekly skin assessment was conducted on 7/13/25, nearly a month later.
A review of R906's “Skin and Wound” evaluations was conducted and revealed the following:
An evaluation dated 6/5/24 that indicated R906 developed a facility acquired, unstageable pressure ulcer with, “slough and/or eschar” measuring 2.0 cm (centimeters) in length x 1.4 cm in width, no depth.
An evaluation dated 6/13/25 that indicated the wound was worsening measuring 4.0 cm in length x 1.3 cm in width, no depth.
An evaluation dated 7/18/25 that indicated the wound was again worsening measuring 7.6 cm in length x 1.6 cm in width, no depth.
An evaluation dated 7/24/25 that indicated the wound had worsened measuring 8.0 cm in length x 2.8 cm in width with 0.1 cm of depth.
A review of R906's treatment administration records was conducted and revealed five missing dressing changes in June 2025 and four missing dressing changes in July 2025.
Continued review of R906's clinical record was conducted, and it was noted the physician documented progress notes numerous times through June 2025 and July 2025, however; none of the progress notes referenced R906 having a facility acquired, unstageable pressure ulcer, a statement of whether the wound was avoidable or unavoidable, or the plan of treatment for the wound. R906's care plans were reviewed and revealed their first care plan for the wound to their left ankle was implemented on 7/29/25, despite the wound being discovered on 6/6/25.
On 9/3/25 at 1:38 PM, an interview was conducted with the facility's Director of Nursing, they acknowledged the concern with R906's facility acquired pressure ulcer.
R905
On 9/2/25 the medical record for R905 was reviewed and revealed the following: R905 was initially admitted to the facility on [DATE], discharged on 8/3/25 and had diagnoses including Dysphagia and Gastrostomy status.
A review of R905's Nursing admission Evaluation dated 7/29/25 revealed the following: Section V. Skin. A. 1. Does the resident have any identified skin conditions/wounds? b. [No] .
A review of R905's progress notes revealed the following: 8/1/2025-Nurses' Notes Writer and DON (Director of Nursing) assessed resident. Resident had MSAD (moisture associated skin damage) to coccyx, heals balanceable
8/3/2025-Nurses' Notes Resident has MASD skin tear on coccyx triad applied. redness on bilateral heels . pictures of coccyx were taken before discharge .
A Wound Evaluation dated 8/3/25 revealed the following: #1-Skin Tear-Category 1. Linear .Body Location: Right Gluteus .Acquired: Present on Admission. Dimensions: Area 0.63 cm (centimeters squared). Length 1.14 cm. Width 0.78 cm. Deepest point 0.1 cm Wound Bed epithelial [yes]. Periwound: Edges [non-attached]. Treatment: Dressing appearance [intact]. Cleansing solution [Generic wound cleanser]. Primary dressing [other]. Other, Specify: Triad.
Further review of R905's wound picture on their 8/2/25 evaluation revealed the following: The picture showed an open area on the right gluteal fold that appeared to be in an area where friction and shear forces would be heightened. The picture also revealed cicatrix (scar of a healed wound) that mirrored the left gluteus.
A review of R905's Physican orders did not reveal any treatment orders for the identified wound on their coccyx/right gluteus area.
A review of R905's July and August 2025 TAR (treatment administration record) revealed no treatments to R905's coccyx/right gluteus wound were administered during their stay in the facility.
On 9/3/25 at approximately 11:18 a.m., The DON was queried regarding the process for the identification of new skin impairments, and they indicated that when a skin impairment is identified, the Physican is notified, and new order tor treatment is put into the record for it and the careplan is updated. The DON was queired regarding R905's wound that was identified on 8/1/25 and the wound evaluation that was done on 8/3/25 that indicated the wound was present on admission and they reported that a Physician's order should have been implemented to treat it and that it should have been implemented upon admission to the facility.
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #2579668Based on interview and record review, the facility failed to ensure enteral feeding ord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #2579668Based on interview and record review, the facility failed to ensure enteral feeding orders were accurately transcribed upon admission and administered correctly for one resident (R905) of two residents reviewed for enteral feeding. Findings include:On 9/2/25 a complaint submitted to the State Agency was reviewed that alleged R905 was fed an incorrect amount of enteral formula. On 9/2/25 the medical record for R905 was reviewed and revealed the following: R905 was initially admitted to the facility on [DATE], discharged on 8/3/25 and had diagnoses including Dysphagia and Gastrostomy status. A review of R905's initial admission hospice Physician orders revealed the following: Evaluate need for supplemental tolerance of Glucerna 1.2 at 40ml/hr (milliliters per hour) for 16 hours.A review of R905's transcribed admission enteral orders revealed the following: Enteral Feed Order every morning and at bedtime every shift Glucerna @45ml/hr (milliliters per hour) x 16hrs via peg tube (percutaneous endoscopic gastrostomy tube) or until a total volume of 720ml. -Start Date- 07/30/2025 0700A progress note dated 7/31/2025 at 08:13 a.m., revealed the following: Received resident in bed with eyes open and resting with family at bedside. Resident feeding was currently running total volume infused when writer stop feeding was 1191 (milliliters), total volume to be infused was 720 ml. Resident abdominal area was hard and distended. Writer pulled 1000cc with residuals. Writer notified on call NP (Nurse Practitioner), who ordered to hold tube feeding and get STAT (immediately) x ray of abdomen. Writer notified DON (Director of Nursing) and on coming nurse of this change.On 9/3/25 at approximately 11:18 a.m., The Director of Nursing (DON) was queried regarding the enteral feeding order for R905 and the error of R905 being overfed on 7/31/25. The DON indicated they were aware of the error and that they had done an in-service with the Nursing staff on ensuring enteral orders are administered appropriately. On 9/3/25 at approximately 2:24 p.m., Nurse A was queried regarding R905 being over fed on 7/31/25. Nurse A reported that after they got shift report then went into R905's room to check their tube feeding (enteral) and observed R905 to have over what they were supposed to have. Nurse A indicated they had to stop the tube feeding pump and called the medical provider who ordered to hold the tube feeding. Nurse A reported that due to the overfeeding, R905's abdomen was distended. Nurse A indicated that the facility enteral pumps had to be set with a stop time otherwise the pump would keep running. Nurse A reported that they informed the Director of Nursing of the error. On 9/4/25 a facility document titled Feeding Tubes was reviewed and revealed the following: Policy: Feeding tubes will be used only as necessary to address malnutrition and dehydration, or when the resident's clinical condition deems this intervention medically necessary to maintain acceptable parameters of nutrition and hydration. Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible 7. Feeding tubes will be utilized according to physician orders .11. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided to include: e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
This citation pertains to intake #2580612Based on observation, interview, and record review the facility failed to assess and provide tracheostomy care per physician's orders for one resident (R906), ...
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This citation pertains to intake #2580612Based on observation, interview, and record review the facility failed to assess and provide tracheostomy care per physician's orders for one resident (R906), of one resident reviewed for respiratory care, resulting in the potential for tracheostomy complications. Findings include: On 9/3/25 at 10:44 AM, an interview was conducted with R904's responsible party and they expressed concerns regarding R904's tracheostomy care.On 9/3/25 at 11:25 AM, R904 was observed in bed. R904 was in a vegetative state, non-verbal, did not track with their eyes and was observed to have a tracheostomy.On 9/3/25 at 11:55 AM a review of R904's physician's orders, medication administration records (MAR) and treatment administration records (TAR) was conducted and revealed missing documentation for assessment of the stoma site under the tracheostomy collar and tracheostomy care on the following dates/times:Day shift 6/9/25, 6/22/25 thru 6/26/25, 6/29/25 and night shift 6/4/25 and 6/6/25.Day shift 7/22/25 and 7/23/25, and night shift 7/10/25.Day shift 8/7/25 and night shift 8/21/25.On 9/3/25 at 1:38 PM, an interview was conducted with the facility's Director of Nursing. They indicated tracheostomy care had been transferred over from respiratory therapy staff to nursing staff and that could have been part of the reason the treatments were not done as nursing may have thought respiratory therapy provided the care.A review of a facility provided policy titled, Tracheostomy Care was conducted and read, .1. Respiratory therapy or trained and competent personnel will provide and document tracheostomy care to all residents with a tracheostomy twice within 24 hours.
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 F0711
(Tag F0711)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physician oversight for wound care for two residents (R#'s 9...
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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 physician oversight for wound care for two residents (R#'s 906 and 903) of three residents reviewed for physician services, resulting in incomplete, comprehensive care. Findings include: R906
On 9/3/25 at 8:00 AM, a review of R906's closed clinical record revealed they originally admitted to the facility on [DATE] with diagnoses that included: traumatic brain hemorrhage, skull fracture, and diffuse traumatic brain injury due to a pedestrian motor vehicle accident. R906 was non-verbal and displayed severely impaired cognition. A review of R906's weekly skin assessments revealed an assessment dated [DATE] that documented a scar to their neck and a blister to their toe. It was noted the next weekly skin assessment was conducted on 6/6/25 and documented an “other” skin impairment to their left lateral malleolus (ankle bone).
A review of R906's “Skin and Wound” evaluations was conducted and revealed the following:
An evaluation dated 6/5/24 that indicated R906 developed a facility acquired, unstageable pressure ulcer with, “slough and/or eschar” measuring 2.0 cm (centimeters) in length x 1.4 cm in width, no depth.
An evaluation dated 6/13/25 that indicated the wound was worsening measuring 4.0 cm in length x 1.3 cm in width, no depth.
An evaluation dated 7/18/25 that indicated the wound was again worsening measuring 7.6 cm in length x 1.6 cm in width, no depth.
An evaluation dated 7/24/25 that indicated the wound had worsened measuring 8.0 cm in length x 2.8 cm in width with 0.1 cm of depth.
Continued review of R906's clinical record was conducted and the following was revealed:
Physician's notes on 6/19/25, 6/20/25, 6/25/25, and 7/7/25, 7/14/25, 7/18/25, 7/21/25, 7/22/25, 7/23/25, and 8/2/25 with no mention of the facility acquired pressure ulcer, no statement of whether it was avoidable or unavoidable, and no treatment plan for the wound.
A Physician note dated 7/9/25 that read, “…Patient doesn't have any current wounds…”
On 9/2/25 at 9:20 AM, R903 was observed in their room. Certified Nursing assistant (CNA) was observed assisting the resident with 1:1 eating. There were scrambled eggs and grits on the tray. The CNA stated that the resident was not eating much but they were about to get residents up and dressed to take him to the dining room.
On 9/2/25 at 9:25 AM, the Director of Nursing (DON) was interviewed about R903's skin impairments and if there were any updates to the plan of care the DON replied that R903 was readmitted to the facility but would find out.
On 9/2/25 at 9:40 AM, R903's skin was observed. A dark wound was present on the left heel and an open area that was a whiteish pink in color was observed located on the left buttocks.
On 9/2/25 a record review was completed and showed that R903 was readmitted to the facility on [DATE] with a medical diagnosis of Alzheimer's disease and muscle weakness. A further review of the record revealed that R903 had a wound care assessment completed and a wound care consult order in.
On 9/2/25 at 9:48AM, the wound care coordinator (WCC) was interviewed. WCC was asked who oversees the wounds at the facility, the WCC reported, they were recently hired into the role, but that primary care provider oversaw wound care until the facility hired a provider. The WCC was then asked who did the weekly wound rounds and provided further guidance if needed to the facility. The WCC reported that they completed weekly rounds with themselves and usually another staff member until the facility hired a provider, but it was no one over looking the wounds. The WCC was asked, had they personally rounded with the primary care providers at the facility for individuals with wounds, the WCC reported no.
On 9/2/25 at 10:06 AM, an interview with the DON and Administrator were conducted, they were asked who oversaw the wounds at the facility. The DON reported that the primary care provider is supposed to oversee the care for wounds. The administrator and DON were asked when the last time they had a Wound Care provider, the DON reported that since late May or early June they had been without. The DON was then asked for the oversite, notes or any documentation from the medical provider for R903's wounds from the beginning of the admission to current.
There was no additional documentation provided by the exit of the survey.
Jun 2025
3 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 intake #MI00153092 and MI00153719
Based on interview and record review, the facility failed to protect...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00153092 and MI00153719
Based on interview and record review, the facility failed to protect the resident ' s right to be free from sexual abuse by a resident for one resident (R901) of four residents reviewed for abuse/neglect/mistreatment resulting in R901 shaking/trembling while their breast was being fondled without consent by R902. Findings include:
On 6/24/25 multiple complaints submitted to the State Agency for review which alleged R902 had sexually abused R901.
R901
On 6/24/25 the medical record for R901 was reviewed and revealed the following: R901 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Aphasia. A review of R901's MDS (minimum data set) with an ARD (assessment reference date) of 5/5/25 revealed R901 was dependent on facility staff for most of their activities of daily living. R901's BIMS score (brief interview for mental status) was six indicating severely impaired cognition. R901 was also noted to have a court appointed public legal guardian.
On 6/24/25 at approximately 10:36 a.m., R901 was observed in their room, laying in their bed. R901 was queried regarding if they had felt uncomfortable by any male residents in the facility and they started talking with unintelligible speech. Further in-depth conversation was attempted regarding how they were feeling in the facility, and they were noted to be unable to follow the conversation and were incomprehensible.
A review of R901's progress notes revealed the following:
4/27/2025 at 16:08-Nurses' Notes-Resident was observed in the dining area resting in Geri chair covered with sheets. Male resident was observed with right arm resting between female resident legs. Resident was moved near nurses station for close observation. Admin (Administrator) and DON notified. Will continue to closely monitor resident.
6/5/2025 at 23:33-Nurses' Notes-CNA (Certified Nursing Assistant) informed nurses that she had observed [R902] with his hand under the resident's shirt. Nurses removed resident from activity area and took her to her room .Nurses contacted Administrator, DON (Director of Nursing), Resident's doctor (MD), and Guardian. No new orders by MD at this time, but requested nurse to log in Dr's book. 15 minute checks in place for resident per DON
6/6/2025 at 15:33-Social Services Progress Notes-Writer met with resident today. Resident is alert and responsive. Her cognitive skills for daily decision making abilities are impaired
R902
On 6/24/25 the medical record for R902 was reviewed and revealed the following: R902 was initially admitted to the facility on [DATE] and had diagnoses including Multiple Sclerosis. A review of R902's MDS (minimum data set) with an ARD (assessment reference date) of 6/11/25 revealed R902 was independent on facility staff for most of their activities of daily living. R902's BIMS score (brief interview for mental status) was 12, indicating moderately impaired cognition.
A review of R902's progress notes revealed the following:
4/27/2025 at 15:01-Orders-General Note from eRecord-Resident observed resting right arm on female resident's wheelchair. Resident educated on resident safety. Resident informed of resident privacy and was compliant with nurse's request to remove his arm.
4/27/2025 at 16:02-Orders-General Note from eRecord-Resident observed for the second time with hand resting between female residents' legs. Resident had been informed that it was an invasion of privacy. resident stated, She likes it, she asked me to do it . Male resident was moved to different area of unit to separate him from female residents. DON notified administrator notified for further instructions .
6/5/2025 at 19:54-Nurses' Notes-CENA (Certified Nursing Assistant) came to writer to let writer know that resident was fondling another resident's chest under her shirt in dining room. CENA said she walked in dining room to see resident in wheel chair next to female resident and when she walked closer, she seen his hand in her shirt. CENA screamed for him to take his hand out of her shirt and separated him from the female resident by wheeling him outside the dining room Both residents immediately separated. Statement taken from witness. DON notified. Administrator notified. Guardian notified via voicemail. 15 minute visual checks implemented on resident to insure other residents safety.
On 6/24/25 a form titled Statement of Witness pertaining to the sexual abuse allegation on 6/5/25 involving R901 and R902 was reviewed and revealed the following: Name and Position of Witness [CNA O] .Date and time of Incident: 6-5-25 Statement of Witness-I seen [R902] was behind [R901]. She was in Geri Chair. I seen [R902] hand in [R901] shirt. [R902] was behind her chair, her chair was lean back and his hand was in her shirt. She was shaken .What did you do? I call his name [R902] he jump and [R901] stop shaken. I told him to leave out of the day room. He rolled himself by the door of Nursing station and he sat there What did you do next? I went to the Nursing station keeping close observation of [R902] and reported to the Nurse .
On 6/24/25 at approximately 12:40 p.m., the Administrator was queried regarding the incident between R901 and R902 on 6/5/25. The Administrator reported that CNA O had witnessed R902's hand inside R901's shirt on their breast and that the CNA had separated the residents and brought R901 to their room and notified the Nurse. The Administrator indicated the Nurse called them to inform them of the incident to speak to CNA O at that time on the phone. The Administrator indicated that after the incident they assigned the resident a 1:1 supervised staff member to supervise R902 and that R902 has had 1:1 supervision since then.
On 6/25/25 at approximately 1:20 p.m., Nurse R was queried regarding the incident between R901 and R902 on 6/5/25 and they reported that CNA O had came and told them that R902 had been fondling R901's breast and had their hand down R901's shirt. Nurse R reported that they took R901 down to their room and R901 was visibly shaking/trembling. Nurse R reported that in the dining room where the incident occurred, water was observed to be around the residents and they did not know if R901 had been trying to fight off R902 which may have caused the water spillage. Nurse R reported that 15 minute visual checks were implemented for R902 for the rest of the shift and after that, they had a 1:1 sitter.
On 6/25/25 at approximately 2:19 p.m., CNA O was queried regarding their witnessing of the incident between R901 and R902 on 6/5/25. CNA O indicated that they had snuck up behind R902 to see what was happening and observed R902 was behind and to the side of R901 and they were folding R901 breasts underneath R901's shirt. CNA O indicated that R901 was trembling and appeared to be frightened. CNA O said the shouted R902's name and they stopped and left the room. At that time, R901 stopped trembling. CNA O was queried if they had been made aware of any other issues between R901 and R902 and they reported they thought there was an earlier issue in which R902 had put their hand in between R901's legs and that had been why R902 was moved to the 2nd floor for awhile. CNA O did not know why R902 was moved back down to the first floor where R901 resided.
On 6/5/24 a facility document titled Abuse, Neglect and Exploitation was reviewed and revealed the following: Policy: 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 Sexual Abuse is non-consensual sexual contact of any type with a resident
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 #MI00153595
Based on observation, interview and record review, the facility failed to ensure an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00153595
Based on observation, interview and record review, the facility failed to ensure an allegation of poisoning was reported to the Abuse Coordinator and State Agency in a timely manner for one resident (R903) of four residents review for abuse/neglect/exploitation. Findings include:
On 6/24/25 a concern submitted to the State Agency was reviewed which indicated R903 went to the hospital because they alleged their roommate [R904] had poisoned them.
On 6/24/25 at approximately 11:18 a.m., R903 was observed in their room, up in their wheelchair. R903 was queried regarding their allegation that they were poisoned by their old roommate [R904[They indicated that they had called the police about it and that they had felt dizzy and that previously R903's roommate (R904) said they wanted them to sleep. R903 was queried how they felt that they were poisoned by the roommate and they reported they didn't know they were just poisoned. R903 reported that after they had returned from the hospital they were moved down to the first floor of the facility and felt safer.
On 6/24/25 the medical record for R903 was reviewed and revealed the following: R903 was initially admitted to the facility on [DATE] and had diagnoses including Chronic obstructive pulmonary disease, Schizoaffective disorder and Anxiety. A review of R903's MDS (minimum data set) with an ARD (assessment reference date) of 5/13/25 revealed R903 needed assistance from facility staff for lower body dressing. R903's BIMS score (brief interview for mental status) was 15 indicating intact cognition.
A review of R903's progress notes revealed the following:
5/31/2025 at 07:48-Nurses' Notes-At approximately 2240, police officers arrived to unit stating resident called emergency services requesting transfer to the hospital. Upon entering resident's room resident claimed to feel unwell and dizzy, stating she believes her roommate poisoned her. Writer provided the resident with reassurance. Resident stated she still wanted to go to the hospital Resident exited facility at approximately 2250. Transferred to [Name of local hospital] .
A review of the facility investigation form titled Statement of Witness by Nurse S revealed the following: Witness and Position of Witness [Nurse S]. Resident Name [R903]. Date and Time of Incident: 5/30/25. Statement of witness-Around 10:40 p.m., we saw police come in saying [R903] called saying she needed to go to the hospital she thinking someone drugged <sic> .When I went into the room I heard her telling the officer that her roommate was trying to kill <sic> 'I took a sip of my water and felt dizzy.' Then she stated her roommate and [name of old roommate] was trying to kill her .I told her that I didn't believe that was true as neither of them can get out of bed. [R903] then stated 'that doesn't mean they are not paying the staff to hurt me' .The office asked if she wanted to to go she said 'yes'. She asked for pain meds (medications) before she left, the cop told her no if you think you were drugged it's not wise to get more. The ER (emergency room) will assess her and see .
A review of the facility reported investigation in the Michigan Facilty Reporting program (MIFRI)revealed the initial report of the allegation to the State Agency was not made until 6/2/25 at 3:58 PM.
On 6/24/25 at approximately 12:40 p.m., during a conversation with the facility Administrator (abuse coordinator) , the Administrator was queried regarding the delay in the reporting time of the allegation that R903's roommate had poisoned them. The Administrator indicated R903's Nurse did not notify them of the allegation and they were made aware of it a few days later in a morning clinical meeting. The Administrator indicated that they had to complete education with Nurse S on notify in the Administrator of any allegations immediately so they could report it to the State Agency.
On 6/25/25 a facility document titled Abuse, Neglect and Exploitation were reviewed and revealed the following: Policy: 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 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 timeframe's: 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
(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 F0635
(Tag F0635)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #'s MI00153092 and Intake #MI00153425.
Based on interview and record review, the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #'s MI00153092 and Intake #MI00153425.
Based on interview and record review, the facility failed to ensure an appropriate admission per facility policy including physician orders and care directives for one Resident (R905) of one resident reviewed for admission. Findings include:
Review of an Intake received by the State Agency on 5/30/25 revealed on 5/28/25 at 7:30 p.m., the complainant reported R905 was admitted to the facility from the hospital on 5/28/25 and received no medication during their stay, as the facility staff allegedly lost their paperwork from the hospital. The report revealed R905 said they watched an EMS (Emergency Medical Services) worker hand over their paperwork to facility staff, who reported it was not received. The complainant reported R905 had to leave the following morning when they did not receive their medications. The complainant reported the facility discharged R905 (AMA - Against Medical Advice) despite no medications being administered during their stay. R905 reportedly had to find their own transportation back to the hospital to receive their medications and transfer their wheelchair and walker back also. The complainant reported R905 was readmitted to the hospital on [DATE] and was being discharged to another nursing home.
Review of R905's facility census confirmed they were admitted to the facility on [DATE] and discharged on 5/29/25.
Review of R905's profile revealed they were their own responsible party.
Review of R905's diagnosis page revealed their primary diagnosis was hypoplasia and dysplasia of the spinal cord (conditions related to abnormal development of the spinal cord), a fall, cervicalgia (neck pain), chronic pain syndrome (persistent pain), atherosclerotic heart disease (hardening of the arteries), depression, and a history of myocardial infarction (heart attack).
Review of R905's physician orders revealed no medications.
Review of R905's medication and treatment administration records (MAR/TAR) revealed no medications were listed and no medications or treatments were administered during their stay.
Review of R905's Electronic Medical Record (EMR) revealed no Care Plan was initiated, or any care directives including a Kardex for the nursing direct care staff to follow.
Review of R905's MDS (Minimal Data Set) assessments had no complete pain assessments which showed if they had pain or their pain level.
Review of R905's vitals showed no logging of any pain/assessment including numerical representation or other standardized assessments.
Review of R905's progress note by Licensed Practical Nurse (LPN) V, dated 5/28/25 at 7:48 p.m., revealed R905 was admitted to the facility on [DATE] at 6:30 p.m The note showed, .(R905) did not arrive to facility with discharge summary or hospital paperwork There was no noted documentation of attempting to obtain the paperwork in this note.
Review of R905's nursing progress note, by Registered Nurse (RN) T, dated 5/29/25 at 1:01 a.m., revealed RN T attempted to obtain a medication list from the hospital without success, and notified the Director of Nursing (DON) and Physician U, without a physician response noted.
Review of R905's EMR showed no physician visit or documentation.
Review of R905's progress note dated 5/29/25 at 11:07 a.m. revealed R905 decided to leave the facility AMA (against medical advice) . and refused to sign the AMA form. This note revealed a physician was notified of R905's discharge, without a response documented.
Review of R905's progress note dated 5/29/25 at11:20 a.m., revealed, Nurse came to writer regarding resident wanting to leave AMA. Nurse reported that resident stated that he did not want to wait for the doctor to send in medications, he just wanted to leave .
Review of R905's nursing assessment, dated 5/28/25, revealed an incomplete assessment. The pain assessment showed as not completed and was unable to be accessed by the survey team. The assessment was unlocked, remaining accessible for documentation.
Review of the EMR revealed R905's hospital discharge summary, including a discharge medication list, was not received by the facility until 5/29/25 at approximately 10:30 a.m., per fax receipt date and time.
On 6/24/25 at 11:57 a.m., Assistant Director of Nursing (ADON) A was asked about R905's stay at the facility. ADON A confirmed they met with R905 during their brief facility stay, per R905's progress notes. ADON A confirmed R905 was admitted to the facility on [DATE] without their discharge paperwork including physician orders and care directives. ADON A explained they could not use the referral paperwork from a few days prior (5/23/25), as this would not have been the accurate hospital discharge medications, as medications typically changed during a resident's hospital stay. ADON A confirmed they did not receive R905's hospital discharge paperwork until 5/29/25 at approximately 11:00 a.m., reportedly right after R905 left AMA and went back to the hospital. The ADON was asked if the facility assisted R905 in returning to the hospital. ADON A confirmed R905 was discharged AMA and thus was not assisted with their discharge to the hospital. The ADON A acknowledged R905 was under the facility's care with no admission instructions or physician orders during their stay, from 5/28/25 at approximately 7:00 p.m. until 5/29/25 until approximately 11:00 a.m., for about 16 hours. When asked if anything could have been done differently, ADON A responded the nurses who were caring for R905 did everything they could have done to obtain the paperwork. The ADON confirmed R905's physician had been notified on 5/29/25 at 1:00 a.m. they were in the facility without medication orders or care directives.
Review of the EMR showed there was no physician follow-up or visit documented after Physician U was notified R905's discharge paperwork and physician orders were not received.
On 6/24/25 at approximately 1:00 p.m., the (current) Director of Nursing (DON), with DON Z, was asked about R905's stay and no physician orders, care directives, or any skilled care received. The DON confirmed R905 was in the facility approximately 16 hours and conveyed they refused skin and nursing assessments and planned to leave. The DON confirmed R905 came into the facility without a medication list and their facility process was their physician could not prescribe medication without laying eyes on the resident. The DON clarified their policy was they would have received a discharge summary from the hospital including a medication list, and their process was they would not admit a resident without a medication list. The current DON reported they started their position at the facility on 6/06/25, after R905's admission, and understood R905 should have returned to the hospital without a medication list or care directives. The DON explained they were not aware of any skilled care provided to R905.
The DON reported their nurses tried to obtain physician's orders from the hospital and a complete discharge summary without success. The DON and DON Z confirmed R905 received no medications during their stay, including their blood pressure or pain medications.
On 6/24/25 at 1:42 p.m., the ADON and nursing management team brought a pain assessment form to the survey team dated 5/28/25 at 21:38 (9:38 p.m.), which showed R905's pain was 2/10 on the admission nursing assessment. Surveyors showed the ADON and nursing management this assessment remained inaccessible to the survey team in the EMR and showed as incomplete. The ADON explained they had other access to a Print function the survey team did not have. This Surveyor explained we needed access to all medical records. This form remained not accessible to the survey team during the survey in the EMR. This Surveyor asked for a time stamp of when this documentation was entered. The management team returned at 1:55 p.m., with a time stamped log which showed the pain assessment showed a date of closed on 6/02/25.
On 6/24/25 at 2:16 p.m., Registered Nurse (RN) T was asked during a phone interview about R905's stay. RN T explained they started their evening shift on 5/28/25 when R905 was under their care, and confirmed per their progress note they attempted to obtain R905's discharge paperwork. RN T reported they notified the Director of Nursing (DON) and Physician U, with no care directives or physician orders received. RN T stated, I could not provide treatment. There were no physician orders .(R905) was supposed to come (to the facility) with physician orders . RN T confirmed R905 was upset there were no physician orders as they wanted their medications, and said not to touch them without their medication orders. RN T stated R905 would not let them take their vitals or do any assessments without any physician orders.
On 6/24/25 at 2:30 p.m., Licensed Practical Nurse (LPN) V was asked during a phone interview about R905's facility admission. LPN V confirmed they were the nurse who admitted R905 from the hospital and stated, They had no paperwork at all (from the hospital) .(R905) did not have one piece of paper . LPN V reported there was nothing they could do for R905 without any discharge paperwork or physician orders, and stated R905 wanted to leave.
On 6/24/25 at 2:50 p.m., an interview was completed with the Medical Director, Physician W. This Surveyor reviewed concerns with Physician W related to R905 being admitted to the facility with no admission paperwork from the hospital including a discharge summary including care directives or physician orders, and nursing staff reporting they could not provide care to R905. Physician W reviewed the Electronic Medical Record (EMR) with this Surveyor and concurred there were no physician orders or care directives. Physician W reported any resident who was admitted to the facility would come with a discharge medication list, and their medications would be put into the EMR. Physician W conveyed they would have expected nursing staff and the physician to get any temporary orders, if the patient was alert and oriented, and obtain a verbal order by contacting the physician who discharged them from the hospital. Physician W was asked if they understood the concern with R905 being admitted without any care directives or physician orders for nursing staff to provide care and medications, and why R905 had not been sent back to the hospital, given they were in the facility about 16 hours. Physician W reported they understood the concern however they believed temporary orders could have been received by a Physician, and none were found in the EMR.
Review of R905's Hospital After Visit (Discharge) Summary, dated 5/20/25 through 5/28/25, showed the facility fax receipt was 5/29/25 at 10:29 a.m The hospital discharge diagnosis was back pain due to injury. Their discharge medications included a Lidocaine topical (pain) patch 5% daily, Metoprolol succinate (medication for high blood pressure) 25 mg (milligrams) daily, atorvastatin (cholesterol medication) 80 mg daily, acetaminophen (pain medication) 500 mg (2 tablets) twice daily as needed, clopidogrel (to prevent blood clots) 75 mg daily, Oxycodone (narcotic pain medication) 10 mg every 4 hours as needed, and Allopurinol (gout medication) 300 mg once daily. R905's new medications upon discharge, which were added during their stay, included Ibuprofen (pain anti-inflammatory medication) 40 mg once daily, methocarbamol (muscle relaxant medication) 750 mg three times daily, and prednisone (steroid for inflammation), tapered, beginning at 20 mg four times a day.
Further review of R905's hospital discharge summary showed they received a one-time dose of Dilaudid narcotic pain medication for severe neck pain on 5/27/25, and their LACE (a standardized assessment showing rehospitalization risk) score was 13/19, showing they were at high risk for rehospitalization.
On 6/25/25 at 2:48 p.m., the Nursing Home Administrator (NHA) acknowledged they understood the concerns, and R905 should have been sent back to the hospital without any medication orders or care directives.
On 6/25/25 at 9:58 a.m., the former DON, RN X, was asked about R905's stay at the facility from 5/28/25 through 5/29/25. RN X confirmed the facility received incomplete discharge documentation and no physician orders. RN X clarified Physician U was contacted, and they were not aware of any follow-up. RN X reported they were aware R905 wanted to leave AMA and would not allow staff to assess them including taking vitals. RN X acknowledged they were aware R905 did not receive their medications for 16 hours, and they were not aware if R905 had any pain.
On 6/25/25 at 1:12 p.m., the Admissions Coordinator, Staff Y, was asked to describe the resident admission process. Staff Y explained they received the history and physical, and the hospital (or discharge) referral packet a few days prior to a resident's admission. Staff Y described although the referral packet may contain a medication list, nursing staff could not use this medication list, as medications and care directives changed prior to a resident's discharge. Staff Y explained typically the emergency medical transport team would provide the facility with a discharge packet including current medications and a discharge summary.
An attempt was made to reach R905 on 6/24/25 at 2:04 p.m., with no call returned during the survey.
Review of the policy, admission to the Facility, revised 1/01/2022, revealed, Policy: The facility will admit only those residents whose medical and nursing care needs can be met. This decision is based on both the needs of the community and the facility's clinical competencies. Admissions are accepted 24 hours a day, 7 days a week. Purpose of admission Policy 1. A primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility . 2. Prior to or at the time of admission, the resident's Attending Physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: a. Type of diet (e.g., regular, mechanical, etc.); b. Medication orders, including (as necessary) a medical condition or problem associated with each medication; and c. Care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan. Applicability 3. Our admission policies apply to all residents admitted to the facility regardless of race, color, creed, national origin, age, sexual orientation, religion, handicap, ancestry, marital or veteran status, and/or payment source. Objectives 4. The objectives of our admissions policies are to: a. Provide uniform guidelines for admitting residents to the facility; utilizing the clinical review/admit guide b. Admit residents who can be adequately cared for by the facility c. Address concerns of residents and families during the admission process d. Review with the resident, and/or his/her representative (sponsor), the facility's policies and procedures relating to resident rights, resident care, financial obligations, visiting hours, etc.; and e. Assure that the facility receives appropriate medical records and financial documentation/authorization(s) prior to or upon the resident's admission .Responsibility 6. The Administrator, through the Admissions Department and admission Team, shall assure that the attending physician, resident and the facility follow applicable admission policies.
Apr 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
This citation pertains to Intake MI00151473
Based on interview and record review, the facility failed to provide needed care and services to administer Total Parental Nutrition (TPN, a special formula...
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This citation pertains to Intake MI00151473
Based on interview and record review, the facility failed to provide needed care and services to administer Total Parental Nutrition (TPN, a special formula given through a vein and provides nutrition) for one resident (R502) of one resident reviewed for TPN, resulting in weakness, fatigue, and a transfer to the hospital for dehydration and electrolyte replacement.
Findings include:
The State Agency received a complaint on 3/25/25 alleging the facility failed to provide R502 with their ordered TPN resulting in hospitalization.
On 4/15/25, Clinical Record review revealed R502 had a past medical history of pancreaticobiliary (pancreas, gall bladder, and bile duct) cancer and was transferred from the hospital for status post paraoesophageal hernia surgery (restoring the normal anatomy of the esophagus and stomach by closing a defect in the diaphragm) and treatment of gastric outlet obstruction (blockage between the stomach and small intestine) and was dependent on nutritional support via Total Parental Nutrition (TPN). admission Nursing assessment documented Alert (x4) times four (refers to a person's level of orientation, fully aware of their surroundings and identity).
On 4/15/25 at 9:18 AM, a telephone interview with the complainant confirmed R502 was accepted to the facility to receive TPN. On Friday 3/21/25, R502 was transferred to the facility and informed the TPN was not available and would have to be ordered. The Doctor ordered Dextrose (sterile sugar water) Intravenously (IV) until the TPN was delivered. The TPN was delivered on Saturday 3/22/25, but there was delay in administering because they (facility) did not have the correct tubing (the incorrect tubing was sent from pharmacy). On Saturday 3/22/25, R502 complained of becoming weak and not feeling right. Sunday morning, 3/23/25 R502 still had not received TPN and insisted on returning to the hospital.
On 4/16/25 at 10:27 AM, a telephone interview with Registered Nurse (RN) C recalled Friday 3/21/25 around 3:30 PM, R502 arrived at the facility and was the admission Nurse for R502 at which time, identified the ordered TPN was not at the facility. Per RN C, orders for TPN are sent prior to arrival to ensure it will be available once the resident arrives. RN C said before R502 got off the stretcher they notified the Director of Nursing (DON) the TPN was not there and discussed sending the resident back to the hospital. The DON said to clarify with the Provider. Nurse Practitoner (NP) G was contacted informing the TPN was not at the facility and ordered IV Dextrose until TPN was delivered.
On 4/15/25 at 11;29 AM, a telephone interview with Central Admissions (CA) B acknowledged R502 was clinically reviewed and accepted for TPN on 3/20/25. On 3/21/25 at 8:21 AM, the resident was officially accepted and the hospital arranged for transport at 2:00 PM. CA B said they had only been in the role for two weeks and this was their first admission with a TPN resident. CA B was unaware they were responsible for ordering the TPN hence why it was not at the facility at the time R502 arrived.
On 4/15/25 at 12:13 PM, an interview with LPN E revealed that they recalled on Saturday 3/22/25, the TPN was delivered, and RN D was called to administer. LPN E recalled RN D was not able to administer because the blue key on the IV tubing was incorrect and would not fit into the pump chamber. NP G was informed the equipment sent was not compatible and they were unable to provide TPN. NP G was notified and ordered to continue with IV fluids. LPN E commented R502 was so frustrated, I understand why she insisted on being sent to the hospital. I couldn't blame her.
On 4/15/25 at 1:23 PM, a telephone interview with RN D confirmed they were called by Nursing staff to administer the TPN for R502 and Pharmacy had sent the TPN in three different bags, provided two pumps and two different sized filter tubing. RN D said in their 27 years of Nursing, they had never seen TPN supplies like this and did not seem normal. RN D was unsuccessful loading the tubing into the pumps and the supplies were incompatible. RN D notified on-call Manager RN C informing neither pump was compatible with the tubing sent by Pharmacy and R502 was unable to receive TPN. RN D said NP G was notified and ordered to continue IV fluids. Per RN D, R502 should have been sent back to the hospital for TPN in their opinion.
On 4/16/25 at 10:27 AM, RN C said they were contacted by night shift Nurses early morning on 3/22/25 informing the TPN was unable to be administered due to the equipment sent was incompatible. RN C said NP G was notified at least three times and told us (Nursing) they (R502) can run on Dextrose and wanted to continue with the same plan and instructed to keep R502 on IV Dextrose. When asked why R502 was not transferred back to the hospital, RN C remarked My question was the same. RN C acknowledged it was not appropriate for R502 to remain without providing their TPN.
Review of Nursing Progress note dated 3/23/25 10:30 AM .Resident request to go to hospital .
On 3/23/25, R502 required hospitalization for weakness and fatigue related to dehydration and would require IV hydration and replacement of Potassium and Magnesium.
On 4/16/25, requested medical records were obtained from the hospital and revealed on 3/20/25 R502's Potassium Level was 4.6 (millimoles per liter) mmol/L and had dropped on 3/23/25 to 2.7 mmol/L. Normal range for Potassium in adults is between 3.5 and 5.0 mmol/L.
Review of laboratory records revealed on 3/21/25, R502's Magnesium level was 2.2mg/dl (milligram/deciliter) had dropped on 3/23/25 to 1.1 mg/dl. Normal range for Magnesium in adults is between 1.6-2.4 mg/dl.
On 4/16/25 at 9:35 AM, The DON remarked themselves and RN C were on the same page and agreed R502 should have been sent back to the hospital sooner.
On 4/16/25 at 11:43, NP G was contacted by phone for interview with no return call by the end of the survey.
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 MI00151473
Based on interview and record review, the facility failed to ensure proper pumps and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00151473
Based on interview and record review, the facility failed to ensure proper pumps and intravenous tubing was provided by Pharmacy to administer Total Parental Nutrition (TPN) (providing nutrition through a vein) per Physician orders for one resident (R502) of one reviewed for TPN resulting in R502 having concerns of weakness and fatigue resulting in hospitalization for dehydration and electrolyte replacement.
Findings include:
The State Agency received a complaint on 3/25/25 alleging the facility failed to provide R502 with their ordered TPN resulting in hospitalization.
On 4/15/25, clinical record review revealed R502 was admitted to the facility on [DATE] and had a past medical history of pancreaticobiliary (pancreas, gall bladder, and bile duct) cancer and was transferred from the hospital for status post paraoesophageal hernia surgery (restoring the normal anatomy of the esophagus and stomach by closing a defect in the diaphragm) and treatment of gastric outlet obstruction and would require nutritional support via Total Parental Nutrition (TPN). admission Nursing assessment documented Alert (x4) times four (refers to a person's level of orientation, fully aware their surroundings and identity).
Record review revealed R502 arrived on Friday 3/21/25 at 3:15 PM and had an order for TPN.
On 3/21/2025 at 4:12 PM, the Nursing progress note documented . TPN order faxed to (contracted pharmacy) they confirmed receiving it and stated it would be in the overnight shipment due to time being after 11am .
On 3/22/25 at 5:57 AM, Nursing Progress note documented the TPN .Order needs clarification . and was not administered.
On 3/22/25 at 11:00 PM, Nursing Progress note from Licensed Practical Nurse (LPN) F documented .awaiting pharmacy delivery for correct equipment .
On 4/15/25 at 11:25 AM, a telephone interview with LPN F clarified the correct equipment from their note was in reference to two pumps and two filter lines that were not compatible. The blue keys on the tubing were not fitting into the pumps. LPN E called the Pharmacy on speaker phone, and was told they (Pharmacy) would be out to deliver the correct tubing.
On 4/15/25 at 12:13 PM, an interview with LPN E confirmed on Saturday 3/22/25 night shift, Registered Nurse (RN) D was called to administer the TPN for R502. LPN E recalled RN D was not able to administer because the blue key on the tubing was incorrect and would not fit into the pump chamber. Around 7:30-8:00 PM, the Pharmacy was called and informed the equipment they sent was not compatible and the TPN could not be given.
On 4/15/25 at 1:23 PM, a telephone interview with RN D detailed they were called by Nursing staff to administer the TPN for R502. RN D confirmed Pharmacy had sent two pumps and two different sized filter tubing. RN D said in their 27 years of Nursing, they had never seen TPN supplies like this and did not seem normal. RN D was unsuccessful loading the tubing into the pumps specifically the blue key that inserts into both chamber pumps would not fit. It was incompatible. RN D notified on the on-call Manager RN C informing neither pump was compatible with the tubing sent by Pharmacy and R502 was unable to receive TPN.
On 4/16/25 at 9:35 AM, the Director of Nursing (DON) acknowledged they were contacted on 3/22/25 by RN C sending a text message of a picture of the TPN bags and informed Nursing was not clear how to administer, and was unaware there were two pumps involved, at which time, the DON instructed to call the Pharmacy. The DON confirmed RN C was no longer at the facility but was involved with this incident and provided their phone number.
On 4/16/25 at 10:27 AM, a telephone interview with RN C remarked they remembered the incident clearly because they were the on-call Nurse that weekend and was the admission nurse for R502.
R502 arrived Friday 3/21/25 around 3:30 PM and identified orders for TPN. Realizing there was no TPN on site at the time they were admitted , I notified the Director of Nursing (DON) and Nurse Practitoner (NP) G informing we did not have the TPN and NP G ordered Intravenous (IV) 10% Dextrose until the TPN arrived. RN C called Pharmacy and was informed delivery of the TPN and equipment (pump and tubing) would arrive on the overnight delivery, which would be on 3/22/25 early morning, which it arrived around 2:00-3:00AM.
RN C was then called by the night shift nurses informing that the TPN was delivered, but the equipment Pharmacy sent was not the correct tubing and it was incompatible. RN C stated they called the Pharmacy (from home) on the morning of Saturday 3/22/25 and told Pharmacy the tubing was not compatible and the TPN could not be administered. The Pharmacy said they would deliver new IV tubing Saturday 3/22/25.
RN C said on Saturday 3/22/25 around 9:30-10:00 PM, they were contacted by night shift Nursing and told the revised equipment was still incompatible and the TPN could not be administered. The Pharmacy was contacted again on 3/22/25 around 10:00 PM and they said they would come out Sunday 3/23/25 and replace the pumps.
According to RN C, the Pharmacy commented to them there was an Equipment Department and they were involved with such concerns, but they leave on Fridays and there is no weekend coverage.
RN C followed up on Sunday 3/23/25 and was informed that R502 insisted on leaving and wanted to go back to the hospital and was transferred that morning.
On 4/16/25, requested medical records were obtained from the hospital and revealed on 3/20/25 R502's Potassium Level was 4.6 (millimoles per liter) mmol/L and had dropped on 3/23/25 to 2.7 mmol/L.
Normal range for Potassium in adults is between 3.5 and 5.0 mmol/L.
Review of laboratory records revealed on 3/21/25, R502's Magnesium level was 2.2mg/dl (milligram/deciliter) had dropped on 3/23/25 to 1.1 mg/dl.
Normal range for Magnesium in adults is between 1.6-2.4 mg/dl.
On 3/23/25, R502 required hospitalization for weakness and fatigue related to dehydration and would require IV hydration in addition to replacements of Potassium and Magnesium.
Feb 2025
10 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
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #2
This citation pertains to Intake Number(s): MI00149629.
Based on observation, interview, and record review...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #2
This citation pertains to Intake Number(s): MI00149629.
Based on observation, interview, and record review, the facility failed to prevent, identify and accurately assess new skin breakdown and administer treatment to vascular wounds according to physician's orders for two (R300 and R301) of three residents reviewed for skin integrity, resulting in R300 developing an open lesion to the back of the knee with exposed tendon and the potential worsening wounds to R301's toes. Findings include:
R300
A review of a complaint submitted to the State Survey Agency (SSA) revealed an allegation that R300 had wounds and was not being positioned frequently. It was also alleged that the facility was short of staff with only one nurse handling wound care.
On 2/4/25 at 10:26 AM, R300 was observed lying in bed in a fetal position with his legs bent and tucked up toward his abdomen. R300 was positioned to the right side. No pillows were observed to offload pressure from R300. A sign hung by R300's family member noted a specific patterned pillow was to be used to position R300. The patterned pillow was observed at the foot of the bed. R300 was receiving nutrition via a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically inserted into the stomach to deliver nutrition. R300 had a tracheostomy (a tube surgically inserted into the windpipe to assist with breathing). When spoken to R300 did not respond or make eye contact.
On 2/4/25 at approximately 12:30 PM, R300 was observed in bed. A family member was visiting. When queried about any concerns, the family member explained R300 had a wound between his right shin and the knee on the back side of his leg. According to R300's family member, she discovered the wound when she noticed blood on R300's bedding a few months ago and when they looked behind R300's knee there was an open area with exposed tendon which has not yet healed.
On 2/5/25 at 8:20 AM, 10:00 AM, and 11:32 AM, R300 was observed lying in bed in the same position. There were no pillows or devices being used to extend R300's right leg.
On 2/5/25 at approximately 4:00 PM, an interview was conducted with the facility's wound care coordinator, Licensed Practical Nurse (LPN) 'D'. When queried about the skin impairment to the back of R300's right knee, LPN 'D' reported R300 had an open lesion to the back of the right knee caused by moisture. LPN 'D' reported that when she first assessed the skin impairment the tendon was exposed. LPN 'D' reported the open lesion has not healed. When queried about any preventative measures that were in place to prevent breakdown to that area and to prevent worsening and promote healing, LPN 'D' reported she would look into it.
A review of R300's clinical record revealed R300 was admitted into the facility on 9/2/21 and readmitted on [DATE] with diagnoses that included: acute respiratory failure with hypoxia, contractures, metabolic encephalopathy, nontraumatic chronic subdural hemorrhage, and hydrocephalus. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R300 had no speech, highly impaired hearing, severely impaired cognition, had upper and lower bilateral range of motion impairment, was dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs), and had two unhealed pressure ulcers, an open lesion, and moisture associated skin damage (MASD).
A review of a Skin Assessment completed on 9/4/24 revealed R300 did not have any new or existing abnormal skin areas. It should be noted that at that time R300 did have two existing pressure ulcers.
A review of a Wound Assessment completed by LPN 'D' and a Surgical Note completed by the consultant wound provider on 9/5/24 revealed R300 had a new, in-house acquired open lesion to the right popliteal fossa (the diamond shaped space located in the back of the knee joint) that measured 0.6 cm (centimeters) in length x (by) 1.8 cm in width x 0.5 cm in depth. It was documented that tendon exposed.
A review of a Skin and Wound Evaluation dated 2/6/25 revealed R300 had an open lesion to the right popliteal fossa that measured 0.7 cm x 1.1 cm x 1.0 cm. It was documented the wound was healable. In the notes section it was documented that wound has increased in size. Wound not likely to heal d/t (due to contractures) .offload at tolerated . A review of the Wound Evaluation which included a photo of the wound revealed R300's tendon was exposed. A review of the previous wound consult notes documented by the wound provider on 1/30/24 revealed the wound decreased in size and was improving.
A review of R300's Physician's orders revealed orders beginning on 11/8/24 that recommended offloading wound with positioning leg in as much extension as possible.
On 2/6/25 at 1:35 PM, an interview with the Director of Nursing (DON) was conducted. When queried about what interventions were put into place to prevent skin breakdown for residents with contractures, the DON reported they would have restorative care and we can't predict something that would pop up. At that time, R300's skin assessment on 9/4/24 and wound assessment on 9/5/24 were reviewed with the DON. The DON reported the weekly skin assessments should be accurate to what is going on with the resident. When queried about what was in place to prevent skin breakdown behind R300's knee prior to the development of a open lesion with exposed tendon and what additional precautions were added after the skin impairment was identified, the DON reported she would look into it.
On 2/6/25 at approximately 2:00 PM, LPN 'D' followed up regarding the information requested from the DON. When queried about any preventative measures that were implemented prior to R300's skin breakdown on the back of the right knee and what additional measures were put into place after the development of the open area, LPN 'D reported she would look into it.
On 2/6/25 at 2:22 PM, LPN 'D' followed up and reported she found old orders for passive ROM, but nothing in place to keep that area free of moisture or to help extend the leg before or after the development of the open lesion.
R301
On 2/4/25 at 10:30 AM, R301 was observed in bed sleeping. R301's right foot was wrapped with dressing which was soiled in the area of his toes which were sticking out of the end of the blanket.
On 2/4/25 at 11:00 AM, R301 was observed in bed. The blanket was no longer covering R301's right foot. The dressing applied to R301's right foot was soiled in the area of his toes. The dressing was dated 2/3/25 with initials (discovered to be Licensed Practical Nurse - LPN 'Q') written with thick black marker which was written over thinner writing that was labeled 1/31/25.
On 2/4/25 at 11:09 AM, an observation of the dressing on R301's right foot was conducted with Unit Manager, Registered Nurse (RN) 'U'. When queried about the date of 2/3/25 written on top of the date of 1/31/25, RN 'U' did not offer a response.
On 2/4/25 at 11:19 AM, an observation of the dressing on R301's right foot was conducted with the DON who replied They just changed it! When queried about who and when, the DON pointed to the dressing which was dated for the day prior, 2/3/25. The DON reported she looked at the dressing and saw the date from yesterday but did not notice the date underneath.
On 2/4/25 at approximately 11:25 AM, R301's right foot and toes were observed with RN 'U'. RN 'U' unwrapped the dressing from R301's foot. The dressing was soiled and stuck to R301's toes which required RN 'U' to moisten the dressing in order to remove it. The top of R301's right great toe was observed to have an open area described by RN 'U' as Red and beefy, draining, with white patches on the inside of the toe. The top of R301's second toe was observed with an open area described by RN 'U' as a little red and a little white, but not draining as much as the other toe. There is white on the side of the toe. R301's right great and second toe were dark in color in comparison to his other toes and the rest of the right foot.
On 2/5/25 at 10:06 AM, an interview was conducted with LPN 'Q' via the telephone. When queried about the date of 2/3/25 written on R301's dressing to his right foot with writing underneath labeled 1/31/25, LPN 'Q' confirmed that he wrote the date on the dressing without actually performing wound care. LPN 'Q' reported he did it because he was assigned to too many residents and could not complete all of his nursing tasks.
A review of R301's Physician's Orders and Treatment Administration Record for February 2025 revealed an order to Cleanse right great toe and second toe with wound cleanser and pat dry. Apply calcium alginate AG with honey-based gel and wrap with dry dressing every day shift . It was signed off on the TAR that the treatment was administered on 2/1/25 and 2/2/25, despite the dressing indicating the last treatment was done on 1/31/25. On 2/2/25, there was no nurse's signature to indicate a treatment was administered to R301's right toes.
A review of R301's clinical record revealed R301 was admitted into the facility on 1/2/24 and readmitted on [DATE] with diagnoses that included: acute respiratory failure with hypoxia.
A review of a Progress Note from a podiatry consult dated 1/8/25 revealed R301 was diagnosed with peripheral vascular disease and had multiple wounds to the right foot. It was recommended that an arterial Doppler be completed. A review of a Radiology Results Report dated 1/9/25 revealed R301 had a right lower extremity arterial Doppler ultrasound completed which revealed monophasic waveforms (slow, blunted systolic blood flow) in the anterior tibial artery (a major blood vessel that supplies blood to the lower leg and foot) with increased velocity, likely related to peripheral vascular disease and monophasic waveforms in the proximal, mid superficial femoral and popliteal arteries (an artery that runs deep in the mid-thigh and through to the knee) in favor of peripheral vascular disease.
A review of a Skin and Wound Evaluation dated 2/6/25 revealed R301 had an Open lesion to the right dorsum first digit (top of great toe) that was in-house acquired that measured 1.4 cm x 2.0 cm x 0.2 cm with evidence of infection (warmth). It was documented that the wound increased in size and R301 was receiving ABX (antibiotics) r/t (related to) soft tissue cellulitis to the right foot. A review of a second Skin and Wound Evaluation dated 2/6/25 revealed R301 had an open lesion to the top of the right second digit (toe) that measured 1.2 cm x 1.0 cm x 0.2 cm.
On 2/5/25 at 2:15 PM, an interview was conducted with LPN 'D' who said the nurses were required to do weekly head to toe skin assessments and to alert LPN 'D' of any changes (new or worsening) to skin and the floor nurses were required to complete the daily wound treatments. LPN 'D' reported she rounded with the wound provider one time per week. LPN 'D' reported she had been following the progression of R301's toes since she started in her position and indicated although they did not worsen after treatment was not done for three days, he currently was being treated for an infection and it was important to complete the wound care as ordered.
A review of a facility policy titled, Wound Treatment Management, revised on 10/26/23, revealed, in part, the following, .Wound treatments will be provided in accordance with physicians orders .
A review of a facility policy titled, Pressure Injury Prevention and Management, revised 3/20/24, revealed, in part, the following, .Licensed nurses will conduct a full body skin assessment .weekly .
Deficient Practice Statement #1
This citation pertains to Intake # MI00149906.
Based on interview and record review, the facility failed to timely assess and intervene for a resident who had a new tracheostomy (an artificial opening in the windpipe to assist with breathing), and who alerted staff that they were in distress by using non-verbal gestures, resulting in the death for one (R313) of three residents reviewed for a change in condition. Findings include:
The IJ began on 1/24/25 when R313 had encountered a change in condition and notified CNA B. The Administrator was notified of the IJ on 2/5/25 at 2:05 PM. A plan of removal was requested at that time to remove the immediacy.
The IJ was removed and verified on 2/6/25 based on the facility's implementation of an acceptable plan of removal.
Although the immediacy was removed, the deficient practice was not corrected and remained isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA).
On 2/4/25 at 10:07 AM, Family Member (FM) R was interviewed via telephone. FM R was asked about the death of R313. FM R reported that before the incident, the facility could not get R313's food texture right. FM R further reported that often themselves or a sibling would be present at the facility at mealtimes because they did not trust the facility to provide the correct diet texture. R313 was on tube feeding in addition to getting food by mouth. FM R stated on the day R313 expired in the facility, a staff member called their sibling and stated R313 aspirated (choked). FM R stated their sibling received a call from a female nurse who was crying and stated that R313 had passed away because they aspirated. FM R stated when they arrived at the facility with their sibling the food tray for R313 was still in the room, and the food was observed to be the incorrect texture. FM R reported family members were usually present at the facility for R313's meals due to previous incidents of the kitchen staff providing the incorrect texture. FM R stated the one dinner they were not present for is the day R313 died. FM R went on to say they provided R313 a board and paper to communicate due to difficulties communicating with a tracheostomy. FM R reported that R313 utilized the board often to communicate their needs. FM R reported, when they went to the facility on the evening of R313's death their communication board was observed to have RT (Respiratory Therapist) written on there by R313. FM R reported, the paper observed in R313's room also had noted that RT was needed. FM R reported, R313 had a fear of choking, so for R313 to die from choking was heart breaking. FM R reported the facility RT manager said that R313 should have been on aspiration precautions and signage was supposed to be placed over R313's bed to ensure all staff knew what to monitor R313 for when eating, drinking and ensuring the bed was in the correct position. FM R reported, R313 was supposed to have assistance with meals and family came daily to assist.
A record review revealed that R313 was admitted to the facility on [DATE] with the diagnosis of Hemiplegia and hemiparesis following a cerebral infraction affecting the left side, acute and chronic respiratory failure with hypoxia, dysphagia-oropharyngeal phase (difficulty with swallowing), Gastrostomy status(a tube surgically inserted in the abdomen for eating) and tracheostomy status. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status Score (BIMs) of 9, which indicated moderate cognitive impairment.
A further review of the record revealed a nursing progress note dated 1/25/25 at 9:18AM that documented, Writer entered into residents' room at 19:45 (7:45 PM) on 1/24/25. Upon entering room writer noticed resident skin was discolored, immediately checked carotid pulse absent. Called residents name-no response. Code blue called and immediately began compressions. Staff in room with defibrillator. 911 called. CPR (cardiopulmonary resuscitation) continued. 20:09 (8:09PM) resident pronounced dead by EMS (emergency medical services)/MD (medical doctor).
On 2/4/25 at 2:00 PM, Nurse A was interviewed via telephone. Nurse A was asked about the day of R313's death. Nurse A reported, they were short on nurses for the afternoon shift, and they were the only nurse on the unit until about 7:00 PM. Certified Nursing Assistant (CNA) B was assigned to R313. Nurse A reported around 5:30 or 6:00 PM, CNA B who was at the end of the hallway stated Uhh they want you. Nurse A reported that they asked CNA B who wanted them, and CNA B just walked away and went on break. Nurse A reported, they had worked with CNA B before and they were always zoned out, did not communicate well and took nothing serious. Nurse A reported that they continued to prepare medications and start medication pass. Nurse A reported, they completed the first cart of medications, around 6:30 or 7:00 PM when CNA B asked them, Did you ever see what they wanted? Nurse B reported, they asked CNA B which resident and what room. CNA B indicated R313's room. Nurse A reported that CNA B did not specify the nature of the situation. Nurse A reported after they prepped medications for the back cart, they entered R313's room. Nurse A noticed R313's head of bed was not elevated, which was abnormal for that resident who preferred their bed at a 90-degree angle. When Nurse A went to adjust the bed for R313 they noticed R313 face was a different color. Nurse A explained they checked R313's pulse and quickly started CPR and 911 was called. Nurse A reported EMS (emergency medical services) told them R313 aspirated on fruit punch. Nurse A reported they informed the family of R313's death. Nurse A reported they followed up with CNA B after R313's death, and asked CNA B was R313 the resident who needed help earlier. CNA B stated, They (R313) were choking and grabbing my arm [NAME]. It was weird they (R313) wouldn't let me go.
On 2/4/25 at 3:00 PM, CNA B was interviewed. CNA B was asked what they remembered about R313's death. CNA B reported, when they came on shift R313 was squirming around on the bed sideways. CNA B reported that R313 was acting up and they were trying to get R313 to calm down. CNA B reported R313 was tripping. CNA B reported, that R313 wrote on their communication board and papers RT (referencing the respiratory therapist). CNA B further reported they went to notify two RTs (RT AA and RT BB) for their help with R313. RT AA and RT BB told CNA B they don't go on that side (to the unit where R313 resided), and the nurse can suction a resident. CNA B was asked if they reported the concern with R313 to Nurse A. CNA B responded, No one was listening man. CNA B was then asked why they went on break, leaving R313 alone and in distress. CNA B did not respond.
On 2/5/25 at 8:42 AM and 4:04PM, RT AA , was called with no response.
On 2/5/25 at 8:56 AM and 4:34 PM, RT BB was called with no response.
On 2/4/25 at approximately 1:00 PM, a request was made to review the two east camera footage for 1/24/25. Regional Corporate Personnel CC reported that the cameras only went back for ten days and the footage was not available.
On 2/4/25 at 3:23 PM, the facility was asked to provide the investigation documents pertaining to R313's death.
A review of CNA B's personnel file revealed a document titled Performance Improvement Form dated 1/25/25 that read, . On 1/24/25 (CNA B) was the assigned CNA for resident (R313 room number) the resident aspirated resulting in her expiring. (CNA B) alerted the assigned nurse of a resident possibly needing assistance. However, he did not state which resident or what the need was at that time. (CNA B) later reported to the assigned nurse that the resident was choking as she was grabbing his arm also stating that it was weird. (CNA B) left the resident and went on break without ensuring that she was properly cared for and safe . It is expected that if a resident is choking that the CNA will provide the Heimlich maneuver technique used for a conscious choking victim . is also expected to stay with a resident and call out for help maintain the resident's safety to the best of his ability until help arrives . The form indicated that CNA B was suspended.
On 2/4/25 at 4:09 PM, The Director of Nursing (DON) was interviewed about the death of R313. The DON reported, they were in the facility when a code blue was called for R313. The DON was asked what was expected from CNA B when they observed R313 in distress. The DON reported that CNA B should have reported clearly to Nurse A and the RTs on who and what the concern was. The DON reported, Nurse A and the RTs should have obtained more information from CNA B and assessed the resident timely.
On 2/4/25 at 4:15 PM, RT Manager C was interviewed. RT Manager C was asked what the RT responsibilities were when notified of the change in condition for R313. RT Manager C reported the RTs should have assessed and treated the Resident timely.
A further review of the record showed that R313 had no care plan in for aspiration precautions, that they were a one person assist with mealtimes. The care plan also showed that R313 had interventions to observe for physical/non-verbal indicators of discomfort or distress and follow up as needed.
A review of the case report from local police department dated 1/24/25 at 8:01 PM, revealed, . Subject Sudden Death . information . (R313) alive at approximately 1800hrs (6:00PM). (Nurse A) found (R313) unresponsive at approximately 1958hrs (7:58 PM) and started CPR (Local Fire department) medical personnel also stated that (R313) was full of fluid and (facility name) staff stated, (R313) might have had aspirated from red fruit punch (shown in photos taken).
The Immediate Jeopardy that began on 1/24/25 was removed and the deficient practice corrected on 2/6/25 when the facility took the following action to remove the immediacy:
Identification of Residents Affected or Likely to be affected:
The facility took the following actions to address the citation and prevent any residents from an adverse outcome. (Completion Date: 02/04/2025).
Current residents residing in the facility were assessed by licensed nurses to ensure that residents with changes in condition needs were met and that physicians, RP/guardians were notified on 02/04/2025.
Actions to Prevent Occurrence/Recurrence:
Education:
The facility took the following actions to prevent an adverse outcome from reoccurring.
(Completion Date: 02/04/2025).
On this date 02/06/2025 we educated nurses, CNAs, and RT on the following:
Head to toe observation for changes in condition for CNAs posted at nurses' station and handout given.
Head to toe observation, clinical pathways for changes in condition and respiratory for Nurses posted at medication carts and handout given.
Hierarchy Notification Steps handout given to nurses, CNAs, and RT.
Notification of Hierarchy
(Steps of Notification of Changes)
Notify floor nurse assigned to resident of changes in condition.
If nurse does not respond notify the RT.
If the RT doesn't respond notify the on call manager.
If the on call manager doesn't respond notify the DON.
Verbal and non-verbal signs of distress
Signs of distress, both verbal and nonverbal, can include: changes in voice tone (e.g., shaky, high-pitched), crying, sighing, complaining, withdrawn behavior, avoiding eye contact, clenched fists, pacing, fidgeting, facial expressions like frowning or grimacing, rapid breathing, sweating, changes in appetite, and disrupted sleep patterns.
Verbal signs of distress:
Changes in voice tone: Speaking in a higher pitch, trembling voice, or a quieter than usual tone.
Complaints: Expressing physical discomfort, pain, or emotional distress through verbal complaints.
Negative self-talk: Putting oneself down or making pessimistic statements.
Crying or sobbing: Tears as a visible expression of emotional distress.
Swearing or using strong language: May indicate heightened frustration or anger.
Asking for help: Directly stating a need for support.
Nonverbal signs of distress:
Facial expressions: Frowning, furrowed brows, narrowed eyes, pursed lips, grimacing
Body language: Crossed arms, hunched posture, avoiding eye contact, tense muscles, fidgeting
Physical changes: Sweating, rapid breathing, increased heart rate, flushed face
Changes in movement: Pacing, rocking, restless behavior, sudden withdrawal
Vocalizations: Sighing, moaning, groaning, muttering
Changes in appetite: Loss of interest in food or overeating
Sleep disturbances: Difficulty falling asleep, frequent waking, insomnia
Self-harm behaviors: Picking at skin, pulling hair, substance abuse
Important considerations:
Context matters:
What might be considered a sign of distress in one situation may be normal behavior in another.
Individual differences:
People express distress differently, so it's important to be sensitive to individual cues.
Observe patterns:
Look for recurring behaviors or changes in behavior to better assess distress.
There was no additional information provided at the exit of survey.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00148587.
Based on observation, interview and record reviews the facility failed to treat t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00148587.
Based on observation, interview and record reviews the facility failed to treat the resident with respect/dignity and ensure to honor their rights per the facility policy, for one (R306) of one resident reviewed for dignity and respect. Findings include:
On 2/4/25 at 11:19 AM, R306 was observed lying on their back in bed. When asked about their stay at the facility R306 stated in part, . The new administrator came on Friday and said I need to get it (refrigerator) out of here. It was rude and why all of a sudden when the prior Administrator approved it? I feel like they treat me differently maliciously and why? It really isn't necessary . she rudely said she will take my refrigerator out of here . I had this refrigerator for more than a year here . The resident went on to verbalize how they were a chef for over 30 years and maintained their refrigerator by ensuring the food containers were dated and the refrigerator was kept clean.
A review of the medical record revealed R306 was admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease, cardiac pacemaker, anxiety disorder and major depressive disorder.
On 2/5/25 at 3:51 PM, a follow up interview was conducted with R306. R306 was observed lying on their back in bed. R306 stated the new Administrator told them they could not have their refrigerator due to State policy and law. R306's refrigerator was observed packed into a box in their room.
On 2/5/25 at 2:13 PM, the Administrator was asked to provide the facility's policy on residents having personal refrigerators in the facility.
A review of a facility policy titled Resident Refrigerators revised 01/01/2022, documented . it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators when approved by the administrator for use in the facility . Dormitory-sized refrigerators are allowed when approved by the administrator prior to admission in a resident's room . Housekeeping staff (or department assigned) shall clean the refrigerator daily . Nursing staff shall clean up spills as needed .
On 2/5/25 at 4:27 PM, the Administrator was interviewed. In attendance were several corporate staff members. The Administrator was asked if they informed R306 that they could no longer have a refrigerator in their room and the Administrator confirmed they had. The Administrator was asked why R306 was unable to have their refrigerator and the Administrator replied their previous facility they were employed at did not allow residents to have their own refrigerator. The Administrator was asked if they reviewed the policy of their current facility which documented that a resident could have a refrigerator from the approval of the Administrator, which R306's refrigerator was approved by the facility's previous Administrator. The Administrator stated they did not review the policy. The Administrator then stated R306's refrigerator was not the correct measurements and the resident could not keep it clean because they required assistance from the staff. The Administrator was reminded that R306's refrigerator was already approved by the previous Administrator which they had for over a year already in the facility and per the facility policy, staff are the personnel designated to clean and maintain the resident's refrigerator. The Administrator was asked if they had adequate staff within the facility to ensure R306's refrigerator was maintained and cleaned? No response was provided. The Administrator was asked to clarify the reason for the removal of R306's refrigerator, was it their belief that refrigerators were not allowed in the facility, the measurement of the refrigerator or the inability of the resident to maintain and clean the refrigerator. In response the Regional Director of Operations (RDO) G stated they will review the policy and change it if needed. RDO G was asked after they reviewed and modified the policy, to inform the surveyor of the ending results.
No further explanation or documentation was provided by the end of the survey.
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 Number(s): MI00149262.
Based on observation, interview, and record review, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00149262.
Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency within the required time frame for one (R303) of three residents reviewed for abuse. Findings include:
A review of a Facility Reported Incident (FRI) submitted to the State Survey Agency (SSA) on 12/13/24 revealed an allegation was made by R303 that Certified Nursing Assistant (CNA) 'H' was rough with her while providing peri-care.
On 2/4/25 at 10:15 AM, the Administrator was asked to provide the facility's investigation into the above alleged incident. A review of the investigation revealed, Administrator 'M' was first notified of R303's allegation against CNA 'H' on 12/11/24. According to the incident report submitted to the SSA, the allegation was not reported to SSA until 12/13/24.
On 2/6/25 at 1:00 PM, R303 was observed lying in bed. R303 did not appear to be able to move in bed independently. When interviewed, R303 reported she required assistance from staff to reposition in bed and staff assisted with brief changes. When queried about what occurred with CNA 'H', R303 reported CNA 'H' was assigned to her, checked on her every two hours to see if she needed a brief change, and during his last rounds, R303 needed a brief change. R303 reported CNA 'H' started to changed her brief and grabbed my vagina roughly. R303 denied that it was sexual in nature, but said it was mean. R303 reported the incident to Licensed Practical Nurse (LPN) 'L'. R303 explained Administrator 'M' (who was no longer employed at the facility) came to talk with her and CNA 'H' did not provide care for her any longer but still worked at the facility.
A review of R303's clinical record revealed R303's was admitted into the facility on 6/10/16 and readmitted on [DATE] with diagnoses that included: rheumatoid arthritis. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R303's had intact cognition and was dependent on staff assistance for bed mobility, and toilet hygiene.
A review of R303's progress notes revealed a Nurse's Note dated 12/11/24 that noted, Administrator was advised by resident that during care a CNA allegedly abuse her. 'I don't know the date that it happened but it was when (LPN 'L') and (CNA 'H') were working and (CNA 'H') was providing care for me. After he (CNA 'H') changed my brief and cleaned me up he grabbed my vagina and it hurt. I reported it to the nurse (LPN 'L'). DON (Director of Nursing) and administrator interviewed resident and completed a skin/pain assessment on resident
A review of a Statement of Witness signed by CNA 'H' on 12/11/24 revealed, On [DATE] 11-7P during my final change, (R303) complained that I was a little rough wiping her .The very next week I had her again and she said that she did not want me as her aide and I swapped her with my hall partner .When this occurred, I reported to the nurse that she said I was too rough with her .
A review of a Statement of Witness signed by LPN 'L' on 12/16/24 revealed, I worked November 26, 7pm-7am first floor and I was the nurse for (R303). I recalled answering her light towards the end of the shift (near the morning). She told me at that time 'I don't want him (CNA 'H') taking care of me'. I asked her why and she did not give me a reason outside of her just not wanting him to take care of her .
On 2/6/25 at 4:00 PM, an interview was conducted with the facility's Administrator, who was the Abuse Coordinator for the facility. The Administrator (who was not employed by the facility at the time of the above allegation) was queried about the protocol when a resident alleged abuse and reported staff were to notify the Administrator immediately and the Administrator was responsible to report the allegation to the State Agency within two hours.
A review of a policy titled, Abuse, Neglect and Exploitation, revised 1/1/22, revealed, in part, the following, .Reporting of all alleged violations to the Administrator, state agency .and to all other required agencies .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .
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 Number(s): MI00149262, MI00148192, and MI00148747
Based on observation, interview, and record r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00149262, MI00148192, and MI00148747
Based on observation, interview, and record review, the facility failed to conduct a thorough investigation into allegations of staff to resident abuse, initiate interventions to prevent further abuse from occurring during the investigation period, and report the results of the investigation to the State Survey Agency (SSA) for three (R303, R310, and R305) of Findings include:
R310
A review of a Facility Reported Incident (FRI) submitted to the State Survey Agency (SSA) on 11/6/24 revealed an allegation made by R310 that Certified Nursing Assistant (CNA) 'H' was rough with her and held her arm while providing care on the midnight shift .staff member was immediately suspended pending investigation. It was noted that as of 11/19/24, an investigation was not submitted to the SSA.
On 2/4/25 at 10:15 AM, the Administrator was asked to provide the facility's investigation into the above alleged incident concerning R310 and CNA 'H'. The following was revealed:
On 2/6/25 at approximately 12:00 PM, R310 was observed lying in bed. An interview was attempted at that time. R310 said she was tired and did not engage in further conversation.
A review of R310's clinical record revealed R310 was admitted into the facility on [DATE] with diagnoses that included: Alzheimer's Disease. A review of Minimum Data Set (MDS) assessments dated 10/15/24 and 1/15/25 revealed R310 had severely impaired cognition, no behaviors, required partial/moderate assistance with bed mobility, and was dependent on staff assistance for toileting hygiene.
A review of R310's progress notes revealed a Nurses' Note dated 1/6/25 written by the Director of Nursing (DON) that read, Resident states that the midnight CNA was changing her and was rough providing care .abuse coordinator notified .
A printed email that indicated the facility's former Administrator (Administrator 'M') submitted the incident report regarding R310 to the SSA on 11/6/24. The email noted, .Based on the information provided, your investigation submission is due no later than 11/14/24 .
There was no summary of the facility's investigation findings included in the file provided by the facility.
A Statement of Witness completed by CNA 'H' on 11/6/24, documented by Administrator 'M' and signed by CNA 'H', revealed CNA 'H' reported the following: (CNA 'O') endorsed the resident to me and informed .me that she (R310) was refusing care. I continued to check on her throughout the night because she continued to refuse care and I reported it to the nurse. Toward the end of the night, around 6am I went in to change the resident and she became combative with me, she was swatting at my arms and hands, scratching me, and she bent my fingers back. She threatened to shoot me. She scratched my arm. I carefully continued the process to get her brief changed. She was cussing at me, using profanity and the like. Her roommate was asking her to stop yelling from ton the other side of the curtain .
A Statement of Witness signed by CNA 'O' on 11/11/24 revealed, .She (R310) is agitated and combative most of the time. She usually refuses all care being provided. That day I did not notice anything out of the norm. I endorsed her to the oncoming CNA and left that unit .
A Statement of Witness signed by Licensed Practical Nurse (LPN) 'P' on 11/6/24 revealed LPN 'P' worked the 7:00 PM to 7:00 AM shift on 1/5/25 with CNA 'H'. The statement noted, Resident (R310) was upset with roommate and agitated all night. CNA came to me about the resident and said she was combative and did not want him to change her .The CNA reported numerous times that she was refusing care and that she scratched his arm .When she was given medication, she calmed down and was able to be changed . (It should be noted that it was said in CNA 'H's statement that he continued carefully to change R310's brief despite the resident's agitation and combativeness.
A review of an incident report included in the investigation file revealed, Resident stated that when care was being provided on midnight shift that the CNA was being rough. When writer asked what he had done she stated that he held her arm while providing care in the attempt of changing her brief.
There was no evidence of any further investigation (other than obtaining statements), such as interviews with other residents or what the outcome of the investigation was, including what was done to prevent further incidents of potential abuse.
On 2/6/25 at approximately 3:00 PM, the Administrator was asked to confirm if there was any additional information regarding the investigation into R310's allegation of rough care by CNA 'H'. The Administrator reported she would look into it. It should be noted that the Administrator did not work in the facility at the time of the alleged incident.
On 2/6/25 at 4:00 PM, and interview was conducted with the Administrator and the DON. The Administrator did not have an explanation as to why there was not a completed investigation or why it was not submitted to the State Agency. The DON who worked in the facility at the time of the facility reported the allegation was investigated by Administrator 'M' and that was who would have submitted the investigation to the SSA. When queried about the outcome of the investigation, the DON did not offer a response. When queried about whether a CNA should continue to provide care to a combative resident who was resisting care, the DON reported they should get the nurse, maybe get a different CNA to provide care, and reapproach later, but not continue to provide care if a resident refused it. When queried about what was done to ensure nobody else was affected by CNA 'H' and how R310 was protected during the investigation, the DON reported CNA 'H' was suspended pending the investigation.
A review of CNA 'H's Time Detail (time punches) record revealed CNA 'H' worked on 11/5/24, 11/7/24, 11/8/24, 11/11/24, 11/14/24, 11/16/24, 11/17/24, 11/19/24, 11/21/24, 11/22/24, 11/26/24, 11/27/24, 11/28/24, 11/28/24, 11/30/24, 12/1/24, 12/3/24, 12/5/24, 12/6/24, 12/7/24, 12/9/24, and 12/10/24.
A review of CNA 'H's personnel file revealed a Performance Improvement Form dated 12/17/24 that noted, On 12/11/24, (CNA 'H') was reported by a resident to have handled her roughly. Upon investigation, Admin could not substantiate any mishandling to the resident, however, it was determined that (CNA 'H') did not follow the care plan to have a 2 person for assistance to change the resident. (CNA 'H') did pericare by himself during this event .
R303
A review of a FRI submitted to the SSA 12/13/24 revealed an allegation was made by R303 that CNA 'H' was rough with her while providing peri-care.
On 2/4/25 at 10:15 AM, the Administrator was asked to provide the facility's investigation into the above alleged incident. A review of the investigation revealed, Administrator 'M' was first notified of R303's allegation against CNA 'H' on 12/11/24 and was reported to the SSA on 12/13/24. There was no summary of the facility's investigation either in the file provided or submitted to the SSA as of 2/4/25.
On 2/6/25 at 1:00 PM, R303 was observed lying in bed. R303 did not appear to be able to move in bed independently. When interviewed, R303 reported she required assistance from staff to reposition in bed and staff assisted with brief changes. When queried about what occurred with CNA 'H', R303 reported CNA 'H' was assigned to her, checked on her every two hours to see if she needed a brief change, and during his last rounds, R303 needed a brief change. R303 reported CNA 'H' started to change her brief and grabbed my vagina roughly. R303 denied that it was sexual in nature, but said it was mean. R303 reported the incident to LPN 'L'. R303 explained Administrator 'M' (who was no longer employed at the facility) came to talk with her and CNA 'H' did not provide care for her any longer but still worked at the facility.
A review of R303's clinical record revealed R303's was admitted into the facility on 6/10/16 and readmitted on [DATE] with diagnoses that included: rheumatoid arthritis. A review of a MDS assessment dated [DATE] revealed R303's had intact cognition and was dependent on staff assistance for bed mobility, and toilet hygiene.
A review of R303's progress notes revealed a Nurse's Note dated 12/11/24 that noted, Administrator was advised by resident that during care a CNA allegedly abuse her. 'I don't know the date that it happened but it was when (LPN 'L') and (CNA 'H') were working and (CNA 'H') was providing care for me. After he (CNA 'H') changed my brief and cleaned me up he grabbed my vagina and it hurt. I reported it to the nurse (LPN 'L'). DON and administrator interviewed resident and completed a skin/pain assessment on resident
A review of a Statement of Witness signed by CNA 'H' on 12/11/24 revealed, On [DATE] 11-7P during my final change, (R303) complained that I was a little rough wiping her .The very next week I had her again and she said that she did not want me as her aide and I swapped her with my hall partner .When this occurred, I reported to the nurse that she said I was too rough with her .
A review of a Statement of Witness signed by LPN 'L' on 12/16/24 revealed, I worked November 26, 7pm-7am first floor and I was the nurse for (R303). I recalled answering her light towards the end of the shift (near the morning). She told me at that time 'I don't want him (CNA 'H') taking care of me'. I asked her why and she did not give me a reason outside of her just not wanting him to take care of her .
There was no evidence that the facility thoroughly investigated the alleged incident to ensure other residents were not affected
On 2/6/25 at 4:00 PM, an interview was conducted with the facility's Administrator who did not have an explanation as to why a full investigation was not completed or why it was not submitted to the SSA, as she did not work in the facility at the time of the incident.
A review of a facility policy titled, Abuse, Neglect and Exploitation dated 1/1/22 revealed, .Investigation of Alleged Abuse, Neglect and Exploitation .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Written procedures for investigations include .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Providing complete and thorough documentation of the investigation .
.Protection of Resident .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation .
.The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies .
R305
A complaint was filed with the SA that alleged on or about 12/5/24 the facility called the police and falsified statements that R305 attempted to assault their roommate, was sent to the hospital for psychiatric services and was not able to contact the facility from the hospital regarding their return.
On 2/6/25 at approximately 10:30 AM, R305 was observed lying in bed. The resident was alert, calm and able to answer all questions asked. R305 was queried about their stay at the facility and any incidents that resulting in the police escorting them to the hospital. R305 noted that there was an incident with a roommate that occurred on 12/5/24. R305 reported that the resident's roommate did not want the door closed and started to call them the N word repeatedly. R305 noted it made them angry and they started yelling back at them. The resident reported that Unit Manager X entered the room with multiple police officers and told the police that they tried to attack their roommate and they were taken out of the facility against their wishes and sent to the hospital.
A review of the R305's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: fracture of lower and upper right femur/leg, fracture of right arm and fracture of right ulna. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition).
Continued review of R305's clinical record, documented, in part, the following:
12/5/24: Psych Eval: Printed and signed 12/6/24 (12:19 AM): Facility requested psych eval for mood as pt.(patient) made suicidal comment .Provider informed facility that he did not have suicidal ideation and intent. But this morning he attempted to hit his roommate and chased him. Staff said that he will be sent out due to violent behavior .
12/5/24: Transfer Form: .Transfer is .b. Unplanned .other reason for transfer: suicidal ideations, assaultive towards peer . *It should be noted that there were no addition notes that detailed violent behavior towards their roommate or suicidal ideations made on 12/5/24; there were no further notes/documents that indicated the resident was assaultive towards peers and/or description of the incident with their roommate.
A request was made for any Incident/Accident (IA) reports. No IAs pertaining to R305 either detailing suicidal ideations and/or violent behavior towards roommate were provided by the end of the Survey.
On 2/6/25 at approximately 12:15 PM, an interview was done with UM X. UM X was asked about the incident that occurred on 12/5/24 and why the resident was sent out for a psychiatric evaluation. UM X reported that they did not observe any incident. However, the midnight nurse reported to them an incident involving R305 and their roommate. UM X noted that when they entered the building R305's roommate had been transferred to another room. When asked if they interviewed any residents or staff to determine what occurred, UM 'X noted that they just completed the transfer form. They additionally noted that they believed a few days prior to the incident with their roommate, they expressed suicidal thoughts to another nurse. UM X was asked about the requested psych eval noted above. They indicated that the Social Worker might be aware of what happened and possibly Nurse Z.
On 2/6/25 at approximately 1:10 PM, an interview was conducted with Social Service Staff Y. When asked if they were familiar with any behavior issues pertaining to R305 they noted that they were not a licensed social worker and believed they were off the day the resident was sent to the hospital. They also reported that their supervising Social Worker was not employed at the time of the incident.
On 2/6/25 at approximately 1:40 PM, an interview was conducted with the Director of Nursing (DON).
The DON was asked if they were aware of any investigations completed regarding R305 for either their aggressive behavior towards their roommate and/or alleged suicidal thoughts. The DON reported that they were not really involved in the incident.
On 2/6/25 at approximately 3:30 PM, an interview was conducted with the Administrator/Abuse coordinator. The Administrator was new to the facility and not employed at the time of the incident. However, when asked the facility's protocol pertaining to resident-to-resident incidents, the Administrator reported that generally an investigation is done to determine what occurred and what follow-up interventions needed to be implemented and if and when the issue should be reported to the State Agency.
On 2/6/25 at approximately 3:37 PM, a phone interview was conducted with Nurse Z. When asked about the incident involving R305 and their roommate, Nurse Z reported that they were fighting about the door being open or closed. They noted they reported the incident to UM X. When asked if they were interviewed by staff as to what occurred, they replied No.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00149262 and MI00148747.
Based on observation, interview, and record review, the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00149262 and MI00148747.
Based on observation, interview, and record review, the facility failed to develop and implement care plans for activities of daily living and suicidal ideations/behaviors for two (R303 and R305) of 14 residents reviewed for care plans. Findings include:
R303
A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) 12/13/24 revealed an allegation was made by R303 that Certified Nurse Assistant (CNA) 'H' was rough with her while providing peri-care.
On 2/6/25 at 1:00 PM, R303 was observed lying in bed. R303 did not appear to be able to move in bed independently. When interviewed, R303 reported she required assistance from staff to reposition in bed and staff assisted with brief changes. When queried about what occurred with CNA 'H', R303 reported CNA 'H' was assigned to her, checked on her every two hours to see if she needed a brief change, and during his last rounds, R303 needed a brief change. R303 reported CNA 'H' started to change her brief and grabbed my vagina roughly. R303 explained that CNA 'H' was the only staff member providing care to her at the time of the alleged incident.
A review of R303's clinical record revealed R303's was admitted into the facility on 6/10/16 and readmitted on [DATE] with diagnoses that included: rheumatoid arthritis. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R303 had intact cognition and was dependent on staff assistance for bed mobility and toilet hygiene.
A review of R303's care plans revealed a care plan initiated on 10/26/23 that noted, Resident has an ADL (activities of daily living) performance deficit related to Rheumatoid arthritis, contractures and prefers to stay in bed . It was noted in the care plan that an intervention for two person assist for toileting was initiated on 10/26/23.
A review of R303's progress notes revealed a Nurse's Note dated 12/11/24 that noted, .After he (CNA 'H') changed my brief and cleaned me up he grabbed my vagina and it hurt .
On 2/4/25, the Administrator was asked to provide the facility's investigation into the above alleged incident. The investigation revealed the following:
A review of a Statement of Witness signed by CNA 'H' on 12/11/24 revealed, On [DATE] 11-7P during my final change, (R303) complained that I was a little rough wiping her .The very next week I had her again and she said that she did not want me as her aide and I swapped her with my hall partner .When this occurred, I reported to the nurse that she said I was too rough with her .
A review of CNA 'H's personnel file revealed a Performance Improvement Form dated 12/17/24 that noted, On 12/11/24, (CNA 'H') was reported by a resident to have handled her roughly. Upon investigation, Admin could not substantiate any mishandling to the resident, however, it was determined that (CNA 'H') did not follow the care plan to have a 2 person for assistance to change the resident. (CNA 'H') did pericare by himself during this event .
On 2/6/25 at 4:00 PM, an interview was conducted with the Director of Nursing (DON) who confirmed CNA 'H' should have had a second staff person to assist while changing R303's brief according to her plan of care.
A complaint was filed with the State Agency (SA) that alleged on or about 12/5/24, R305 and their roommate got into an argument that escalated to the point where the resident was sent to the hospital based on suicidal ideations and/or violent behavior(s).
On 2/6/25 at approximately 10:30 AM, R305 was observed lying in bed. The resident was alert and able to answer all questions asked. R305 was queried about their stay at the facility and any incidents that resulting in them being discharged to the hospital. R305 reported that they had been a resident at the facility for approximately two years following a significant auto accident. They noted that there was an incident with a roommate that occurred on 12/5/24. R305 reported that the resident's roommate did not want the door closed and started to fight with the resident and started yelling at them calling them the N word. Following the incident, the police arrived and took them to (name redacted) hospital for a psychiatric evaluation based on suicidal ideation/threats and the issue with their roommate.
A review of the R305's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: fracture of lower and upper right femur/leg, fracture of right arm and fracture of right ulna. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact cognition).
12/1/24: Nurses Notes: Writer asks resident was he okay? Resident states if he had a gun with one bullet he would be better . do you have a plan to hurt oneself? Resident states only if he had access to a gun. But that he was really irritated due to breaking up with girlfriend. Writer confronts resident and says that someone is always around to talk if need be .
12/5/24: Psych Eval: Printed and signed 12/6/24 (12:19 AM): Facility requested psych eval for mood as pt.(patient) made suicidal comment .Provider informed facility that he did not have suicidal ideation and intent. But this morning he attempted to hit his roommate and chased him. Staff said that he will be sent out due to violent behavior .
12/5/24: Transfer Form: .Transfer is .b. Unplanned .other reason for transfer: suicidal ideations, assaultive towards peer .
R305's Care Plan was reviewed regarding interventions pertinent to suicidal ideations. No documentation was noted in R305's care plan following their comment to nursing staff on 12/1/24 or their return from the hospital on [DATE].
On 2/6/25 at approximately 12:15 PM, an interview was done with UM X. UM X was asked about the incident that occurred on 12/5/24 and why the resident was sent out for a psychiatric evaluation. UM X reported that they did not observe any incident. However, the midnight nurse reported to them an incident involving R305 and their roommate. When asked if their care plan had been updated , UM X noted they were not aware and suggested talking to the Social Worker.
On 2/6/25 at approximately 1:10 PM, an interview was conducted with Social Service Staff Y When asked if they were familiar with any behavior issues pertaining to R305 and possible updates in their care plan they noted that they were not a licensed social worker and believed they were off the day the resident was sent to the hospital. They also reported that their supervising Social Worker was not employed at the time of the incident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00149629 and MI00149369.
Based on observation, interview, and record review, the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00149629 and MI00149369.
Based on observation, interview, and record review, the facility failed to follow nursing professional standards of practice related to wound treatment and entering medication orders for two (R301 and R302) of two residents reviewed. Findings include:
On 2/4/25 at 11:00 AM, R301 was observed in bed. A dressing applied to R301's right foot was observed to be soiled in the area of his toes. The dressing was dated 2/3/25 with initials (discovered to be Licensed Practical Nurse - LPN 'Q') written with thick black marker which was written over thinner writing that was labeled 1/31/25.
On 2/4/25 at 11:09 AM, an observation of the dressing on R301's right foot was conducted with Unit Manager, Registered Nurse (RN) 'U'. When queried about the date of 2/3/25 written on top of the date of 1/31/25, RN 'U' did not offer a response.
On 2/4/25 at 11:19 AM, an observation of the dressing on R301's right foot was conducted with the DON who replied They just changed it! When queried about who and when, the DON pointed to the dressing which was dated for the day prior, 2/3/25. The DON reported she looked at the dressing and saw the date from yesterday but did not notice the date underneath. The DON reported the treatment should be done according to the physician's order and signed out on the Treatment Administration Record (TAR) when completed.
On 2/5/25 at 10:06 AM, an interview was conducted with LPN 'Q' via the telephone. When queried about the date of 2/3/25 written on R301's dressing to his right foot with writing underneath labeled 1/31/25, LPN 'Q' confirmed that he wrote the date on the dressing without actually performing wound care. LPN 'Q' reported he did it because he was assigned to too many residents and could not complete all of his nursing tasks.
A review of R301's Physician's Orders and Treatment Administration Record for February 2025 revealed an order to Cleanse right great toe and second toe with wound cleanser and pat dry. Apply calcium alginate AG with honey-based gel and wrap with dry dressing every day shift . It was signed off on the TAR that the treatment was administered on 2/1/25 and 2/2/25, despite the dressing indicating the last treatment was done on 1/31/25. On 2/2/25, there was no nurse's signature to indicate a treatment was administered to R301's right toes.
A review of R301's clinical record revealed R301 was admitted into the facility on 1/2/24 and readmitted on [DATE] with diagnoses that included: acute respiratory failure with hypoxia. A review of a Minimum Data Set (MDS) dated [DATE] revealed R301 had moderately impaired cognition and had open lesions to his skin.
R302
A complaint was filed with the State Agency (SA) that alleged that the facility stopped providing IV (intravenous) antibiotics as ordered for R302.
A review of the R302's clinical record detailed the following:
12/13/24: Patient Discharge Summary : admission date (to hospital) 12/4/24 .Projected discharge date to facility 12/13/24 .Primary Diagnosis: Bed Sores .Assessment and Plan .Left trochanteric wound .debridement done by surgery .Recommend: .IV antibiotics .Prescription Details: Rx (medication): Zosyn (Piperacillin Sod-Tazobactam) 4.5 g (grams) IV Piggyback q8h (every 8 hours) for 28 days .
Following their stay at the hospital, R302 was admitted to the facility on [DATE] with diagnoses that included: acute osteomyelitis (inflammation of the bone caused by infection), fecal impaction and quadriplegic cerebral palsy. An initial assessment (12/13/24) completed by Nurse N noted the resident had two infected wounds and was to receive antibiotic treatment (ABT) at the facility. The initial assessment and following Minimum Data Set (MDS) noted the resident was severely cognitively impaired and required extensive help with all activities of daily living.
Order details (12/13/24):Order summary: Piperacillin Sod-Tazobactam .use 4.5 gram intravenously every 8 hours for infection for 7 days . *End date of 12/20/24.
PMR (physician medicine and rehabilitation) progress note (12/17/24): .Patient admitted to facility on 12/13/24 .PMR consulted to evaluate rehab needs .I personally reviewed the hospital records .continues with RUE right upper extremity) PICC (peripherally inserted central catheter) for antibiotic tx (treatment) of Osteomyelitis (infection in bone) till 1/8/25 . *If order was correct R302 would have received 28 days of antibiotic.
R302's MAR (medication administration record) noted the resident received the above order (Piperacillin) starting on or about 12/13/24. The antibiotic was noted to be provided through 12/20/24 (last dose at 2 PM). The MAR did not document that the medication was provided on 12/18/24 at 2PM or 12/19/24 (2 PM). Further review noted that there were no more attempts to administer the medication 12/21/24 through 12/30/24. The MAR noted attempts to administer the antibiotic on 12/31/24 at 2 PM and 10 PM with a note that indicated the medication was hold/see progress note.
12/31/24: Note: Piperacillin Sod-Tazobactam So Intravenous Solution .use 4.5 gram intravenously every 8 hours for Osteomyelitis for 21 days begin after picc line is placed awaiting IV to be placed in.
On 2/4/25 at approximately 4:00 PM, an interview was conducted with Nurse N who was queried as to the facility protocol for newly admitted patients, specifically ensuring necessary medications prescribed by hospital physicians are provided to the resident(s) during their stays. Nurse N reported that upon admission nursing staff will review the hospital discharge records, including, but not limited to medication orders. Once they review the orders they are sent to the residents treating physicians and nursing staff will place the orders in to the residents clinical records. Nurse N was asked about R302 as it appeared they had completed the initial assessment. Nurse N noted that they had been working with another Nurse (herein Nurse E) who put in R302's medication orders. Nurse N was asked if they were aware that the initial order expected the facility to provide IV antibiotics for 28 days and it appeared as the original order was only for 7 days. Nurse N noted that they were aware that there had been some confusion, and the facility tried to restart the medication again but there were some issues with the PICC line.
On 2/5/25 at approximately 3:28 PM, an interview was conducted with Nurse 'E. Nurse E reported that they had been employed by the facility for about six months. When asked if they were familiar with R302, they noted that they were. When asked about entering R302's IV order antibiotic order upon their admission, Nurse E reported that they recently reprimanded by the Director of Nursing (DON). Nurse E could not provide a specific date that the DON spoke with them, but noted they were educated on double checking orders and ensuring correct orders are put in place.
On 2/5/25 at approximately 1:40 PM, an interview was conducted with the DON. The DON was queried as to the failure to correctly place R302's hospital order for antibiotics. The DON replied that they were aware of the situation and had educated Nurse E.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00148240
Based on observation, interview and record review the facility failed to prevent, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #MI00148240
Based on observation, interview and record review the facility failed to prevent, timely identify a pressure wound and ensure interventions were in place for one (R309) of three residents reviewed for pressure ulcers resulting in R309 sustaining a facility acquired stage III pressure ulcer to their right ear. Findings include:
A complaint was filed with the State Agency (SA) that alleged on 10/16/24 they observed that a piece of skin was missing from R309's ear and blood was observed on the resident's pillow. The complainant further alleged that R309's ear appeared as if it turned black and thought it was because the resident was continuously lying on their right side and not turned frequently.
On 2/4/25 at approximately 11:05 AM, R309 was observed lying in bed, a tracheostomy (artifical airway inserted in the windpipe) was present and their head was turned to the right side. Their right ear was not visible. The resident was alert, however not able to communicate. Follow-up observations were conducted on 2/4/25 at approximately 1:00 PM and again at 1:36 PM, the resident was still in the same position as observed at 11:05 AM. At 3:00 PM, R309 was observed in the same position leaning on their right side.
A review of the resident's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: chronic respiratory failure, cerebral infarction (stroke) and Lupus (an immune chronic illness). A review of the resident's Minimum Data Set (MDS) noted the resident was severely cognitively impaired and required extensive one to two person assist for most Activities of Daily Living (ADLs).
A Turn and Reposition Task (dated 2/4/25) noted inconsistencies in turning. The following times were marked: 3:21 AM (times two), 3:22 AM (times one), 6:13 AM (times one), 9:04 AM(times two), 12:32 PM (times one), 1:47 (times one), 4:33 PM (times one), 8:20 PM (times two) and 10:54 PM (times one).
A skin assessment form dated 10/17/24 documented, in part, the following: .Are there any new abnormal skin areas (NO) .Are there any existing abnormal skin areas (YES) .List sites: abdomen, sacrum . *This skin assessment had no documentation pertaining to the resident's ear, nor were there any progress notes indicating issues to the right ear, including blood coming from the resident's right ear.
A skin assessment form dated 10/24/24 documented, in part, the following: .Are there any new abnormal skin areas (NO) .Are there any existing abnormal skin areas (YES) .List sites: abdomen, sacrum . *This skin assessment had no documentation pertaining to the resident's right ear. No additional nursing notes were noted in the record.
A Wound Evaluation (dated 10/24/24 and including pictures) noted, .Pressure: Stage 3 .Body location: Front Right [NAME] (Outer ear) .acquired: In-house Acquired .Area .89 cm, length 1.44 com, width .76 cm .Deepest point .2 cm .Type: Pressure .Stage 3 .acquired: In-House acquired .Location: Front Right Ear.
Care Plan: Focus (date initialed: Resident has impaired skin integrity as evidenced by admission Pressure injury to the right ear (reopening) .(date initiated 10/4/23 .Revision on 10/24/24) .Interventions: .Right ear: Skin prep .Right Ear Calcium Alginate bordered foam .Assist resident with turning and repositioning as needed using positional devices . (10/24/24).
Order (10/25/24): Cleanse right ear with wound cleanser. Pat dry. Apply Calcium Alginate to fit open area and cover with a 2x2 bordered foam dressing every day shift for Wound healing .
On 2/5/25 at approximately 2:15 PM, an interview was conducted with Wound Nurse D. Nurse D was asked about the facility's protocol for preventing and identifying skin issues. Nurse D reported that residents receive head-to-toe skin assessments by nursing staff weekly. If they become aware of an issue they should report their concerns. Additionally, Nurse D can review assessments and sometimes Certified Nursing Assistance (CNAs) will report concerns. Nurse 'D was queried as to when they became aware of the resident's open area on their right ear as the head-to-toe skin assessments (10/17/24 and 10/24/24) contained no information regarding the resident's ear. Nurse D reported that most likely R309's family brought it to their attention and they initiated the assessment and treatment orders. Nurse D noted that staff should be the ones to report and added they believed nursing staff are often overwhelmed and have too much work.
On 2/6/25 at approximately 2:13 PM, an interview was conducted with the Director of Nursing (DON) regarding R309's pressure ulcer on the right ear. The DON reported that the wound was acquired at the facility about two years ago, was resolved and most likely developed again. When asked as to what interventions were in place to prevent the pressure ulcer to the ear and why nursing staff failed to notice a change in their skin, the DON reported that the resident should be turned at least every two hours and documented as done, and that wound care should be notified immediately with a change in condition.
A facility policy titled, Pressure Injury Prevention and Management (3/20/24) was reviewed and documented, in part: Policy: The facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition .define and implement interventions that are consistent with the residents needs .monitor and evaluate the impact of the interventions; or revise the interventions as appropriate .
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 F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to timely review and report abnormal lab results to the Physician and/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to timely review and report abnormal lab results to the Physician and/or Nurse Practitioner (NP) for one (R314) of three residents reviewed for death. Findings include:
Review of the medical record revealed R314 was admitted on [DATE] with diagnoses that included: Dementia and Anemia.
A review of the progress notes documented the following:
A NP note (later identified as NP K) dated 12/24/24 at 3:41 PM, documented in part . recent hospitalization 12/6 - 12/11 for anemia (Hgb - Hemoglobin 5.2) . received 2 units of pRBC's (packed Red Blood Cells) and IV (intravenous) iron at the hospital and gastroenterology was consulted .
A Nursing note dated 1/6/25 at 11:28 AM, documented in part . order STAT (immediate) redraw if HGB is still low send to ER (Emergency Room) .
A NP K note dated 1/6/25 at 2:16 PM, documented in part . Anemia: Hgb 6.6 on 1/3. STAT CBC (Complete Blood Count) ordered. Patient to be transferred to ED (Emergency Department) if Hgb< (less than) 7 for transfusion .
A Nursing note dated 1/7/25 at 1:45 AM, documented in part . unresponsive . TOD (time of death) 0109 . This note was documented by Licensed Practical Nurse (LPN) J.
Review of a lab report dated 1/6/25, documented as Reported Date: 1/6/2025 17:59 (5:29 PM) . noted a HGB of 6.415 L (low) - (reference range: 11.60-15.00).
Review of the record revealed no documentation of the staff to identify the abnormal HGB range or notification to the Physician or NP. Further review revealed the resident was not sent to the hospital as directed by the NP for the low hemoglobin.
A review of a facility policy titled Laboratory and Diagnostic Guidelines revised date 10/26/23, documented in part . This guideline is set up to track the timely completion, reporting and monitor of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status . The physician should be notified of all lab/diagnostic test results based on the below parameters . Critical lab results or urgent diagnostic should be called to the physician upon receipt . All notifications, attempts at notifications, and response should be noted in the resident's medical record .
On 2/6/25 at 2:26 PM, the Director of Nursing (DON) was interviewed and asked how the facility receives their lab results from their lab company. The DON stated once the labs are complete they are uploaded to the residents chart. The DON was then asked about the lab results for R314 for the date of 1/6/25 that notes it was reported to the facility at 5:29 PM. The DON was asked why R314 was not sent out per the clinicians directive as documented for the low HGB level and why there was no documentation of the Physician and/or NP to have been notified. The DON stated they would look into it and follow back up.
On 2/6/25 at 2:36 PM, LPN J was interviewed via telephone and asked if they had notified the Physician or NP of R314's low hemoglobin results and LPN J stated No, they along with the nurse they received report from on 1/6/25 (dayshift nurse) had looked into the system and did not find results for the resident. LPN J stated it was not until the next day that the unit manager had showed them where the results were and how to obtain them. LPN J explained R314 had two last names (hyphenated last name). LPN J stated they along with the off going nurse on 1/6/25 looked under one of the last names and their was no result. LPN J stated the unit manager showed them where to look and obtain the results moving forward.
On 2/6/25 at 2:53 PM, an attempt to contact R314's assigned Physician at the facility (Physician I) was made via telephone. A voice message was left with the number to return the call. A return phone call was not received by the end of the survey.
On 2/6/25 at 3:09 PM, NP K was interviewed via telephone and was asked if they were informed of R314's abnormal HGB on 1/6/25 that required them to be transferred to the hospital as they directed and NP K stated they were not informed by the staff of the abnormal STAT HGB level.
No further explanation or documentation was provided before the end of the survey.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
This citation pertains to Intake Number(s): MI00149629, MI00149425, and MI00149174.
Based on observation, interview, and record review, the facility failed to ensure there was an adequate supply of li...
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This citation pertains to Intake Number(s): MI00149629, MI00149425, and MI00149174.
Based on observation, interview, and record review, the facility failed to ensure there was an adequate supply of linens for three (R300, R301, and R305) of three residents reviewed for linens and the potential to affect all residents on the second floor. Findings include:
A review of a complaint submitted to the State Survey Agency (SSA) revealed an allegation that the facility was short on wash cloths and that they were stained with feces.
A review of a second complaint to the SSA revealed an allegation that the facility ran out of clean towels and wash cloths on a regular basis. In addition, it was alleged there was a limited number of blankets and they were not washed regularly.
A review of a third complaint submitted to the SSA revealed an allegation that the facility is always short on linens.
R300
On 2/4/25 at approximately 12:00 PM, an interview was conducted with R300's family member who reported a concern about the facility switching from using wipes to washcloths to clean residents up. According to R300's family member, the facility often ran out of towels and washcloths since they made that change. R300 reported being asked by management to fill out a concern form regarding that issue.
A review of a Quality Assistance Form dated 1/8/24 that indicated R300's family member brought the following concern to the Director of Nursing's (DON) attention: Today towel was brought in the room that was dingy from being used on changing someone with bowels, wipes (are) needed its unsanitary, water does not get hot enough to clean the linen especially with patients having wounds. There are shortage of linens to even provide care. The concern was assigned to the former Administrator, Administrator 'M'. The sections for Findings, Plan/Actions, and whether the concern was resolved was left blank.
R301
On 2/4/25 at 1:56 PM, R301's family member indicated via e-mail communication that the facility frequently ran out of washcloths and they had to purchase their own. R301's family member reported R301 required to be cleaned up frequently due to secretions that came out of their tracheostomy tube (tube inserted into the windpipe to assist with breathing).
R305
On 2/4/25 at approximately 10:56 AM, an interview was conducted with Certified Nursing Assistant (CNA) W. When asked if the facility provided enough supplies to clean and wash the residents, CNA W reported that the facility no longer provides wipes to clean the residents and they currently use washcloths. When asked if the facility provided enough washcloths, CNA W stated No. CNA W then escorted the Surveyor to the linen storage closet(s) on the 2nd floor. There were no wash clothes observed in linen closet. An observation was then conducted on the first floor. In the linen storage room on the [NAME] Hall (1st floor) there were approximately 10 washcloths. The linen room on the East Hall (1st floor) did not have any washcloths.
On 2/6/25 at approximately 10:30 AM, R305 was observed lying in bed. The resident was alert and able to answer all questions provided. R305 was asked if the facility provided enough linen to provide care, the resident stated No. They then pointed to a large towel at the end of their bed and noted I rarely get a washcloth to clean myself and they are no longer providing wipes.
On 2/6/25 at 8:35 AM an observation of two of four of the facility's linen closets and laundry room was made with the Director of Nursing (DON) and the Administrator. Further observations revealed that the linen closet on the second floor had a few face towels, three big towels, a couple of fitted sheets, no flat sheets or gowns. The DON was asked was this considered enough supplies for staff to efficiently complete their job. The DON reported no, but explained there was available linen in the laundry room that staff could use.
On 2/6/25 at 8:49 AM an observation of the facility's laundry room was made. The laundry room had two clean linen carts. Neither linen cart had linen on them. The Administrator asked House Keeping Manager DD was the linen on the units all that staff have access too at this time. The House keeping manager DD reported yes and explained that the laundry room had a leak, and a washer machine was down.
There was no additional information provided by exit of survey.
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 F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake # MI00149369
Based on interview and record review, the facility failed to ensure that residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake # MI00149369
Based on interview and record review, the facility failed to ensure that residents medication orders were entered correctly upon admission for one (R302) of two sampled residents reviewed for antibiotics, resulting in R302 initially missing 10 days of their antibiotic, being sent to the hospital to correct an issue with their PICC (peripherally inserted central catheter) line and needed an extended stay at the facility to ensure they received all antibiotics prescribed. Findings include:
A complaint was filed with the State Agency (SA) that alleged that the facility stopped providing IV (intravenous) antibiotics as ordered for R302. Additional allegations noted the failure to follow hospital ordered antibiotics resulted in R302 returning to the hospital on or about 1/1/25 for PICC line placement and then returning to the facility for an extended stay to complete their antibiotics.
A review of the R302's clinical record detailed, in part, the following:
12/13/24: Patient Discharge Summary : admission date (to hospital) 12/4/24 .Projected discharge date to facility 12/13/24 .Primary Diagnosis: Bed Sores .Assessment and Plan .Left trochanteric wound .debridement done by surgery .Recommend: PICC .IV antibiotics .Prescription Details: Rx (prescribed medication): Zosyn (Piperacillin Sod-Tazobactam) 4.5 g (grams) IV Piggyback q8h (every eight hours) for 28 days .
Following their stay at the hospital, R302 was admitted to the facility on [DATE] with diagnoses that included: acute osteomyelitis (inflammation of the bone caused by infection), fecal impaction and quadriplegic cerebral palsy. An initial assessment (12/13/24) completed by Nurse N noted the resident had two infected wounds and was to receive antibiotic treatment (ABT) at the facility. The initial assessment and following Minimum Data Set (MDS) noted the resident was severely cognitively impaired and required extensive one to two person assistance with all activities of daily living.
Order details (12/13/24):Order summary: Piperacillin Sod-Tazobactam .use 4.5 gram intravenously every 8 hours for infection for 7 days . *End date of 12/20/24.
PMR (physician medicine and rehabilitation) progress note (12/17/24): .Patient admitted to facility on 12/13/24 .PMR consulted to evaluate rehab needs .I personally reviewed the hospital records .continues with RUE PICC for antibiotic tx of Osteomyelitis till 1/8/25 . *It should be noted there was no indication in the initial facility order (12/13/24) that the resident was to receive antibiotics until 1/8/25 (28 days).
R302's MAR (medication administration record) noted the resident received the above order (Piperacillin) starting on or about 12/13/24. The antibiotic was noted to be provided through 12/20/24 (last dose at 2 PM). The MAR did not document that the medication was provided on 12/18/24 at 2PM or 12/19/24 (2 PM). Further review noted that there were no more attempts to administer the medication 12/21/24 through 12/30/24. The MAR noted attempts to administer the antibiotic on 12/31/24 at 2 PM and 10 PM with a note that indicated the medication was hold/see progress note.
12/31/24: Note: Piperacillin Sod-Tazobactam So Intravenous Solution .use 4.5 gram intravenously every 8 hours for Osteomyelitis for 21 days begin after picc line is placed awaiting IV to be placed in.
12/31/24: Orders Administration Note: Piperacillin Sod-Tazobactam So Intravenous Solution .Use 4.5 gram intravenously every 8 hours for Osteomyelitis for 21 days begin after picc line is placed .
1/1/25-Progress note: .unable to insert PICC line .Resident sent out to (name redacted) Hospital for PICC line insertion .
(Name redacted) Hospital Records (1/1/24): .Vascular Surgery Consult .Reason for consult: IV access .Plan: when reviewing the chart patient requires another 3 weeks of IV antibiotics .
On 2/4/25 at approximately 4:00 PM, an interview was conducted with Nurse N who was queried as to the facility protocol for newly admitted patients, specifically ensuring necessary medications prescribed by hospital physicians are provided to the resident(s) during their stays. Nurse N reported that upon admission nursing staff will review the hospital records, including, but not limited to medication orders. Once they review the orders they are sent to the residents treating physicians and nursing staff will place the orders in to the residents clinical records. Nurse N was asked about R302 as it appeared they had completed the initial assessment. Nurse N noted that they had been working with another Nurse (herein Nurse E) who put in R302's medication orders. Nurse N was asked if they were aware that the initial order expected the facility to provide IV antibiotics for 28 days and it appeared as the original order was only for 7 days. Nurse N noted that they were aware that there had been some confusion, and the facility tried to restart the medication again but there were some issues with the PICC line.
On 2/5/25 at approximately 3:28 PM, an interview was conducted with Nurse 'E. Nurse E reported that they had been employed by the facility for about six months. When asked if they were familiar with R302, they noted that they were. When asked about entering R302's IV order antibiotic order upon their admission, Nurse E reported that they recently reprimanded by the Director of Nursing (DON). Nurse E could not provide a specific date that the DON spoke with them, but noted they were educated on double checking orders and ensuring correct orders are put in place.
On 2/5/25 at approximately 1:40 PM, an interview was conducted with the DON. The DON was queried as to the failure to correctly place R302's hospital order for antibiotics. The DON replied that they were aware of the situation and had educated Nurse E. When asked as to the 10 day lapse in providing R302 with antibiotics and the concern regarding the closed PICC line, the DON again stated that Nurse 'E was reeducated. No specifics were provided as to the issue with the PICC line re-insertion.
A review of the facility policy titled, Medication Administration (1/1/22) read, in part: Policy: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice .correct any discrepancies and report to nurse manager .
Oct 2024
14 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0710
(Tag F0710)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R30
Record review revealed R30 was a long-term resident admitted to the facility on [DATE]. R30's admitting diagnoses included a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R30
Record review revealed R30 was a long-term resident admitted to the facility on [DATE]. R30's admitting diagnoses included acute and chronic respiratory failure, anoxic (lack of oxygen) brain damage, and quadriplegia (paralysis of both upper and lower extremities).
Review of R30's clinical record revealed that they were on ventilator, under pressure-controlled ventilation (a mechanical ventilation technique that uses a set pressure to inflate a patient's lungs). Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care since [DATE].
R19
Record review revealed R19 was a long-term resident of the facility, admitted on [DATE]. R19's admitting diagnoses included dependence on a ventilator/respirator due to respiratory failure, chronic obstructive pulmonary disease (COPD), cirrhosis of liver, and malnutrition.
Review of R19's clinical record revealed that they were on ventilator, under assist control (AC) ventilation setting (the ventilator setting that delivers a set volume of air to the patient's lungs at a set rate, either when the patient breathes or at fixed intervals). Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care since [DATE].
R42
Record review revealed R42 was a long-term, ventilator dependent resident of the facility. They were admitted to the facility on [DATE]. R42's admitting diagnoses included chronic respiratory failure, cardiac arrest, anoxic brain damage, and dependence on ventilator.
Review of R42's clinical record revealed that they were on ventilator, under pressure-controlled ventilation (PCV - a mechanical ventilation technique that uses a set pressure to inflate a patient's lungs). Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care since [DATE].
R35
Record review revealed R35 was a long-term, ventilator dependent resident of the facility. They were admitted to the facility on [DATE]. R35's admitting diagnoses included bone marrow failure syndrome, respiratory failure, diabetes, and COPD.
Review of R35's clinical record revealed that they were on ventilator, under pressure-controlled ventilation (PCV - a mechanical ventilation technique that uses a set pressure to inflate a patient's lungs). Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care since [DATE].
An interview with Nurse Practitioner (NP) T was completed on [DATE]. During the interview they were queried if they were overseeing the care for ventilator dependent residents and they reported that they were only overseeing residents who were assigned to the medical director. They were queried about the ventilator settings and coordination of care with the pulmonologist for ventilator dependent residents. NP T reported that they did not handle that and they were only coordinating the care with the attending physician who was also the Medical Dierctor.
The Administrator (NHA) submitted the following accepted removal plan on [DATE] at 5:53 PM:
Identification of Residents Affected or Likely to be affected: All residents with ventilator assistance.
The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE])
The NHA notified the Medical Director of the incident.
The Pulmonologist will complete physical assessments on all like residents to identify any changes in condition and confirm current ventilator settings on [DATE]
The Pulmonologist has received education outlining responsibility for oversight for respiratory care for all Ventilator residents including but not limited to
o
Completing physical assessments
o
Monitoring ongoing care
o
Documenting consultations/evaluations
o
Providing orders for weaning for ventilator residents
The pulmonologist has agreed to round for the residents on the ventilator unit at least 2 times per week. She is available to take call 24 hours in coordination with Primary Care Provider.
Ventilator orders sets are entered on admission.
o
Oxygen: RUN @ []L/MIN VIA []N/C []MASK []TRACH[] HOURS PER DAY [] PRN [] CONTINUOUS
o
Assess stoma site and under trach collar
o
Trach Change. Trach brand: Trach size:
o
Change trach collar/strap every 3 days and prn
o
Visual check of ventilator dependent residents per care plan and prn.
o
Weaning prn, per physician order, or respiratory protocol
o
Enter time in minutes to complete airway equipment management task
o
Evaluation/Assessment of resident on (Vent/Tracheostomy)
o
Oxygen saturation q shift and prn
o
Oxygen tubing/filter change every week. Enter time in minutes to complete task
o
Suction tracheostomy as needed
o
Resident/Resident Representative Education
o
Trach Care PRN (as needed)
o
Trach tie change with baths and as needed
o
Settings: Mode: RR: PEEP: PS:
o
Change circuits monthly and PRN. Enter time in minutes to complete circuit change task.
o
Trach care every shift and as needed
Based on interviews and record reviews the facility failed to ensure residents that required Ventilator care were provided ongoing medical supervision and oversight by a Physician for their respiratory care, ventilator and/or tracheostomy care, including the weaning process for ventilator residents, respiratory examinations, assessments and respiratory/ventilator changes in status throughout their inpatient stay, for nine (R's 40, 30, 55, 57, 35, 41, 10, 19 & 42) of 15 residents reviewed for ventilator care resulting in an identified systemic failure of interdisciplinary approach and Physician oversight for residents that required Ventilator and respiratory care, including adequate implementation of policies and procedures to monitor and supervise the weaning process for mechanical ventilation, and responding to mechanical ventilation alarms and respiratory needs, which resulted in the increased likelihood of serious harm, serious injury and/or death to occur.
Findings include:
The Immediate Jeopardy (IJ) was identified on [DATE] at 11:51 AM.
The IJ began on [DATE].
The Administrator and Ventilator Unit Administrator A was notified of the IJ on [DATE] at 1:34 PM. A plan of removal was requested at that time to remove the immediacy.
The IJ was removed and verified on [DATE] based on the facility's implementation of an acceptable plan of removal.
Although the immediacy was removed, the deficient practice was not corrected and remained patterned with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA).
R40
Review of a closed record death at the facility for R40 revealed the following:
R40 was admitted to the facility on [DATE] and expired in the facility less than a month later on [DATE]. Admitting diagnoses included: acute and chronic respiratory failure, epilepsy and epileptic syndromes, history of sudden cardiac arrest, acute systolic congestive heart failure, atrial fibrillation, hemiplegia/hemiparesis affecting right dominant side, tracheostomy status, gastrostomy status and ventilator dependent.
Review of the progress notes revealed the following for the date of [DATE]:
A Respiratory Note (RT) at 9:00 AM, documented in part . Per protocol, placed pt (patient) on CPAP (continuous positive airway pressure) /PSV (pressure support ventilation) vent mode; appeared to be tolerating wean . [NAME] (no apparent respiratory distress) noted. Will con't (continue) to monitor resp (respiratory) status.
A RT note at 7:06 PM, documented in part . patient received from previous shift, non-verbal, non-focused response, moderately diminished gag/cough reflex, oral, nasal and tracheal secretions suctioned in moderate to large amounts, patient not tolerating PSV vent settings and change to AC (assist control) due to persistent low minute volume alarms, low RR (respiratory rate), grayish facial skin, slightly diaphoretic, will continue to monitor.
A Nursing note at 10:44 PM, documented in part . At 2244 (10:44 PM), found to have no pulse. Chest compressions started and also bagged with full support. Patient already traced and vented. 911 in and used thumper machine. Seven does <sic> of epinephrine used. Patient underlying rhythm asystole. Patient pronounc <sic> 2326 (11:26 PM). Patient's daughter notified and came up to the facility. Patient medical service and DON (Director of Nursing) called about event .
Review of a policy titled Ventilator Unit- Weaning protocols for the mechanically ventilated patient revised on [DATE], documented in part . Purpose - To facilitate the liberation of patients from mechanical ventilation and provide a consistent approach to the ventilator weaning process. This pathway is a collaborative plan mean to guide the care of ventilator patients. It may be modified based on clinical indication, if appropriate and documented, or in emergency situations . Weaning from mechanical ventilation will be initiated with a physician's order only. Nurses and Respiratory Therapists will be responsible for the care of eligible residents . The ventilator weaning protocol will be implemented following the order of a physician. Eligibility for ventilator liberation will be assessed daily through a collaborative evaluation between respiratory therapy and nursing . Mechanical ventilator weaning will be initiated if: 1. The physician concurs that the patient's condition is consistent with weaning and is clinically stable. 2. The physician may write weaning parameter orders. 3. A pulse oximeter will be utilized on all patients to follow specifically ordered weaning parameters. 4. If at any time the patient develops respiratory distress, or does not tolerate the weaning procedure, returning the patient to safe acceptable ventilator settings and notify the physician.
Review of R40's medical record revealed no assessments/evaluations documented by a physician to determine if R40's condition was clinically stable and was eligible for weaning, no weaning parameter orders/protocol, no ongoing pulse oximeter readings documented during the weaning process and no documentation of notification to the physician once R40 was identified to have a change of condition. There was also no identified ongoing nursing assessments documented in the residents record after the identified change of condition. The record revealed no physician order implemented for Pressure Support Ventilation to start the weaning process for R40.
Further review of the medical record revealed no examinations/evaluations completed by the facility's Pulmonologist or Physician regarding their ventilator and respiratory care.
On [DATE] at 3:39 PM, a telephone interview was attempted with Registered Nurse (RN) G (the nurses assigned to R40 the evening they expired in the facility) and a message was left for RN G to return the call.
On [DATE] at 3:31 PM, a telephone interview was attempted with Respiratory Therapist (RT) H (the evening RT who provided care to R40 on [DATE]) and a message was left for RT H to return the call.
On [DATE] at 8:32 AM, a second attempt for a telephone interview with RT H was unsuccessful.
On [DATE] at 10:20 AM, an interview was conducted with the Respiratory Therapy Director (RTD) I. RTD I was asked if they were aware of R40's change of condition on [DATE] and the physician to not have been notified. RTD I stated they talked to RT H because they had worked the night shift and they questioned RT H about the incident on [DATE]. RTD I stated RT H found that R40 was not tolerating the weaning process and that R40 was not breathing well. RTD I stated RT H then stated they put R40 back on full ventilator support. RTD I stated that RT H verbalized R40's nurse being in the room at the time, so they did not feel the need to chart any more or contact the physician. RTD I stated they educated RT H at . length about documentation and the importance of making sure it's in the medical record. RTD I was asked the facility's protocol on weaning, due to the review of R40's medical record revealed no documentation of the weaning protocol they utilized on [DATE]. RTD I stated . It's a little vague on the weaning . but stated they will find the sheet that they use.
On [DATE] at 12:27 PM, the primary Physician for R40, (Physician J ) was interviewed via telephone and asked if they had been notified of R40's change of condition after the unsuccessful weaning process on [DATE] and Physician J stated they were not notified.
On [DATE] at 2:36 PM, RN G returned the call and was interviewed. RN G was asked about [DATE] and the events leading up to R40 being found unresponsive. RN G stated R40 was not tolerating the weaning because the alarm (on the ventilator) was going off consistently. RN G stated they informed RT H that R40 was not tolerating the weaning process and needed to go back on full support. RN G stated they did not have any other issues with R40 until they were found unresponsive. RN G was asked the facility's monitoring process for a resident who was identified with a change of condition after an unsuccessful weaning attempt and RN G stated they never seen a protocol in place to wean a person. RN G stated that R40 was in pretty bad shape and prognosis was poor prior to the attempted wean. RN G was then asked who decided that R40 was an eligible candidate to wean if they were in such bad shape and RN G stated they were not sure. RN G denied being informed of R40 to have been grayish in color and diaphoretic as noted by RT H.
On [DATE] at 4:07 PM, RT H returned the call and was interviewed regarding R40 on the date of [DATE]. RT H stated at the start of their shift they had received report from the off going RT who stated R40 was being weaned and was tolerating the wean. RT H stated the off going RT instructed RT H to leave R40 on their current weaning settings throughout the night since they were tolerating the wean. RT H stated R40 was comatose and didn't move. RT H was asked who decided R40 was an eligible candidate to wean and RT H stated they were not sure. RT H stated RN G informed them of R40's vent alarms continuously going off and that they were not tolerating the wean. RT H stated the ventilator alarms were going off and the resident was not looking good and was diaphoretic and they had never seen the resident like that before. RT H stated they put R40 back on full ventilator support. RT H stated that RN G was aware of R40's change of condition. RT H stated in part . he was only breathing 8 (respiration rate) per minute and this patient usually is in the 20's and 30's and he was 8 because the air is not getting through to him . RT H stated they work night shift in the facility and would usually not wean the residents at night due to the fact that they weaned during the day and needed to rest and recuperate throughout the night. RT H stated they did not have any other interactions with R40 until they were notified of the code called for R40 due to being unresponsive. RT H was asked where the weaning protocol or order could be found for R40 and RT H stated . I already pointed it out numerous times that it should be a doctor's order to do it . RT H went on to say that they verbally communicate the orders and . there is no order so I have to do what I see fit and he (R40) was not tolerating it (wean) so I changed him (back to full ventilator support) . RT H stated they responded to the code, R40 was identified with a lot of vomit and they suctioned them. RT H stated R40 did not have a gag reflex and vitals were absent. RT H stated that's when the nurses came in to do CPR (Cardiopulmonary Resuscitation). RT H stated the facility initiates standard orders to wean residents when they are admitted , however felt it was . a big thing . that an ordered weaning protocol was not in place. RT H stated at one point of time the facility did have a weaning protocol in place. RT H stated usually a person being weaned would be done under observation and monitoring with the right equipment. RT H stated they are not getting a true picture of the residents oxygenation levels because of the lack of monitoring implemented for the residents they are weaning. RT H stated . when you are weaning someone they are able to breathe on their own but the machine ventilator was giving him (R40) his breaths. I didn't see orders so I'm basically on my own . this was an emergency . As far as I'm concerned we didn't have to call our primary or pulmonary (physician) and there was no order and we really don't call them unless the resident is being sent out (to the hospital) . They should really do trial runs on people (for weaning eligibility) but whoever is being told to do the weaning protocols they supposedly chart on it and let them run for a whole 12 hours . RT H denied informing the Physician or Pulmonologist of R40's change of condition.
On [DATE] at 4:48 PM, the RTD I was recalled for a second interview and asked how often the facility's Pulmonologist completes their evaluations/assessments on ventilator residents. RTD I stated Not frequent. That's why I've been trying to get it changed . Everyday we do a weaning protocol with our residents. We still try them no matter what. If they are tolerating the wean we would wean by protocol . RTD I was asked a second time for the weaning protocol due to none being found in the medical record for R40. RTD I stated they were doing a slow wean because his (R40) acuity . RTD I was asked how they decided that R40 was eligible to wean since their acuity and prognosis was poor as stated by their staff. RTD I stated every vent resident has an as needed order implemented to wean. When asked for the examinations/evaluation from the physician that determined the residents to be an eligible candidate to wean, RTD I replied the Pulmonologist for the facility does not come often enough. RTD I stated . the vagueness with this policy is what bothers me . in reference to the weaning protocol. RTD I stated the Pulmonologist has never charted their examinations or assessments. RTD I stated they will sometimes reach out to the Pulmonologist for concerns with no response. RTD I stated they completed an audit of all the ventilator residents to ensure the trach supplies, ambu bag and ventilator settings matched the orders and found that most of the settings did not match the physician orders. RTD I stated the Pulmonologist will not address anything regarding the care of residents with a tracheostomy.
On [DATE] at 5:21 PM, a second interview was conducted with R40's primary Physician J and Physician J was asked if they assess or examined R40's respiratory care, ventilator care/settings and eligibility for weaning and Physician J stated No, that's the pulmonologist, they come weekly. Physician J stated the Pulmonologist handles that, not them.
Review of the Pulmonologist contract with the facility revealed the following:
On [DATE] Pulmonologist K signed a contract that documented in part, . the facility desires to avail itself of the services of the physician as the Pulmonologist of the facility . The Pulmonologist is licensed to practice medicine in the State where the facility is located . and agreement set forth herein, the Parties agree as follows . The Pulmonologist shall provide oversight for the Facility's Respiratory Unit as follows . Conduct weekly visits and review individual respiratory residents' care plans with the Unit Manager and Respiratory Staff . Review and approve policies specific to the Respiratory Unit . Provide care for tracheostomy and vent patients, and consult on equipment needs . Provide education, as needed, to facility staff, upon request of the Administrator of the Facility . Consult with Facility Staff on changes in status and other resident needs .
Due to the identified concern with R40's care the survey team expanded the sample and reviewed additional medical records of ventilator residents. The team identified no documentation in any of the ventilator resident records from Pulmonologist K.
Review of a typed Ventilator Weaning Protocol . Ventilator Discontinuance/Trach Weaning/Capping Trials (undated) that was provided by RTD I revealed no documentation of it to have been reviewed by a Physician or Pulmonologist K. The typed protocol was not found to be implemented in any of the medical records of the residents dependent on the Ventilators.
On [DATE] at 8:54 AM, Pulmonologist K was interviewed and asked if they were the contracted Pulmonologist for the facility and Pulmonologist K explained they were not contracted with the facility and operated independently. Pulmonologist K was asked how often they come to the facility to assess/examine the residents and Pulmonologist K' stated every two to three weeks. Pulmonologist K was asked where they documented their assessments and examinations and Pulmonologist K stated they document their notes in the medical record. Pulmonologist K was informed that the survey team was unable to identify any consultations, exams or assessments in any of the ventilator dependent residents for the last year and Pulmonologist K stated they had access to the facility's electronic medical system and input their notes in the system. Pulmonologist K was asked their involvement in identifying eligible candidates to wean off ventilators and stated the facility had a protocol for weaning and if they have difficulty they would discuss it. Pulmonologist K was asked if the residents being weaned should be monitored and documented continuously during the weaning process and Pulmonologist K stated Yes. Pulmonologist K stated in part . It's not safe to wean residents sometimes . Pulmonologist K was asked if they were informed of R40's unsuccessful wean and change of condition on [DATE] and Pulmonologist K stated they were not familiar with R40 and denied being notified on [DATE]. Pulmonologist K stated usually the residents are weaned during the day and put back on full support at night which is the safest way. When asked how the vent settings are determined for each ventilator resident, Pulmonologist K stated the facility follows the vent settings from their admission. Pulmonologist K was asked the expectations of the staff if a ventilator resident condition changed and needed modifications to their ventilator settings and Pulmonologist K stated the facility has a protocol for modifications for the resident ventilators.
On [DATE] at 9:20 AM, the Administrator and Ventilator Unit Administrator A was asked to provide the policies for Ventilator care/management, Tracheostomy care/management, pulmonologist visits, ventilator settings protocol & ventilator weaning protocol.
A policy was not provided regarding ventilator settings and the ventilator weaning protocol is documented in full as noted above, which does not contain parameters or a protocol for the weaning process.
On [DATE] at 9:21 AM, the facility's Medical Director (MD) L was interviewed via telephone and asked their involvement in the respiratory care for the facility's ventilator residents. MD L stated they had nothing to do with the respiratory care for the ventilator residents. MD L stated the facility has a Pulmonologist to take care of the respiratory care, however, knew the facility was having a lot of problems with the current Pulmonologist. MD L denied ensuring collaboration of respiratory care was being provided to the mechanical ventilator residents and stated in part . I don't do anything with them, my role is not to run different parties .
On [DATE] at 11:45 AM, the Administrator and Vent Unit Administrator A were interviewed and informed of the concern regarding the lack of Physician oversight, monitoring and supervision of respiratory care for residents that required mechanical ventilators. The Administrator and Vent Unit Administrator A was asked to provide all Physician documentation regarding the respiratory care, assessments and evaluations for all of the residents that required mechanically ventilation. At 1:34 PM, the Administrator and Vent Unit Administrator returned and stated they were unable to provide any documentation completed by the Pulmonologist K or provide documentation of Physician oversight regarding the respiratory care for the ventilator dependent residents. The Administrator stated Pulmonologist K would be in the facility later in the evening to provide the facility with their documentation.
On [DATE] at approximately 2:50 PM, the exit conference was conducted with the facility's Administration team and Corporate staff. Corporate Personnel (CP) F stated the facility had identified the concerns with the Physician services and had plans on fixing it, however they failed to address it in time and now are forced to look into it and change their system.
On [DATE] at approximately 3:00 PM, Pulmonologist K approached the survey team in the parking lot of the facility and asked what documentation the State Agency was looking for. Pulmonologist K was informed that all assessments, evaluations, collaboration with care, weaning protocols should be identified in each residents record. Pulmonologist K asked if it was too late to provide the documentation and Pulmonologist K was referred to consult with the facility's Administration team.
No further information or documentation was provided by the end of the survey.
R10
On [DATE] the medical record for R10 was reviewed and revealed the following: R10 was initially admitted to the facility on [DATE] and had diagnoses including Chronic respiratory failure with hypoxia and Dependence on respirator ventilator status.
Further review of R10's medical record revealed Physician's orders that indicated the following: Vent settings: PCV (pressure controlled ventilation) Targeted Vt (volume targeted), PIP 30 (Peak inspiratory pressure) (Vt 450ml), RR (respiratory rate) 14, PEEP 5 (Positive end-expiratory pressure)
A second Physician's order dated [DATE] revealed the following: [Name of pulmonologist] to consult and participate in care.
R41
On [DATE] the medical record for R41 was reviewed and revealed the following: R41 was initially admitted to the facility on [DATE] and had diagnoses including Chronic respiratory failure with hypoxia and Dependence on respirator ventilator status.
Further review of R41's medical record revealed Physician's orders that indicated the following: Settings: Mode: AC (assistive control) RR:16 PEEP:5 Vt 450
A second Physician's order dated [DATE] revealed the following: Evaluation/Assessment of resident on ventilator .
R55
On [DATE] the medical record for R55 was reviewed and revealed the following: R55 was initially admitted to the facility on [DATE] and had diagnoses including Chronic respiratory failure with hypoxia.
Further review of R55's medical record revealed Physician's orders that indicated the following: Settings: AC 18, 450, Peep+5 every 12 hours
A second Physician's order dated [DATE] revealed the following: Evaluation/Assessment of resident on (Ventilator) as needed .
R57
On [DATE] the medical record for R57 was reviewed and revealed the following: R57 was initially admitted to the facility on [DATE] and had diagnoses including Chronic respiratory failure with hypoxia.
Further review of R57's medical record revealed Physician's orders that indicated the following: Settings: Mode: A/C RR: 14 PEEP: 5 VT 450ml
On [DATE] at approximately 1:37 p.m., the facility Administrator and Ventilator Unit Administrator, were queired if they were able to provide any documentation from the facility contracted pulmonologist that indicated R10, R41, R55 and R57 had been assessed/evaluated by them for ongoing respiratory/ventilator care at all during their stay in the facility and they reported they could 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 ensure the correct resident/ legal representative signed Advanced D...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the correct resident/ legal representative signed Advanced Directives/DNR (do not resuscitate) form for one resident (R50) of one residents reviewed for advanced directives. Findings include:
On 10/21/24 the medical record for R50 was reviewed and revealed the following: R50 was initially admitted to the facility on [DATE] and had diagnoses including Adult failure to thrive and Dementia. A review of R50's MDS (minimum data set) with an ARD (assessment reference date) of 8/19/24 revealed R50 needed assistance from facility staff with their activities of daily living R50's BIMS score (brief interview of mental status) was 15 indicating intact cognition.
An advanced directives from signed by R50's son on 8/13/24 was reviewed that documented R50 was not to have any intubation or feeding tubes and was to have a DNR code status.
Further review of the medical record did not reveal any documentation that R50 had been deemed mentally incapacitated and unable to make their own medical decisions.
On 10/23/24 at approximately 12:35 p.m., Social Service worker B (SSW B) was queried regarding the advanced directives for R50 and why R50's son had signed their advanced directives instead of R50. SSW B reported that the form was completed with the previous Social Service worker. SSW B was queried if the resident had been deemed mentally incapacitated and they indicated they had not and that they would correct it by by taking a new advanced directive form to R50 and reviewing their options with them instead of their son.
On 10/23/24 a facility document titled Advanced Directives was reviewed and revealed the following: 1. Prior to or upon admission of a resident to our facility, the Social Services Director or
designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 2. Each resident will also be informed that our facility ' s policies do not condition the provision of care or discriminate against an individual based on whether or not the individual has executed an advance directive. 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. 4. Should the resident indicate that he or she has issued advance directives about his or her care and treatment, documentation must be recorded in the medical record of such directive and a copy of such directive must be included in the resident ' s medical record .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R17
Record review revealed R17 was admitted to the facility on [DATE] with diagnoses that included dementia, chronic respiratory...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R17
Record review revealed R17 was admitted to the facility on [DATE] with diagnoses that included dementia, chronic respiratory failure, muscle weakness and chronic obstructive pulmonary disease. Based on the Minimum Data Set (MDS) assessment dated [DATE], revealed R17 had a Brief interview for Mental Status (BIMS) of 9/15 indicative of moderate cognitive impairment.
During an observation on 8:55 AM, R17 was observed sitting in the dining room eating breakfast. There was another resident eating in the dining room. There were no staff members in the dining room. R17 was eating their oatmeal. An interview was completed with R17 after approximately 15 minutes. Throughout the observation no staff member came in and assisted R17. R17's breakfast tray had an unopened carton of milk and apple juice on it. When queried about their breakfast R17 reported that they did not like eggs and liked their oatmeal. When queried about the milk and juice, they reported they liked it and they would drink it but needed assistance to open the carton. R17 had a cup of coffee in a regular cup and they were drinking their coffee.
Review of R17's Electronic Medical record (EMR) revealed an order dated 2/2/24 that read, regular diet- level-3 texture, regular fluid, thin consistency, needs assistance with meals.
Review of R17's care plan revealed an intervention dated 9/20/23 that read, Eating- offer assistance with meal setup as needed and encourage resident to use cup with lids when handling hot liquids.
There were no lids on the meal tray.
R20
Record review revealed R20 was a long-term resident of the facility admitted on [DATE]. R20's admitting diagnoses included diabetes, dysphagia (difficulty swallowing), heart failure, dementia, cachexia (a condition that causes significant weight loss and muscle loss). Based on the MDS assessment dated [DATE], R20 had a BIMS score of 8/15, indicative of moderate cognitive impairment. R20 was dependent on staff assistance with their mobility and positioning.
An initial observation was completed on 10/21/24 at approximately 8:55 AM. R20 was observed in the dining room with another resident. R20 was sitting up in a Geri-chair (a large, padded reclining chair used for residents with limited strength or balance and/or mobility). R20 was eating their breakfast and had an unopened carton of milk on their tray. The chair back was reclined with their legs propped up i.e. the chair was not in upright position to accommodate safety during meals. R20 had scrambled eggs and a slice of French toast.
There were no staff members in the dining room during the meal. A follow-up observation was completed on 10/22/24 at approximately 8:45 AM. R20 was sitting in the dining room. R20's Geri-chair was reclined with legs propped up and they were eating breakfast. There were no staff member in the dining room.
Review of R20's EMR revealed orders that included: an order dated 10/18/24 that read, Diet level 3 texture, regular fluid, thin consistency, set up support. Assist with cutting items and ST (speech therapy) evaluation complete. ST to treat 5/wk (week). x 4 weeks for increased diet tolerance, dysphagia management, and compensatory strategies. Review of R20's care plan revealed that R20 needed staff assistance with their mobility and positioning and for eating read, Supervision - offer assistance with meal setup as needed dated 8/8/24.
An interview was completed with Director of Rehab (DOR) P on 10/22/24 at approximately 9:05 AM. DOR P was queried about R20 and if they were receiving skilled speech therapy services. They reported that they have been working with R20 for their swallowing management. When queried about R20's needs and what they were working on, they added that R20 was on level 3 (mechanical soft). DOR P added that the focus for R20 included upright positioning during their meals and staff supervision with verbal reminders periodically as needed to ensure that they were taking smaller bites. They added that R20 tends to take large bites and needed assistance with setting up the food and supervision for verbal cues as needed.
An interview was completed with the Unit Manager (UM) E on 10/22/24 at approximately 8:55 AM in the dining room. During the interview there were no staff members in the dining room. UM E was notified of the dining room observations from 10/21/24 and 10/22/24. During this time R20 was trying to open their milk and UM E went and assisted the resident, after the concern was brought to their attention. UM E reported that they were supposed to have a staff member in the dining room to assist residents and supervise them as needed. They reported that they understood the concern.
An interview was completed with Director of Nursing (DON) on 10/23/24 at approximately 10:15 AM. The DON was notified of the dining room observations from 10/21/24 and 10/22/24 for R17 and R20 and queried on expectations of the staff. The DON reported that they expect a staff member to stay in the dining room to provide supervision and assistance as needed. The DON reported that they understood the concerns.
A facility provided document titled Resident Meal Service with a revision date of 1/1/22 read in part, Policy: Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance.
Policy Explanation and Compliance Guidelines:
1. The interdisciplinary staff, including nursing staff, the Attending Physician and the Dietitian will
assess each resident's nutritional needs, food likes, dislikes and eating habits. They will develop a
resident care plan based on this assessment.
2. Nursing personnel will ensure that residents are served the correct food tray.
3. Prior to serving the food tray, the Nurse Aide/Feeding Assistant must check the tray card to ensure that the correct food tray is being served to the resident. If there is doubt, the Nurse Supervisor will check the written physician's order.
4. If an incorrect meal has been delivered, nursing staff will report it to the Food Service Manager so
that a new food tray can be issued.
5. To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the
danger zone (41degress F to 135 degrees F) will be kept to a minimum. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded.
6. Assistive devices will be made available to residents who need them.
7. Nursing personnel will evaluate food and fluid intake in residents with, or at risk for, significant
nutritional problems. Nursing staff will assess and document the amounts eaten as indicated for
individuals with, or at risk for, impaired nutrition .
Review of the document titled Activities of Daily Living (ADLs) with a revision date of 12/28/23 read in part: Policy: The facility takes measures to minimize the loss of residents functional abilities, including activities of daily living (ADLs). Activities of Daily Living include the ability to:
1. Bathe, dress, and groom;
2. Transfer and ambulate;
3. Toilet;
4. Eat; and
5. Use speech, language or other functional communication systems.
Policy Explanation and Compliance Guidelines:
1. Conditions which may demonstrate unavoidable decline in ADLs include
a. Natural progression of the resident ' s disease state with known functional decline.
b. Deterioration of the resident ' s physical condition associated with the onset of a physical or
mental disability while receiving care to restore or maintain functional abilities.
c. Refusal of care and treatment by the resident or his/her surrogate to maintain functional
abilities.
2. The facility provides maintenance and restorative program to assist residents in achieving and maintaining the highest practicable outcome based on their comprehensive assessment.
3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
Based on observation, interview and record review, the facility failed to ensure feeding assistance/supervision and regular bathing were provided for three residents (R17, R20, and R174) of four residents reviewed for activities of daily living (ADL's). Findings include:
R174
On 10/21/24 at approximately 9:18 a.m., R174 was observed in their room, laying in their bed. R174 was queried if they had any concerns regarding their care in the facility and they indicated they have not received any showers since being admitted to the facility and reported they did not feel clean.
On 10/22/24 the medical record for R174 was reviewed and revealed the following: R174 was initially admitted to the facility on [DATE] and had diagnoses including Heart failure and Severe Calorie-protein malnutrition. A review of R174's MDS (minimum data set) with an ARD (assessment reference date) of 10/15/24 revealed R174 had a BIMS score (brief interview of mental status) of 13 indicating intact cognition.
A review of R174's comprehensive plan of care revealed the following: Focus-Resident has an ADL self-care performance deficit related to generalized weakness. Date Initiated: 10/11/2024 .
A review of R174's bathing (scheduled on Mondays/Thursdays) documentation revealed the following dates in which R174 was documented as having been provided bathing: 10/21 (bed bath) 10/22 (not available). No bathing documentation was provided for 10/14 or 10/17. No documentation that R174 refused any offered bathing was noted in the record.
On 10/23/24 at approximately 2:14 p.m., during a conversation with the Director of Nursing (DON), the DON was queried where the Certified Nursing Assistant (CNA's) document offered bathing in the medical record and they reported that it was in the CNA task screen and that bathing should be offered twice a week. At that time, the DON was informed that R174 only had one episode of being offered bathing (10/21) and they indicated they would have to look into it.
No further documentation that R174 was offered bathing twice a week per their schedule was received by the end of the survey.
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 timely assess/follow-up change in condition, obtain 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 timely assess/follow-up change in condition, obtain an order and transfer resident(s) (R275) to a hospital in a timely manner, for one of four residents sampled for hospitalization, resulting in prolonged suffering and illness with continued decline in health of the resident(s) resulting in death of one (R275) resident and hospitalization of the other (R64) resident. Findings include:
R275
Record review revealed R275 was long-term resident admitted to the facility on [DATE]. R275 had a most recent hospitalization between [DATE] and they were readmitted to the facility on [DATE]. R275's admitting diagnoses included sepsis, failure to thrive, pneumonia, respiratory failure and dementia. Based on the Minimum Data Set (MDS) assessment dated [DATE], R275 had a Brief Interview for Mental Status (BIMS) score of 8/15, indicative of moderate cognitive impairment. R275 had a public guardian who was making decisions for the resident.
Review of R275 advance directives (a legal document that states a resident's wish regarding medical treatment when they were unable to make their choices), dated [DATE], signed by their legal guardian revealed that they were a Full Code i.e. that they wished to receive all life sustaining measures.
R275 was readmitted to the facility on [DATE] after hospitalization with pneumonia, respiratory failure and sepsis. R275's was receiving nutrition and hydration through enteral feeding administered via a PEG (Percutaneous Endoscopic Gastrostomy tube surgically placed directly placed on stomach to receive nutrition and hydration). Review of R275's vital signs and care plan revealed that they were receiving oxygen at 2 L/min (liters/minute) via nasal cannula.
Review of R275's physician orders revealed an order for a chest x-ray dated [DATE] due to shortness of breath.
A nursing progress note dated [DATE] at 10:08 revealed that the NP (Nurse Practitioner) for the attending physician was notified and there were no new orders. Review of the x-ray results revealed that there was questionable pneumonia or pulmonary edema (fluid build up in lungs) and the examination was limited due to positioning during the x-ray procedure.
A practitioner note dated [DATE] revealed R275 was seen for anxiety and restlessness and it read Spo2 (oxygen saturation) was in the high 80's and low 90s, patient restless, she was given Xanax 0.5 mg (milligram), it was effective .SpO2 (pulse oximetry) improves to the 90s.
Further review of the progress notes did not reveal any follow up by the practitioner or physician after [DATE], when nursing staff had communicated the x-ray results to the nurse practitioner (NP) Q.
Review of the form titled SBAR (Situation-Background-Assessment-Request) communication and progress note dated [DATE] at 7:30 AM revealed that the decline/change in condition started on [DATE]. R275 had a respiratory rate of 30 breaths/minute with a heart rate of 109 bpm (beats per minute). The note read, Increased O2 from 2 L/min (liters/minute) (at 89%) to 6 L/min. humidified 91-94% and R275 had a tan color emesis (vomiting) at 6:00 AM. The assessment also revealed that R275's breathing was labored and was identified as positive for sepsis (life-threatening medical emergency that occurs when the body has an extreme response to an infection). The nursing assessment also revealed that R275 was possibly experiencing respiratory or gastrointestinal problems.
Review of the change of condition assessment revealed that based on the nursing assessment, recommendations included transfer to hospital. The notification section to primary care clinician revealed that the nurse had left messages for the attending physician and the nurse practitioner.
R275 expired at the facility on [DATE] at 12:54 PM. Review of the form titled change of condition/return to hospital risk dated [DATE] at 7:33 AM revealed the nurse had contacted the attending physician and practitioner and had left messages and waiting for a call back. There was no evidence that the attending physician/practitioner had followed up timely.
Review of vital sign report revealed that O2 was changed from 2 l/min to 6l/min on [DATE] at 23:45 (11:45 PM), but there was no physician order.
Review of R275's Electronic Medical Record (EMR) revealed a nursing progress note dated [DATE], at 16:20 (4:20 PM) revealed in part, Writer received in report that resident exhibited signs of reduced oxygen. Midnight nurse reported they increased oxygen liters from 2L to 6L. Post report writer into room to assess resident's condition; resident alert and responding to verbal and tactile stimuli. Resident displayed no signs of acute respiratory distress or discomfort at the time. Writer obtained vital signs and vitals noted at BP (blood pressure); 100/54; HR (heart rate)111; SPO2 94% on 6L of O2; Temp 97.6; and RR (respiratory rate) 18 bpm (beats per minute). Writer then contacted MD (Medical Doctor) of condition and received no response at that time. Writer then administered all scheduled meds and treatments and resident's baseline remained the same. At 12 noon, writer doing hourly rounds noted the resident unresponsive. Writer called code and began compressions at .911 was called. Staff continued with rounds of CPR (cardiopulmonary resuscitation) while awaiting Fire Department and Police arrival. Staff had done four rounds of CPR by the time 911 emergency arrived. At 12:17pm the fire department and police arrived at the scene. At 12:17 pm Fire Department began their runs. 12:25pm IV (intravenous) initiated and started on the resident and at 12:27 pm first round of epinephrine administered. 12:30 pm the resident was incubated. At 12:34 pm, second round of epinephrine administered. 12:35 pm a third round of epinephrine was administered. At 12:37pm pulse check done; and no pulse was palpable. 12:38 pm a fourth round of epinephrine was administered. At 12:43pm a fifth round of epinephrine administered and a sixth round of epinephrine administered at 12:46 pm. At 12:48pm resident checked for a pulse; no pulse palpable. 12:49 pm a seventh dose of epinephrine administered. At 12:51 pm; resident checked for pulse; no pulse palpable. At 12:54 pm the time of expiration called .
An initial interview was completed with Nurse Practitioner (NP) Q on [DATE] at 12:34 PM. During the interview they were queried that if they had received calls from the facility regarding R275's change in condition and if they had followed up. They reported they knew that R275 had expired and they were not able to recall if they had received any calls; they would check their voicemail and they would get back.
A follow up interview was completed with NP Q on [DATE] at 2:28 PM and 2:39 PM. During the interview the practitioner reported they received the voicemail on the weekend on [DATE] around 12 AM and they did not get the message until later when they had found out R275 had passed. The practitioner Q was queried how they had covered after hours or weekend calls. NP Q reported they regularly rounded the facility on weekdays and staff would have to contact the medical director if they were not able to get in touch with the attending physician. They did not provide any further explanation.
An initial interview with Director of Nursing (DON) was completed on [DATE] at approximately 1:15 PM. The DON was queried about R275 and their change of condition and their expectations with the staff follow up. The DON reported that they were aware of the situation and it happened over a weekend. They reported that the nurses had completed a timely assessment and shared the SBAR assessment and added that the physician ordered to increase the O2 from 2L/min to 6l/min and the nurse failed to transcribe the order.
During a follow-up interview with the DON on [DATE] at approximately 2:35 PM, they were queried about the staff and physician timely follow up after the identified change of condition from [DATE] midnight shift to [DATE], 12 noon when R275 was observed unresponsive. The DON reported that staff should contacted the medical director if they were not able to get in touch with the attending physician and in this case R275 was a full code and they should have transferred the resident out to the hospital. They were notified of the concern and they reported that they understood the concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 facility failed to implement range of motion/splinting interventions for two (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility failed to implement range of motion/splinting interventions for two (R4 and R43) of two residents with contractures reviewed for positioning/range of motion resulting in the potential for extreme pain, discomfort, and worsening of contractures. Findings include:
R4
Record review revealed that R4 was a long-term resident admitted to the facility on [DATE]. R4's admitting diagnoses included head injury, encephalopathy, seizures, and history of right knee pain. Based on the Minimum Data Set (MDS) assessment dated [DATE], R4 had a Brief Interview for Mental Status (BIMS) of 0/15, indicative of severe cognitive impairment. R4 needed substantial assistance from staff with her Activities of Daily Living (ADLs) and mobility. The MDS assessment also revealed that R4 had limited range of motion in both lower extremities.
An initial observation was completed on 10/21/24 at approximately 10:55 AM. R4 was observed in their bed, lying on their back with their eyes closed. Both knees were pulled up (bent) with feet resting on their bed. R4 did not respond when called their name. A Geri-chair (a padded reclining chair with wheel used for patients with limited mobility, range of motion, impaired trunk control, etc.) was inside the room and an assigned staff member explained the chair was for R4.
Later that day multiple follow-up observations were completed at approximately 1:15 PM, 3:30 PM, and 4:15 PM. R4 was observed in bed with their knees bent and eyes closed. On 10/22/24 observations were completed at approximately 8:45 AM, and 11:30 AM. R4 was observed in their bed lying on their back, with both knees bent. R4 stayed in their bed throughout the day during these observations. R4 was unable to respond to any questions.
Review of R4's Electronic Medical Record (EMR) revealed an order dated 10/7/23 that read Baclofen oral tablet 10 milligrams for muscle spasms. Review of R4's care plan revealed a focus area that read Resident has an impaired musculoskeletal status related to bilateral knee contractures. Review of the interventions for the knee contractures revealed no restorative /maintenance interventions for both lower extremities to prevent worsening of contractures. Further review of physician orders and Certified Nursing Assistant (CNA) task list did not reveal any range of motion/maintenance program.
Review of the facility provided document titled Range of Motion Evaluation Chart revealed on Page 2 of the document, that read attempted to range but patient resisting with no other specifics on a plan and did not have any name or credentials of the clinician.
An interview was completed with the Director of Rehab (DOR) P on 10/21/24 at approximately 4:15 PM. During the interview the DOR P reported that R4 was not receiving any skilled services currently and they were due for an annual range of motion assessment. The DOR P reported that the facility had a restorative program and they were unsure of R4 was on a restorative/maintenance program.
On 10/22/24 at approximatley 10:40 AM, an interview was completed with the Unit Manager (UM) E (for the unit where R4 was residing) who was also overseeing the restorative nursing program. During the interview UM E was queried about the restorative program and how they had determined which residents qualified for the restorative/nursing maintenance program. They reported that they recently took over the program and they were based on referral from physical/occupational therapy services. They added that the restorative team was managing all residents with splints or devices. When queried if they had R4 on any restorative/maintenance program for their lower extremity contractures, they reported that R4 was not receiving services. UM E was queried and they reported that they were not sure why they were not receiving any services and that R4 would benefit with services. They were notified of the concern and they reported that they understood the concern and they would address it.
An interview was completed with the Director of Nursing (DON) on 10/23/24 at approximately 10:30 AM. The DON was notified of the concerns with maintenance/restorative program for R4 and the follow up with UM E. They reported that they understood the concern and agreed that R4 should have been on a range of motion program and added that they would have their team address the concern.
A review of the facility policy titled Range of Motion with a revision date of 10/21/24, read in part, Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Definitions: Range of Motion means the full movement potential of a joint.
Policy Explanation and Compliance Guidelines:
1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care.
2. Assessment for Range of Motion:
a. The resident's range of motion (such as current extent of movement of his/her joints and the
identification of limitations) shall assess on admission/readmission, quarterly, and upon a
significant change.
b. Residents who exhibit limitations in range of motion, initially and thereafter, shall refer to
the therapy department for a focused assessment of range of motion and/or restorative
nursing program.
c. Nursing assistants will report any significant changes in range of motion, as noted during
daily care activities, to the resident's nurse when any changes are noted.
3. Care Planning a. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes but is not limited to:
i. Appropriate services (specialized rehabilitation, restorative, maintenance).
ii. Appropriate equipment (braces or splints).
iii. Assistance as needed (active assisted, passive, supervision) .
R43
On 10/21/24 at 9:26 AM, R43 was observed lying on their back in bed. Enteral feeding was observed infusing via gastrostomy tube and both the left and right hands were observed contracted. No device or padding was observed in the palms of R43's hands.
Review of the medical record revealed R43 was initially admitted to the facility on [DATE] with a readmission date of 9/15/24 and diagnoses that included: acute respiratory failure with hypoxia, quadriplegia, and contracture of muscle to the left and right upper arms.
Review of the Physician orders and care plans revealed no implemented plan of care for R43's hand contractures.
Review of a Physical Medicine Rehabilitation (PMR) follow up note dated 9/25/24 at 8:17 PM, documented in part . CHIEF COMPLAINT: Mobility and ADL (assistant daily living) dysfunction secondary to respiratory failure . Patient seen and examined. Patient observed in bed with eyes wondering . She has a rolled wash cloth in hand, tight hand contractures noted. Patient has trach (tracheostomy) and is ventilator dependent. She does not appear to be in any pain . ASSESSMENT/PLAN . OT (occupational therapy) will work on ADL and functional mobility training and hygiene. PT (physical therapy) will work on strengthening . Manual Tx (treatment): stretching of shortened connective tissue to hands, elbow jts (joints) and shldrs (shoulders). Noted to nsg (nursing) to having yeast growing at elbow jts . Contracture . b/l (bilateral) hand contractures . to use rag rolls for hands to help with hand hygiene. Hands are too tight for hand splints .
Review of the medical record revealed no intervention implemented for the rag rolls for R43's right and left hand contractures.
On 10/22/24 at 10:22 AM, Therapy Director (TD) M was interviewed and asked to provide all PT and OT evaluations and encounters for R43.
Review of the Therapy documents provided revealed no documentation addressing or implementing the PMR practitioners note on 9/25/24. Further review of the therapy documentation revealed no identification or plan of care for R43's bilateral hand contractures.
On 10/23/24 at 11:30 AM, TD M was interviewed and asked who's responsible to review the plan of care documented by the PMR clinician and asked about the PMR plan of care documented on the 9/25/24 consult. TD M stated they recently talked with the PMR clinician and addressed a few of their concerns, one being that the PMR clinician would write recommendations on their consults without informing the therapy team.
No further explanation or documentation was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure sufficient staffing for one resident (R274) of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure sufficient staffing for one resident (R274) of one reviewed for staffing needs, resulting in the potential for unmet care needs of residents who reside in the facility.
Findings include:
R274
Record review revealed R274 was admitted to the facility on [DATE] with diagnoses including heart failure, atrial fibrillation and Chronic Obstructive Pulmonary Disease. R274 had a recent hospitalization and they were admitted to the facility for skilled nursing and rehabilitation needs.
An initial observation was completed on 10/22/24 at approximately 8:20 AM. R274 had their call light on and this surveyor was walking down the hallway. R274 waved and called this surveyor and asked if they could assist. R274 was sitting on their bed and reported that they had been waiting for someone to help them and it had been a while and appeared upset. When queried further they reported, That light (call light) doesn't mean anything. A staff member (Certified Nursing Assistant - CNA) was in the hallway passing water and they were notified by the nurse to go in to assist R274. Later that day at approximately 12:20 PM a follow up interview was completed. During the interview R274 reported that they had been in the facility for a few days. When queried about the staff assistance and call light response they reported that the responses are slow in general and it took longer at nighttime. When queried about the time frame, R274 reported that it took over an hour and stated it just happened this morning.
An interview was completed with a Certified Nursing Assistant (CNA) X on 10/2/24 at approximately 10:55 AM. They were queried about facility staffing. CNA X reported that the facility had hired a lot of new staff recently. When queried if they were able to meet the needs of all their residents timely they reported that they do their best as they covered both hallways. They added they covered part of the hallway from 107-114 and then the other side of the hall. They added that this hallway (with rooms 101-106) had 2 CNAs and they were 2 CNA's to cover the other hallway as well (from rooms 107-114). CNA X further explained that even though the other hallway had fewer residents, they get tied up down this hallway as almost 50% of the residents in the hallway needed 2-person assistance and they needed to stay and assist the other CNA. They added it gets harder if they were assisting with showers as it may take longer. When queried who would assist the residents on the other hallway, they reported that the nurse would have to assist and go to back and forth between both hallways. They added most of the times they were tied up on this side of the hall. When queried about nurses having their own responsibilities they stated that they are doing the best they can to meet the needs of their residents. When asked what would help, they added that may be having another CNA assist for part of the shift would help.
An interview was completed with LPN Y on 10/22/24 at approximately 1:45 PM. They were queried about the staffing to meet the needs of all their residents. They added that lot of residents in this hall needed extensive staff assistance and they would help the CNAs on the floor because the staff needed that help. They agreed it was hard for the CNAs to complete the tasks if the nurses were not able to assist them.
An interview was completed with the staffing coordinator (SC) Z on 10/23/24 at approximately 9:55 AM. They reported that they had been in that role for 6 months. They reported that they had many new staff members and had few open positions. When queried about their weekend staffing, they reported that it had gotten better in the last 3 months. When queried about the staffing prior to June, they reported that it was challenge prior to June.
An interview was completed with Director of Nursing (DON) on 10/23/24 at approximately 10:30 AM. They were queried about the staffing and they agreed it was a challenge prior and it had gotten better in the last few months. They added that they were trying to have additional staff to cover call offs.
Review of the facility submitted staffing report to Centers for Medicare and Medicaid Services for the period of 4/1/24 to 6/30/24 revealed that facility had excessively low weekend staffing.
Review of the facility assessment with a revision date of 5/1/24 revealed that facility's nursing assistants staffing ratio will be based on the residents acuity/care needs.
On 10/21/24 at approximately 4:11 p.m., during the anonymous group meeting, the group was queried regarding the staffing levels in the the facility and one resident reported that weekends call button answering was still not good and that the weekend staffing levels are low. They also reported that there are excessive call off's from the weekend staff and the facility does not fill the holes in the schedule.
On 10/21/24, a review of the resident council minutes revealed the following complaints related to staffing: May 2024-Showers, water not being received consistently. October 2024-Consistency in passing water on every shift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure non-pharmacological interventions were attempte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure non-pharmacological interventions were attempted prior to PRN (as needed) psychotropic mediation administration for one resident (R68) of five residents reviewed for unnecessary psychotropic medications. Findings include:
On 10/21/24 the medical record for R68 was reviewed and revealed the following: R68 was initially admitted to the facility on [DATE] and had diagnoses including Liver disease and Spinal stenosis. A review of R68's MDS (minimum data set) with an ARD (assessment reference date) of 9/9/24 revealed R68 needed some assistance from facility staff with most of their activities of daily living. R68's BIMS score (brief interview for mental status) was eight indicating moderately impaired cognition.
A Physician's order dated 10/11/24 revealed the following: ALPRAZolam Oral Tablet 0.25 MG (milligrams) (Alprazolam) *Controlled Drug* Give 1 tablet by mouth every 12 hours as needed for for anxiety. Further review of the order revealed no end date and it was ordered for an indefinite period of time.
A review of R68's September and October 2024 Medication administration records (MAR) revealed the following dates in which R68 was administered their PRN alprazolam: 9/4, 9/7, 9/11, 9/12, 9/14, 9/16, 10/13, 10/14, 10/15, 10/16, 10/9, 10/20, 10/21.
Further review of R68's progress notes and MAR's did not reveal any documentation that R68 was offered non-pharmacological interventions prior to the administration of their PRN alprazolam.
On 10/22/24 at approximately 12:45 p.m., during a conversation with the Nurse Manager E (NM E), NM E was queried regarding the administration of PRN alprazolam for R68 and where the non-pharmacological interventions were documented that were attempted prior to administration to ensure the medication as necessary and they reported it was in the progress notes. NM E was queried if it was the standard of practice to ensure that the Nursing staff attempt non-pharmacological interventions prior to administering PRN psychotropic medications and they indicated it was.
On 10/23/24 a facility document titled Medications-PRN was reviewed and revealed the following: Policy: PRN medications are administered by staff who are legally authorized to do so through certification or licensure, in accordance with a physician ' s order. Definitions: PRN medication refers to a medication that is taken as needed for a specific situation. It is not provided routinely, and requires assessment for need and effectiveness. Indications for use is the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident ' s condition and therapeutic goals and is consistent with manufacturer ' s recommendations and/or current evidence-based practices or standards. Policy Explanation and Compliance Guidelines:
1. Documentation will be provided in the resident ' s medical record to show adequate indications for a medication ' s use and the diagnosed condition for which it was prescribed. 2. Orders for medications to be given on an as needed basis shall have clear instructions about how and when to administer them. Examples include, but are not limited to: a. The symptom or condition for which the medication is to be given (i.e., pain, nausea). b. How much of the medication may be given (the dose), and in some instances how much may be given in a set period of time (i.e., one dose five minutes apart for a maximum of three doses). c. When to administer the medication (i.e., every four hours), and in some instances when to take scheduled and PRN medications for a single health problem (i.e., administer routine pain medication as scheduled, and administer prn medication for breakthrough pain at least one hour later).3. When administering a PRN medication: a. Verify physician ' s order for the medication. b. Document the reason voiced by the resident and/or assessment findings that show why the resident needs the medication. Verify the reason is for the prescribed indication for the
medication. c. Document the time of administration. d. Document the resident response to the medication. 4. Recurrent use of or repeated requests for PRN medications may indicate the need to reevaluate the situation, including the current medication regimen. Some clinical conditions or situations may require using several analgesics and/or adjuvant medications (e.g., antidepressants or anticonvulsants) together. 5. PRN orders for psychotropic drugs are limited to 14 days. If the prescriber believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident ' s medical record and indicate the duration for the PRN order .
Further review of the policy did not indicate that non-pharmacological interventions should be attempted before administering a PRN psychotropic medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure proper sanitation and disposal of medication tablets for one of two medication carts reviewed. Findings include:
On 10/...
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Based on observation, interview and record review the facility failed to ensure proper sanitation and disposal of medication tablets for one of two medication carts reviewed. Findings include:
On 10/22/24 at approximately 8:35 AM, the medication cart from the 2 [NAME] hallway was reviewed with Licensed Practical Nurse (LPN) N. Upon observation of the first medication drawer, three unidentified pills (peach, white and tan colored round tablets) were laying on the bottom of the drawer.
Review of the second drawer revealed seven white and one peach tablet on the bottom of the second drawer.
Review of the third drawer revealed one green and one blue round tablet at the bottom of the drawer.
LPN N was questioned about the pills found, however was unable to identify the medication and whom it belonged to.
During the review of the 2 [NAME] hallway medication cart the Director of Nursing (DON) was asked to observe the pills identified on the bottom of each drawer. The DON stated the medication drawers should be kept clean and the pills should have been discarded per the facility policy.
No further explanation or documentation was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed for one resident (R50) of one residents reviewed for diagnostics.
Findings include:
On 10/21/24 the medical record for R50 was reviewed and revealed the following: R50 was initially admitted to the facility on [DATE] and had diagnoses including Adult failure to thrive and Dementia. A review of R50's MDS (minimum data set) with an ARD (assessment reference date) of 8/19/24 revealed R50 needed assistance from facility staff with their activities of daily living R50's BIMS score (brief interview for mental status) was 15 indicating intact cognition.
A Physicians order dated 9/22/24 revealed the following: CBC (complete blood count) , BMP (basic metabolic panel), AND Troponin. Further review of the medical record did not reveal any results form the labs that were ordered on 9/22/24.
On 10/22/24 at approximately 12:45 p.m., Nurse Manager E (NM E) was queried regarding the labs results from 9/22/24 and reported that they never got done and there was a miscommunication and the lab was never made aware of the order. NM E reported they had to reorder the labs and would get the completed.
On 10/23/24 a facility document titled Laboratory and Diagnostic Guidelines was reviewed and revealed the following: Policy: This guideline is set up to track the timely completion, reporting and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels. Policy Explanation and Compliance Guidelines:
1. The facility may consider tracking laboratory (lab) and diagnostic test through various sources. The system is based on the lab provider and facility efficiency. a. Tracking log b. Electronic portal c. Calendar d. Other 2. Routine laboratory or diagnostic test may be placed on a calendar or schedule, or other mechanism. The mechanism should allow for ease of the facility staff to recognize upcoming
lab and diagnostic tests. 3. Lab and diagnostic test ordered for future dates should also be placed in the same system, again to allow for ease of the facility staff to recognize. 4. Each Lab or entity will have its own process for requisitions. 5. When a new order for labs/diagnostic test is received the nurse should review previous orders for like test to determine if there is conflict, overlap, or rescheduling required. 6. Unless specifically ordered by the physician, routine orders that would fall on a Saturday, Sunday, or holiday may be drawn on the following business or lab day. 7. STAT labs may be obtained per physician order 7 days per week. 8. Orders which require more than one sample, for example stools for occult blood should be placed on a separate line on the log/calendar or per laboratory requirements. 9. The physician should be notified of all refused lab/diagnostic test orders and reason why. 10. The physician should be notified if the lab/diagnostic test is unable to be completed, reason why, and request for new orders. 11. The physician should be notified of all lab/diagnostic test results based on the below parameters. a. Critical lab results or urgent diagnostic should be called to the physician upon receipt. o If at any time the resident is symptomatic or if in the clinician ' s expert opinion the resident needs evaluation and there has been no response
from a physician, the Medical Director will be notified. b. Non-critical or non-urgent test results that are abnormal should have physician notification within 24 hours unless the physician has provided specific notification parameters. c. Normal lab/diagnostic results may be faxed to the physician to be reviewed during normal physician hours, unless the physician has ordered immediate reporting of the result. 12. All notifications, attempts at notifications, and response should be noted in the resident ' s medical record. 13. Results should also be reported to the resident and/or responsible party, including any new orders
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
Based off observations, interviews, and record review the facility failed to provide accurate medical record documentation for services provided for one(R49) resident of four residents reviewed for me...
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Based off observations, interviews, and record review the facility failed to provide accurate medical record documentation for services provided for one(R49) resident of four residents reviewed for medical records. Findings include:
On 10/21/24 at 10:00AM, R49 was observed in bed with tube feeding running. There were no splints or other adaptive devices present on R49.
On 10/21/24 at 1:08 PM, R49's legal guardian(LG) was interviewed regarding care rendered to R49. The LG stated they did have a few concerns. LG stated that R49 was supposed to be on restorative services and that they were afraid that R49 was not getting the services because their hands were becoming more contracted due to it not being enough staff to apply their splints. The LG continued to explain that R49 did not get out of bed on a regular basis because they had a pressure injury on their coccyx and would like to see the Resident up more to promote wound healing.
On 10/22/24 at 10:55AM, an interview with the Therapy Manager was conducted and he was asked if R49 was on their case load. The Therapy manager explained the that the Resident was not on case load and they only did the initial screening of the Resident and gave them (the screens) to nursing with recommendations. The Therapy manager was then asked if R49 required bilateral splints for their contractures. The Therapy manager confirmed the resident should have splints and would confer with nursing.
On 10/22/24 at 10:57 AM, the Restorative Nurse was interviewed and asked if R49 was on their case load and did they require splints. The Restorative Nurse replied that R49 was on case load and that they did require splints and that should be placed on during the day with periods of rest at night, R49 also had elbow protectors that should be placed on as well. The restorative nurse was informed that R49 did not have on any of the items on and the Restorative nurse stated that they were short a restorative aid but the floor staff should have still completed it.
A review of the record revealed that on 10/21/24 that the splint task was signed out and marked tolerated well although the resident did not have the splints on as ordered.
On 10/22/24 at 11:20 AM, an interview with the Director of Nursing (DON) was conducted and she was made aware of how R49 presented with no splints but it was documented at 1:34 PM that R49 tolerated well. The DON replied that she did not know the certified nursing assistant would chart that if it did not happen.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview and record reviews the facility failed to implement an effective antibiotic stewardship program for three R's 46, 3, 223 of three sampled residents reviewed. This deficient practice...
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Based on interview and record reviews the facility failed to implement an effective antibiotic stewardship program for three R's 46, 3, 223 of three sampled residents reviewed. This deficient practice had the ability to affect multiple residents that resided in the facility who was prescribed an antibiotic. Findings include:
Review of the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 2015:
.Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year .studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic- resistant organisms .Infection prevention coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections .Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection prophylaxis and implement specific interventions to improve use .
Review of the March, June & July 2024 infection surveillance logs revealed the following:
March- R223 was documented to have a Urinary Tract Infection (UTI) no documentation was noted whether the infection met the McGeer's criteria (the standard utilized to determine the appropriate use of antibiotics to avoid unnecessary use), no signs/symptoms noted, and no documentation of the antibiotic prescribed. Review of the Medication Administration Record (MAR) documented Ceftriaxone intravenous solution as the antibiotic prescribed.
June- R3 was documented to have a UTI that did not meet McGeer's criteria. Cefdinir was the antibiotic noted.
July- R46 was documented to have a UTI that did not meet McGeer's criteria. Doxycycline was the antibiotic noted.
Review of the medical records for R's 223, 3 and 46 revealed no documentation that either antibiotic was reviewed for appropriateness.
On 10/23/24 at 1:56 PM, the Infection Control Nurse (ICN) O (who also served as the facility's Infection Preventionist) was interviewed and asked about the oversight of the facility's Antibiotic Stewardship Program and the review of antibiotic appropriateness for R's 223, 3 and 46. ICN O stated they would look into it and follow back up. At 3:43 PM, ICN O returned and stated they were unable to provide any further documentation.
No further information or documentation was provided by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
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 effectively maintain a backup for the facility's resident call system...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to effectively maintain a backup for the facility's resident call system during a partial power outage (for approximately 12 hours) affecting all residents (R26, R33 and R44) on the one west hall resulting in the potential for a delayed emergency response and/or negative resident outcome. Findings include:
R26
Record review revealed R26 was a long-term resident of the facility. R26 was residing in the one [NAME] Hall. R26 was admitted to the facility on [DATE]. R26's admitting diagnoses included heart failure with presence of pacemaker, atrial fibrillation, chronic pain, and chronic kidney disease. Based on the Minimum Data Set (MDS) assessment dated [DATE], R26 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative on intact cognition. R26 needed extensive staff assistance with their mobility in bed and transfers.
During an initial interview with R26 completed on [DATE] at approximately 9:10 AM. During the interview R26 reported that the facility had some generator issue on [DATE], in the afternoon, after 5 PM. R26 added that the facility lost part of the power and their call light system on the unit were not working. When queried further R26 reported that it happened approximately around 5 PM on [DATE] and they did not get the power back until [DATE] morning. They added that red plugs/outlets (emergency outlets) on their side of the room did not work. The showed the remote pacemaker monitor (that was plugged to the outlet behind the bed) and stated that it was not working and they were concerned because the call light system was also not working. When queried if facility has provided a backup system/bell to alert the staff, R26 reported that the facility did not provide any back up system to alert staff and that was why they were concerned. When queried if staff members were aware of the concern, R26 reported that staff were aware. R26 reported that they had called the facility Receptionist V on [DATE] and spoke with them and they had requested to speak with the facility administrator and the receptionist had notified R26 that administration had left for the day. When queried how they had alerted the staff members, R26 reported that they had to yell out to alert staff. R26 reported that they had called the ombudsman and had left a message for them.
During a follow up interview completed on [DATE] at approximately 4:15 PM, R26 confirmed the above details that they had provided to the surveyor on [DATE].
R33
Record review revealed R33 was a long-term resident originally admitted to the facility on [DATE]. R33's admitting diagnoses included Chronic Obstructive Pulmonary Disease (COPD) and panic disorder. Based on the MDS assessment dated [DATE], R33 had a BIMS score of 15/15, indicative of intact cognition.
An interview with R33 was completed on [DATE] at approximately 12:30 PM. During the interview they were queried about the power outage. R33 reported that it happened on [DATE] and the call light system on their unit was not working.
A follow-up interview was completed on [DATE] at approximately 4:10 PM. During this interview R33 confirmed that call light system on their unit was not working throughout the night of [DATE] and they were not provided with any back up call system to alert staff when they needed help. R33 also confirmed that the facility staff were aware of the non-working call light.
R44
Record review revealed R44 was a long-term resident admitted to the facility on [DATE]. R44's admitting diagnoses included COPD, heart failure, obstructive sleep apnea, and diabetes. Based on the MDS assessment dated [DATE], R44 had a BIMS score of 15/15, indicative of intact cognition. An initial observation was completed on [DATE] at approximately 10:30 AM. R44 was observed in their bed. R44 was receiving oxygen through a nasal cannula. They had confirmed that the facility had power outage on [DATE] and the call lights were not working during this time.
A follow-up interview was completed on [DATE] at approximately 10 AM. They were sitting on the edge of the bed and receiving oxygen. They were queried about the power outage on [DATE]. R44 reported that on [DATE] afternoon (around 4:30 PM) the facility had a partial power outage and the red outlets behind their bed were not working and their call light were not working through the whole night until the next morning, approximately 8 AM. They added that the staff were aware that the call light were not working and they did not have alternate means to alert the staff of help they needed. When queried further R44 added that their oxygen concentrator and Continuous Positive Airway Pressure (CPAP) machine were not working that night and they were using a portable oxygen tank. R44 added that they had to use their cell phone to call the facility to alert staff when they needed a new oxygen tank. R44 showed the phone to the surveyor and there were calls made to the facility on [DATE] at 2:40 AM and 5:57 AM.
An interview was completed with the receptionist V on [DATE] at approximately 4:25 PM. Receptionist V confirmed that they had a power outage on [DATE]. They were queried if they had received any calls from the residents that evening with any concerns. They reported that they received calls from different residents, including R26 and they reported that their call lights were not working. They added that they had notified maintenance.
An interview with the ombudsman W was completed on [DATE] at approximately 11 AM. During the interview Ombudsman W confirmed that they had received a call from resident(s) about the power outage on [DATE] and call lights were not working.
An interview with facility's Assistant Administrator (AA) A was completed on [DATE] at approximately 10:15 AM. They reported that they were not in the facility on the day of the incident, but they were aware of the situation as they were receiving the group messages and they were able to answer questions about the outage. AA A reported that they had a faculty generator transfer switch that caused the outage on [DATE]. They were queried if they were aware of call lights that were not working on one west unit and they reported that they were not aware of the issue. They added that the facility had two generators and the call light system was connected to the smaller generator and they did not have any trouble with that unit. AA A was notified of the call light concerns from [DATE] reported by multiple residents in the one [NAME] hallway. They reported that they would check with the facility vendor and provide additional documentation to show the facility's call light system was connected to the smaller generator. Later they reported that they had an appointment with the vendor and would provide additional documentation.
No further explanation or additional information was provided prior to the survey exit.
An interview with the Director of Nursing (DON) was completed on [DATE] at approximately 3:45 PM. The DON reported that they were at the facility till 10 PM on the day of the power outage and they were unaware that the call lights on the one west unit were not functioning. They added that they would have provided bells or an alternate system for the residents if they were made aware of the situation.
The DON was notified of the concern from multiple residents from the one west hall and they reported that they understood the concern.
A facility provided document titled Call Lights: Accessibility and Timely Response with a revision date [DATE] read in part, Policy: 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.
Policy Explanation and Compliance Guidelines:
1. Staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access to the call light.
2. Residents are educated on how to call for help by using the resident call system.
3. Each resident will be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system.
4. Special accommodations will be identified on the resident's person-centered care plan, and provided accordingly. (Examples include touch pads, larger buttons, bright colors, etc.)
5. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and provides immediate or alternative solutions until the problem can be remedied. (Examples include replace call light, provide a bell or whistle, increase frequency of rounding, etc.) .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0841
(Tag F0841)
Could have caused harm · This affected most or all residents
An interview with Nurse Practitioner (NP) T was completed on 10/24/24. During the interview they were queried if they were overseeing the care for ventilator dependent residents and they reported that...
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An interview with Nurse Practitioner (NP) T was completed on 10/24/24. During the interview they were queried if they were overseeing the care for ventilator dependent residents and they reported that they were only overseeing residents who were assigned to the medical director. They were queried about the ventilator settings and coordination of care with the pulmonologist for ventilator dependent residents. NP T reported that they did not handle that and they were only coordinating the care with the attending physician who was also the Medical Director.
Based on interview and record review the facility failed to ensure the assigned medical director was aware of their job description and fulfilled their responsibility for the coordination of respiratory care for residents that required mechanical ventilation, this had the ability to affect 66 of 66 residents that resided in the facility at the time of the survey. Findings include:
During the course of the survey, a systemic failure regarding the Pulmonologist services was identified in the facility that affect all residents that required mechanical ventilation. Due to the severity of the concern, an interview was conducted with the facility's Medical Director.
On 10/24/24 at 9:21 AM, the Medical Director (MD) L was interviewed via telephone and asked their involvement in the respiratory care for the facility's ventilator residents. MD L stated they had nothing to do with the respiratory care for the ventilator residents. MD L stated the facility has a Pulmonologist to take care of the respiratory care, however, knew the facility was having a lot of problems with the current Pulmonologist. MD L denied ensuring collaboration of respiratory care was being provided to the mechanical ventilator residents and stated in part . I don't do anything with them, my role is not to run different parties . At that time MD L was made aware that they are indeed listed on the facility's documentation as the Medical Director which would require them to ensure coordination of care amongst all parties in the facility. MD L responded and stated that was not their understanding when they took over the role. Their understanding was that they were assigned to a set of residents and that it was their responsibility to take care of the residents assigned to them. MD L stated there are . a lot of issues that I bring to the Administration staff and it's never fixed . MD L stated if the medical director is responsible for the whole facility then they resign. MD L stated they were calling their employer because that was not the job they signed up for.
On 10/24/24 at 11:31 AM and 1:43 PM, the Administrator and Vent Unit Administrator A was interviewed and asked to provide the contract signed by MD L informing them of their job duties and responsibilities. The Administrator and Vent Unit Administrator was informed of the concern regarding the interview conducted with MD L. No explanation was provided.
MD L contract and/or additional documentation was not provided by the end of the survey.
On 10/24/24 at approximately 8:42 a.m., Nurse Practitioner U (NP U) was queried if they were the attending NP for any residents in the facility and they indicated that they were. CP U was queried if they oversaw any of the ventilator or tracheostomy (trach) orders for the respiratory/ventilator residents and they indicated they did not. NP U was queried if they knew what Physician over saw the respiratory orders and evaluated the resident ventilator settings that were on ventilators and they reported they did not know.
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 ensure consistent standards of practice for Infection Control were implemented by all staff and ensure the implementation of an...
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Based on observation, interview and record review the facility failed to ensure consistent standards of practice for Infection Control were implemented by all staff and ensure the implementation of an effective infection control surveillance program, this had the ability to affect all 66 of 66 residents that reside in the facility at the time of the survey. Findings include:
On 10/21/24 at 9:05 AM, the Social Service (SS) personnel B was observed walking into the room of a resident with a signage on the door for Enhanced Barrier Precautions which required everyone who entered and exited to complete hand hygiene. SS B did not complete hand hygiene upon entering. Once inside, SS B conversed with the resident and then was seen exiting the room and heading into another residents room. SS B did not complete hand hygiene prior to exiting the room. SS B was interviewed and asked about the signage on the door and asked why they did not complete hand hygiene before entering and exiting the room. SS B replied they were not providing care to the resident. Additional observations of a Respiratory Therapist was made of them donning on a gown and only tying it at the waist side. The neck and shoulder area of the gown was observed dropping down continuously while the RT was providing tracheostomy care. Another observation was made of a housekeeper entering the room of a resident with an EBP signage on their door, grabbing their breakfast tray and exiting the room. The housekeeper failed to perform hand hygiene upon entering and exiting the room.
Infection Surveillance Program
Review of the facility's Infection Surveillance Program revealed the following for 2024:
September- No monthly analysis or line listing completed.
August- No monthly analysis or line listing completed.
July- No line listing completed.
June- No line listing completed.
March- No mapping of infections completed.
February- No line listing or mapping completed.
January- No documentation maintained for this month.
On 10/23/24 at 1:56 PM, the Infection Control Nurse (ICN) O (who also served as the facility's Infection Preventionist) was interviewed and asked about the identified missing components of the Infection Surveillance for the facility from January to current. ICN O explained they had resumed the role of the Infection Control nurse in February 2024 and would look into the missing documentation of the surveillance program. ICN O was informed of the many observations made by the survey team of improper infection control practices by the facility staff and ICN O acknowledged the concern.
No further explanation or documentation was provided by the end of the survey.
A review of a facility policy titled Infection Prevention and Control Program revised 12/27/23, documented in part . The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious disease . A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and other individuals . The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any other corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment Performance Improvement .
Sept 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
This citation pertains to intake #MI00146596
Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for pressure ulcers for one resident ...
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This citation pertains to intake #MI00146596
Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for pressure ulcers for one resident (R504) of three residents reviewed for pressure ulcers, resulting in the potential for worsening of pressure ulcers. Findings include:
On 9/17/24 at 10:05 AM, R504 was observed in their bed uncovered. R504 was positioned slightly on their right side exposing their left trochanter. An undated border foam dressing was observed to be applied and shadowing from wound drainage was present.
On 9/17/24 at 12:05 PM, a review of R504's clinical record was conducted and revealed they admitted into the facility on 8/2/24 with diagnoses that included: stroke, respiratory failure, diabetes, presence of a tracheostomy and feeding tube. Continued review of the record further revealed R504 developed a stage III (full-thickness tissue loss that extends through the skin into deeper tissue and fat, but does not expose bone, tendon, or muscle) during their stay in the facility.
On 9/17/24 at 12:15 PM, R504's physician orders and Treatment Administration Record (TAR) were reviewed and revealed treatments to the left trochanter scheduled on the night shift not documented as completed on 9/7/24, 9/10/24, 9/13/24, 9/15/24, and 9/16/24.
On 9/17/24 at 12:35 PM, R504's family was visiting in the room. At that time, they were repositioning R504 and they were asked if the left trochanter could be observed. They gave permission and the border foam dressing to the left trochanter was observed undated with shadowing from wound drainage present.
On 9/18/24 at 9:43 AM, an observation of R504's left trochanter was conducted with Nurse 'D'. R504's left trochanter had an undated, border foam dressing with shadowing from wound drainage present. Nurse 'A' was asked about the undated dressing and said they had not completed the treatment yet on their shift.
On 9/18/24 at 10:30 AM, an interview was conducted with the facility's Director of Nursing. They reported staff should perform the treatments on their shift and document on the TAR.
A review of a facility provided policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol revised 3/2024 was conducted and read, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
This citation pertains to intake #MI00146596
Based on observation, interview, and record review, the facility failed to ensure safe wheelchair transport for two residents (R#'s 505 and 506) of two res...
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This citation pertains to intake #MI00146596
Based on observation, interview, and record review, the facility failed to ensure safe wheelchair transport for two residents (R#'s 505 and 506) of two residents reviewed for accidents, resulting in the potential for injury. Findings include:
On 9/17/24 at 10:42 AM, Certified Nurse Aide (CNA) 'B' was observed transporting R505 back to their room from the shower room. R505 was seated in a shower chair facing backward and CNA 'B' was observed to be pulling the chair in a forward motion, as opposed to having R505 in the chair facing forward and the chair being pushed from behind.
On 9/17/24 at 10:46 AM, CNA 'C' was observed transporting R506 to their room from the shower room. R506 was seated in a geri-chair facing backward and CNA 'C' was observed to be pulling the chair in a forward motion, as opposed to having R506 in the chair facing forward and the chair being pushed from behind.
On 9/18/24 at 10:30 AM, an interview with the facility's Director of Nursing was conducted and they were asked if it was appropriate to have a resident in a wheelchair, shower chair, or geri-chair facing rearward being pulled down the hall and they said it was not.
A review of a facility provided policy titled, Use of Assistive Devices revised 10/2023 was conducted and read, .4. Facility staff will provide appropriate assistance .6. The resident's assigned nurse will monitor for the consistent use of the device and safety in the use of the device .
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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00146596
Based on observation, interview, and record review, the facility failed to ensure i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00146596
Based on observation, interview, and record review, the facility failed to ensure indwelling urinary catheter care, proper positioning of urinary catheter drainage bags, and the use of catheter anchors for three residents, (R#'s 501, 502, and 504) of three residents reviewed for indwelling urinary catheters resulting in the the potential for the development of infection and genitourinary injury. Findings include:
R502
On 9/17/24 at 9:28 AM, R502 was observed in their bed. R502 was not responsive to attempts at verbal communication. R502 was further observed to have an indwelling urinary catheter with a drainage bag to the right side of the bed. The bag was observed to be in contact with the tile floor.
On 9/18/24 at 10:06 AM, R502's urinary catheter drainage bag was observed on the right side of the bed in contact with the tile floor.
A review of R502's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure, anoxic brain damage, sepsis, quadriplegia, urinary retention, tracheostomy, dependence on mechanical ventilation, and presence of a feeding tube. A Minimum Data Set (MDS) assessment dated [DATE] revealed R502 had severely impaired cognition and was dependent on staff for all activities of daily living (ADL's).
Continued review of R502's clinical record included a review of the Certified Nurse Aide (CNA) tasks and it was noted there was no task on the list for urinary catheter care. A review of R502's physician's orders was conducted and revealed orders to monitor R502's urine, and orders to change the drainage bag, and ensure an anchor was in place, but no orders for urinary catheter care. R502's care plan for an indwelling urinary catheter was reviewed and revealed an intervention that read, Assist resident with indwelling catheter care as needed.
R504
On 9/17/24 at 12:25 PM, R504 was observed in their bed. It was observed R504 had an indwelling catheter with a drainage bag to the left side of the bed. R504's family was at the bedside and was asked if they could uncover R504's left upper leg for an observation of the presence of a urinary catheter anchor. When the upper leg was uncovered a urinary catheter anchor was not present and the catheter tubing appeared taut, leaving a deep indentation into R504's thigh.
On 9/18/24 at 9:43 AM, R504 was observed with Nurse 'D'. It was observed R504 did not have a urinary catheter anchor in place and the tubing appeared taut, leaving a deep indentation into R504's thigh. Nurse 'D' acknowledged the absence of catheter anchor and concern for the potential for skin breakdown due to the catheter on R504's thigh.
A review of R504's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: stroke, acute respiratory failure, diabetes, neuromuscular dysfunction of the bladder, tracheostomy, and presence of a feeding tube. A review of R504's physician's orders and Medication Administration Record (MAR) and Treatment Administration Record (TAR) was conducted and it was noted the presence of a catheter anchor had been signed out as completed on both the day and night shift on 9/17/24, despite no anchor observed on 9/17/24 or in the morning of 9/18/24.
R501
A review of R501's closed clinical record was conducted and revealed they admitted to the facility on [DATE], discharged to the emergency room on 5/16/24, re-admitted on [DATE], and discharged on 8/4/24. R501's diagnoses included: stroke, dysphagia, diabetes, and presence of a feeding tube.
Continued review of R501's clinical record included a review of the CNA tasks and it was noted there was no task on the list for urinary catheter care after their re-admission to the facility on 5/16/24. A review of R501's physician's orders was conducted and revealed orders to monitor R501's urine, and orders to change the catheter and drainage bag monthly or as needed, however; their were no orders to perform catheter care.
On 9/18/24 at 10:30 AM, an interview was conducted with the facility's Director of Nursing (DON), they were asked who was responsible for performing urinary catheter care and where it was documented. They indicated the CNA's performed the care and it appeared on their task list for them to document the care was completed. They were also asked if catheter anchors should be in place and said they should be. Observations of R504's catheter and the indentations into their skin caused by the catheter tubing were shared with the DON and they said they would be looking into it.
A review of a facility provided policy titled, Appropriate Use of Indwelling Catheters revised 12/2023 was conducted and read, .Policy Explanation and Compliance Guidelines: 1 It is the policy of this facility to ensure residents with urinary incontinence .c. Who is incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections .8. Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible .
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
This citation pertains to intake #MI00146596.
Based on observation, interview, and record review, the facility failed to address tube feeding pump errors in a timely manner for two residents (R#'s 503...
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This citation pertains to intake #MI00146596.
Based on observation, interview, and record review, the facility failed to address tube feeding pump errors in a timely manner for two residents (R#'s 503 and 507) of three residents reviewed for tube feeding, resulting in the delay of delivery of tube feeding nutrition and the development of a clogged feeding tube. Findings include:
R503
On 9/17/24 at 9:53 AM, R503 was observed in their room. R503 was not responsive to attempts at verbal communication. It was observed R503 had a tube feeding pump and pole with a bottle of feeding formula and an empty bag that was to contain water for hydration and flush connected to the pump. The pump was audibly beeping and the digital screen on the front of the pump indicated there was a, Flush error.
On 9/17/24 at 10:42 AM, R503's tube feeding pump remained audibly beeping, the water bag was empty, and the pump indicated a, Flush error. Observations from the hallway were conducted from 10:42 until 11:06 AM and the beeping pump in R503's room could be heard from the hallway. Multiple staff members were observed up and down the hallway performing their duties and at no time during the observation did anyone enter the room and address the beeping tube feeding pump.
R507
On 9/17/24 at 11:08 AM, R507 was observed in their bed slightly agitated, fidgeting and had had partially removed their gown. R507 was observed to have a tube feeding pump and pole with a full bag of water for hydration and flush, and a bottle of tube feeding formula with 325 mL (milliliters) of formula remaining in the bottle. The pump was audibly beeping and the digital screen on the pump indicated there was an error that read, Clog in the line downstream of the pump.
On 9/17/24 at 12:20 PM, R507 was observed in bed, no longer fidgeting or restless and a gown had been placed on them. R507's tube feeding pump was audibly beeping with an error that read, Clog in the line downstream of the pump. The tube feeding bottle revealed 325 mL of formula remained in the bottle, and the water bag was full.
On 9/17/24 at 1:00 PM, 2:05 PM, 3:06 PM, and 4:09 PM, R507's tube feeding pump was audibly beeping with an error on the pump that read, Clog in the line downstream of the pump. The tube feeding bottle had 325 mL of formula remaining and the water bag was full.
A review of R507's clinical record was conducted and revealed orders for tube feeding formula to be delivered at 75 mL per hour. A calculation of 75 mL per hour for five hours revealed 375 mL of formula should have been delivered between 11 AM and 4 PM, however; the feeding formula bottle observed approximately hourly between 11:08 AM and 4:09 PM revealed 325 mL remained in the bottle during each observation.
On 9/17/24 at 4:17 PM, an interview was conducted with Nurse 'D', R507's assigned nurse. They said they were assigned to care for R507 at 3:15 PM, they checked on them around that time and noticed the tube feeding pump was off. They were asked why the pump was off and said they did not know but they turned the pump on and exited the room. They were asked if they were aware the tube feeding pump had been beeping with an error message since approximately 11:00 AM and multiple observations between 11:00 AM and 4:00 PM revealed 325 mL of feeding formula remained in the bottle. They said they were not aware, but would check on it. Nurse 'D' went to R507's room and was observed to attempt to flush the feeding tube and discovered it was clogged. Nurse 'D' was not able to unclog the tube with warm water and had to obtain a specialized tube feeding de-clogging device.
On 9/18/24 at 10:30 AM, an interview was conducted with the facility's Director of Nursing (DON) They were asked if they were aware of the tube feeding concerns communicated to staff on 9/17/24. They said they were. They were asked if Certified Nurse Aides (CNA's) should turn off tube feeding pumps and said they should not. They were then asked if staff should address alarming tube feeding pumps and said staff should let the nurse know so the nurse could address it.
A review of a facility provided policy titled, Feeding Tubes revised 6/2022 was conducted and read, .Feeding tubes will be maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00146293
Based on observation, interview, and record review, the facility failed to ensure t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00146293
Based on observation, interview, and record review, the facility failed to ensure tracheostomy and ventilator care was performed and respiratory medications were administered per physician's orders for three residents (R#'s 502, 503 and 504) of four residents reviewed for respiratory care and services, resulting in the potential for respiratory complications. Findings include:
R502
On 9/17/24 at 10:40 AM, R502 was observed in their bed with a tracheostomy receiving mechanical ventilation. R502 was not responsive to attempts at verbal communication.
A review of R502's clinical record revealed they admitted to the facility on [DATE] and re-admitted on [DATE]. Their diagnoses included: acute respiratory failure, anoxic brain damage, sepsis, quadriplegia, tracheostomy, and dependence on mechanical ventilation. R503's Minimum Data Set assessment date 7/13/24 indicated they had severely impaired cognition and required assistance from staff for all activities of daily living.
A review of R502's Physician's orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) was conducted and revealed the following:
An order for an evaluation/assessment of a resident on a ventilator with a tracheostomy scheduled every shift not signed out as completed on 8/5/24, 8/13/24, 8/16/24 thru 8/18/24 on the night shift, and 8/22/24, 8/26/24, and 8/27/24 on the day shift.
An order for tracheostomy care every shift and an order for visual checks on ventilator residents every shift not signed out on 8/5/24, 8/13/24, and 8/16/24 on the night shift.
An order for ipratropium-albuterol medication (respiratory medication) administered via the ventilator four times a day not signed out as administered on 8/3/24 at 9 PM, 8/4/24 at 3 AM and and 9 PM, 8/6/24 at 3 AM, 8/7/24 at 9 PM, 8/13/24 and 8/14/24 at 3 AM, and 8/17/24 at 3 AM and 9 PM.
R503
On 9/17/24 at 9:34 AM, R503 was observed in their bed with a tracheostomy, on mechanical ventilation, and had a feeding tube. R503 was not responsive to attempts at verbal communication.
A review of R503's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted to the facility on [DATE]. R503's diagnoses included: acute and chronic respiratory failure, dysphagia, sepsis, quadriplegia, presence of a tracheostomy and a feeding tube. A Minimum Data Assessment (MDS) dated [DATE] revealed R503 had severely impaired cognition and required staff assistance for all activities of daily living.
A review of R503's MAR and TAR was conducted and revealed the following:
An order to change to change the tracheostomy collar every three days not signed out as done on 8/18/24, 8/24/24, and 8/30/24.
An order to assess the tracheostomy stoma site not signed out as done on 8/14/24, 8/18/24, 8/20/24, 8/24/24, 8/25/24, 8/28/24, and 8/30/24 on the night shift.
An order to perform tracheostomy care every shift not signed out as done on 8/14/24, 8/18/24, 8/20/24, 8/24/24, 8/25/24, 8/28/24, 8/29,/24 and 8/30/24.
R504
On 9/17/24 at 10:05 AM, R504 was observed in their bed asleep. It was observed R504 had a tracheostomy, feeding tube, and indwelling urinary catheter.
A review of R504's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: stroke, acute respiratory failure, diabetes, neuromuscular dysfunction of the bladder, tracheostomy, and presence of a feeding tube. An MDS assessment dated [DATE] indicated R504 had severely impaired cognition and was dependent on staff for all activities of daily living.
A review of R504's physician's orders, MAR's, and TAR's was conducted and revealed the following:
Physician's orders for assessing the tracheostomy stoma site and performance of tracheostomy care not signed out as done on: 8/21/24, 8/23/24, and 8/29/24 on the day shift and 8/3/24, 8/5/24, 8/6/24, 8/13/24 thru 8/15/24, 8/17/24, 8/18/24, 8/22/24, 8/24/24, 8/25/24, 8/28/24, 8/30/24, 9/1/24 thru 9/6/24, 9/9/24, 9/13/24, and 9/16/24 on the night shift.
On 9/18/24 at 10:30 AM, an interview was conducted with the facility's Director of Nursing and said respiratory therapy staff were responsible for completing and documenting the respiratory tasks on the MAR and they would be letting the Respiratory Therapy Manager know of the concern.
A review of a facility provided policy titled, Tracheostomy Care revised 10/2023 was conducted and read, Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences .
Jul 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00145374
Based on observation, interview, and record review, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00145374
Based on observation, interview, and record review, the facility failed to maintain the building at a safe and comfortable temperature on the second floor for 15 (R701, R703, R704, R705, R706, R707, R709, R710, R711, R712, R713, R714, R715, R716, and R717) of 17 residents reviewed for a safe, clean, comfortable, homelike environment, resulting in expressions of physical discomfort. Findings include:
On 7/31/24 at 8:45 AM, upon entrance into the facility, the Director of Nursing (DON) reported she had to set the surveyors up in the day room on the first floor because it was too hot in the day room on the second floor. Upon entrance to the first floor day room, it was observed to be hot and humid.
On 7/31/24 at approximately 11:00 AM, an interview was conducted with R701 in his room. The room was very hot despite a portable air condition (A/C) unit running. R701 reported it was uncomfortable in his room and has been going on for some time. R701 pointed to the thermostat that was set at 50 degrees Fahrenheit (F). The temperature of the room displayed on the thermostat was 82 degrees F.
On 7/31/24 at approximately 11:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 'B' who was assigned to the 2 East Unit. When queried about the temperature in R701's room, LPN 'B' reported there was an issue with the A/C and it had been going on for a while and worse in the past week. LPN 'B' reported that she had been trying to monitor residents more frequently and that it was difficult to work in the heat. LPN 'B' said back in June 2024, some residents were given portable A/C units, but not everyone received one. When queried if every room was hot on the 2 East unit, LPN 'B' reported almost all rooms except two were hot.
On 7/31/24 at approximately 11:35 AM, an interview was conducted with Housekeeper 'C'. When queried about the temperature in the building, Housekeeper 'C' said she just returned from vacation that day and was gone for a week. Housekeeper 'C' said the temperature was not that hot in the building before she left for vacation.
On 7/31/24 at approximately 12:15 PM, an interview was conducted with the Administrator for the ventilator unit (Administrator 'A') and Maintenance Director 'D'. According to Administrator 'A', Maintenance Director 'D' began working in the facility on 7/23/24. When queried about any issues regarding temperature in the building, Administrator 'A' reported that back in June 2024 there were issues but they were repaired. At that time, Administrator 'A' reported they provided portable A/C units to the affected residents. When queried about what was going on currently with the temperatures in the building, Administrator 'A' reported he was not aware of any rooms that had temperatures out of range (over 81 degrees Farenheit - F). At that time, room temperature monitoring logs were requested since June 2024, along with any documented servicing or repairs to the facility's cooling system.
On 7/31/24 at 1:12 PM, Administrator 'A' provided Logbook Documentation for Test and log air temperatures from 5/21/24 through 7/5/24. There was nothing logged after 7/5/24 and no temperatures outside of the required range (no temperatures over 81 degrees).
On 7/31/24 at 1:16 PM, Administrator 'A' was asked via email with the whole facility Administrator included in the email if the information provided was complete. Administrator 'A' reported it was.
On 7/31/24 at 1:20 PM, an interview was conducted with Administrator 'A'. When queried about why room temperature monitoring had not been completed since 7/5/24 when there were obvious temperature issues in the facility (as evidenced by observation, the DON mentioning it upon entrance, and resident and staff interviews), Administrator 'A' reported there might be additional room temperature logs, but he would have to look for them because there was a transitional period with maintenance staff. Administrator 'A' reported the former Maintenance Director's last day was 7/19/24 and the new Maintenance Director (Maintenance Director 'D') started on 7/23/24. It was reported there was a Maintenance Assistant as well. Administrator 'A' reported that room temperatures were to be monitored on a regular basis and if nursing staff or maintenance staff identified any concerns, they were to be brought to his attention or the Administrator. Administrator 'A' said no nursing or maintenance staff reported any issues with the temperatures in the building as of that day (7/31/24). At that time, a request was made to interview the Administrator. Administrator 'A' reported she was not in the building at that time and would return later. Prior to the end of the survey, it was unknown that the Administrator returned to the facility.
On 7/31/24 at 1:27 PM, an interview was conducted with Maintenance Director 'D'. When queried about any monitoring of room temperatures that was done since he began working in the facility, Maintenance Director 'D' reported he had not monitored any temperatures in resident rooms.
On 7/31/24 at 1:32 PM, an observation of the Ventilator Unit (unit that housed residents who were not able to breathe on their own without mechanical ventilation) and the 2 East Unit was conducted with Maintenance Director 'D'. Maintenance Director 'D' obtained room temperatures using an infared laser temperature gun. The following temperatures were observed:
Ventilator Unit
R705 and R706 - 83.1 degrees F
R707 - 83.1 degrees F
R710 - 83.3 degrees F
R709 - 82 degrees F
R711 - 83.1 degrees F
2 East Unit
R704 and R712 - 84.2 degrees F
R713 and R714 - 84.2 degrees F
R715 was observed lying in bed. R715 reported it had been hot in her room for days and it was making her asthma worse.
R701 - 85.0 F degrees with a portable A/C unit running
R703 was observed lying in bed. Two portable air condition units were running on high in her room. R703 reported it was so hot in her room, her husband had to buy the air condition units to cool the room off. R703 reported it made it difficult to breathe when it was hot due to asthma. R703 was observed with oxygen being administered via nasal cannula.
R716 and R717 - 82 degrees F
On 7/31/24 at approximately 2:15 PM, the high room temperatures (above 81 degrees F) was discussed with Administrator 'A'. When queried about what was put into place to ensure residents were comfortable and that they were hydrated and medically stable, Administrator 'A' reported he was not aware of the temperatures until the surveyor notified him. Administrator 'A' then said there were people currently in the building working on the A/C issue.
On 7/31/24 at 3:19 PM, an interview was conducted with the mechanical contractor staff (Contractor 'F') present in the building. When queried about what job they were completing the the facility on that day, Contractor 'F' reported they replaced filters and an exhaust fan in the kitchen. Contractor 'F' reported that they did some work on the cooling system a while back and various quotes were given, but they were not there to work on that at that time.
A review of R705's clinical record revealed R705 was admitted into the facility on 3/3/23 and readmitted into the facility on 7/18/24 with diagnoses that included: pneumonia and chronic respiratory failure. A review of R705's Minimum Data Set (MDS) assessment dated [DATE] revealed R705 had no speech, had severely impaired cognition, and was dependent on a mechanical ventilator to breathe.
A review of R706's clinical record revealed R706 was admitted into the facility on 2/15/23 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia. A review of R706's MDS assessment dated [DATE] revealed R706 had no speech, had severely impaired cognition, and was dependent on a mechanical ventilator to breathe.
A review of R707's clinical record revealed R707 was admitted into the facility on 1/20/22 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia and epilepsy. A review of R707's MDS assessment dated [DATE] revealed R707 had no speech, had severely impaired cognition, and was dependent on a mechanical ventilator to breathe.
A review of R710's clinical record revealed R710 was admitted into the facility on 4/2/24 and readmitted on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia. A review of R710's MDS assessment dated [DATE] revealed R710 had no speech, had severely impaired cognition, and was dependent on a mechanical ventilator to breathe.
A review of R709's clinical record revealed R709 was admitted into the facility on [DATE] an readmitted on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia. A review of R709's MDS assessment dated [DATE] revealed R709 had no speech, had severely impaired cognition, and was dependent on a mechanical ventilator to breathe.
A review of R711's clinical record revealed R711 was admitted into the facility on 2/22/24 and readmitted on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia. A review of R711's MDS assessment dated [DATE] revealed R711 had no speech, had severely impaired cognition, and was dependent on a mechanical ventilator to breathe.
A review of R704's clinical record revealed R704 was admitted into the facility on 3/9/24 and readmitted on [DATE] with diagnoses that included: acute respiratory failure with hypoxia. A review of R704's MDS assessment dated [DATE] revealed R704 had severely impaired cognition.
A review of R712's clinical record revealed R712 was admitted into the facility on 1/7/20 and readmitted on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia, obstructive sleep apnea, and muscular dystrophy. A review of R712's MDS assessment dated [DATE] revealed R712 had intact cognition.
A review of R713's clinical record revealed R713 was admitted into the facility on 2/22/22 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure and chronic obstructive pulmonary disease (COPD). A review of R713's MDS assessment dated [DATE] revealed R713 had severely impaired cognition and a tracheostomy (a tube surgically inserted into the windpipe to assist with breathing).
A review of R714's clinical record revealed R714 was admitted into the facility on 5/23/20 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia. A review of R714's MDS assessment dated [DATE] revealed R713 had severely impaired cognition and a tracheostomy.
A review of R715's clinical record revealed R715 was admitted into the facility on 6/4/24 and readmitted on [DATE] with diagnoses that included: asthma. A review of R715's MDS assessment dated [DATE] revealed R715 had intact cognition.
A review of R701's clinical record revealed R701 was admitted into the facility on [DATE] with diagnoses that included: multiple fractures after a motorcycle accident. A review of R701's MDS assessment dated [DATE] revealed R701 had intact cognition.
A review of R703's clinical record revealed R703 was admitted into the facility on 3/24/23 with diagnoses that included: acute and chronic respiratory failure and COPD. A review of R703's MDS assessment dated [DATE] revealed R703 had intact cognition.
A review of R716's clinical record revealed R716 was admitted into the facility on 6/25/24 with diagnoses that included: COPD. A review of R716's MDS assessment dated [DATE] revealed R716 had intact cognition.
A review of R717's clinical record revealed R717 was admitted into the facility on [DATE] with diagnoses that included: acute and chronic respiratory failure, emphysema, and COPD. A review of R717's MDS assessment dated [DATE] revealed R717 had moderately impaired cognition and received oxygen therapy.
No additional information was provided prior to the end of the survey.
A review of a facility policy titled, Safe and Homelike Environment, revised on 1/1/22, revealed, in part, the following, .Comfortable and safe temperature levels means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to .hyperthermia and is comfortable for the residents .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 .
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
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: MI00144465.
Based on observation, 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 intake: MI00144465.
Based on observation, interview, and record review, the facility failed to ensure an allegation of misappropriation was reported to the State Agency (SA) for one resident (R902), of one resident reviewed for misappropriation of funds. Findings include:
Review of a complaint submitted to the SA documented concerns of $500.00 to have been taken out of R902's bank account on 5/7/24 and transferred to a prepaid credit card by a facility staff person.
Review of the medical record revealed R902 was initially admitted to the facility in 2022, with a readmission date of 4/11/24 and diagnoses that included multiple sclerosis. A Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 13, indicating intact cognition and required staff assistance for Activities of Daily Living.
On 6/11/24 at 10:27 AM, R902 was observed in bed with a nebulizer treatment being administered. Once the treatment was completed, R902 was asked about the missing $500.00 from their bank account. R902 explained they were aware of the missing money, and their family member had contacted R902's bank to inform them of the fraudulent activity, wherein the bank started an investigation. R902 said they had not signed any documents with the facility staff regarding money, nor had approved anyone to access their account or monies. R902 said some weeks prior, facility staff lost their paperwork for Medicaid that contained their social security number and believed the person accused used the lost information to commit the fraudulent activity. R902 said they believed a staff member accessed their account, however; they did not want go give any names until the investigation was completed. R902 was asked if they had discussed their concerns with anyone at the facility and R902 said they told a business office person (later identified as Business Office Manager, BOM I). When asked what BOM I said when they were made aware of the allegation, they said BOM I told them they wished they would have reported it sooner because they could have helped. R902 further reported BOM I was ending their employment with the facility in the upcoming weeks. R902 was asked if any of the Administration staff followed up with them regarding the allegation and R902 said they had not.
On 6/11/24 at 11:13 AM, BOM I was interviewed and asked about the conversation with R902 regarding the allegation of the misappropriation of $500.00 during their stay in the facility. BOM I said R902 did inform them of the money taken out of their account some time ago and R902 told BOM I they had not informed anyone at the facility because there was investigation going on. BOM I was asked if they informed the Administrator or anyone of the allegation and BOM I said they did not. BOM I further said R902 did not want to blame anyone at the facility and was waiting for the investigation results.
Review of the facility policy titled Abuse, Neglect and Exploitation dated 1/1/21, documented 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 . misappropriation of resident property . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies . law enforcement . Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .
On 6/11/24 at 11:30 AM, the facility's Administrator and Vent Unit Administrator (VUA) A were interviewed and asked if they were aware of R902's allegation of misappropriation of $500.00 from their bank account by a staff member in May 2024. The Administrator and VUA A denied knowledge of the allegation. The Administrator and VUA A were then made aware R902 reported their allegation to BOM I. They were asked about the protocol for reporting misappropriation allegations and said BOM I should have reported the allegation to the Administrator, who was also the facility's Abuse Coordinator. The Administrator and VUA A acknowledged the concern and said they would follow-up.
No further information or documentation was provided by the end of the survey.
May 2024
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to immediately report an instance of neglect by a staff member affecting multiple residents on the first floor to the Abuse Coordinator and Sta...
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Based on interview and record review the facility failed to immediately report an instance of neglect by a staff member affecting multiple residents on the first floor to the Abuse Coordinator and State Agency.
Findings include:
On 5/2/24 during interview with staff, several residents reported concerns regarding a Certified Nursing Assistant (CNA) walking off the job last Friday (4/26/24).
According to the facility's policy titled, Abuse, Neglect and Exploitation dated 1/10/2024:
.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .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 .neglect .Identification of Abuse, Neglect and Exploitation .Possible indicators of abuse include, but are not limited to .Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Protection of Resident .Responding immediately to protect the alleged victim and integrity of the investigation .Reporting/Response .Reporting of alleged violations to the Administrator, state agency .within specified timeframes as required by state and federal regulations .Immediately, but not later than 2 hours after the allegation is made .
On 5/1/24 at 3:45 PM, an interview was conducted with Unit Manager 'F'. When asked if they could verify if there were any concerns with an employee walking off the job on Friday 4/26, Unit Manager 'F' reported they weren't sure if they could discuss this with the surveyor. They were asked to follow-up with Administration since their supervisor was out of the facility for a training and to provide additional information. Unit Manager 'F' did not return, or provide any additional information.
On 5/1/24 at 4:55 PM, an interview was conducted with the Administrator and Vent Administrator. When informed of discussion with Unit Manager 'F', they both denied being notified or aware of what had been requested earlier.
When asked if they could provide any details of what occurred on Friday 4/26/24, and the allegation reported by several residents that an employee walked off the job, the Administrator reported there was a CNA that punched in and walked out without notifying the Nurse Supervisor. They were asked to provide any documentation of what had been addressed regarding this.
On 5/1/24 at 5:01 PM, the Administrator and Vent Administrator provided an employee discipline notice for CNA 'G' that documented:
.Today's Date: 04/30/2024 .Supervisor: [Name of Director of Nursing/DON] Reason for Counseling/Corrective Action: Article VII Discipline, Suspension or Discharge (Section 1-Leaving the facility without prior approval from the assigned manager or supervisor.) On 4/26/24 [Name of CNA 'G'] was scheduled to work 3P-11P at the facility. On 4/26/24, [Name of CNA 'G'] clocked in at 3:00 PM for her shift and at approximately 3:16 PM she punched out and left the facility without notifying a supervisor. This was an unauthorized leave .Counseling sessions/corrective actions. Speak to a supervisor before leaving assignment/facility within the working shift . This document was signed by Unit Manager 'F' and Union Steward 'R' on 4/30/24.
When asked whether CNA 'G' was suspended or not, the Administrator reported they had not and they had also worked since then.
The Administrator confirmed they were the Abuse Coordinator. When asked if when they had first become aware of CNA 'G' leaving the facility without notifying their supervisor, the Administrator reported I became aware of this on Tuesday (4/30/24). The further reported CNA 'G' had refused to sign the notice of discipline and the Union Steward had signed as a witness.
When asked if they had been notified of this incident, what would they have done as the Abuse Coordinator, the Administrator reported they would've suspended pending investigation immediately. (They did not identify they would report to the State Agency.) When asked about the delay in discipline (four days following the incident), the Administrator reported that was because the discipline was done when CNA 'G' returned to work next. The Administrator was requested to provide CNA 'G's time punches since 4/26/24, however that documentation was not provided by the end of the survey.
On 5/1/24 at 5:04 PM, a phone interview was conducted with CNA 'G' who reported they were currently working at the facility. When asked to recall the events that occurred on Friday 4/26/24, and why they left their assignment without notifying anyone, CNA 'G' reported, that was because the facility had scheduled them to work by themselves for 20-23 residents. When asked if they let anyone know they were leaving, CNA 'G' reported they did not and no one paid them any attention. When asked if they had been suspended pending investigation, they reported No'. CNA 'G' did report that they had discussed with with the Director of Nursing (DON) the next day (Saturday).
On 5/1/24 at 5:20 PM, the Administrator and Vent Administrator were asked why they did not identify the incident of CNA 'G' leaving their assignment and residents without notifying their supervisor as an instance of neglect and they reported the clinical staff did not make them aware that CNA 'G' did this so it could've been addressed. They were also notified that according to CNA 'G', the DON had been aware of this concern on Saturday 4/27/24. The Administrator was informed of the concern with lack of identification of neglect, failing to report, investigate and protect other residents pending outcomes of the investigation since CNA 'G' continued to work.
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
Based on interview and record review, the facility failed to ensure the protection of residents and investigate an instance of neglect affecting multiple residents on the first floor, resulting in the...
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Based on interview and record review, the facility failed to ensure the protection of residents and investigate an instance of neglect affecting multiple residents on the first floor, resulting in the potential for additional instances of neglect to go unidentified and not be thoroughly investigated.
Findings include:
On 5/2/24 during interview with staff, several residents reported concerns regarding a Certified Nursing Assistant (CNA) walking off the job last Friday (4/26/24).
According to the facility's policy titled, Abuse, Neglect and Exploitation dated 1/10/2024:
.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .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 .neglect .Identification of Abuse, Neglect and Exploitation .Possible indicators of abuse include, but are not limited to .Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Protection of Resident .Responding immediately to protect the alleged victim and integrity of the investigation .
On 5/1/24 at 3:45 PM, an interview was conducted with Unit Manager 'F'. When asked if they could verify if there were any concerns with an employee walking off the job on Friday 4/26, Unit Manager 'F' reported they weren't sure if they could discuss this with the surveyor. They were asked to follow-up with Administration since their supervisor was out of the facility for a training and to provide additional information. Unit Manager 'F' did not return, or provide any additional information.
On 5/1/24 at 4:55 PM, an interview was conducted with the Administrator and Vent Administrator. When informed of discussion with Unit Manager 'F', they both denied being notified or aware of what had been requested earlier.
When asked if they could provide any details of what occurred on Friday 4/26/24, and the allegation reported by several residents that an employee walked off the job, the Administrator reported there was a CNA that punched in and walked out without notifying the Nurse Supervisor. They were asked to provide any documentation of what had been addressed regarding this.
On 5/1/24 at 5:01 PM, the Administrator and Vent Administrator provided an employee discipline notice for CNA 'G' that documented:
.Today's Date: 04/30/2024 .Supervisor: [Name of Director of Nursing/DON] Reason for Counseling/Corrective Action: Article VII Discipline, Suspension or Discharge (Section 1-Leaving the facility without prior approval from the assigned manager or supervisor.) On 4/26/24 [Name of CNA 'G'] was scheduled to work 3P-11P at the facility. On 4/26/24, [Name of CNA 'G'] clocked in at 3:00 PM for her shift and at approximately 3:16 PM she punched out and left the facility without notifying a supervisor. This was an unauthorized leave .Counseling sessions/corrective actions. Speak to a supervisor before leaving assignment/facility within the working shift . This document was signed by Unit Manager 'F' and Union Steward 'R' on 4/30/24.
When asked whether CNA 'G' was suspended or not, the Administrator reported they had not and they had also worked since then.
The Administrator confirmed they were the Abuse Coordinator. When asked if when they had first become aware of CNA 'G' leaving the facility without notifying their supervisor, the Administrator reported I became aware of this on Tuesday (4/30/24). The further reported CNA 'G' had refused to sign the notice of discipline and the Union Steward had signed as a witness.
When asked if they had been notified of this incident, what would they have done as the Abuse Coordinator, the Administrator reported they would've suspended pending investigation immediately. When asked about the delay in discipline (four days following the incident), the Administrator reported that was because the discipline was done when CNA 'G' returned to work next. The Administrator was requested to provide CNA 'G's time punches since 4/26/24, however that documentation was not provided by the end of the survey.
On 5/1/24 at 5:04 PM, a phone interview was conducted with CNA 'G' who reported they were currently working at the facility. When asked to recall the events that occurred on Friday 4/26/24, and why they left their assignment without notifying anyone, CNA 'G' reported, that was because the facility had scheduled them to work by themselves for 20-23 residents. When asked if they let anyone know they were leaving, CNA 'G' reported they did not and no one paid them any attention. When asked if they had been suspended pending investigation, they reported No'. CNA 'G' did report that they had discussed with with the Director of Nursing (DON) the next day (Saturday).
On 5/1/24 at 5:20 PM, the Administrator and Vent Administrator were asked why they did not identify the incident of CNA 'G' leaving their assignment and residents without notifying their supervisor as an instance of neglect and they reported the clinical staff did not make them aware that CNA 'G' did this so it could've been addressed. When asked why there was no investigation initiated once they became aware, the Administrator offered no further explanation. The Administrator was informed of the concern with lack of identification of neglect, failing to report, investigate and protect other residents pending outcomes of an investigation since CNA 'G' continued to work.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00143778.
Based on observation, interview and record review, the facility failed to ensure t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00143778.
Based on observation, interview and record review, the facility failed to ensure timely care and monitoring of a surgical wound for one (R804) of one resident reviewed for skin management.
Findings include:
Review of a complaint received by the State Agency alleged the facility was not providing proper monitoring of R804's surgical incision following placement of a pacemaker.
On 5/1/24 at 9:00 AM, R804 was observed laying in bed, naked from the waist up with a bedsheet around their waist. There was a healed surgical scar over their upper left chest. When asked about the surgical scar, R804 reported it had healed but had concerns there was a delay in the care of it when they returned from the hospital.
Review of the clinical record revealed R804 was initially admitted into the facility on 4/15/19, been discharged to the hospital on 3/25/24 and readmitted into the facility on 3/31/24 with diagnoses that included: chronic diastolic (congestive) heart failure and presence of cardiac pacemaker.
According to the Minimum Data Set (MDS) assessment dated [DATE], R804 had intact cognition, and had a surgical wound.
Review of the physician orders and Treatment Administration Records (TAR) revealed there was no order or documentation to show treatment changes were done to monitor R804's surgical incision until 4/5/24 (five days after readmission) which read, Check Placement of Pacemaker Dressing to Left Chest every shift.
On 5/1/24 at 2:11 PM, an interview was conducted with Unit Manager 'F'. When asked about R804's surgical incision site and whether they were aware of any concerns, Unit Manager 'F' reported they recalled they had replaced a gauze bandage when R804 came back and they had contacted the wound care nurse and wound physician to be consulted.
On 5/1/24 at 3:45 PM, an interview was conducted with the Wound Care Nurse (Nurse 'S'). When asked about R804's surgical incision upon readmission on [DATE] and what had been implemented, Nurse 'S' reviewed the clinical record via their computer and reported the resident had refused to see them on their wound rounds. When asked if that had been documented, Nurse 'S' reviewed the clinical record and reported that was not documented. Nurse 'S' further reported the resident allowed them to see the incision on 4/5/24 and that's when they implemented the order to monitor. When asked to see if they could verify any discontinued orders before 4/5/24, Nurse 'S' reviewed the clinical record and reported they did not see anything. Nurse 'S' further reported that sometimes the hospital had specific orders to not remove a dressing for a period of time and upon review of the discharge documentation, Nurse 'S' reported they didn't see anything like that for R804.
According to their policy titled, Wound Treatment Management' dated 10/26/2023:
.In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse .The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00144134.
Based on observation, interview, and record review, the facility failed to secure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00144134.
Based on observation, interview, and record review, the facility failed to secure smoking materials and implement a safe smoking assessment per policy for one (R805) of one resident reviewed for smoking.
Findings include:
Review of a complaint filed with the State Agency included allegations that a resident was told by staff they needed to go further away from the building to smoke, but staff were allowed to smoke on the property.
On 5/1/24 at 8:30 AM, the Vent Unit Administrator (acting as the point person since the current Administrator was unavailable) was asked to provide a list of residents that smoked. They further reported that the Administrator was out of the building for a court hearing, the Director of Nursing (DON) was out of the building for a training, and the Social Service Director was on vacation until next Tuesday.
Review of the documentation provided for smoking revealed a document dated 5/1/24 which read, There are no smokers in the facility.
According to the facility's policy titled, Smoking Policy Non-Smoking Campus-Residents dated 1/1/2022 documented:
It is the policy of this facility to establish and maintain safe resident smoking practices for a non-smoking campus .Residents with smoking privileges shall not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, etc., either on his or her person or within his/her living or sleeping area, at any time .This facility shall have the authority to make periodic checks to determine if residents have any smoking articles that are in violation of our smoking regulations .It must be remembered that safety is of the primary concern and that smoking privileges are not being withheld from the resident.
On 5/1/24 at 11:04 AM, the receptionist was interviewed about the process for residents that go on leave of absences (LOAs) and reported if the residents leave the property they sign out in the book and showed the LOA binder. R805 had no LOA sheets. When asked about whether they knew if R805 went out, the receptionist stated the resident usually likes to just hang outside the front door on the patio area. When asked why there were no LOA sheets for him, they reported they thought he signed out at the nursing desk upstairs.
On 5/1/24 at 11:07 AM, R805 was observed using the therapy equipment in the gym. When requested to speak with the resident, they requested to go outside to talk.
On 5/1/24 at 11:12 AM, R805 was observed to self-propel themselves through the front door by punching in the alarm code, and making their way outside and down the ramp. Once outside, R805 reported they were upset because about a week or so ago the new business office manager whose office windows faced the front patio area got upset with them smoking and further reported they knew it was a bad habit but had recently picked it back up again.
When asked where they keep their smoking materials, R805 reported they kept them in their room. R805 further reported this new business office manager and the social worker talked to them about being 20 feet away and possibility of blowing up the building because of the oxygen and gases. The resident stated they were upset about this and never heard of anything about the campus being a non-smoking campus until now. They reported they liked to go outside and had many visits with their girlfriend who they smoked with. They are upset because the staff have a bench and cigarette extinguishing pole outside the facility and asked why they were allowed to smoke if it was a smoke free campus and residents couldn't?
R805 then requested to go around the perimeter of the facility to see where the staff smoke.
Observations revealed just outside the east side exit/entrance of the facility, there was a picnic table with a cigarette extinguishing pole and trash can on a small island in the facility's parking lot (within the facility's property).
Review of the clinical record revealed R805 was their own responsible person and admitted into the facility on [DATE] with diagnoses that included: other fracture of upper and lower end of right fibula, fracture of other specified skull and facial bones right side, displaced transverse fracture of shaft of right ulna, displaced comminuted fracture of shaft of radius, right arm, displaced Tri malleolar fracture of right lower leg, displaced fracture of head of right radius, and other motorcycle driver insured in collision with fixed or stationary object in traffic accident.
Further review of the clinical record, which included progress notes and assessments revealed no mention of R805 being identified as a resident that smokes.
Review of the care plans revealed on 4/30/24 a smoking care plan was initiated by an unknown staff member. (The facility was asked to identify who implemented this care plan but that information was not provided by the end of the survey.) The care plan documented:
Resident chooses to smoke. Date initiated 4/30/24
Interventions included:
Inform resident or /family/responsible <sic> regarding the center's smoking policy, designated smoking areas, and storage of smoking materials. Date initiated 4/30/24.
Observe the resident's safety during smoking. Date initiated 4/30/24.
Offer resident a smoking cessation program. Date initiated 4/30/24.
Periodically complete safe smoking evaluation. Date Initiated 4/30/24.
Resident educated that facility is a non-smoking area and regarding option to LOA if he wishes to smoke. Date initiated 4/30/24, revision on 4/30/24.
On 5/1/24 at 12:05 PM, review of the documentation for involuntary discharges included one for a resident (not R805) that was identified as a resident that smokes but was not following facility policy.
On 5/1/24 at 12:27 PM, an interview was conducted with the Business Office Manager. When asked to explain any discussion with R805, they reported they were their Caring Partner (staff assigned to a specific resident to review any concerns). The Business Office Manager further reported they had met with the resident along with the Social Service Director because we got a complaint they (R805 and their girlfriend) were out in the back smoking. They discussed they told the resident they could smoke but had to go off the premises, we offered a patch or even to find another facility that allows smoking. They reported they even asked the Medical Director, and Director of Nursing and got an LOA order for him. They were unable to identify if any smoking assessments or clinical documentation/assessment had been completed.
On 5/1/24 at 12:50 PM, an interview was conducted with the Regional Director of Operations (RDO). When asked about the facility's smoking practices, they reported they thought there were no residents that smoked, but thought staff might be allowed. They were informed of the concerns that there was no documentation of anything related to R805 smoking, or staff interactions in the clinical record. They reported they would have to have the staff follow-up.
On 5/1/24 at 5:20 PM, a follow-up interview was conducted with the Administrator and the Vent Unit Administrator. When asked about the why there were containers for smoking materials next to the picnic table on the property if the facility policy was truly a non-smoking campus, the Vent Unit Administrator reported they would have to look into that further.
Feb 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 F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00142478.
Based on observation, interview and record review the facility failed to ensure pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00142478.
Based on observation, interview and record review the facility failed to ensure professional standards of practice were followed for one (R701) of six residents reviewed for professional standards. Finding include:
A complaint was filed with the State Agency (SA) that alleged R701 was not getting their medication as needed.
On 2/13/24 at approximately 11:17 AM, R701 was observed in the hallway in their wheelchair. The resident was seeking assistance back into bed and appeared upset that there was no one to help at that time. At approximately 11:35 AM, R701 was transferred into bed. On their tray table were three cups of what appeared to be medication. Two had liquids in them (one clear and one yellowish) and the other contained approximately seven to ten pills of different colors/sizes. Unit Manager Nurse A was in the room by the resident's bed. R701 asked Nurse A if they knew what the medications were. Nurse A stated that they were not sure and noted that they worked on a different floor and just came to assist the resident into bed. R701 stated, They do this all the time. Just leave things and don't tell me what they are. The resident then swallowed the medication.
Following the observation noted above, UM A was asked if it was facility protocol to leave medications by the resident's bedside without telling the resident the name of the medications and/or observing if the medications were taken. UM A reported that the medications should not have been left by the bedside.
A review of R701's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, adjustment disorder and sepsis.
A review of the resident's Medication Administration Record (MAR) noted the following medications were given on 2/13/24 at 9:00 AM: Ascorbic Acid 500 mg (milligram), Ferrosol Oral 325 MG, Folic Acid 1 MG, Furosemide Oral 40 mg, Multivitamin, Olanzapine 5 mg, Spironolactone 100 mg, Thiamine 100 mg, Vitamin D3 capsule 400 units, Zinc Oral Capsule 220 mg, Carvedilol oral 6.25 mg, Keppra 100 ml, Lactulose oral 10 gm, and Pantoprazole 40 mg. The MAR was signed by Nurse F.
On 2/14/24 at approximately 1:09 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if it was the facility's policy to leave medication on resident's rooms without observing the medication was taken. The DON reported that she was aware that Nurse F left the medication at the bedside table and noted that the nurse should not have left the medication without observation and should not have checked that it was administered.
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 F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a sanitary and comfortable environment for one (R701) of two ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a sanitary and comfortable environment for one (R701) of two three reviewed for environment. Findings include:
On 2/13/24 at approximately 11:35 AM, R701 was observed in their room. Two staff members were present in the residents' rooms attempting to transfer the resident into bed. The resident noted that they had not had their linen changed in over a week. R701's roommate also noted that they were not getting the linen changed in a timely manner and on a number of occassions they sat in a wet bed.
A review of R701's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, adjustment disorder and sepsis. The resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact).
On 2/13/24 at approximately 12:17 AM, the linen closet located on the hall where R701 resided had one top sheet and no bottom sheets.
On 2/14/24 at approximately 10:45 AM, an observation of the linen closets on the 2nd floor was conducted with Certified Nursing Assistant (CNA) D. CNA D noted that there were no sheets available and we were told to go take linen from the first floor closet and if there was none in that closet they were to go to the laundry room.
On 2/14/24 at approximately 11:00 AM, the linen closet on the first floor was observed. There were no bed linens in the closet at that time.
On 2/14/24 at approximately 11:20 AM, an observation of the laundry room was conducted with the Administrator. What was noted as the Clean Laundry Room was observed to have linen all over the floor and a pile of what appeared to be discolored linen was in the corner of the room. The Administrator was asked if there was any clean linen available. The Administrator noted that there may be some in the washing machine and directed the Surveyor to the Housekeeping Manager (HM) I.
On 2/14/24 at approximately 12:31 PM a second observation was made in the Clean Laundry room with HM I. When asked about the items on the floor and the pile of non-folded discolored linen in a corner of the room, HM I reported that they only had one person doing laundry. HM I noted that the items scattered on the floor where there to block the door leading to the dirty laundry room and the pile of discolored linens were to be discarded. When asked if there was any clean linen for the residents, they replied the linen was getting washed.
A review of the facility policy titled Handling Clean Linen was conducted and documented, in part: Policy: 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 .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
This citation pertains to Intake(s) MI00142095 MI00142376, and MI00141953
Based on observation, interview and record review the facility failed to ensure needed respiratory therapists were available t...
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This citation pertains to Intake(s) MI00142095 MI00142376, and MI00141953
Based on observation, interview and record review the facility failed to ensure needed respiratory therapists were available to provide care and services to those residents receiving tracheostomy and ventilation services. This deficient practice had the potential to affect all residents (including R702,R704 and R705) receiving tracheostomy and ventilation services. Findings include:
Complaints were filed with the State Agency (SA) that alleged the facility did not have respiratory therapists providing services for 19 ventilator/tracheostomy residents on 1/5/24. In addition, the facility had limited respiratory therapy services on the night shifts. Further allegations noted that nurses have not been fully educated to care for respiratory residents and that the Vent Administrator was not able to cover services to the residents.
On 2/13/24 at approximately 1:09 PM, an interview was conducted with RT A. When asked about RT staffing at the facility, they reported that staffing has been difficult given the increase in admission of residents that receive respiratory and/or tracheostomy care. RT A reported that the RT staff was responsible for doing their own scheduling. They indicated that scheduling usually required a minimum of two RTs on each 12 hours shift. RT A stated that on days when there was either no RT's or one RT for all the residents, the nurses were responsible for providing the care. RT A noted that at times nursing staff have been asked to do the same tasks as the RT, however they felt residents would not be receiving the same care. RT A was not certain if nurses had been fully trained to provide the services needed for respiratory residents.
On 2/13/24 at approximately 1:55 PM, an interview was conducted with R705. R705 was alert and able to answer questions asked. When asked about staffing, specifically RT, R705 reported that there have been times when RTs are not available for care. R705 reported that they feel more comfortable when RTs are performing needed tracheostomy care.
On 2/13/24 at approximately 12:20 PM, the facility was asked to provide the Respiratory Therapist schedule from 1/1/24 through 2/13/24. A list was provided that noted, in part, the following: 1/5/24 (no respiratory therapist on the night shift), Limited to one RT (night shift) on 1/11, 1/29, 1/30, 2/8, 2/9 and 2/13.
On 2/13/24 at approximately 2:22 PM, a phone interview was conducted with Nurse E. Nurse E reported they had been employed with the facility for about five years. They indicated that they mostly work the night shift from 7 PM to 7 AM on the ventilator/trach unit(s). When asked about staffing, Nurse E reported that staffing has been difficult with both respiratory care as well as limited CNA (certified nursing assistant) care. Nurse E was asked if there was ever a time there was a lack of respiratory therapists, they responded that in the beginning of January 2024 there was no respiratory therapist in the evening and that they along, with another nurse (hereinafter Nurse G) had to take over the role of the therapist. Nurse 'E stated that they were told by Management that they were to provide care to the best of their ability and if anything were to happen that they could not take care of the resident(s) they were to call 911. Nurse E reported that it was a difficult evening and they tried to care for as many of the residents as possible. They further noted that they felt comfortable providing some of the care (i.e. suctioning) however did not feel they knew enough about mechanical ventilator systems. When asked if the facility had provided training on the use of the ventilator machines, they noted that they received very limited training some time ago and had not received any current training.
On 2/13/24 at approximately 4:51 PM, a phone interview was conducted with Nurse 'G. Nurse G was queried as to the lack of RT services. Nurse G recalled working the night of 1/5/24 without a RT present. Nurse G stated that it was a stressful evening as there was usually an RT present in the facility. They noted that they were nervous about those on a ventilator machine and were told by the Vent Administrator to contact 911 if there were problems. Nurse G further reported that there has been a decrease in RTs on the evening shift.
A sample of residents were reviewed to determine if they received respiratory care services on 1/5/24. R704's MAR documented the resident did not receive the following trach/ventilator services on 1/5/24 (night): Assess stoma site and under trach collar .every night shift for Airway Patency Enter time in minutes in complete airway equipment management task .night shift) .Trach Care .Visual check of ventilator dependent residents .night shift for Resident status . R702's MAR was also reviewed and noted that the resident's stoma site was not checked for Airway Patency nor was the airway equipment management task completed. There were no visual respiratory notes for R704 and R702 noted the evening of 1/5/24.
On 2/14/24 at approximately 12:43 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the lack and decrease in RT staffing. The DON noted that they were not responsible for scheduling the RTs, nor did they provide any education. When asked if they had received training to work with residents on ventilators and/or tracheostomy, the DON noted that they were not.
On 2/14/24 at approximately 1:50 PM, an interview was conducted with the Vent Administrator (VA) A. VA A was asked about the lack of RTs on 1/5/24 and a decline in RT staffing. They reported that they were not in charge of scheduling the RTs. When asked if they were aware of the lack of RTs on 1/5/24 and the decline in two person RTs on the evening shift, VA A reported that they were but noted that nurses were in the building.
The facility was asked to provide nurse competency evaluations for Nurse E and G. Clinical Performance Evaluations dated 10/7/22 were provided for Nurse E and an evaluation dated 10/17/22 was provided for Nurse G. There were no follow-up evaluations provided.
A review of the facility policy titled, Ventilator Unit- General (revised 11/15/23) read, in part: .Policy: This policy establishes the minimum guidelines for respiratory and licensed nursing care for Residents who are ventilator and tracheostomy care dependent. Policy Explanation and Compliance Guidelines: 1. There must be multiple ventilator types used at the facility .All respiratory therapists and licensed nurses will have all ventilator and tracheostomy related competencies validated, current and documented .Respiratory therapists are onsite as required by State Medicaid Manual related to Ventilator Dependent Care Units .Visual checks are done every 2 hours and documented .Ventilator alarms are priority and are responded to immediately .
Nov 2023
15 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** Based on observation, interview and record review the facility failed to protect Protected Health Information (PHI) for three (R...
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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 protect Protected Health Information (PHI) for three (R4, R22 and R49) residents residing on the 1 [NAME] Unit from being displayed in a public area. Findings include:
On 11/30/23 at 11:15 AM, the door to R4 and R22's room on the 1 [NAME] Unit was observed closed, and signs were posted on the door titled, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19.
On 11/30/23 at 11:17 AM, the medication cart on the 1 [NAME] Unit was observed against the East wall approximately halfway down the hall. The computer was on, R49's electronic medical record was open and PHI information could be seen. The nurse was not observed anywhere in the hallway. Then the nurse was observed coming around the corner onto the hall.
Review of the clinical record revealed R4 was admitted into the facility on 2/9/17 and had tested positive for COVID-19 on 11/29/23.
Review of the clinical record revealed R22 was admitted into the facility on 9/16/23 and had tested positive for COVID-19 on 11/29/23.
Review of the clinical record revealed R49 was admitted into the facility on 7/29/22 and readmitted [DATE] with diagnoses that included: multiple sclerosis, diabetes and depression.
On 11/30/23 at 11:38 AM, the Interim Director of Nursing (DON) B and Former DON D were interviewed concurrently and asked if a residents' diagnosis should be posted on the outside of their door. DON D explained it depended on what the diagnosis was. When asked if it mattered what the diagnosis was, DON B explained the sign on the door should be for what type of precaution was needed, no PHI should ever be revealed.
On 11/30/23 at 12:20 PM, the Facility Administrator A was interviewed and asked if a residents' diagnosis should be posted on their door. Administrator A explained no diagnosis should be posted in a public area.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to report an injury of unknown origin to the facility's abuse coordinator for one resident (R48) of two residents reviewed for ab...
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Based on observation, interview, and record review the facility failed to report an injury of unknown origin to the facility's abuse coordinator for one resident (R48) of two residents reviewed for abuse. Findings include:
A review of a facility provided policy titled, Abuse, Neglect and Exploitation revised 10/2022 was conducted and read, IV. Identification of Abuse, Neglect, and Exploitation .3. Physical injury of a resident of unknown source .VIII Reporting/Response .1. Reporting of all alleged violations to the Administrator .
On 11/28/23 at 8:27 AM, R48 was observed in their bed. R48 did not respond to attempts at verbal communication but tracked with their eyes. It was further observed R48 had a tracheostomy, was on a ventilator, was receiving tube feeding via a pump and had bilateral hand contractures. At that time, it was also observed R48 had approximately a two inch abrasion that appeared scabbed over underneath their right eyebrow.
On 11/28/23 at 11:32 AM, a review of R48's orders revealed an order placed by Nurse Practitioner 'R' on 11/27/23 for bacitracin (antibiotic ointment) to be applied to their right eyebrow every day shift for an, abrasion. A review of R48's progress notes was conducted and revealed no documentation regarding an abrasion to R48's right eyebrow.
On 11/29/23 at approximately 12:20 PM, the facility's Administrator was requested to provide any incident/accident reports or investigations for R48. At 12:37 PM, the Administrator reported there were no incident/accident reports or investigations for R48.
On 11/29/23 at 2:52 PM, an interview with NP 'R' was conducted regarding their order for antibiotic ointment for the abrasion on R48's right eyebrow. NP 'R' said they talked to the nurse (Registered Nurse 'S') about it but was not sure what happened to cause it. They were asked if they reported it to the facility's Abuse Coordinator and said they did not. When asked why it was not reported as an injury of unknown origin, NP 'R' said an allegation of abuse had not occurred.
On 11/30/23 at 10:25 AM, an interview was conducted with RN 'S' who was assigned R48's care on the day NP 'R' discovered the abrasion. They were asked if they reported the abrasion to the facility's Abuse Coordinator and said they did not think it was an abrasion, they thought it was a rash so it was not reported.
On 11/30/23 at 2:16 PM, an interview was conducted with the facility's Administrator/Abuse Coordinator. They said they had been made aware of the issue, however; it should have been reported immediately after the discovery.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R12
R12 was admitted to the facility on [DATE]. R12's admitting diagnoses included dementia, chronic kidney disease, and altered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R12
R12 was admitted to the facility on [DATE]. R12's admitting diagnoses included dementia, chronic kidney disease, and altered mental status. R12 was admitted to the facility for skilled nursing and rehabilitation services after a recent hospital stay. R12 had a Brief Interview of Mental Status (BIMS) score of 00/15, indicative of severe cognitive impairment, based on Minimum Data Set assessment dated [DATE]. R12 needed extensive assistance with their personal hygiene and dependent on staff assistance with their mobility.
An initial observation was completed on 11/28/23, at approximately 10:15 AM. R12 was observed in their bed with their eyes closed. R12 was not dressed. They were in a gown provided by the facility and had food particles on their gown over the resident. R12 did not have any clothing protector. R12 was not shaved and had long facial hair. R12's breakfast tray was on the bedside table. A signage was posted over R12's bed that read, shave (relationship omitted), keep mustache. Another signage over the bed read to use clothing protector for R12 while eating.
An interview with the R12's representative was completed on 11/28/23 at approximately 10:15 AM via phone. During the interview R12's representative confirmed that they had visited their family member most of the days during the week. They had made the sign and had posted over R12's bed, as R12 did not prefer to have any facial hair except their mustache, all their life. Resident representative also confirmed that R12 did not have any shave since they were admitted to the facility from hospital, (approximately a month ago) and reported that R12 was resistive one time when they had attempted to shave, and they were not offered any assistance after. Representative reported that they were in the facility most of the days and they were able to assist the staff and reported that R12 became combative when staff did not explain what they were going to do before providing care and this environment was new for R12. R12's Representative reported that the facility staff also did not consistently assist R12 to get out of their bed and sit up in their wheelchair unless they had asked the staff to assist. They had brought up their concerns with facility administration a few weeks ago and they were not resolved.
A second observation was completed on 11/28/23, at approximately 12:45 PM. R12 was in their bed and lunch was served in bed. R12 was still in their bed in their gown with facial hair and hair disheveled. R12 did not have any clothing protector on. A third observation was completed on 11/29/23, at approximately 11:30 AM. R12 was observed sitting in their wheelchair, in the dining room after their therapy session. R12 was dressed, hair was not combed, with long facial hair, not shaved.
Another observation was completed on 11/30/23, at approximately 9:15 AM. R12 was lying on their bed, in a facility provided gown. They were eating breakfast. R12 did not have any clothing protector on and did not have a shave of their facial hair.
A review of R12's Electronic Medical Record (EMR) revealed a care plan for Activities of Daily living (ADLs) that R12 needed 1-2-person assistance with their ADLs. The care plan also read in part, Resident's daughter has been educated on the need to request assistance and approval for her to complete care needs and transfers.
A review of R12's progress note revealed social services note dated 11/13/23 read in part, Resident refusing care during brief changes .Interventions attempted: Redirect and reproach resident: Explain to resident care being provided before providing it .
A review of facility provided Quality Assistance Document (grievance form) dated 11/13/23, filed to the facility administration by R12's representative, revealed that had concerns with R12's ADL care. The form section under plan/interventions read Requested to have CENA (certified educated nurse assistant/CNA) trim nails and shave resident. Resident combative today, attempt was unsuccessful. The form was completed on 11/23/23 (10 days after the grievance was filed). The form also revealed that the follow up was not communicated to the representative. A review of R12's ADL's task record on personal hygiene revealed that R12 needed extensive staff assistance to dependent from 11/1/23 to 11/29/23.
An interview was completed with the unit manager (Staff member T) on 11/30/23, at approximately 9:35 AM. During the interview Staff member T was queried on the R12's ADL care and the grievance that was brought up to their attention and their follow up. Staff member reported that R12 refused care at times. Reported that R12's family was involved and willing to assist. When queried why that R12 has not had a shave since admission, staff member T reported that they would not be comfortable going to the resident with the razor when they were combative and refusing care. Staff member T agreed that R12 was not always combative. Staff member T reported that they worked during the day shift, and they were not in the facility to follow up with their afternoon staff. When queried further why the facility did not involve family when they were willing to assist and make any further attempts to assist R12 with their care on the shifts when they were there, there was no further explanation. Staff member T reported that they understood the concern and they would follow up with their staff.
This citation pertains to Intake Number: MI00140679
Based on observation, interview, and record review the facility failed to provide appropriate and resident preferred activity of daily living (ADL) care for fingernails and facial hair for two residents, (R#'s 48 and 12) of three residents reviewed for ADL's. Findings include:
A review of a facility provided policy titled, Activities of Daily Living (ADLs) revised 1/2022 was conducted and read, .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
On 11/28/23 at 8:27 AM, R48 was observed in their bed. R48 had a tracheostomy, was receiving mechanical ventilation, and nutrition through a feeding tube. R48 was non-verbal and did not respond to attempts at communication. At that time, R48's bilateral hands appeared clenched and contracted with fingernails that appeared to exceed greater than a half an inch in length beyond the nail bed with large amounts of brown debris underneath them.
A review of R48's clinical record revealed they admitted to the facility on [DATE], most recently re-admitted on [DATE] with diagnoses that included: respiratory failure, anoxic brain damage, stroke, epilepsy, diabetes, pressure ulcers, and sepsis. R48's Minimum Data Set assessment dated [DATE] indicated R48 had severely impaired cognition.
On 11/29/23 at 11:50 AM, an observation of R48's hands and fingernails was conducted with Registered Nurse (RN) 'V'. At that time, R48's fingernails remained long with large amounts of debris under them. Nurse 'V' was asked if they were able to open R48's hands despite the contractures and was able to open them slightly. When the right hand was opened a foul odor was detected from inside the hand, confirmed by Nurse 'V'. It was further observed R48's fourth digit (ring finger) had a band-aid around the tip of the finger. When the left hand was opened, again a foul odor was detected from inside the hand and the fifth digit had a band-aid around the tip of the finger. Nurse 'V' was asked about the condition of R48's hands and nails and said the nails should be cleaned and trimmed, and the insides of the hands should be washed.
On 11/29/23 at 3:31 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding nail care. The DON indicated nail care should be provided as needed with routine ADL care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R33
On 11/28/23, 11/29/23, and 11/30/23, multiple observations were made of R33. Upon each observation, R33 was observed in thei...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R33
On 11/28/23, 11/29/23, and 11/30/23, multiple observations were made of R33. Upon each observation, R33 was observed in their bed, non-verbal and not responsive to attempts at verbal communication. During the observations, R33 was not observed to be engaged in any type of meaningful activity.
On 11/29/23 at 12:05 PM, a review of R33's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: acute respiratory failure with dependence on mechanical ventilation, anoxic brain damage, presence of a tracheostomy, dysphagia, contractures, quadriplegia, pressure ulcers and presence of a feeding tube. R33's most recent Minimum Data Set (MDS) assessment dated [DATE] was reviewed and indicated R33 had severe cognitive impairment.
On 11/29/23 at approximately 12:30 PM, a review of R33's Certified Nursing Aide (CNA) tasks for activities for a 30-day look-back period was conducted and revealed only Music documented on 11/3/23, and 11/8/23, and Discuss current events documented on 11/9/23 and 11/25/23.
R48
On 11/28/23, 11/29/23, and 11/30/23, multiple observations were made of R48. During each observation, R48 was in bed, non-verbal and not responsive to attempts at verbal communication. During the observations, R48 was not observed to be engaged in any type of meaningful activity.
On 11/29/23 at 12:35 PM, a review of R48's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: presence of a tracheostomy, acute and chronic respiratory failure with dependence on mechanical ventilation, anoxic brain damage, stroke, epilepsy, contractures, diabetes, sepsis, pressure ulcers, and presence of a feeding tube. R48's most recent MDS assessment dated [DATE] was reviewed and revealed R48 had severe cognitive impairment per a staff assessment.
On 11/30/23 at approximately 9:35 AM, a review of a review of R48's CNA tasks for activities for a 30-day look-back period was conducted and revealed only Music documented on four occasions and Other documented on two occasions.
On 11/30/23 at 9:55 AM, an interview was conducted with Activity Aide AA. They were asked how often they provided activities for residents such as R33 and R48 and said they were provided one-on-one activities at least three times a week.
Based on observation, interview, and record review, the facility failed to provide a program of meaningful activities that supported the needs, interests, and capabilities of four (R33, 61, and 48) of four residents reviewed for activities. Findings include:
On 11/28/23 at 9:45 AM, R61 was observed lying in bed positioned on their right side facing the wall. There was no music or television or any visually stimulating items in the room. When addressed, R61 did not respond and only groaned.
On 11/28/23 at 11:48 AM, R61 was observed lying on their right side facing the wall. No stimulating activities such as staff interaction, music, or television were observed.
On 11/30/23 at 9:15 AM, R61 was observed lying in bed, wearing a hospital gown. No music, television, or staff interacting with the residents were observed.
Upon entrance to R61's room each time, their roommate complained about anyone entering the room and demanded that the door be left closed.
Review of R61's clinical record revealed the following:
R61 was admitted into the facility on [DATE] with diagnoses that included: sepsis, mild protein-calorie malnutrition, and acute respiratory failure. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R61 had severely impaired cognition, was dependent on staff assistance for mobility including rolling from side to side, transfers, and all activities of daily living.
On 11/30/23 at 10:13 AM, an interview was conducted with Activities Aide (AA) 'P', who was identified as the person to interview in the absence of the Activities Director who was not working that week. AA 'P' explained that she worked day shift on Tuesdays through Fridays with the Activities Director, and Sundays by herself. AA 'P' explained she was working alone this week due to the Activities Director being off. When queried about whether she was able to provide an activities program for all residents, including those who were on ventilators, AA 'P' reported she was able to. When queried about how activities programs were developed for each resident to ensure they had activities available to meet their individual needs, preferences, and abilities, AA 'P' reported she provided activities based off of what the Activities Director told her to do.
At that time, AA 'P' was further interviewed regarding R61's activities program. AA 'P' stated, He's on the tube so we can't do a lot. When asked for clarification about the tube, AA 'P' indicated she was talking about the tracheostomy tube (a tube inserted into the windpipe to assist with breathing). When queried about whether she was aware that R61 no longer had a tracheostomy tube, AA 'P' stated, The last time I saw him, he had it. The observations of R61 lying in bed on 11/28/23 and 11/30/23 without any stimulation or activities, AA 'P' reported due to R61's roommate not wanting people in the room, they were not always able to provide activities. When queried about whether they reported the roommates behaviors to anyone in administration, AA 'P'' reported they did not. AA 'P'' reported they played music for R61 and the last time they did that was on Sunday, 11/26/23. When queried about whether R61 understood English and what kind of music he preferred, AA 'P' reported she did not know if he understood English and did not know what kind of music he preferred. AA 'P' stated, We don't get to see the information provided at admission. AA 'P' reported R61's main activity was the tablet. It was unclear what that activity entailed. AA 'P' reported that all activities were documented in the activities Tasks in the electronic medical record (EMR).
Review of R61's Activities Evaluation completed on admission, dated 10/18/23, revealed R61 spoke English and Arabic, actively participated in their religion, and enjoyed cooking/baking, Cultural events/News, Education programs/Activities, Family/friend visits, Gardening/Outdoors, movies/TV, Music/Talk Radio, and Walking. In the section that documented what self recreating material was needed, the following was noted, TV channels to news and cooking, and nature shows. Likes to walk and get outdoors. Music Muslim, Arabic music. R61's preferred location of activities was in their own room in the morning and afternoon. In the section titled, What can Activities do to make you stay more comfortable/homelike? the following was documented, Make sure TV is on and 1:1 visits by activities staff. The documented source of information was Family/Friend.
Review of R61's care plans revealed the following initiated on 10/18/23, The resident has little or no activity involvement r/t (related to) immobility, physical limitations. The following interventions were initiated on 10/18/23: .Explore past interests with resident .For events the resident could not attend, include resident by showing tape of event, telling stories from event .Offer aroma therapy .Provide activity visits to build rapport .Provide education/assistance for participation in recreational programs while remaining on ventilator (It should be noted that R61 was never on a ventilator) .Provide music .Provide reading materials and/or talking books .
On 11/30/23 at 2:13 PM, an interview was conducted with Administrator 'A'. When queried about what was done to ensure residents who needed assistance getting out of bed and were unable to speak for themselves were provided with activities, Administrator 'A' reported they were provided 1 to 1 activities. Administrator 'A' reported she was not aware that R61's roommate prevented activities staff from providing activities to him.
Review of a facility policy titled, Activities, revised on 2/6/22, revealed, in part, the following: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as, encourage both independence and interaction within the community .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow-up timely on a lost hearing aid for one (R26) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow-up timely on a lost hearing aid for one (R26) of one resident with hearing loss, reviewed for ancillary services resulting in unmet care needs, frustration, with potential for worsening of their hearing.
Findings include:
R26
R26 was originally admitted to the facility on [DATE]. R26's admitting diagnoses included depression, heart failure, gout, and hearing loss. R26 had a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition, based on the Minimum Data Set (MDS) assessment dated [DATE].
An initial observation was completed on 11/28/23, at approximately 12:15 PM. R26 was observed in their bed. An interview was completed during the initial observation. During the interview R26 reported that they were hard of hearing and asked the surveyor to speak louder. R26 reported that they had been at the facility for several months. They had lost their left hearing aid while they were being transferred to this facility from one of their sister facilities. They needed the left hearing aid to hear better. R26 reported that the facility was aware of the lost hearing aid. R26 reported they were not checked out for hearing and did not hear back from the facility. R26 reported that they stayed in their room most of their day.
Two subsequent observations were completed on 11/29/23 at approximately 11 AM and 11:15 AM. R26 was in their bed. R26 reported that their spouse will be in to visit them later. R26 confirmed that they did not have their left hearing aid and had not received any follow up from the facility.
A review of R26's Electronic Medical Record (EMR) revealed the MDS assessment dated [DATE]. The assessment revealed that R26 had moderate difficulty with hearing, and they were using hearing aid. A review of R26's care plan revealed that R26 had impaired communication related to bilateral (both ears) hearing loss.
A review of the Quality Assistance Form dated 3/28/23 (grievance form) provided by the facility revealed that R26's family requested the facility administration to follow up on the lost hearing aid during R26's transfer from their sister facility. The finding section of the form read, transportation from (location name omitted) to (location name omitted). No hearing aid found in vehicle. The plan/action section of the form revealed that the leadership of the sister facility was notified and family member to follow up. The form revealed the grievance was not resolved. Further review of R26's EMR did not reveal any follow up to replace the lost hearing aid.
An interview with Director of Social Service (Staff member U) was completed on 11/30/23, at approximately 8:55AM. Staff member U reported that they had been working at the facility since June 2023. Staff member U was queried if they were responsible to follow up on with ancillary services (audiology, vision etc.) for residents. Staff member U confirmed that they were responsible for following up on ancillary services for the residents. Staff member U was queried on R26's hearing aid follow up. Staff member U reviewed R26's EMR and their binder in the office and reported that they did not see consults. Staff member U also reported that the audiologist typically recommended ear wax removal prior to hearing aid exams. Staff member U was queried if they were aware of a lost hearing aid for R26 and the grievance form that was initiated from 3/28/23. Staff member U reported that they were not aware of the grievance form and loss of R26's hearing aid. Staff member U reported that this grievance was initiated before they had started work at this facility and they were not aware of this grievance and reported that grievances were handled by the Administrator and they would follow up with the provider on setting up the audiology services for R26.
An interview with unit manager (Staff member T) was completed on 11/30/23, at approximately 9:30 AM. Staff member T had initiated and followed up on the grievance on the lost hearing aid. Staff member T was queried on their follow up on the lost hearing aid. Staff member T reported that they had followed up with the sister facility and they were unable to locate the hearing aid in the transportation van. They had asked the family to follow up. When queried further on what follow up had been completed after 3/30/23 (approximately 8 months later) to address the hearing loss of the resident, staff member T did not have any further explanation and reported that they would follow up.
An interview with the Administrator was completed on 11/30/23, at approximately 1:30 PM. During the interview, the Administrator was queried on the grievance on the lost hearing aid for R26. The Administrator reported that their team was following up on the lost hearing aid and they would review their grievance follow up process.
A facility provided document titled Hearing and Vision Services' with a revision date of 10/30/23 read in part, It is the policy of this facility to ensure that residents have access to and receive proper treatment and assistive devices to maintain vision and hearing abilities.
Policy Explanation and Compliance Guidelines:
1. The facility will utilize the comprehensive assessment process for identifying and assessing a
resident's vision and hearing abilities in order to provide person-centered care. This process includes: .
2. Employees should refer any identified need for hearing or vision services/appliances to the social worker/social service designee.
3. The social worker/social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources (e.g., Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number: MI00139850.
Based on observation, interview, and record review, the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number: MI00139850.
Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent the development of new pressure ulcers and implement treatment in a timely manner after a new skin impairment was identified for one (R61) of three residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) that required surgical debridement (removal of dead or devitalized tissue) to R61's left hip and a deep tissue injury (DTI - Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue that results from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to the right hip. Findings include:
On 11/28/23 at 9:45 AM, R61 was observed lying in bed positioned on their right side facing the wall. A heel protector boot was observed on R61's right foot. R61's left foot made direct contact with the mattress. R61 had a specialty air mattress set to normal pressure and float. When spoken to, R61 did not respond. At times, R61 made a groaning noise. At that time, R61 was receiving nutrition through a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube surgically placed through the abdominal wall into the stomach to provide a means of delivering nutrition when a person cannot eat enough or at all by mouth).
On 11/28/23 at 11:48 AM, R61 was observed lying on their right side facing the wall. A heel protector boot was observed on R61's right foot. R61's left foot made direct contact with the mattress.
Review of R61's clinical record revealed the following:
R61 was admitted into the facility on [DATE] with diagnoses that included: sepsis, mild protein-calorie malnutrition, and acute respiratory failure. When admitted into the facility, R61 had a PEG tube and a tracheostomy tube (a tube surgically placed through the front of the neck into the windpipe in order to keep the airway open for breathing). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R61 had severely impaired cognition, was dependent on staff assistance for mobility including rolling from side to side, was at risk of developing pressure ulcers, and had one Stage 2 (partial thickness skin loss) pressure ulcer (to the left heel) and two unstageable pressure ulcers that were present upon admission (to the sacrum and right heel).
Review of a BRADEN SCALE - For Predicting Pressure Sore Risk assessment dated [DATE], R61 was at very high risk for developing pressure ulcers, indicated by a score of 7 (a score of 9 or below indicates very high risk).
Review of R61's care plans revealed R61 required the assistance of two staff members for bed mobility, toilet assistance, and transfers with a mechanical lift. On 10/16/23, a care plan was initiated that noted, Resident is at risk for impaired skin integrity . On 10/16/23, interventions were initiated to Assist resident with turning and repositioning as needed and Consult dietitian as needed. On 10/17/23, interventions were initiated to assist as needed to elevate heels off the mattress as tolerated or soft boots .Pressure redistribution mattress to bed LAL (low air loss) .
Review of a weekly Skin Assessment dated 11/7/23 revealed, a new abnormal skin area was identified during the skin assessment. According to the skin assessment on that date, R61 had scratches to the left trochanter (hip). It was documented that treatment was initiated. Review of R61's progress notes revealed no documentation of the newly identified scratches on 11/7/23. Review of a Physician Progress Note dated 11/8/23 addressed the previously existing wounds, but did not mention the scratches.
Review of a Surgical Note (wound consultation conducted by the facility's contracted wound care provider, Physician 'W' revealed the following during the exam performed on 11/9/23: Wound .Rear Left Trochanter .Pressure injury/ulcer - Wound Stage: Unstageable Pressure Injury .Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue .20 (percent) slough (non-viable yellow, tan, gray, green or brown tissue) .continue offloading: turn per facility protocol. Continue low air loss mattress . The documented measurement of the wound was 6.1 centimeters (cm) in length by 9.1 cm in width with undetermined depth. The documented treatment was triad (a hydrophilic wound dressing that absorbs drainage and softens/loosens necrotic tissue) with bordered foam dressing.
Further review of R61's full clinical record revealed no documentation of any changes to skin integrity to the left hip other than the scratches noted on 11/7/23.
Review of R61's physician's orders revealed an order to Cleanse area with normal saline. Pat dry. Apply Triad to left rear trochanter and cover with bordered foam every day shift with a start date of 11/14/23, five days after R61 was seen by Physician 'W' and diagnosed with an unstageable pressure ulcer to the left hip. Review of the Treatment Administration Record (TAR) revealed treatment was not administered on 11/15/23 and 11/17/23.
On 11/29/23 at 5:51 PM, further review of R61's care plans revealed no new pressure ulcer interventions were initiated since 10/17/23 and the care plans did not address the development of a facility acquired unstageable pressure ulcer to the left hip on 11/9/23.
On 11/30/23 at 9:00 AM, an interview was conducted with Physician 'W'. When queried about the optimal setting for R61's air mattress, Physician 'W' reported it should be alternating pressure. Physician 'W' reported that they evaluated R61's wounds that morning and the left hip worsened and R61 developed a new wound to the right hip which is diagnosed as a deep tissue injury at that time.
On 11/30/23 at 9:15 AM, R61 was observed in bed with pillows offloading the hips and sacral area off the bed. A heel protector boot was observed on the right foot. R61's left foot was not floated and made direct contact with the mattress. The air mattress was set to float (the other option was alternating) and normal pressure (the other setting was low pressure).
On 11/30/23 at 9:25 AM, R61's clinical record was further reviewed and revealed no nutrition assessment or dietary progress notes after R61 developed the unstageable pressure ulcer to the left hip.
On 11/30/23 at 11:01 AM, an interview was conducted with Director of Nursing (DON) 'B' and DON 'D'. When queried about how residents were monitored for skin breakdown, it was explained that weekly skin assessments were conducted by the nurses and Certified Nursing Assistants (CNAs) were to notify nurses if they noticed any changes in skin integrity during care. According to DON 'D', if new skin breakdown was identified, a treatment was put in place by the nurse immediately after the wound was identified and the wound provider, DON, attending physician, and resident's responsible party were notified. It was explained that the wound treatment orders were entered into the electronic medical record (EMR) by the nurse. When queried about how the facility ensured treatments were administered as ordered, DON 'D' explained that it was the nurses responsibility to administer the treatments and management's responsibility to track the documentation and do spot checks on the dressings. When queried about how staff knew settings of the pressure reliving mattresses, DON 'D' reported there were stickers on each mattress pump. When queried about nutritional interventions for residents who developed pressure ulcers, it was explained that the dietitian was to assess the resident on the next business day to determine if additional nutritional support was needed.
At that time, DON 'B' and DON 'D' were queried about the delay in treatment to R61's facility acquired pressure ulcer to the left hip, identified on 11/9/23 and the scratches identified to the same area on 11/7/23. They reported they would look into it. When queried about missed treatments, DON 'B' reported all treatments administered should be signed off on the TAR otherwise they were not considered done. DON 'B' further explained that on Thursdays the treatments were done no matter what because Physician 'W' came to the building. At that time, the following information was requested: interventions implemented upon admission and what new interventions were implemented after R61 developed a new pressure ulcer.
On 11/30/23 at 12:55 PM, an interview was conducted with Registered Dietitian (RD) 'H' along with Regional Dietitian 'X'. RD 'H' reported they began working in the facility two months ago. When queried about how RD 'H' became aware of residents who needed nutritional evaluations for new pressure ulcers, RD 'H' reported new or worsened wounds were discussed in daily morning meetings. When queried about whether they were notified of the pressure ulcer R61 developed on their left hip, RD 'H' reported they were notified, but they did not further assess R61 since admission. RD 'H' reported they were going to assess R61 that day and explained they would not need to change anything. Regional Dietitian 'X' explained that it would not be known if any changes were needed until the assessment was completed.
On 11/30/23 at 1:08 PM, DON 'B' and DON 'D' followed up. DON 'D' explained that upon admission the facility put all the interventions we could in place and therefore did not implement any additional interventions after R61 developed the pressure ulcer to the left hip. When queried about how it was monitored to ensure all the interventions were being carried out, DON 'D' reported they do not have a monitoring tool and staff are expected to follow the care plan. When queried about how R61 developed two pressure ulcers, one on each hip, while in the facility if the interventions were effective and being implemented, a response was not given. DON 'D' stated, You can have all the interventions in place and still get a pressure ulcer. No explanation was given as to why RD 'H' did not see R61 after the first facility acquired pressure ulcer was identified to the left hip on 11/9/23. DON 'B' and DON 'D' confirmed there was no treatment implemented to R61's left hip until five days after the wound was identified.
Review of a facility policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised on 1/1/22, revealed, in part, the following: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual ' s clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
R43
On 11/28/23 at 10:39 AM, R43 was observed in bed. R43 was able to communicate via cellphone and nodding/shaking of their head. There was a cup with water on the bedside table dated 11/23. R4 repor...
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R43
On 11/28/23 at 10:39 AM, R43 was observed in bed. R43 was able to communicate via cellphone and nodding/shaking of their head. There was a cup with water on the bedside table dated 11/23. R4 reported that water/juice is not offered on a regular basis. There was a second cup of orange juice (undated), the Resident reported it was from breakfast yesterday (cup was not dated). R43 communicated that they felt their personal space was cluttered (by old cups of juice/water).
On 11/28/23 at 12:02 PM, R43 was observed in bed, there was no fresh water, and the two previously mentioned cups remained on her bedside table.
On 11/28/23 at 1:32 PM, R43 was observed in bed, the Resident had a full cup with of juice at bedside (not labeled). R43 reported that the juice was her own and that her family brings it in for her.
On 11/29/23 at 10:30 AM, R43 was observed to have fresh water labeled with today's date, the unlabeled orange juice from 11/28/23 remain at her bedside.
On 11/29/23 at 3:47 PM, R43 was observed to still have the same orange juice from yesterday (remained unlabeled), R43 stated that she is drinking it slowly, reported that she brings in her own juice because the facility fails to provide it to her, she specifically reported that they are supposed to be offering her juice from the kitchen after dinner and that is not happening.
An interview was completed with Administrator A on 11/30/23 at 2:31 PM. Administrator A explained that the Certified Nursing Assistants were to pass water with each meal and Styrofoam cups should be labeled.
Based on observation, interview, and record review, the facility failed to provide fresh drinking water for two residents (R#'s 47 and 43) of two residents reviewed for hydration, as well as for multiple residents who participated in the group meeting, resulting in verbalized feelings of frustration from lack of fresh drinking water. Findings include:
A review of a facility provided policy titled Hydration revised 10/2023 was conducted and read, .The facility offers each resident sifficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health .
On 11/28/23 at 8:21 AM, R47 was observed in bed with an undated foam cup of liquid on their bedside table. They were asked what was in the cup and they said it was lemonade. They were asked if they had been provided with drinking water and said no. They were asked if staff routinely provided fresh drinking water and said they did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R13
On 11/28/23 at 10:42 AM R13 was observed in bed sleeping with an alarm for tube feeding administration was going off, the Je...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R13
On 11/28/23 at 10:42 AM R13 was observed in bed sleeping with an alarm for tube feeding administration was going off, the Jevity bag was hanging, but not infusing.
On 11/28/23 at 10:56 AM, upon exiting the room, the tube feeding alarm was still going off.
On 11/28/23 at 12:02 PM, the tube feeding was noted to still not be running, the alarm continued to sound, and per interview with roommate, it had been alarming since last observation (the roommate communicates by nodding/shaking her head, hand gestures or via typed notes on her cellphone).
On 11/28/23 at 1:33 PM, the tube feeding was no longer alarming and was noted to be infusing at the correct rate of Jevity 50 mls(milliliters)/hour with an additional 25mls of water for flush (per review of physician orders on 11/28/23 at 11AM).
On 11/29/23 at 10:30 AM, (Jevity) tube feeding was observed to be running at 50mls with 25ml flush.
On 11/29/23 at 10:40 AM Per review of physician orders, the tube feeding should be Jevity at a rate of 65mls/hour and 50ml/hr of water for flush, (a new order for rate change was placed on 11/28/23).
Based on observation, interview and record review, the facility failed to ensure accurate administration of enteral feed formula in accordance with the physician order for three (R57, R33 and R13) of three resident reviewed for tube feeding. Findings include:
Review of a facility policy titled Feeding Tubes revised 6/30/22 read in part, .11. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided to include: .e. Ensuring that the administration of enteral nutrition is consistent with and follows the practitioner's orders . 12. Direction for staff regarding how to manage and monitor the rate of flow will be provided: .c. Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders .
R57
On 11/28/23 at 8:15 AM, R57 was observed sitting in a wheeled padded reclining chair (geri chair) next to their bed. R57 did not respond to attempts of verbal communication. R57 was observed to be receiving enteral feed formula delivered by a pump. The rate programmed into the pump was set for 35 milliliters (mL) per hour, the auto flush (water) was set for 60 mL per hour.
Review of the clinical record revealed R57 was admitted into the facility on 9/29/22 with diagnoses of acute respiratory failure, anoxic brain damage and epilepsy. According to the Minimum Data Set (MDS) assessment dated [DATE], R57 had severely impaired cognition and was dependent on staff for all activities of daily living (ADL's).
Review of R57's physician orders revealed and enteral feed order dated 11/21/22 that read in part, two times a day for nutrition provide jevity 1.5 @ 40 mL/hr (per hour) . Auto flush 30 mL/Hr .
Review of R57's November 2023 Medication Administration Record (MAR) revealed a previous enteral feed order dated 1/31/23 and discontinued 11/21/23 that read in part, two times a day for nutrition provide jevity 1.5 @ 35 mL/hr . Auto flush 30 mL/Hr .
Review of R57's progress notes revealed an enteral review note dated 11/21/23 at 1:16 PM that read in part, .Resident on a diuretic with a hx (history) of CHF (congestive heart failure) . Estimated fluid needs: 1125-1350 ml/day . Recommend increase tube feeding rate to better meet nutritional needs. Order Jevity 1.5- goal rate of 40ml/hr x 18 hours= 720 ml . Continue with current water flush at 30ml/hr. TF (tube feed) + water flush = total of 1087 ml freewater .
It should be noted that with the enteral feed pump settings, R57 was receiving 1620 ml/day of freewater.
On 11/29/23 at 8:18 AM, R57 was observed lying in bed. The enteral feed pump was set for 35 ml/hr and auto flush 60 ml/hr.
Review of R57's weights revealed R57's most recent weight was documented as 177.7 pounds (lbs) on 11/9/23.
On 11/29/23 at 11:40 AM, the Interim Director of Nursing (DON) B was asked to weigh R57. DON B, Registered Nurse E and Certified Nursing Assistant (CNA) F were observed to use a mechanical lift to obtain R57's weight of 182.4 lbs, a 4.5 lbs weight gain.
On 11/29/23 at 12:07 PM, Licensed Practical Nurse (LPN) G, R57 assigned nurse, was asked the procedure for hanging a bottle of enteral feed formula. LPN G explained usually the midnight nurses hang the tube feed, but when the day nurses did hang a bottle, they did not change the pump settings, they would just hang the bottle. When asked who did set the rate settings, LPN G explained they were set by the dietitian.
On 11/29/23 at 12:21 PM, Registered Dietitian (RD) H was interviewed and asked about enteral feed orders. RN H explained she makes the recommendations, nursing puts the orders in and sets the pump and hangs the formula. RD H was asked if she did audits to check the rates of the enteral feed pump settings. RD H explained she would do random checks of the pumps. When asked if she had checked R57's pump since the change of orders on 11/21/23, RD H explained she had not. RD H was informed R57 was receiving 5 ml/hr less of nutrition and twice as much fluid per hour than what the order was for and had gained 4.5 lbs in less than three weeks. RD H explained she would go check on R57.
On 11/29/23 at 12:30 PM, DON B was interviewed and asked who was responsible for the settings on the enteral feed pump. DON B explained the nurse assigned to the resident should check the settings at the start of their shift, and when hanging a new bottle to ensure the pump was at the correct rate. When informed R57 was receiving less nutrition and twice as much fluid and had gained 4.5 lbs, DON B explained she would have R57 checked by a Respiratory Therapist and would call R57's doctor.
R33
On 11/28/23 at 8:35 AM, 10:52 AM and 2:40 PM, and 11/29/23 at 11:40 AM, R33 was observed in their bed. R33 was non-verbal and was receiving Jevity 1.5 tube feeding formula. The settings on the pump administering the formula were reviewed and indicated the tube feeding formula was being delivered at 55 mL (milliliters)/hour with an additional 60 mL/hour of water for flushing and hydration being delivered.
On 11/29/23 at 12:05 PM, a review of R33's physician's orders was conducted and revealed the current, active order for R33's tube feeding was for the formula to be delivered at 50 mL/hour with 40 mL/hour water for flushing and hydration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessment and dressing changes for a midline ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessment and dressing changes for a midline catheter (long flexible catheter inserted into a large vein in the arm for the delivery of intravenous fluids or medications) for one resident (R48) of one resident reviewed for midline catheters, resulting in the potential for blood infections. Findings include:
On 11/28/23 at 10:45 AM, and 11/29/23 at 8:10 AM, R48 was observed in their bed. R48 was non-verbal, and did not respond to attempts at verbal communication. During the observation, it was noted R48 had a midline catheter in their right upper arm and the transparent dressing covering the insertion site was dated 11/19/23.
On 11/29/23 at 12:35 PM, a review of R48's clinical record revealed the most recently re-admitted to the facility on [DATE] with diagnoses that included: anoxic brain damage, respiratory failure with dependence of mechanical ventilation, tracheostomy, presence of a feeding tube, epilepsy, pressure ulcers, diabetes and sepsis. A review of R48's physician's orders was conducted and revealed an order dated 11/12/23 that indicated the transparent dressing to the catheter insertion site was to be changed every seven days. A review of R48's treatment administration record was conducted and revealed the dressing was scheduled to be changed on 11/26/23, however; the record was left blank for the completion of the dressing change.
On 11/29/23 at 3:31 PM, an interview with the facility's Director of Nursing (DON) was conducted and they were asked how often midline catheter dressing changes were to be completed and they indicated it was every seven days.
A review of a facility provided document titled, Nurses Infusion Manual For Long Term Care Facilities was reviewed and Appendix B in the manual indicated site maintenance and transparent dressing changes were to be completed, .On admission or 24' (hours) post insertion, then weekly and PRN (as needed) .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene and glove use during medication pass for one resident (R41) of two residents reviewed during ...
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Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene and glove use during medication pass for one resident (R41) of two residents reviewed during the medication pass observation, resulting in the potential for the spread of infection.
On 11/29/23 at 09:01 AM, Nurse 'O' was observed preparing multiple medications (pills, liquids, subcutaneous injections, inhalers, and a nebulized medication) for administration to R41. Nurse 'O' prepared multiple medications including a Spiriva inhaler (an inhaler that contains a capsule with powder that when the the inhaler is activated the capsule pill is pierced releasing the powder for inhalation). Nurse 'O' was observed to remove the capsule from it's foil packaging with their bare hand and place it into the inhaler. Nurse 'O' also prepared three different insulin syringes at that time. After the insulin was drawn up into the syringes, RN 'O' capped all the needles and placed them in the top pocket of their uniform top. At the end of the medication prep, Nurse 'O' entered R41's room from the hallway, but did not perform hand hygiene prior to administering the oral and inhaled medications. Nurse 'O' then donned clean gloves and administered three insulin injections into R41's abdomen. Nurse 'O' recapped all the insulin needles and placed them in their uniform top pocket and exited the room to the hallway with their gloves on. Once in the hallway with their gloves on, Nurse 'O' retrieved the syringes from their pocket and disposed of them in the sharps container. Nurse 'O' then doffed the gloves and discarded them in the trash.
On 9/29/23 at 3:31 PM, the observation of Nurse 'O's infection control practices were shared with the Director of Nursing and they indicated gloves should not be worn in the hallway and insulin syringes should not be placed in uniform pockets.
A review of a facility provided policy titled, Medication Administration revised 1/2022 was conducted and read, .4. Wash hands prior to administering medication .13. Remove medication from source, taking care not to touch medication with bare hand .15. Observed resident consumption of medication. 16. Wash hands using facility protocol . A review of a second facility provided policy titled, Hand Hygiene revised 1/2022 was conducted and read, .6. Additional considerations: a. The use of gloves does not replace hand hygiene, if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .
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 F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to resolve concerns expressed by the resident council group for nine of nine residents who attended the resident council intervi...
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Based on observation, interview, and record review, the facility failed to resolve concerns expressed by the resident council group for nine of nine residents who attended the resident council interview who wished to remain anonymous. Findings include:
On 11/29/23 at 11:00 AM, an interview was conducted with members of the resident council and other residents who wished to attend a resident group interview.
When queried about how the facility addressed and resolved concerns expressed by the resident council, multiple residents reported that the facility did not resolve many concerns they brought up. The residents explained that they report the concerns during resident council meetings, but the concerns are not fixed.
Multiple residents explained that they had issues with their toilets not working and/or clogging. Two residents who shared a room reported their toilet had not worked for over a month and there was an attempt to fix it, but it did not resolve the issue. The residents reported the toilet did not flush.
All nine residents in attendance reported fresh water was not passed on a regular basis, especially in the morning. When queried about whether they could get water if they asked for it, one resident reported when they asked, the staff said they would come back with it, but often they never return with water. They reported it was a current issue and has been a concern for several months.
All nine residents in attendance reported by a show of hands that the certified nursing assistants (CNAs) did not provide care in a timely manner. Multiple residents reported they often saw staff seated at the nurses station while call lights were going off. Multiple residents reported having to wait a long time to get changed if they needed assistance at shift change. One resident reported the nurses did not ensure the CNAs did their jobs. One resident stated, They just don't care! Another resident stated, If they don't want to help the residents, they have no business working here. Multiple residents reported they had to ask CNAs to change their bed sheets or to bring water and stated, What about people that can't speak up and ask? Two residents who shared a room reported the room was assigned two different CNAs at times and if they asked one CNA for something, they say they are assigned to a different CNA. The resident stated, How is it fair that one person gets care and the other person does not if they are in the same room.
Multiple residents reported concerns with food being served cold. One resident reported the food cart was often left in the hallway and the CNAs did not pass out the trays. The resident reported they had to ask the nurses to ask the CNAs to pass out the trays.
Eight of nine residents reported that they experienced CNAs talking on their personal cell phones during care.
Eight of nine residents reported they were not consistently offered snacks in the evening time. Five of the eight residents reported they would like a snack in the evening.
Review of meeting minutes from the facility's resident council meetings since June 2023 and the associated Quality Assistance Forms revealed the following:
On 6/12/23, the following was documented in the meeting minutes, .Old Business .Ice water not handed out consistently .Cold food continues. Response to call lights need to be more timely .New Business .Call lights .Personal phone use .Evening snacks not consistent . Review of a Quality Assistance Form dated 6/12/23 revealed the resident council communicated concerns about .call lights, personal phones use. Dietary snacks .Findings: .Inservice on phone use. Dietary to address snacks .Plan/Actions: (Was left blank) Resolution (Yes was marked to indicate the concerns were resolved) . The form did not indicate if the results were reported to the resident council. The form was signed by the former Administrator and was undated.
On 7/10/23, the following was documented in the meeting minutes, Old business was read and continues to be a problem .New Business .CNA's need improvement with timely call light response and changing, passing of food trays when cart arrived, passing water, and passing midnight snacks .Midnight snacks they are not getting .cold food . Review of a Quality Assistance Form dated 7/10/23 revealed the resident council communicated concerns about .Call light response time not favorable .Plan/Actions: .Nursing address call lights . The form did not indicate whether the concern was resolved or if the results were reported back to the resident council. The form was signed by the former Administrator on 7/16/23.
On 8/28/23, the following was documented in the meeting minutes, Old business was read and continues to be a problem .New Business .some toilets not flushing .CNAs continue to not respond to call lights for changing on a timely manner, not passing food trays when cart arrived in a timely manner, not passing ice water consistently, and not passing midnight snacks . Review of a Quality Assistance Form dated 8/28/23 revealed the resident council communicated concerns about cold food and the concern was assigned to Administrator 'A' to review. The form documented, Findings: Residents report food being cold .Plan/Actions: Ensure trays are being passed immediately once receive on floors . It was not documented whether the concern was resolved and noted, Staff to pass trays ensuring food stays warm. Keep cart closed. Test trays are being completed. The form was signed by Administrator 'A' on 8/31/23. There were no Quality Assistance Forms or evidence of steps taken to resolve the other concerns expressed by the resident council such as, passing ice water and snacks consistently and call light response.
On 9/27/23, the following was documented in the meeting minutes, Old business was read and some things continue to be a problem .Maintenance: Some of the toilets were clogged and not able to flush .Some staff are not passing ice water and H/S (night time) snacks consistently .Cold food has improved a bit and receiving more warm trays . Review of a Quality Assistance Form dated 9/27/23 revealed the resident council communicated concerns about .Toilet not flushing in (two resident room numbers) . It was documented that the flush valves were replaced on those toilets which resolved the concern. The form was signed on 9/30/23. Review of a Quality Assistance Form dated 9/27/23 revealed the resident council communicated the following: Not passing ice water consistently. Not passing midnight snacks .Plan/Actions: Educate staff about passing H/S snacks and waters at each shift change .Will monitor through CP (Caring Partners). The form did not indicate the results were reported to the resident council. The form was signed on 9/30/23 (three days after the concerns were expressed).
On 10/16/23, the following was documented in the meeting minutes, We discussed .toilets that previously not flushing correctly .have been resolved. (CNAs) not consistently passing water - this has gotten a lot better. H/S snacks being passed have been improved . Review of a Quality Assistance Form dated 7/10/23 revealed the resident council communicated concerns about .Call light response time not favorable .Plan/Actions: .Nursing address call lights . The form did not indicate whether the concern was resolved or if the results were reported back to the resident council. The form was signed by the former Administrator on 7/16/23.
On 11/13/23, it was documented in the resident council meeting minutes that everything stated from last month continued to work with process .
On 11/29/23 at 12:55 PM, an interview was conducted with Maintenance Director 'N'. Maintenance Director 'N' reported they were not aware of any issues with toilets. At that time, an observation was made of the toilet in the residents' room who reported issues during the resident council interview. When Maintenance Director 'N' attempted to flush the toilet, it did not flush. Maintenance Director 'N' reported they did not know what was going on and nobody informed them it was not working.
During the survey, on 11/28/23 in the morning, two residents were observed without fresh water available to them and cold food was identified during the lunch meal.
On 11/30/23 at 1:58 PM, an interview was conducted with Administrator 'A'. When queried about how the facility addressed and resolved concerns expressed by the resident council, Administrator 'A' reported they utilized their grievance process after review of the meeting minutes. Administrator 'A' further explained that the concerns were documented on Quality Assistance Forms and looked into. When queried about the concerns about fresh water, snacks, and untimely response from CNAs that were expressed multiple times in the past six months per the resident council meeting minutes, Administrator 'A' reported no concerns have been brought up recently through the caring partners program (a program in the facility where a staff member interviews residents about any concerns). When queried about the toilet observed with Maintenance Director 'N' that was not working, Administrator 'A' reported it was fixed and must have broke again. When queried about the observations of residents without fresh water on the morning on 11/28/23, Administrator 'A' and the cold food observed on 11/28/23, the Administrator reported she was not aware of any current concerns. When queried about resident complaints about not receiving snacks in the evening time, Administrator 'A' reported the facility identified that as a concern and audits to ensure snacks are passed. When queried about how the audits were conducted and how sustained compliance was monitored, Administrator 'A' reported they had the CNAs sign off that they passed the snacks. When queried about how it was known that the snacks were actually distributed, Administrator 'A' did not offer a response.
Review of an audit document titled, HS-Snack Delivery Log for 11/1/23 through 11/31/23 revealed initials each day on each unit that according to Administrator 'A' meant the CNAs delivered snacks to the residents. Review of the nursing staff schedules for 11/26/23 through 11/29/23, the initials documented on the audit did not match with any CNAs who worked on those days.
Review of a facility policy titled, Resident Council revised on 10/30/23, revealed, in part, the following: .A Resident Council Minutes and Quality Assistance Form will be utilized to track issues and their resolution .The Administrator reviews the minutes to ensure .all group concerns and grievances are investigated .any responses from departments within the facility are provided back to the council .Issues documented on Quality Assistance Forms may be referred to the Quality Assurance Committee .
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** R39
On 11/28/23 at 7:49 AM, R39 was observed sleeping in bed. The floor in R39's room had debris scattered all over the floor, s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R39
On 11/28/23 at 7:49 AM, R39 was observed sleeping in bed. The floor in R39's room had debris scattered all over the floor, some debris appeared to have been stepped on and tracked around the room, the floor was sticky to walk on. A fall mat was observed on the right side of the bed, on it were a used glove and a medicine cup. The trash can was observed without a liner and had items in it. The other bed in the room had no mattress on it, just the frame all the way down so it was on the floor.
On 11/29/23 at 8:22 AM, R39 was observed in the room. The floor had a dried puddle right when going in the door, there was the same spots that appeared to be adhered to the floor. The other bed still had no mattress, just the frame.
Review of the clinical record revealed R39 was admitted into the facility on 5/18/19 and readmitted [DATE] with diagnoses that included: stroke, dementia and depression. According to the Minimum Data Set (MDS) assessment dated [DATE], R39 had severely impaired cognition.
On 11/30/23 at 2:24 PM, the Housekeeping Manager was interviewed and asked about R39's room. The Housekeeping Manager explained it was known that R39's room needed to be cleaned frequently. The Housekeeping Manager was asked about the spots on the floor. The Housekeeping Manager explained he would have it mopped. When informed it was doubtful the spots would be removed by a mop, the Housekeeping Manager explained probably the floor needed to be stripped and waxed. The Housekeeping Manager was asked why the other bed in the room had no mattress on it, just the frame. The Housekeeping Manager had no answer.
Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable, homelike environment for eight (R39, R36, R41, R38, R40, R44, R48, R61) residents and nine of nine residents who attended the resident council interview who wished to remain anonymous. Findings include:
On 11/28/23 at 8:16 AM and 1:45 PM, R40 was observed in bed and not responsive to verbal communication. The floor in the room was dirty and soiled and the rubber coating from the wheel of the bed had disintegrated and separated littering the floor with black debris.
On 11/28/23 at 8:27 AM, R48 was in bed. The floor in the room had multiple yellowish/brown sticky stains. It was further noted R48 had no personal items in the room to create a homelike environment.
On 11/28/23 at 8:35 AM and 10:55 AM, R44 was observed in their bed awake, but not responsive. A large brown stain soiled the floor under their bed. R38's bed controls on the foot of the bed were broken with exposed wires hanging from them. R38 had no personal items at or near their bedside to create a homelike environment. It was further observed an unmade bed was stored in the room.
On 11/28/23 at 8:47 AM, a rolling blood pressure machine was observed in the hallway. The machine was observed to have dark brown dried stains on the base of the wheels.
R61
On 11/28/23 at 9:48 AM, 11:50 AM, and 12:20 PM and 11/30/23 at 9:15 AM, R61 was observed lying in bed. R61 was not able to communicate. R61 was observed lying in bed turned toward the wall or toward the door which was closed. There was a bed, dresser, and tube feeding pole in their room. There were no decorations, pictures, or anything to add stimulation to the room.
Resident Council
On 11/29/23 at 11:00 AM, an interview was conducted with nine residents of the resident council who wished to remain anonymous. Facility staff brought the residents to the second floor activities room. Upon entrance to the room, it was observed to be very cold. Activities Aide (AA) 'P' reported if it were up to her, she would not have brought the residents to that room due to the heat being out. AA 'P' brought blankets and wrapped them around each resident. The residents expressed being cold, but many were assisted upstairs from downstairs and did not want to move back downstairs.
During the resident council interview, R36 and R41 reported they shared a room and bathroom and their toilet has not worked in over a month. They reported it did not flush. It was explained that someone did try to fix it but it was still broken and it was unable to be flushed.
On 11/29/23 at 12:55 PM, an interview was conducted with Maintenance Director 'N'. Maintenance Director 'N' reported they were not aware of any issues with toilets. At that time, an observation was made of the toilet in the R36 and R41's room. When Maintenance Director 'N' attempted to flush the toilet, it did not flush. Maintenance Director 'N' reported they did not know what was going on and nobody informed them it was not working. At that time the toilet bowl was observed to be dirty with a black ring around the toilet bowl.
On 11/29/23 at 1:05 PM, an observation of R39's bathroom was made with Maintenance Director 'N'. The toilet bowl was observed to be dirty with a black ring around the toilet rim. Maintenance Director 'N' reported the toilet should be cleaner than that.
On 11/29/23 at approximately 1:15 PM, an observation of the activities room where the resident council interview was conducted was made. Maintenance Director 'N' took the room temperature read as 58 degrees Fahrenheit (F) on the side of the room where most of the residents sat for the interview.
On 11/30/23 at 1:58 PM, an interview was conducted with Administrator 'A'. When queried about what the facility has done to ensure residents had an environment that was welcoming and homelike, Administrator 'A' reported they were working on making the rooms more homelike.
On 11/30/23 at 2:25 PM, an interview was conducted with the Housekeeping Manager. When queried about how often residents' bathrooms and toilets were cleaned, the Housekeeping Manager reported they were cleaned daily.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R21
On 11/29/23 at 11:30 AM record review was completed for R21the medication administration record (MAR) revealed a PRN (as nee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R21
On 11/29/23 at 11:30 AM record review was completed for R21the medication administration record (MAR) revealed a PRN (as needed) Tylenol orders with route (the way the medication should be administered, for example, by mouth) specified as via vent (ventilator).
On 11/29/23 at 3:36 PM Interview was conducted with Administrator B two Tylenol orders on the MAR with a route of via vent, she stated that the route should have been clarified by the nurse and/or should have been caught by the pharmacist.
Based on observation, interview, and record review, the facility failed to ensure nursing services met professional standards for medication administration and pain assessments for four residents (R#'s 41, 33, 48, and 21), of four residents reviewed for professional standards. Findings include:
R41
On 11/29/23 at 9:01 AM, Registered Nurse (RN) 'O' was observed preparing medications for administration to R41. During the course of the preparation, RN 'O' was observed to use an insulin syringe to draw two units of insulin from a Novalog Flex Pen (a specialized pen style insulin delivery syringe with attached vial and disposable needles that contains a dial to manually program the dosage for administration). RN 'O' then prepared two additional syringes of insulin for scheduled administration. At the completion of the medication preparation RN 'O' was observed to place all three insulin syringes in their shirt pocket and enter R41's room. RN 'O' removed the syringes after entering the room and placed them on the bedside table. RN 'O' then swabbed R41's abdomen with an alcohol swab and administered each insulin dosage, but was not observed to swab the skin in between each administration. At the completion of the medication administration, RN 'O' recapped the empty insulin syringes, placed them back into their shirt pocket and exited the room.
On 11/29/23 at 9:44 AM, RN 'O' was asked if the facility had any needles for the Novalog Flex pen and said they did not know for sure. They were then asked about drawing insulin with a syringe from the vial on the Flex Pen and said that was they way they were used to doing it.
On 11/29/23 at 3:31 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the observation of RN 'O's preparation of the Novalog insulin and whether the facility had needles for the Flex Pen. The DON said they facility had the needles and RN 'O' should not have drawn up insulin from the flex pen into a separate syringe.
A review of the pharmacy package insert for the Novalog Flex Pen delivery system was reviewed and indicated a new disposable needle should be attached to the pen for every administration of the medication.
R33
On 11/28/23 at 8:35 AM-R33 was observed in their bed. R33 had a tracheostomy, was on mechanical ventilation, and received nutrition through a feeding tube. R33's bilateral elbows, hands, and legs were observed to be contracted. R33 was non-verbal and did not respond to any attempts at verbal communication.
On 11/29/23 at 12:05 PM, a review of R33's clinical record revealed they admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: respiratory failure, anoxic brain damage, dysphagia, contractures, pressure ulcers, and cardiac arrest. A review of R33's quarterly Minimum Data Set assessment dated [DATE] indicated R33 had severe cognitive impairment.
Continued review of R33's clinical record was conducted and revealed multiple (21 of 70) pain assessments documented via the numeric pain scale (a pain scale that requires a verbal rating of 0-10 with zero being no pain and 10 being the worst pain), versus an appropriate pain assessment tool for residents who cognitively impaired and, or, non-verbal.
R48
On 11/28/23 at 8:27 AM, R48 was observed in their bed. R48 had a tracheostomy, was on mechanical ventilation, and received nutrition through a feeding tube. R48's bilateral hands were clenched, and appeared contracted. R48 was non-verbal and did not respond to any attempts at verbal communication.
On 11/29/23 at 12:35 PM, a review of R48's clinical record revealed they admitted to the facility on [DATE], most recently re-admitted on [DATE] with diagnoses that included: respiratory failure, anoxic brain damage, stroke, epilepsy, diabetes, pressure ulcers, and sepsis. R48's Minimum Data Set assessment dated [DATE] indicated R48 had severely impaired cognition.
Continued review of R33's clinical record was conducted and revealed multiple (45 of 101) pain assessments documented via the numeric pain scale versus an appropriate pain assessment tool for residents who cognitively impaired and, or, non-verbal.
On 11/29/23 at 3:31 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the use of the numeric pain scale for cognitively impaired or non-verbal residents and further said the numeric scale would not be appropriate for R33 or R48.
A review of a facility provided policy titled, Pain Management revised 10/2023 was conducted and read, .Pain Assessment: 1. The facility may use an assessment tool to assist staff in the assessment of pain. 2. An assessment or an evaluation of pain based on professional standards of practice by the appropriate members of the interdisciplinary team .may necessitate gathering the following information, as applicable to the resident: .b .Asking the patient to rate the intensity .using a numerical scale or a verbal or visual descriptor that is appropriate .
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 11/28/23 at 8:46 AM, R7 was observed lying in bed. R7 was asked about the food at the facility. R7 explained the food was alw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 11/28/23 at 8:46 AM, R7 was observed lying in bed. R7 was asked about the food at the facility. R7 explained the food was always cold when the tray was delivered.
On 11/28/23 at 9:03 AM, R7's breakfast tray was observed being carried into R7's room after it was taken off the food cart. R7 was asked about the temperature of the food. R7 took the cover off the coffee cup and immediately stuck a finger into the coffee and explained one would not be able to hold their finger in coffee if it was hot. When asked about the food, R7 explained the eggs, toast and hash browns were cold, the only item that was the least bit warm was the oatmeal.
Review of the clinical record revealed R7 was admitted into the facility on 7/5/22 and readmitted [DATE] with diagnoses that included: gangrene, peripheral vascular disease and diabetes. According to the Minimum Data Set (MDS) assessment dated [DATE], R7 was cognitively intact and required the assistance of staff for some activities of daily living (ADL's).
This citation pertains to Intake #: MI00140679
Based on observation, interview, and record review, the facility failed to ensure food was held and served at a palatable temperature. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 11/28/23 at 12:15 PM, the temperature of the hash browns on the steam table was measured, with the temperatures ranging between 108-111 degrees Fahrenheit. An entire cart had already been loaded with trays of food served from the steam table. When queried about the temperature on the steam table, Dietary Staff looked down at the temperature control knob, and noticed that it was turned off. Dietary Staff stated the steam table controls should have been set to high.
According to the 2017 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: 1. (1) At 57ºC (135ºF) or above .
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
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 store, prepare and serve food in accordance with professional standards for food service safety. This deficient practice had ...
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Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
On 11/28/23 between 7:05 AM-7:30 AM, during an initial tour of the kitchen, the following items were observed:
The paper towel dispenser at the handwashing sink was observed to be empty. Dietary Staff BB confirmed that there were no towels in the dispenser.
According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels;.
In the walk-in cooler, there was an opened, undated package of deli turkey, 3 cases of 2% milk cartons with a use-by date of 11/27/23, and 1 case of 2% milk cartons with a use-by date of 11/26/23.
According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
In the dry storage room, there was a buildup food debris on the floor.
According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.
On the bread rack, there was a package of hamburger buns with a large tear in the outer bag, and the buns were hard and dried out.
There were numerous wet pans stacked on the clean storage rack. On 11/28/23 at 8:30 AM, DM AA confirmed the dishware should be dry before stacking.
According to the 2017 FDA Food Code section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, .(B) Clean equipment and utensils shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and
(2) Covered or inverted.
On 11/28/23 at 8:20 AM, a personal cell phone was observed on the food prep counter, and a wet wiping rag was stored on the counter instead of inside the sanitizer bucket.
According to the 2017 FDA food code, Section 7-209.11 Storage, Except as specified under §§ 7-207.12 and 7-208.11, Employees shall store their personal care items in facilities as specified under 6-305.11(B), and Section 6-403.11 Designated Areas, .(B) Lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, linens, and single-service and single use articles can not occur.
According to the 2017 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114;
Sept 2023
7 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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake(s): MI00138580, MI00138907 & MI00139261.
Based on observation, interview, and record reviews th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake(s): MI00138580, MI00138907 & MI00139261.
Based on observation, interview, and record reviews the facility failed to timely implement adequate preventive wound interventions and consistently assessed, monitored and notified the physician for the worsening of wounds for two (R's 802 & 804) of three residents reviewed for pressure ulcers, resulting in R804 to have developed multiple pressure ulcers including a Stage 4 wound to the sacrum within a little over a month after admission into the facility and for R802 to have developed a stage II pressure ulcer to the coccyx. Findings include:
R804
On 9/28/23 at 2:33 PM, R804 was observed lying on their back in bed, the resident was connected to a mechanical ventilator and was observed to have a tracheostomy in place. R804 was able to shake their head yes or no to interview questions. A brief interview was held with the resident at that time.
Review of the preadmission paperwork provided to the facility by the transferring facility on 7/13/23, documented the resident to have been at the prior facility from 6/2/23 until 7/13/23 with no documentation of the resident to have developed any wounds.
Review of the medical record revealed R804 was admitted to the facility on [DATE] with a readmission date of 9/22/23 and diagnoses that included: acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease, type 2 diabetes mellitus, tracheostomy status, gastrostomy status, and a history of transient ischemic attack. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs).
Review of an admission braden assessment dated [DATE] at 1:31 PM, documented a score of 17.0 . AT RISK .
Review of an admission skin assessment dated [DATE] at 1:40 PM, documented in part . Right buttock- bruising/ mole . Left buttock- Bruising . Sacrum- Redden .
Review of the care plan titled . resident has potential for skin impairment . initiated 7/13/23, documented the following interventions . Avoid scratching and keep hands and body parts from excessive moisture, Keep fingernails short, Educate resident/family/caregivers of causative factors and measures to prevent skin injury, Keep skin clean and dry. Use lotion on dry skin. Do not apply on skin impairment area(s) .
These interventions were not adequate in preventing worsening and/or the development of a pressure ulcer to the sacrum and buttock areas.
Review of a facility policy titled Pressure Injury Prevention and Management dated 1/1/22, documented in part . This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . Licensed nurses will conduct a pressure injury risk assessment, using . Braden tool . After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .
Review of the July 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed on 7/13/23, the following order was implemented . Miconazole Nitrate External Cream 2% . Apple to buttocks, Groin and folds topically two times a day for skin care until 7/20/23 . The cream was not applied on 7/20/23, however stopped as directed after.
Review of the medical record revealed no documentation of treatment or physician notification for the redden sacrum area and no physician follow up to ensure the prescribed cream was effective for the buttock area.
Review of a Nursing note dated 7/23/23 at 11:55 AM, documented in part . A new skin problem was observed. Coccyx unstageable DTI (Deep Tissue Injury). Notification place in DON (Director of Nursing) box .
This indicated the sacrum wound had worsened.
Review of the July 2023 MAR and TAR revealed the following in part . Cleanse with wound cleanser. Pat dry. Apply Bordered Foam as directed to Coccyx. Skin barrier wipe to peri wound at bedtime for DTI . Start Date- 07/23/2023 . D/C (discontinued) Date- 07/28/2023 .
Review of a wound consultation note dated 7/27/23, documented in part . Consultation and evaluation of a wound found at the sacrum . LOCATION: Sacrum . Wound Stage: Deep Tissue Pressure Injury . DRESSING USED: Triad, Bordered Foam . EXUDATE: Scant, Serous . PERIWOUND: Unhealthy . Length (cm- centimeters) 4.0, Width 4.0, Depth Utd (unable to determine), Wound area (cm2- centimeters squared) 16.00 . WOUND PROGRESS: Undetermined: first visit . The wound is stable and requires continued topical wound dressing therapy as noted above .
Review of a wound consultation note dated 8/3/23, documented in part . evaluate a wound found at the sacrum . Wound Stage: Unstageable Pressure Injury . DRESSING USED: Calcium Alginate with Honey, Bordered Foam . Underlying dti starting to open up to unstageable . 40% Slough . 10% Necrotic Tissue . 3.8 Length, 2.2 Width, Utd Depth, 8.36 Wound area .
Review of the care plan titled The resident has a DTI to Sacrum . Initiated 8/8/23, documented the following intervention . Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage .
Review of the medical record revealed no documentation of the staff to have identified or reported to the physician the worsening of the sacrum wound from 7/27/23 to 8/3/23 (the day the wound physician identified worsening of the sacrum wound.)
Review of a Nursing note dated 8/16/23 at 7:17 PM, documented in part . Writer observed wounds on BL (bilateral) heels during ADL care. Reported to husband on site, bl heel boots applied, heels floated, wounds assessed, and treatment initiated .
Review of the care plans revealed the lack of adequate interventions implemented to protect the resident heels prior to the identification of the right wound heel.
Review of a wound consultation note dated 8/17/23, documented in part . evaluate wounds found at the sacrum and right heel . Sacrum . Wound Stage: 4 - Pressure Injury . Necrotic tissue . Subcutaneous tissue debridement performed by surgical excision of devitalized subcutaneous tissue. A total area of 19.2 sq (square) cm of devitalized tissue was debrided with no loss of blood. The pre-op wound area was found to be 6.5 cm x 5.9 cm x Utd cm (38.4 sq cm). The post-op wound area was 6.5 cm x 5.9 cm x Utd cm (38.4 sq cm) . DRESSING USED: Calcium Alginate with Silver, Honey-based Gel . UNDERMINING: 1.5 CM AT 2 o'clock, ODOR: Mild, EXUDATE: Moderate, Serous . 40% Slough, 20% Granulation, 40% Necrotic Tissue . Right Heel . Wound Stage: Deep Tissue Pressure Injury . DRESSING USED: Skin Prep . 3.2 Length, 2.7 Width, Utd Depth, 8.64 Wound area .
Review of the medical record revealed no documentation of the staff to have identified or reported to the physician the worsening of the sacrum wound from 8/3/23 to 8/17/23.
On 9/28/23 at 3:53 PM, the Director of Nursing (DON) was interviewed and asked the facility's protocol on the identification of a skin impairment or worsening of a wound, the DON replied the nurse would notify the physician and ensure the appropriate treatment is in place. The DON was asked the facility's protocol on the implementation of preventive interventions to prevent skin impairments and the accuracy of braden assessments completed and the DON replied the braden assessments are conducted when the resident admits to the facility and the nurses are responsible for implementing interventions. The DON was then asked why timely interventions was not implemented for R804 and the consistent lack of monitoring and identification of the worsening of the sacrum wound to report to the physician. The DON stated the wound nurse was not working during the duration of the survey, however they would look into it and follow back up.
No further explanation or documentation was provided by the end of the survey.
R802
Review of the medical record revealed R802 was admitted to the facility on [DATE] with diagnoses that included: respiratory failure, injured in motor-vehicle accident, traumatic cerebral edema with loss of consciousness, tracheostomy status, gastrostomy status, and dependence on respirator ventilator status. A MDS assessment dated [DATE], documented Severely impaired cognitive skills for daily decision making and required staff assistance for all ADLs.
Review of an admission skin assessment dated [DATE] at 3:52 PM, documented no identification of a pressure wound.
Review of the July 2023 MAR and TAR documented the following orders:
. border foam dressing to coccyx daily for prophylaxis every night shift for prophylaxis . Start Date- 7/7/23.
. Cleanse with wound on Sacrum with wound cleanser and apply Dermaseptin and covered with bordered form <sic> daily. One time a day . Start Date- 7/29/23.
Review of the progress notes revealed no documentation of the wound or the wound characteristics.
Review of the care plans revealed inadequate interventions to prevent the development of a pressure wound to the coccyx area.
Review of the first Skin & Wound Evaluation completed (dated 8/4/23) documented in part . Pressure . Stage 2: Partial-thickness skin loss with exposed dermis . Location Coccyx . In-House Acquired . New . 0.9 cm2 (centimeters square) Area, 2.2 cm (centimeters) Length, 0.6 cm Width .
On 9/29/23 at 10:56 AM, an observation of R802 buttock area was conducted with Unit Manager (UM) F and Certified Nursing Assistant (CNA) G. UM F and CNA G removed the brief of R802 and turned the resident on their side. Initial evaluation revealed no protective treatment applied to the resident's coccyx area. When UM F was questioned about the treatment, UM F replied the resident does not have prescribed treatment to the coccyx area. R802's coccyx area was intact, observed was a healed pressure ulcer that revealed a light tan/brown discoloration to the coccyx area.
Review of the physician orders documented in part, . Cleanse with wound cleanser. Pat dry. Apply Bordered Foam as directed to coccyx. Skin barrier wipe to peri wound every day shift .
This order was not applied to the coccyx as ordered by the physician.
Review of a care plan titled resident has history of skin integrity of the following location coccyx . implemented on 8/4/23, documented the following intervention . Keep skin clean and dry and apply foam dressing .
On 9/29/23 at 1:22 PM, an interview was conducted with the DON, the DON was asked why preventive interventions was not implemented timely to prevent pressure wounds for R802 and why the ordered foam dressing was not applied as ordered by the physician for R802's coccyx area on 9/29/23 observation. The DON replied they would look into it. The DON returned shortly after, and stated staff was recently educated on pressure wounds.
No further explanation or documentation was provided by the end of the survey.
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 Number(s): MI00138253.
Based on observation, interview, and record review, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00138253.
Based on observation, interview, and record review, the facility failed to report allegations of neglect to the State Agency for two (R807 and R808) of four residents reviewed for abuse and neglect. Findings include:
Review of a complaint submitted to the State Agency revealed allegations that when Certified Nursing Assistant (CNA) 'G' works on the 2 East unit, they left the unit, did not let anyone know they were leaving so that residents could be supervised, and did not come back until over an hour at times. It was further alleged that CNA 'G' did not do regular checks and changes, raised their voice at residents, and neglected to change their clothing at times.
On 9/27/23 at 2:55 PM, a phone interview with the complainant was conducted. The complainant reported they had notified previous and current management multiple times about their concerns regarding CNA 'G' not changing residents and leaving the unit without notifying anyone. The complainant reported CNA 'G' just gets sent home or moved to another unit because there were so many complaints about her from residents, family, and staff.
Review of a facility policy titled, Abuse, Neglect and Exploitation dated 10/24/22, revealed, in part, the following:
.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .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 .Identification of Abuse, Neglect and Exploitation .Possible indicators of abuse include, but are not limited to .Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning .The facility will have written procedures that include: .Reporting of all alleged violations to the Administrator, state agency .within specified timeframes: .Immediately, but not later than 2 hours after the allegation is made, if the vents that cause the allegation involve abuse or result in serious bodily injury .
On 9/28/23 at 10:00 AM, R807 was observed in bed. When queried about their care, R807 reported they had to wait a long time to get changed and they were not cleaned well after bowel movements. When queried about any concerns they had with specific staff members, R807 reported they were afraid of being retaliated against because the Director of Nursing (DON) recently asked if they could give the CNA another chance. When queried about what CNA they were referring to, R807 reported CNA 'G'. R807 reported CNA 'G' left their roommate (R808) laying on their side and walked out. When R807 said they needed to be changed from a soiled brief, CNA 'G' ignored R807 and left the room.
Review of R807's clinical record revealed R807 was admitted into the facility on 9/17/21 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure, cellulitis of abdominal wall, asthma, morbid obesity, and seizures. Review of a Minimum Data Set (MDS) assessment revealed R807 had intact cognition and no behaviors, including rejection of care.
On 9/28/23 at 10:15 AM, R808 was observed lying in bed. When queried about their care, R808 reported they had to sit in feces and urine for long periods of time. When queried about any concerns with specific staff members, R808 reported CNA 'G' did not do their job, pushed on their knees instead of their hips so R808 could grab the enabler bars to turn onto their side. When R808 explained how to comfortably turn them, CNA 'G' argued with R808, got mad, and left R808 on their side, naked, with a soiled bed sheet underneath them. R808 reported they were wet and the bed sheet needed to be changed and CNA 'G' just left and didn't say anything. I didn't know if she was coming back. I pressed the call light and laid there for about 45 minutes. R808 reported the DON asked if CNA 'G' could work with them again. R808 agreed to it, but did not feel comfortable with that CNA.
Review of R808's clinical record revealed R808 was admitted into the facility on 3/24/23 with diagnoses that included: acute and chronic respiratory failure, congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. Review of a MDS assessment dated [DATE] revealed R808 had moderately impaired cognition, no behaviors, including rejection of care, requires extensive physical assistance with bed mobility, transfers, and toilet use, and was always incontinent of urine and stool.
Review of CNA 'G' personnel file revealed the following:
A Performance Improvement Form dated 7/24/23 that documented, On July 18, 2023, the DON was notified by three residents that (CNA 'G') did not provide bowel/bladder care when asked. In fact, two of the resident's stated she exited their room without a response and the third resident stated (CNA 'G') did not return to their room to complete a brief change. Two of the residents reported their issue occurred on July 17, 2023 .CNA to ensure pericare is provided when needed as remaining soiled for long period of time increases the change for yeast, infections, and skin breakdown .
On 9/28/23 at 12:38 PM, the Administrator was asked to provide any grievance forms, incident reports, and any investigations pertaining to R807 and R808 for the past six months.
Review of a Quality Assistance Form dated 7/18/23 revealed R807 communicated the following concern to the DON: Resident reports # concern regarding toileting. It was documented the concern was assigned to the DON to review. The Findingssection was left blank. The following was documented in the Plan/Actions section: CENA will no longer care for this resident per request. It was documented the concern was not reportable to the State Agency and that it was resolved, noting CENA will not longer care for this resident. The form was signed as resolved by R807 and the DON on 7/18/23. There was no explanation of what R807's concern with toileting was.
Review of a Quality Assistance Form dated 7/18/23 revealed R808 communicated the following concern to the DON: Resident voiced concern regarding toileting. It was documented the concern was assigned to the DON to review. In the findings section, the following was documented, A different CENA changed the resident as her assigned CNA was unavailable. The following was documented in the Plan/Actions section: CENA removed from resident room for future care. It as documented the concern was not reportable to the State Agency and that it was resolved. The form was signed by R808 and the DON. There was no explanation of what R807's concern with toileting was.
No associated investigations were provided with the Quality Assistance Forms for R807 and R808 mentioned above.
On 9/28/23 at 3:41 PM, an interview was conducted with the DON. When queried about the facility's protocol when a resident expressed an allegation of abuse or neglect, the DON reported they contacted the Administrator immediately and they would develop a plan to investigate to validate the allegation. When queried about the Quality Assistance Form for R807 and what the resident's concern was about, the DON reported R807 asked their CNA to change them and she said the CNA left out. When queried about what that would be considered, if a staff member ignored a resident's request for care and did not provide the care, the DON did not offer a response. When queried about who the CNA was, the DON reported it was CNA 'G'. The DON reported they reported the incident to the Administrator and CNA 'G' was not permitted to care for R807 anymore. When queried about the Quality Assistance Form for R808 and what the resident's concern was about, the DON reported R808 asked another CNA to change her because her CNA was not available. When queried about what they did after they became aware of the allegation, the DON reported they took statements from R808's roommate, reported it to the Administrator, and wrote the CNA up. When queried about whether they knew if the allegation was reported the State Agency, the DON reported it was not because someone else changed her so it was not neglect. When queried about why the intervention was for the CNA not to care for R808 anymore and if CNA 'G' was assigned to R808 after the allegation was made, the DON reported (R808) never really said she didn't want her. I asked her if it was ok for (CNA 'G') to care for again and she said it was okay.
At that time, CNA 'G's personnel file was reviewed with the DON. The Performance Improvement Form dated 7/24/23 was reviewed. The DON confirmed that the Performance Improvement Form for CNA 'G' was related to R807 and R808's concerns documented on the Quality Assistance Forms dated 7/18/23.
On 9/28/23 at 4:35 PM, an interview was conducted with the Administrator (who was the facility's Abuse Coordinator) and the Ventilator Administrator. When queried about the facility's protocol when a resident alleged abuse or neglect by a staff member, the Administrator reported the person who it was reported to should contact their supervisor and/or the Administrator as soon as possible so an investigated could be started. When queried about when an allegation of abuse or neglect was reported to the State Agency, the Administrator reported within 24 hours and stated, We do an investigation first and then decide whether it's abuse. When queried about whether R807 and R808's concerns about CNA 'G' that were documented on the Quality Assistance Forms and in a Performance Improvement Form that alleged, On July 18, 2023, the DON was notified by three residents that (CNA 'G') did not provide bowel/bladder care when asked. In fact, two of the resident's stated she exited their room without a response and the third resident stated (CNA 'G') did not return to their room to complete a brief change, the Administrator explained it was not reported to the State Agency. The Administrator reported they investigated the concerns and did not report it because we looked at it as a care concern. When queried about what the investigation entailed and where it was documented, the Administrator reported she had to look into it. When queried about whether ignoring residents requests for assistance, walking out of their room without a response, and not completing a brief change was considered neglect, the Administrator stated, If someone else ends up completing the care, it's not neglect.
No additional information was provided prior to the end of the survey.
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 Number(s): MI00138253.
Based on observation, interview, and record review, the facility failed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00138253.
Based on observation, interview, and record review, the facility failed to provide evidence of a thorough investigation into allegation of neglect for two (R807 and R808) of four residents reviewed for abuse and neglect. Findings include:
Review of a complaint submitted to the State Agency revealed allegations that when Certified Nursing Assistant (CNA) 'G' works on the 2 East unit, they left the unit, did not let anyone know they were leaving so that residents could be supervised, and did not come back until over an hour at times. It was further alleged that CNA 'G' did not do regular checks and changes, raised their voice at residents, and neglected to change their clothing at times.
On 9/27/23 at 2:55 PM, a phone interview with the complainant was conducted. The complainant reported they had notified previous and current management multiple times about their concerns regarding CNA 'G' not changing residents and leaving the unit without notifying anyone. The complainant reported CNA 'G' just gets sent home or moved to another unit because there were so many complaints about her from residents, family, and staff.
Review of a facility policy titled, Abuse, Neglect and Exploitation dated 10/24/22, revealed, in part, the following:
.Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .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 .Identification of Abuse, Neglect and Exploitation .Possible indicators of abuse include, but are not limited to .Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning and positioning .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse neglect or exploitation occur. Written procedures for investigations include: .Identifying staff responsible for the investigation .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse, neglect .has occurred, the extent, and cause .Providing complete and thorough documentation of the investigation .
On 9/28/23 at 10:00 AM, R807 was observed in bed. When queried about their care, R807 reported they had to wait a long time to get changed and they were not cleaned well after bowel movements. When queried about any concerns they had with specific staff members, R807 reported they were afraid of being retaliated against because the Director of Nursing (DON) recently asked if they could give the CNA another chance. When queried about what CNA they were referring to, R807 reported CNA 'G'. R807 reported CNA 'G' left their roommate (R808) laying on their side and walked out. When R807 said they needed to be changed from a soiled brief, CNA 'G' ignored R807 and left the room.
Review of R807's clinical record revealed R807 was admitted into the facility on 9/17/21 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure, cellulitis of abdominal wall, asthma, morbid obesity, and seizures. Review of a Minimum Data Set (MDS) assessment revealed R807 had intact cognition and no behaviors, including rejection of care.
On 9/28/23 at 10:15 AM, R808 was observed lying in bed. When queried about their care, R808 reported they had to sit in feces and urine for long periods of time. When queried about any concerns with specific staff members, R808 reported CNA 'G' did not do their job, pushed on their knees instead of their hips so R808 could grab the enabler bars to turn onto their side. When R808 explained how to comfortably turn them, CNA 'G' argued with R808, got mad, and left R808 on their side, naked, with a soiled bed sheet underneath them. R808 reported they were wet and the bed sheet needed to be changed and CNA 'G' just left and didn't say anything. I didn't know if she was coming back. I pressed the call light and laid there for about 45 minutes. R808 reported the DON asked if CNA 'G' could work with them again. R808 agreed to it, but did not feel comfortable with that CNA.
Review of R808's clinical record revealed R808 was admitted into the facility on 3/24/23 with diagnoses that included: acute and chronic respiratory failure, congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. Review of a MDS assessment dated [DATE] revealed R808 had moderately impaired cognition, no behaviors, including rejection of care, requires extensive physical assistance with bed mobility, transfers, and toilet use, and was always incontinent of urine and stool.
Review of CNA 'G' personnel file revealed the following:
A Performance Improvement Form dated 7/24/23 that documented, On July 18, 2023, the DON was notified by three residents that (CNA 'G') did not provide bowel/bladder care when asked. In fact, two of the resident's stated she exited their room without a response and the third resident stated (CNA 'G') did not return to their room to complete a brief change. Two of the residents reported their issue occurred on July 17, 2023 .CNA to ensure pericare is provided when needed as remaining soiled for long period of time increases the change for yeast, infections, and skin breakdown .
On 9/28/23 at 12:38 PM, the Administrator was asked to provide any grievance forms, incident reports, and any investigations pertaining to R807 and R808 for the past six months.
Review of a Quality Assistance Form dated 7/18/23 revealed R807 communicated the following concern to the DON: Resident reports # concern regarding toileting. It was documented the concern was assigned to the DON to review. The Findingssection was left blank. The following was documented in the Plan/Actions section: CENA will no longer care for this resident per request. It was documented the concern was not reportable to the State Agency and that it was resolved, noting CENA will not longer care for this resident. The form was signed as resolved by R807 and the DON on 7/18/23. There was no explanation of what R807's concern with toileting was.
Review of a Quality Assistance Form dated 7/18/23 revealed R808 communicated the following concern to the DON: Resident voiced concern regarding toileting. It was documented the concern was assigned to the DON to review. In the findings section, the following was documented, A different CENA changed the resident as her assigned CNA was unavailable. The following was documented in the Plan/Actions section: CENA removed from resident room for future care. It as documented the concern was not reportable to the State Agency and that it was resolved. The form was signed by R808 and the DON. There was no explanation of what R807's concern with toileting was.
No associated investigations were provided with the Quality Assistance Forms for R807 and R808 mentioned above.
On 9/28/23 at 3:41 PM, an interview was conducted with the DON. When queried about the Quality Assistance Form for R807 and what the resident's concern was about, the DON reported R807 asked their CNA to change them and she said the CNA left out. When queried about who the CNA was, the DON reported it was CNA 'G'. The DON reported they reported the incident to the Administrator and CNA 'G' was not permitted to care for R807 anymore. The DON was not sure if they had evidence of an investigation. When queried about the Quality Assistance Form for R808 and what the resident's concern was about, the DON reported R808 asked another CNA to change her because her CNA was not available. When queried about what they did after they became aware of the allegation, the DON reported they took statements from R808's roommate, reported it to the Administrator, and wrote the CNA up. When queried about where the statement was located, the DON was not sure and reported they would look into whether they had an investigation. When queried about why the intervention was for the CNA not to care for R808 anymore and if CNA 'G' was assigned to R808 after the allegation was made, the DON reported (R808) never really said she didn't want her. I asked her if it was ok for (CNA 'G') to care for again and she said it was okay. When queried about how it was determined that other residents did not experience neglect from CNA 'G', the DON did not offer a response.
At that time, CNA 'G's personnel file was reviewed with the DON. The Performance Improvement Form dated 7/24/23 was reviewed. The DON confirmed that the Performance Improvement Form for CNA 'G' was related to R807 and R808's concerns documented on the Quality Assistance Forms dated 7/18/23.
On 9/28/23 at 4:35 PM, an interview was conducted with the Administrator (who was the facility's Abuse Coordinator) and the Ventilator Administrator. When queried about the facility's protocol when a resident alleged abuse or neglect by a staff member, the Administrator reported the facility conducted an investigation to determine if the allegation was actually abuse. When queried about any documented investigation into the allegation of neglect made by R807 and R808 per the Quality Assistance Forms and the Performance Evaluation Form for CNA 'G', the Administrator reported they would look into it, but that they looked at it as a care concern and not neglect. The Administrator stated, If someone else ends up completing care, then it's not neglect. When queried about how the allegations were corrected and how it was ensured they did not persist, the Administrator reported CNA 'G' was reprimanded and moved to another unit. When queried about how it was known that other residents were not affected by the alleged neglect, the Administrator did not offer a response.
No additional information was provided prior to the end of the survey.
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 F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake(s): MI00138907 & MI00139261.
Based on observation, interviews, and record reviews the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake(s): MI00138907 & MI00139261.
Based on observation, interviews, and record reviews the facility failed to ensure non pharmacological interventions were implemented and behavioral health services was provided for one (R804) of one resident reviewed for psychotropic medications. Findings include:
On 9/28/23 at 2:33 PM, R804 was observed lying on their back in bed, the resident was connected to a mechanical ventilator and was observed to have a tracheostomy in place. R804 was able to shake their head yes or no to interview questions. A brief interview was held with the resident at that time.
Review of the medical record revealed R804 was admitted to the facility on [DATE] with a readmission date of 9/22/23 and diagnoses that included: acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease, tracheostomy status, gastrostomy status, generalized anxiety and major depressive disorder. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs).
Review of the July 2023 & August 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following:
Diazepam 10 mg (milligram) tablet via PEG (Percutaneous Endoscopic Gastrostomy) at bedtime.
Risperdal 1 mg tablet via PEG every 12 hours for Mania.
Mirtazapine 15 mg (2 tablets) via PEG at bedtime for Depression.
Review of the medical record revealed no consultations with the facility's behavioral group.
Review of September 2023 MAR and TAR documented the following:
Mirtazapine 30 mg via PEG Tube at bedtime for Depression.
Diazepam 10 mg via PEG Tube as needed for Anxiety.
Review of the care plans revealed no documented targeted behaviors or non-pharmacological interventions implemented.
Review of a Physician Progress Note dated 9/4/23 at 2:39 PM, documented in part . Seen and examined . Patient has history of anxiety and currently is on Diazepam 10mg to be given once as needed at bed time maintain this medication as patient do need antianxiety medication as needed. Patient husband does not want her to be on any psychiatric medication or any, it is Benzodiazepam, will maintain this for patient anxiety. Will consult psych to reassess patient . Discussed this plan with nursing staff .
Review of the medical record revealed no consultation with psych services in the medical record. Further review revealed no behavioral incidents documented.
On 9/28/23 at 2:50 PM, the facility's Social Service Director (SSD) A was interviewed and asked if they were the liaison for the facility and behavioral health services and SSD A replied they were. SSD A was asked how often the behavioral/psych group consults with the facility residents' and SSD A stated twice a week. SSD A explained the therapist comes every Thursday and the Psych practitioner comes every Friday. When asked where resident behaviors are documented SSD A stated the progress notes and care plans. SSD A was asked who oversees the residents on psychotropic medications ensuring the gradual dose reductions are attempted and abnormal involuntary movement scale is completed, and SSD A stated the behavioral group oversees the psychotropic medications. SSD A was then asked what behaviors R804 had, SSD A stated they would have to look into it. SSD A was asked if R804 is seen by the facility's behavioral group and SSD A stated they would have to look into it. SSD A was asked to provide the documentation of all targeted behaviors for R804, non- pharmacological interventions, any GDR attempts or AIMS completed and all behavioral consultations. At 3:13 PM, SSD A returned and stated they could not provide any documentation for R804 and stated they saw the doctor's documentation to have the resident seen by the behavioral/psych group, however an order was never implemented. The SSD A stated the order will be placed and R804 will be added to the list to be seen by the behavioral group. SSD A then stated they could not find any targeted behaviors or non- pharmacological interventions in the resident's care plan.
No further explanation or documentation was provided by the end of the survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store and maintain tube feeding supplies in a sanitar...
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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 store and maintain tube feeding supplies in a sanitary manner for two (R805 and R806) of three residents reviewed for tube feeding. findings include:
On 9/28/23 at 11:20 AM, R805 was observed lying in bed. R805 was observed to have a tracheostomy tube (a tube surgically inserted into a person's windpipe used to assist with breathing) and was receiving oxygen through it. R805 was receiving nutrition via a PEG (percutaneous endoscopic gastrostomy) tube (a tube surgically inserted into the stomach to deliver nutrition). An irrigation syringe (used to administer medications and flush water via the PEG tube) was observed in a plastic bag labeled 9/27/23. In the bottom of the bag was yellow fluid and in the syringe there was clear and yellow fluid).
On 9/28/23 at 11:23 AM, R806 was observed lying in bed. R806 was receiving nutrition via a PEG tube and was receiving oxygen via a tracheostomy tube. R806 did not speak or make eye contact. An irrigation syringe was observed in a plastic bag with fluid pooled in the bottom of the bag. The bag was labeled 9/27/23.
On 9/28/23 at approximately 11:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) 'H' who was assigned to R805 and R806. LPN 'H' reported the irrigation syringes should have been cleaned and/or changed out on the midnight shift.
On 9/28/23 at 10:09 AM, an interview was conducted with the Director of Nursing (DON). When queried about whether used, irrigation syringes should be put back in the plastic bag without cleaning or replacing them, the DON said they should not.
Review of R805's clinical record revealed R805 was admitted into the facility on 5/23/20 and readmitted on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia (low oxygen), hemiplegia (one sided weakness or paralysis), dysphagia (difficulty swallowing), diabetes, seizures, and had a PEG tube and tracheostomy. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R805 had severely impaired cognition and was totally dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs).
Review of R806's clinical record revealed R806 was admitted into the facility on 2/22/22 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure, chronic obstructive pulmonary disease, dysphagia, quadriplegia (paralysis of all four limbs), and had a PEG tube and tracheostomy. Review of a MDS assessment dated [DATE] revealed R806 had severely impaired cognition and was totally dependent on staff for bed mobility, transfers, and all ADLs.
Review of a facility policy titled, Flushing a Feeding Tube dated 6/30/22, revealed, in part, the following: Upon completion of the administration, remove plunger from barrel and wash all reusable equipment with warm water. Dry the equipment thoroughly. store in a bag or container for next use.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
This citation pertains to intake: MI00138580.
Based on observation, interviews, and record reviews the facility failed to ensure weekly weights were obtained and collaboration for weight loss was com...
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This citation pertains to intake: MI00138580.
Based on observation, interviews, and record reviews the facility failed to ensure weekly weights were obtained and collaboration for weight loss was completed with the physician for one R802 of three residents reviewed for tube feedings. Findings include:
On 9/29/23 at 10:56 AM, R802 was observed sitting up in bed. A skin observation was conducted with the facility staff. An interview was attempted but could not be conducted due to the resident's current cognitive status.
Review of the Weight Summary documented the following:
6/6/23- 103 lbs. (pounds)
9/20/23- 94.8 lbs.
This indicated a -8.14% weight loss within three and a half months of being admitted to the facility.
Review of a progress note dated 7/7/23 at 7:50 AM, documented in part . Nursing request for RD (Registered Dietician) to review TF (Tube Feeding) and significant weight loss . Recommends continuing with weekly weight monitoring to determine efficacy of new TF regimen .
Review of a Pertinent Charting- Nutrition/Hydration note dated 8/4/23 at 4:28 AM, documented in part . Weight loss . Continue to monitor patient weekly weight .
Review of a Pertinent Charting- Nutrition/Hydration note dated 8/12/23 at 4:49 AM, documented in part . Weight loss . Continue to monitor weight weekly .
Review of a Enteral Review note dated 8/28/23 at 2:17 PM, documented in part . underweight . Resident has hx (history) of significant weight changes . Weekly weight monitoring .
Further review of the weights revealed the staff did not consistently obtain R802's weekly weights.
Review of the physician notes revealed no documentation of the identification of the resident weight loss, collaboration with the dietician or Interdisciplinary team or further interventions implemented regarding the resident weight loss from the physician.
On 9/29/23 at 9:47 AM, the Director of Nursing (DON) was interviewed and asked the status on facility's dietician and the DON stated the facility does not currently have a fulltime dietician and the facility is currently utilizing contracted dieticians. The DON was then asked about the multiple recommendations regarding the facility staff to obtain weekly weights on R802 (who is under the ideal body weight), and the DON stated they would look into it. The DON was then asked why the interdisciplinary team have not collaborated with the physician regarding the continuous weight loss for R802 and the DON stated they would look into it. The DON was asked to provide all documentation that may address the concerns discussed.
No further explanation or documentation was provided by the end of the survey.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00139188.
Based on observation, interview, and record review, the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00139188.
Based on observation, interview, and record review, the facility failed to ensure there was sufficient nursing staff for the 2 East Unit for two (R805 and R806) of three residents reviewed for staffing. This had the potential to affect all 23 residents who resided on the 2 East Unit. Findings include:
Review of a complaint submitted to the State Agency revealed an allegation that the facility was short staffed.
Review of a facility policy titled, It is the policy of this facility to provide sufficient staff .to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment .
On 9/28/23 at approximately 9:45 AM, Licensed Practical Nurse (LPN) 'H' was observed on the 2 East Unit. LPN 'H' was switching back and forth between two medication carts. When queried, LPN 'H' reported they were the only nurse assigned to the 2 East Unit that day. LPN 'H' reported at times there was a second nurse, but not on that day. When queried about whether they would be able to complete all of their nursing duties, LPN 'H' reported they did not know and reported they would not be able to pass all of the 9:00 AM medications on time.
On 9/28/23 at 11:20 AM, R805 was observed lying in bed. Their tube feeding pump was beeping with a message on the pump that read, Flush error .bag empty .clog in line .valve not loaded. The flush bag was observed to be empty. An irrigation syringe (used to administer medications and flush water via a PEG - percutaneous endoscopic gastrostomy tube - a tube surgically inserted to provide nutrition directly to the stomach) was observed in a plastic bag labeled 9/27/23. In the bottom of the bag was yellow fluid and in the syringe there was clear and yellow fluid). R805 was observed to have a tracheostomy tube (a tube surgically inserted into a person's windpipe used to assist with breathing) and was receiving oxygen through it. R805 was unable to speak.
On 9/28/23 at 11:23 AM, R806 was observed lying in bed. R806 was receiving nutrition via a PEG tube and was receiving oxygen via a tracheostomy tube. R806 did not speak or make eye contact. An irrigation syringe was observed in a plastic bag with fluid pooled in the bottom of the bag. The bag was labeled 9/27/23.
On 9/28/23 at 11:41 AM, R805 and R806's irrigation syringes were replaced and R805's flush bag was filled with water.
On 9/28/23 at 11:53 AM, R805's clinical record was reviewed and revealed their 9:00 AM medications had not been administered as of that time.
On 9/28/23 at 11:55 AM, R806's clinical record was reviewed and revealed their 9:00 AM medications had not been administered as of that time.
On 9/29/23 at approximately 8:00 AM, an interview was conducted with LPN 'H'. LPN 'H' reported they were the only nurse assigned to the 2 East Unit that day. When queried about when they finished passing 9:00 AM medications the previous day, 9/28/23, LPN 'H' reported it was around 11:00 AM or 12:00 PM. When queried about how many residents they were assigned to on the 2 East unit, LPN 'H' reported there were 23 residents. When queried about the acuity of the unit, LPN 'H' reported there were approximately 15 residents with PEG tubes, seven residents with tracheostomies and/or bi-paps, and six residents with pressure ulcers. LPN 'H' reported there were two Certified Nursing Assistants assigned to the 2 East unit, but that most residents on that unit required two person physical assistance. LPN' H' reported they were responsible to take all of the residents' vital signs as well and that took a long time.
Review of the nursing staff schedule for 9/28/23 provided by the facility revealed LPN 'H' was the only nurse assigned to the 2 East unit from 7:00 AM until 3:00 PM. Review of the nursing staff scheduled for 9/29/23 revealed LPN 'H' was the only nurse assigned to the 2 East unit from 7:00 AM until 7:00 PM.
On 9/29/23 at 10:09 AM, an interview was conducted with the Director of Nursing (DON). When queried about how staffing needs were determined on the 2 East Unit, the DON reported there was a standard staffing ratio. When queried about whether it was typical to have one nurse assigned to the 2 East Unit, the DON reported there were call offs. When queried about what the facility did when staff called off, the DON reported they sent out alerts to see if anyone could pick up the shift. The DON reported even though they would prefer two nurses on 2 East, it's technically not short because it's based on our ratios. When asked if there was enough nurses assigned if medications were passed late, the DON reported medications should be passed on time which was within one hour before or one hour after the scheduled time. The DON explained that if the nurse needed help it was their responsibility to let management know. When queried about whether they were aware there was only one nurse assigned to the 2 East Unit, the DON reported they were aware. When queried about why a nurse manager or another nurse available onsite did not split the unit with LPN 'H', the DON reported management did not assist unless the nurse asked for help.
On 9/29/23 at 1:05 PM, an interview was conducted with the Staffing Coordinator . When queried about staffing on 2 East on 9/28/23 and 9/29/23, the Staffing Coordinator reported there were call ins. The Staffing Coordinator reported another nurse came in at 3:00 PM on 9/28/23, but LPN 'H' worked from 7:00 AM until 3:00 PM alone and on 9/29/23, they had not been able to find someone to come in.
Review of a list of residents who resided on the 2 East unit that was provided by the Administrator revealed there were eight residents who had tracheostomies, eight residents who had PEG tubes, and nine residents who required wound treatments.
Further review of R805's clinical record revealed R805 was admitted into the facility on 5/23/20 and readmitted on [DATE] with diagnoses that included: chronic respiratory failure with hypoxia (low oxygen), hemiplegia (one sided weakness or paralysis), dysphagia (difficulty swallowing), diabetes, seizures, and had a PEG tube and tracheostomy. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R805 had severely impaired cognition and was totally dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs).
Further review of R806's clinical record revealed R806 was admitted into the facility on 2/22/22 and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure, chronic obstructive pulmonary disease, dysphagia, quadriplegia (paralysis of all four limbs), and had a PEG tube and tracheostomy. Review of a MDS assessment dated [DATE] revealed R806 had severely impaired cognition and was totally dependent on staff for bed mobility, transfers, and all ADLs.
Jul 2023
6 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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00138158.
Based on interview and record review the facility failed to prevent and identify ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00138158.
Based on interview and record review the facility failed to prevent and identify the root cause of a second degree burn for one (R809) of two residents reviewed for accidents, resulting in R809 being transferred and admitted to the hospital for treatment to a Second degree burn of left upper arm. Findings include:
Review of a complaint submitted to the State Agency (SA) documented in part, . On 7/02/2023, (R809 name) was transported to the hospital for a second degree burn on (R809) left arm. It is unknown how (R809) got the burn .
Review of the medical record revealed R809 was admitted to the facility on [DATE] with diagnoses that included: nontraumatic subarachnoid hemorrhage, cerebral infarction, acute respiratory failure, hypertension, and gastrostomy status. A Minimum Data Set (MDS) assessment dated [DATE], documented Severely impaired cognitive skills for daily decision making and was dependent on staff assistance for all Activities of Daily Living (ADLs).
Review of the progress notes revealed the following:
A Nursing note dated 7/1/23 at 8:18 PM, documented in part . rash appeared on resident's upper left arm. Red skin, with blisters, warm to the touch. Notified (doctor's name). hydrocortisone cream was ordered as well as Medrol pack. Called pharmacy and requested drop ship so meds (medications) will start on time. This note was documented by Registered Nurse (RN) C.
A Nursing note dated 7/1/2023 at 8:37 PM, documented in part . one area of redness seems smaller. There are more blisters now, and they are larger.
A Nursing note dated 7/2/23 at 9:07 AM, documented in part . reddened area is smaller, blisters are large. Notified DON (Director of Nursing) and MD (Medical Doctor). MD said to send her to the hospital .
Review of the hospital medical record revealed the following:
An ED (Emergency Department) Provider Note dated 7/2/23 at 9:58 AM, documented in part . evaluation of blisters and erythema to left upper arm . was taken for shower when she (R809) came back there is an area of erythema and blistering on the left lateral shoulder . symptoms concerning for partial-thickness burns to left upper extremity . clinical exam is consistent with partial-thickness burn to left upper arm; likely from shower as patient was visualized by family without having lesion before and it was present after the shower occurred. Concern for incidental burn from water during shower. Family members requesting patient not be send back to her facility . Patient admitted to hospital for further care and evaluation of the partial-thickness burn to left upper arm . Diagnosis . Second degree burn of left upper arm . Partial thickness burn of left upper arm . I spoke at length with mother and sister who are acting as independent historians and state that mother saw pt (patient) the day before and when she was lotioning her after shower the pt had what appeared to be a burn on her left upper arm . She was admitted for wound care and antibiotics treatment .
Review of the hospital picture of R809's upper left arm was reviewed and clearly revealed a second-degree burn, with redden skin and blisters noted to the whole upper left arm and extending down towards the elbow area.
Review of R809's Task documentation for July 2023, revealed a shower was provided to R809 on 7/1/23 by Certified Nursing Assistant (CNA) B.
On 7/25/23 at 2:16 PM, a telephone interview was conducted with RN C when asked, RN C stated they were first notified of the R809's redden area by R809's mother. RN C stated R809's family regularly visited R809 and was present the day of R809's shower. RN C confirmed that R809 did have a shower on the evening of 7/1/23. When asked RN C stated that CNA B had not informed them of anything abnormal regarding R809's shower or skin. RN C stated R809 did not go out to the hospital the evening of the shower but the next day. When asked if the facility's Administration team followed up with them regarding the incident RN C replied the facility's Administrator and Director of Nursing (DON) completed a telephone interview with them.
On 7/25/23 at 2:27 PM, a telephone interview was conducted with CNA B. CNA B was asked about R809 and the shower they provided on 7/1/23. CNA B stated it was a normal shower and the only thing different was that R809's family provided a different shower gel to use on the resident. When asked how they test the water temperature before they started R809's shower, CNA B replied they test the water with their hand or the resident's feet before washing them. When asked CNA B denied that the water temperature was hot when they provided R809's shower. CNA B stated in part . From what I understand the water doesn't get that hot to burn anybody, because they (facility staff) tested it . When asked CNA B stated R809 is nonverbal and confirmed that R809 is dependent on staff for all ADLs. CNA B stated they did not notice anything abnormal with R809 after the shower and was told later that a blister had formed. CNA B stated the facility's Administration staff followed up with them regarding the incident and took a statement from CNA B at that time.
On 7/25/23 at 2:39 PM, the facility's maintenance staff (later identified as Maintenance Director- MTD D) was requested to meet the surveyor by the shower room with a thermometer to test the water in the shower room used to shower R809. At 2:57 PM, the facility's Administrator for the Ventilator unit, identified as NHA Vent A met with the surveyor and stated MTD D was currently not in the facility and NHA Vent A would complete the water temperatures of the shower room. Upon entering the shower room two shower heads were identified on opposite sides of the shower room. Shower #1 water temperature was tested by NHA Vent A and was observed to reach the highest at 98.3. Shower #2 was tested and observed to reach the highest at 97.4. When asked what the water temperature levels should be, NHA Vent A stated between 105-120 for a safe and comfortable level. When asked, NHA Vent A was unsure on why the temperature was not maintaining a comfortable level. At this time the facility's water temperature testing logs was requested from June 1, 2023, to July 1, 2023.
On 7/26/23 at 8:31 AM, a second request was made to the Administrator for the facility's water temperature testing logs. Shortly after the Administrator and MTD D arrived in the conference room and provided the water temperature logs. Review of the water temperature logs in the presence of the Administrator and MTD D was completed. The water temperature logs provided were for the weeks of 6/8/23, 6/19/23, 6/28/23 and 7/13/23. The Administrator and MTD D was asked about the testing logs for the weeks between 6/28/23 and 7/13/23, when the incident occurred and MTD D replied they had no logs for that week. The Administrator asked MTD D if another maintenance personnel could have possibly tested the water that week and MTD D replied they were the main personnel that would test the water temperature and they did not have logs for the period between 6/28/23 and 7/13/23. When asked how the facility ensured the water temperature was at a safe and comfortable temperature between the weeks of 6/28/23 and 7/13/23, there was no reply. Further review of the facility waterlog documents revealed the last water temperature check completed prior to 7/1/23 (the date of the incident) was 6/28/23. The prior logs dated 6/19/23 and 6/28/23, documented numbers in the 70's (6/19/23) and 20's (6/28/23) which the MTD D could not explain what the temperatures were or what the numbers meant, when asked. This confirmed the facility water temperatures were not accurate for the weeks prior to the date of the alleged incident.
On 7/26/23 at 9:05 AM, the Administrator was asked if they were made aware of the facility's water temperature not maintaining a comfortable level and stated they were informed by NHA Vent A, and the facility is currently in the process of putting in a service call. The Administrator was asked to provide any documentation of the scheduled date for the third party to assess and address the facility's water temperature issue. The Administrator stated they would follow back up. No further documentation was provided by the end of survey.
Review of the facility's investigation into the incident with R809 revealed the following typed Administrative Statement Investigation Analysis completed by the former Administrator who no longer was employed at the facility, later identified as Former Administrator (FM) E. The report documented the following in part . Date of Occurrence: 7-1-2023 . Time of Occurrence: Approximately 6:45 PM . Allegation: Resident had an injury of unknown origin to her left upper arm . Resident had received shower by caregiver which took approximately 10 minutes. Responsible party reported noted irritation to arm 2.5 hours after shower was provided. The minor injury was examined by a nurse and reported to MD who initiated orders for hydrocortisone cream and Medrol pack . Upon being informed of this allegation the Administrator (LNHA) immediately began an investigation . Nurse aide went to resident's room at approximately 3:45 PM to provide resident her shower . CNA stated she showered resident for approximately 8 to 10 minutes . After caregiver returned resident to her room, her responsible party applied lotion to resident and assisted with brief change . It was then reported by responsible party at 6:45 PM that resident had small bumps and a rash on her left arm. The nurse reported the next morning at 9 AM that the afflicted area became smaller but there were more blisters, and the MD (Medical Doctor) requested the resident be transferred to the hospital . resident was transferred to the hospital earlier that day and diagnosis from ER (Emergency Room) was unspecified burn . on the picture the area is rectangle and flatten (referring to picture of R809's upper left arm) . The alleged injury is much localized. The upper left arm only was involved, while the resident's entire body was showered. Also, where resident was showered the shower holder is broken, which would rule out water being applied to a particular area for any extended prior of time . The water temperature was not high enough to cause a second-degree burn. The temperature of the water in the hot water tank was measured and found to be 115 F . The shower room is located a long distance from the hot water tank since it is located on the second floor . This injury of unknown origin could not be classified as water being origin of injury . New product was applied to skin, which could contribute to chemical vs (verses) thermal skin injury in addition to history of family applying heating device per staff . The resident family member brings a tote bag each visit . Responsible party declined having or using a heating device despite numerous nursing staff stating they have seen them previously . During interview facility staff noted that they have observed responsible party using a heating pad / blanket on resident. Staff states the responsible party was advised to prohibit bringing the heating pad/ blanket into the facility. The facility concludes that the injury of unknown origin is unable to be determined. The injury may be the result of cellulitis or possibly a chemical burn caused by the use of a new personally hygiene product or some type of heating device due to the uniformity of the affected area. It's highly unlikely that resident would be burned by water in only one area of her upper extremity . We cannot substantiate an injury of unknown origin was cause by facility .
On 7/27/23 at 3:55 PM, a telephone interview was attempted with FM E. A message was left for FM E to return the call. A return phone call was not received by the end of the survey.
Further review of the facility's investigation into the injury of unknown origin with R809 revealed no accurate documentation of water temperatures obtained for the time frame prior to the incident with R809. Review of the facility staff statements revealed no staff member identified that witnessed R809's family member to have ever bring a heated pad or blanket into the facility. There was no documentation of the facility to have ever identified R809's family bringing in a heating device nor was their documentation of the facility to have ever educated R809's family on bringing heating devices into the facility as noted in the investigation above. The description of the wound and diagnosis documented in the above investigation completed by the facility was also found to be incorrect. The injury was not minor as documented in the facility's investigation.
On 7/26/23 at 9:05 AM, the Administrator was interviewed and asked to identify the staff the facility documented in their investigation who witnessed R809's family to have brought into the facility a heating pad, blanket or device and the Administrator stated they could not identify a staff member that actually seen the family bring in the device. The Administrator was then asked to provide statements from the staff that witnessed R809's family to have brought and used a heating device on R809 and to provide the education documentation that was provided to R809's family as stated in the facility's investigation and the Administrator confirmed the facility had no eye witness staff statements of staff witnessing R809's family using a heating device in the facility nor did the facility have documentation to provide that R809's family was ever educated on this matter as documented in the facility's investigation. The Administrator was asked what the facility concluded the cause of the second degree burn for R809 and again the Administrator stated they believed it was from a heating device placed by R809's family. The Administrator was asked to provide all documentation the facility had to support the claims documented by the facility in their investigation.
No further documentation was provided by the end of survey.
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
Based on interview and record review the facility failed to accurately report to the State Agency (SA) an allegation of an injury of unknown origin for one (R809) of two residents reviewed for acciden...
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Based on interview and record review the facility failed to accurately report to the State Agency (SA) an allegation of an injury of unknown origin for one (R809) of two residents reviewed for accidents, resulting in the facility to have submitted a investigation report that omitted factual information and contained misleading information which made the injury of unknown origin appear less serious than it was, based on the documentation submitted to the SA, the allegation was desk reviewed and closed by the SA with no substantiated findings. A complaint submitted to the SA resulted in an onsite investigation regarding the injury of unknown origin for R809 and revealed substantiated findings including the inaccurate information that was submitted to the SA by the facility. Findings include:
Review of a complaint submitted to the State Agency (SA) documented in part, . On 7/02/2023, (R809 name) was transported to the hospital for a second degree burn on (R809) left arm. It is unknown how (R809) got the burn .
Review of the initial submission to the SA on 7/3/23 at 4:52 PM, revealed the facility submitted the following information in part . Responsible party informed nurse about a rash on resident's arm. Nurse assessed area, notified MD (Medical Doctor) and initiated new orders. Resident observed in no distress.
The onsite investigation revealed the facility Administrator and Director of Nursing (DON) was aware of R809's diagnosis of a second degree burn when the initial submission was submitted to the SA on 7/3/23. On 7/26/23 at 9:05 AM, an interview was conducted with the Administrator and DON. The DON stated they were informed of the second degree burn diagnosis by the physician who attended R809 at the facility and had also consulted with R809 at the hospital they were transferred to.
Review of the facility's investigation report submitted to the SA on 7/11/23, documented the following in part . Date of Occurrence: 7-1-2023 . Time of Occurrence: Approximately 6:45 PM . Allegation: Resident had an injury of unknown origin to her left upper arm . Resident had received shower by caregiver which took approximately 10 minutes. Responsible party reported noted irritation to arm 2.5 hours after shower was provided. The minor injury was examined by a nurse and reported to MD (Medical Doctor) who initiated orders for hydrocortisone cream and Medrol pack . Upon being informed of this allegation the Administrator (LNHA) immediately began an investigation . Nurse aide went to resident's room at approximately 3:45 PM to provide resident her shower . CNA (Certified Nurse Assistant) stated she showered resident for approximately 8 to 10 minutes . After caregiver returned resident to her room, her responsible party applied lotion to resident and assisted with brief change . It was then reported by responsible party at 6:45 PM that resident had small bumps and a rash on her left arm. The nurse reported the next morning at 9 AM that the afflicted area became smaller but there were more blisters, and the MD requested the resident be transferred to the hospital . resident was transferred to the hospital earlier that day and diagnosis from ER (Emergency Room) was unspecified burn . on the picture the area is rectangle and flatten (referring to picture of R809's upper left arm) . The alleged injury is much localized. The upper left arm only was involved, while the resident's entire body was showered. Also, where resident was showered the shower holder is broken, which would rule out water being applied to a particular area for any extended prior of time . The water temperature was not high enough to cause a second-degree burn. The temperature of the water in the hot water tank was measured and found to be 115 F . The shower room is located a long distance from the hot water tank since it is located on the second floor . This injury of unknown origin could not be classified as water being origin of injury . New product was applied to skin, which could contribute to chemical vs (verses) thermal skin injury in addition to history of family applying heating device per staff . The resident family member brings a tote bag each visit . Responsible party declined having or using a heating device despite numerous nursing staff stating they have seen them previously . During interview facility staff noted that they have observed responsible party using a heating pad / blanket on resident. Staff states the responsible party was advised to prohibit bringing the heating pad/ blanket into the facility. The facility concludes that the injury of unknown origin is unable to be determined. The injury may be the result of cellulitis or possibly a chemical burn caused by the use of a new personally hygiene product or some type of heating device due to the uniformity of the affected area. It's highly unlikely that resident would be burned by water in only one area of her upper extremity . We cannot substantiate an injury of unknown origin was cause by facility . Facility respectfully asks for a desk review . This report was completed by the former Administrator who no longer was employed at the facility, later identified as Former Administrator (FM) E.
On 7/12/23 at 7:49 AM, the information was reviewed by the SA and closed with no substantiated concerns.
An onsite investigation was conducted regarding the complainant concerns submitted to the SA for R809's injury of unknown origin.
On 7/25/23 through 7/27/23 the onsite investigation revealed the following findings:
-
Review of the facility waterlog documents revealed the last water temperature check completed prior to 7/1/23 (the date of the incident) was 6/28/23. Further review of the prior logs dated 6/19/23 and 6/28/23, documented numbers in the 70's (6/19/23) and 20's (6/28/23) which the Maintenance Director (MTD D) could not explain what the temperatures were or what the numbers meant. This confirmed the facility water temperatures were not accurate for the weeks prior to the date of the alleged incident.
-
Review of the facility investigation revealed the facility Administration staff had not identified any staff who witnessed R809's family bringing into the facility or utilizing a heating device of any kind.
-
Review of the facility investigation revealed no prior educations provided to the family of R809 regarding a heating device.
-
Review of the facility investigation revealed no staff statements that witnessed R809's family utilizing a heating device on R809.
-
The injury was not minor and was diagnosed by the hospital physician as a Second degree burn of left upper arm. Review of the hospital picture of R809's upper left arm revealed a second-degree burn, despite the minor description of the wound that was submitted by the facility to the SA. R809 was admitted to the hospital for treatment of the second-degree burn.
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At the time of the survey the water temperature was observed to not be maintained at a comfortable temperature. Observations made with the Nursing Home Administrator for the Vent Unit (NHA Vent A) who tested the shower room that R809 was showered in on 7/1/23, concluded with the observation of Shower #1 highest temperature at 98.3 Fahrenheit (F) and Shower #2 was tested and observed to reach the highest at 97.4 F. On 7/26/23 at 11:03 AM, the facility's mixing valve was observed with the Maintenance Director (MTD D) which stated and seen by observation that the mixing valve thermometer was at 90 F, MTD D stated it should be at 115 F. For both observations NHA Vent A and MTD D stated the numbers observed were not in the correct range and would put in a service call to have the issue checked by a third party.
On 7/27/23 at 3:55 PM, a telephone interview was attempted with FM E. A message was left for FM E to return the call. A return phone call was not received by the end of the survey.
On 7/27/23 upon exit of the survey, the Administrators, DON, and corporate team was made aware of the concern of the facility to have submitted misleading information to the SA regarding R809's injury of unknown origin. The Administration and Corporate staff acknowledged the concern and had no further questions when presented with the information that was submitted to the SA compared to the survey findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #: MI00134679, MI00132898, and MI00135013
Based on observation, interview, and record review, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #: MI00134679, MI00132898, and MI00135013
Based on observation, interview, and record review, the facility failed to provide timely and appropriate assistance with Activities of Daily Living (ADL) for two (R805 and R810) of five Residents reviewed for ADL care with potential for negative physical, psychosocial outcomes, and potential loss of dignity for residents who are dependent on staff for assistance.
Findings include:
Complaints reported to the State Agency revealed concerns with provision of ADL care for residents who needed staff assistance.
R805
R805 was a long-term resident of admitted to the facility on [DATE]. R805's diagnoses included heart failure, muscle weakness, chronic pain, osteoarthritis, and major depressive disorder. R805 had a Brief Interview of Mental Status (BIMS) score of 15, indicative of intact cognition. R805 needed extensive staff assistance with their bed mobility, dressing, and personal hygiene based on Minimum Data Set (MDS) assessment dated [DATE].
An initial observation was completed on 7/26/23, at approximately 9:45 AM. R805 was observed in their bed, in a facility provided gown. R805 had an overhead trapeze bar (bar that is designed to hang over the bed to assist with mobility) set up over their bed. During this observation an interview was completed. R805 reported concerns with their ADLs, specifically with baths/showers and the staff not providing the assistance they need with ADLs.
A second observation was completed on 7/27/23, at approximately 3:20 PM. R805 was observed in their bed. There was strong offensive odor in the room. R805 reported that they have been at the facility for a few years. They had not been receiving the staff assistance they need to have their bed baths. R805 reported that they could complete part of the bed bathing task with set up and they needed staff assistance for the rest of the task; to clean the areas of their body that they are not able to reach lying on their bed. R805 was queried about the frequency of their bed baths/showers and reported that they received occasional bed baths and they just had a shower on 7/25 after a long time.
Review of R805's Electronic Medical Records (EMR's) revealed that R805 had received five bed baths and one tub bath between the dates of 6/1/23 and 7/27/23 (57 days), based on the ADL - Bathing activity report provide by the facility. The report revealed that R805 received a tub bath on 7/25/23 and bed baths on 7/21/23, 7/11/23, 6/16/23 and 6/13/23. A review of R805's care plan revealed that R805 needed two-person assistance with their ADL care.
R810
R810 was long term resident of the facility. R810 was originally admitted to the facility on [DATE]. R810's admitting diagnoses included acute and chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), pressure ulcer, contractures (contractures are the chronic loss of joint mobility caused by structural changes in non-bony tissue, including muscles, ligaments etc.), and quadriplegia (paralysis of all four limbs and body from neck down). R801 was receiving their nutrition and hydration via Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube directly placed on stomach). R810 had a tracheostomy tube (Tracheostomy is a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck) in place for their breathing. R810 was bed bound and totally dependent on staff assistance for all their ADLs.
An initial observation was completed on 7/26/27, at approximately 11:30 AM. R810 was observed in their bed with eyes closed and a staff member was in the room assisting the resident. An interview was completed after the observation with the Guardian N for R810 was completed via phone, at approximately 1:40 PM. During the interview R810's guardian reported they had concerns with the ADL care that R810 received and reported there had been inconsistencies with hygiene and baths. The guardian also reported that they had been spending a significant amount of time at the facility.
A review of the showers/bed baths for the past 30 days from 7/27/23 revealed that R810 had 2 showers and one bed bath. The report revealed, R810 had showers on 7/1/23, 7/12/23 and a bed bath on 7/26/23 in the last 30 days. R810 is bed bound and was totally dependent on staff assistance. R810's care plan dated 8/18/22, revealed that R810 needed total assistance from 2 staff members to complete the bathing.
An interview was completed with the staff member J (unit manager) on 7/27/23, at approximately 3:30 PM, regarding the facility showers/bed bath process. Staff member J reported that showers/bed were documented on the EMR system. Residents received two showers/bed baths every week and that they had a shower schedule for residents. The nurses assigned the schedule to CNA (Certified Nursing Assistants) on their schedule and were following up. Staff member J was queried on why R810 had only two showers and one bed bath in the last 30 days and reported that was not acceptable and they would follow up.
An interview was completed with Director of Nursing (DON) on 7/27/23, at approximately 1:45 PM. DON reported that showers were scheduled twice a week and CNAs documented on the EMR. Reported the concerns with showers.
A facility provided document titled Activities of Daily Living (ADLs) read in part, A resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #: MI00137670
Based on observation, interview, and record review, the facility failed to proper...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #: MI00137670
Based on observation, interview, and record review, the facility failed to properly manage pain for one Resident (R801) of one resident reviewed for pain, resulting in discomfort, with potential for physical decline and emotional distress.
Findings include:
Complaints reported to the State Agency revealed the complainant had concerns with the facility pain management for R801.
R801 was originally admitted to the facility on [DATE]. R801's admitting diagnoses included acute and chronic respiratory failure, Chronic pain syndrome, obstructive sleep apnea, and metabolic encephalopathy (Metabolic encephalopathy is a problem in the brain caused by a chemical imbalance in the blood). R801 was receiving their medication and hydration via Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube directly placed on stomach). R801 had an order for mechanical soft diet and thin liquids. R801 had a tracheostomy tube (Tracheostomy is a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck) in place for their breathing and they were on a ventilator (Machine that acts as bellows to move air in and out of the lungs). R801 was bed bound and dependent on staff assistance for all their activities of daily living (ADLs). R801's was able to communicate their needs verbally or through writing. R801 had a Brief Interview of Mental Status (BIMS) score of 12/15, indicative of moderate cognitive impairment based on the Minimum Data Set assessment dated [DATE].
An initial observation was completed on 7/26/23, at approximately 2 PM. R801 was observed in their bed. During this observation, an interview was completed. R801 was able to communicate and answer questions. R801 was queried about their concerns. R801 reported that they had concerns with the pain management plan they were on. When queried further R801 reported that the current pain medication and the regimen that they are on were not effective. They had requested to see the pain specialist. R801 also reported that they had concerns that they were not getting the pain medications timely and that they had addressed their concerns with the staff members and management, it was still ongoing.
A follow up observation was completed later the same day, at approximately 5 PM. R801 was observed in their bed. R801 was queried about their pain patch order. R801 reported that they had right elbow pain and the patch was ordered. R801 was asked if they had their patch. R801 moved their elbow and showed the elbow. There was no pain patch on R801's right elbow. R801 reported that they received the patch for a couple of days, and they did not receive it after. The patch was not staying on and they had asked the staff to fix the issue. There was no follow up after and they had received the pain patch for their elbow after if t was reported that there was still some elbow pain.
Review of R801's Electronic Medical Record (EMR) revealed that R801 had an order for the following orders for to treat pain:
Ask resident if their pain program is effective. If not able to communicate use the Wong-Baker Pain scale, every shift. Order effective as of 4/30/23.
Acetaminophen Tablet 325 mg. - Give one tablet via PEG tube every 6 hrs (hours). as needed for pain - Do not exceed 3 Gm (grams)/24 hrs. order effective 4/29/23.
Cold and Hot plus menthol external patch 4-1% (Lidocaine - Menthol). Apply to right elbow topically every 12 hrs. as needed for pain. Order effective as of 7/7/23.
Hydrocodone-Acetaminophen oral tablet 5-325 - Give one tablet via PEG tube every 6 hours as needed for pain. Order effective as of 6/19/23.
A review of R801 electronic Medication Administration Record (e-MAR) revealed that R801 had received their pain patch for their right elbow on 7/7/23 and 7/8/23 and they were effective, marked by the e-MAR key E. The e-MAR did not have entries under the medication from 7/9/23 to 7/26/23 (18 days). There was no documentation on the e-MAR or nursing progress note on why the ordered pain patch was not provided to R801.
Further review of R801's e-MAR for in June 2023 and July 2023 also revealed that that on several shifts that administered PRN hydrocodone was ineffective based on pain assessment; marked by the e-MAR key I. R801 also had an order to receive Tylenol as needed for breakthrough if the other medication was not effective. There was no documented evidence that this was offered to the R801 when the other medication was ineffective. There was no nursing documentation on R801's EMR on follow up interventions completed when the pain medication was ineffective.
A review of R801's progress notes revealed that R801had chronic pain and was followed up by a pain specialist outside of the facility. A social services progress note dated 7/24/23 read in part, Resident asked me to schedule a pain doctors visit . There were no additional nursing progress notes that addressed R801's ineffective pain medication between 6/25/23 and 7/26/23.
An interview was completed with the Director of Nursing (DON) on 7/26/23, at approximately, 5 PM. DON was queried about the facility's pain management protocol. The DON reported that nurses would administer the pain medication as ordered by the provider and assess the effectiveness of medication. If the ordered medication were not effective, then the nurses would let the providers know. The DON was queried on the R801's pain medication concerns and the pain patch for the elbow that was not administered, ineffective pain medications and not offering/administering the breakthrough pain medications consistently and nursing e-MAR entries/documentation. The DON reported that R801 was being followed by a pain specialist and R801 refused the medication at times. The DON provided additional physician documentation from 5/31/23, 6/2/23 and 6/8/23, but there was no additional nursing documentation.
A facility document titled Pain Management dated 1/1/22 read in part, The facility will ensure the pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences
Policy Explanation and Compliance Guidelines:
The facility utilizes a systematic approach for recognition, assessment, treatment, and monitoring of pain.
Recognition:
1.
In order to help a resident, attain or maintain his/her highest practicable level of well-being and to prevent or manage pain, the facility should:
a.
Recognize when a resident is experiencing pain and identified the circumstances when the pain is anticipated.
b.
Evaluate the resident upon admission, during ongoing scheduled assessments .
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 F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #: MI00134679
Based on observation, interview, and record review, the facility failed to follo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake #: MI00134679
Based on observation, interview, and record review, the facility failed to follow-up when the attending physician or the Nurse Practioner (NP) did not evaluate the resident's medical care needs timely for one Resident (R810) of one resident reviewed for follow up/physician care, resulting in the potential for a change in condition. Findings include:
Findings include:
R810 was long term resident of the facility. R810 was originally admitted to the facility on [DATE]. R810's admitting diagnoses included acute and chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), pressure ulcer, contractures (contractures are the chronic loss of joint mobility caused by structural changes in non-bony tissue, including muscles, ligaments etc.), and quadriplegia (paralysis of all four limbs and body from neck down). R801 was receiving their nutrition and hydration via Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube directly placed on stomach). R810 had a tracheostomy tube (Tracheostomy is a procedure to help air and oxygen reach the lungs by creating an opening into the windpipe from outside the neck) in place for their breathing. R810 was bed bound and totally dependent on staff assistance for all their activities of daily living (ADLs).
An initial observation was completed on 7/26/27, at approximately 11:30 AM. R810 was observed in their bed with eyes closed and a staff member was in the room assisting the resident. An interview was completed after the observation with the Guardian N for R810 via phone, at approximately 1:40 PM. During the interview R810's guardian reported that they had concerns with the care, facility following up on physician orders and communication. The guardian also reported that they had been spending a significant amount of time at the facility throughout week consistently.
A review of the R810's Electronic Medical Record (EMR) revealed a progress note dated 7/18/23 at 19:21, read in part, Resident was put on doctors log, patient has a strong urine smell .will continue to monitor. Further review of the record revealed another nursing progress note dated 7/23/23, at 20:51 that read, Resident has a strong odor from her urine. This writer put patient on doctors' log. Patent also has a rash on her back and legs, will continue to monitor. Further record review did not reveal any follow up physician visit note or orders from 7/18/23 - 7/25/23. A review on the Physician log for the attending physician revealed the following notes: 7/18/23 - patient has a strong urine smell. She needs U/A (urinalysis) done; 7/23/23 - patient has rash on her back and legs. Patent will need U/A soon and has her last BUN (Blood Urea Nitrogen); 7/25/23 - PEG leakage. The nurses' notes on the physician log were crossed off on the log indicating that the logged concerns were addressed by the physician or the Nurse Practioner (NP). The last NP visit in the EMR was dated 7/12/23.
An interview was completed with a staff member K on 7/27/23, at approximately 8:20 AM. Staff member K was queried on the physician log and the follow up process. Staff member K reported that the attending physician's NP had been visiting the facility three times/week. The staff had contacted them via phone as needed and had utilized the physician log for the NP to follow up on their next visit. Staff member K confirmed that once the NP or Physician had reviewed and addressed the concerns the note on the log was crossed off by the provider.
An interview was completed with Director of Nursing (DON) on 7/27/23 at approximately 11:25 AM. The DON was queried on the physician or NP follow up process when nurses identified any concerns with the residents. The DON reported that the providers were contacted via phone or messaging on any emergent needs. Non emergent concerns were logged on the physician books for the providers to follow up during their next visit. The DON confirmed that the NP for attending physician for R810 had been coming to the facility three days/week. The DON was queried on why the NP had not followed up or addressed the concerns that were logged multiple times and no additional explanation was provided.
An interview was completed with the Nurse Practioner L on 7/27/23, at approximately 11:30 AM. NP L reported that they had been visiting the facility at least three times/week. NP L was queried on the how they had addressed the communication process on the medical concerns. NP L reported that staff had called on via phone and were given verbal orders as needed. NP L also reported that they reviewed the logbook when they visited the facility. NP L confirmed that they had documented on the facility's EMR after their follow up visit. NP was queried on R810 regarding the nurse's notes and logged concerns on 7/18/23 and 7/23/23 about the urine odor, labs, and rash. NPL was queried if they were addressed. NP Lreported that R810 had a long-term Foley (urinary) catheter use and that is why they had not addressed it. NP L was queried why they had not addressed it when there was a change or a new sign that was observed and reported by multiple staff members over several days. NP L reported that there was another provider who was also providing services besides them, and they would follow up to address the concern.
A facility document titled Physician Services Guideline read in part, A physician must supervise medical care of each resident. The physician must visit based on a frequency noted below and must review the resident's total program of care, including medications and treatments, at each visit and write, sign and date progress notes. The physician and /or Nurse Practitioner/Physician Assistant is available 24 hours a day and will have a designated on-call physician when not available .
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** This citation pertains to intake: MI00136241.
Based on interview and record review the facility failed to maintain functional wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00136241.
Based on interview and record review the facility failed to maintain functional water pressure throughout the facility and ensure a comfortable environment, this deficient practice had the ability to affect multiple residents that resided in the facility, resulting in multiple documented complaints regarding the facility's water pressure. Findings include:
Review of a complaint submitted to the State Agency (SA) documented concerns of the resident rooms sinks and toilets water pressure being an ongoing issue at the facility.
On 7/26/23 at 10:44 AM, an observation was conducted of room [ROOM NUMBER]'s sink and toilet. The toilet was flushed and flushed okay. The hot water was turned on and ran okay. The cold water was turned on it trickled slowly from the faucet. The toilet was attempted to be flushed a second time and would not flush with the sink running water at the same time. A third attempt was made to flush the toilet and the water would not flush at the same time the sink water was turned on.
On 7/26/23 at approximately 11:13 AM, the Maintenance Director (MTD D) was interviewed and asked about the water pressure in room [ROOM NUMBER], why the toilet wouldn't flush if the sink was running water and why the cold water was barely running from the faucet when turned on. MTD D explained that for some time no residents resided on that hallway. Recently the facility opened back up that whole way and started moving residents into the rooms. MTD D stated they have been having issues with the water pressure for the rooms in that hallway since. MTD D was asked to provide invoices of the water pressure issues being addressed. MTD D stated they would look into it and follow back up.
No further explanation or documentation was provided by the end of the survey.
Review of the facility's resident council meeting minutes revealed the following:
On 4/7/23 at 1:30 PM, documented complaints made by the residents of the water pressure with the toilets.
On 5/22/23 at 1:50 PM, documented complaints made by the residents of the facility's water pressure and toilets flushing.
On 6/12/23 at 1:45 PM, documented resident concerns with the facility's water pressure.
On 7/10/23 at 1:30 PM, documented the following in part . Residents stated Water Pressure has not improved in showers and toilets .
On 7/27/23 at 11:27 AM, the Administrator was interviewed and asked about the multiple concerns regarding the facility's water pressure and what the facility is doing to correct the problem, the Administrator replied they were unaware of the facility's water pressure issues. When asked about the resident council minutes to have documented the concerns made by the resident every month since April 2023 to current, the Administrator stated they were unaware.
No further explanation or documentation was provided by the end of the survey.
Oct 2022
22 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to consistently complete a root cause analysis of falls, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to consistently complete a root cause analysis of falls, complete a fall risk assessment upon admission per the facility policy and implement adequate and effective interventions in an attempt to prevent future falls for one (R55) resident with a history of falls and assessed as a high fall risk, and failed to ensure proper positioning while in bed, unattended for one (R28) of three residents reviewed for falls. Findings include:
R55:
On 10/17/22 at 10:06 AM, R55 was observed sitting on the side of their bed. At this time an interview was attempted. Some questions were answered appropriately but most questions were not.
Review of the medical record revealed R55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: abnormalities of gait and mobility, bilateral osteoarthritis of knee and muscle weakness. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 11 indicating moderately impaired cognition and required staff assistance for ambulation, transfer and bed mobility.
Review of the preadmission documents provided to the facility documented the following:
A diagnosis of Repeated Falls on the face sheet.
. Fall risk . Confusion . on a Physical Therapy Treatment Encounter Note.
. brought into the hospital after a fall . states she sprained her ankle with the fall . Extremity Weakness . This is a chronic problem .Documented in a Physician Progress Note dated 6/1/22 at 3:25 PM.
Review of the medical record revealed a Fall Risk Evaluation was not completed on the resident upon admission into the facility.
Review of a care plan titled The resident is at risk for falls related to: muscle weakness, psychotropic medication use, abnormality of gait and mobility revised on 6/29/22 documented one intervention . Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . initiated 6/17/22.
Review of a facility policy titled Fall Prevention Program revised 1/1/22, documented in part . Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls . Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk . The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk .
The facility failed to complete an admission fall assessment and implement effective and adequate interventions to prevent falls.
Review of the progress notes documented the following:
. 7/5/22 11:00 . post fall skin assessment . no skin abnormalities at site of pain . 7/5/22 12:27 . legal guardian, notified of fall and transfer to hospital .
Review of facility incident report dated 7/5/22 at 11 AM, documented in part . Physically Impaired . Decision making impaired . Unobserved Fall . Resident was found on floor next to bed by RT (Respiratory Therapist). Resident stated she was trying to get into the bed . pain on left side of forehead no bruise/redness .
Review of a facility Fall RCA (root cause analysis) Investigation Tool dated 7/5/22, documented in part . face up next to bed - partly sitting up, trying to stand . MATTRESS WAS NOT COMPLETELY ON BED FRAME . confused at baseline . confused after fall . She was on the floor the opposide <sic> of the bed her walker is on. The mattress was partially off the bed. It doesn't seem likely that she was trying to get into the bed . ROOT CAUSE OF THIS FALL- (Blank) . Describe initial interventions to prevent future falls . asked resident to use call light when getting out of bed . Falls Team Meeting Notes . Summary of Meeting: Systemic or operational conditions that may contribute to falls? Any patterns or trends to the resident falls? (Blank) . Conclusion (Blank) . Additional Care Plan / Nurse Aide Assignment Updates (Blank) . Signatures (Blank) .
Review of a facility Quality Assessment & Assurance Investigation Report attached to the incident report was not completed.
Review of a facility incident report dated 7/5/22 at 12:00 PM, documented in part . Memory impaired . Physically impaired . Decision making impaired . Fall . Resident observed in room on floor next bed <sic>, laceration noted on mid (middle) Lt (left) forehead approximately I inch in length, superficial steristrips applied. Resident assessed, assisted back to bed . Resident transferred to hospital for CT scan . Call 911 . Sent to Hospital .
Review of a facility Quality Assessment & Assurance Investigation Report dated 7/5/22 at 12:00 PM, documented in part . Resident stated she was trying <sic> get into the bed. Resident was observed on floor in room on the left side of bed .
Review of a Fall RCA Investigation Tool dated 7/5/22 at 1200 PM, documented in part . Resident lost their balance . Found on the floor (unwitnessed) . Attempting to self-transfer . A & O x1 (Alerted and Oriented times one- to person) . Root Cause Of This Fall- Amount of assistance in effect . Medical status/Physical condition/Diagnoses . Mood or mental status . What appears to be the initial root cause(s) of the fall? Transferring without assistance or walker . Describe initial interventions to prevent future falls: To be assessed upon return form hospital . Falls Team Meeting Notes . Summary of meeting: Systemic or operational conditions that may contribute to falls? Any patterns or trends to the residents' falls? Conclusion, Additional Care Plan/ Nurse Aide Assignment Updates, Signatures (all blank) .
The facility then completed an Admission Fall Risk Evaluation and added two additional interventions to the resident's care plan.
Review of a Fall Risk Evaluation dated 7/5/22 at 1:55 PM, documented a score of 15.0 indicating interventions Required.
Review of the care plan titled The resident is at risk for falls related to: muscle weakness, psychotropic medication use, abnormality of gait and mobility documented two additional interventions, . Bed at the following height when not providing care. At knee height to facilitate safe transfer . [NAME] locked at bedside when resident is in the bed. Both interventions were added on 7/5/22.
Review of a hospital Internal Medicine H&P (History and Physical) dated 7/5/22, documented in part . Chief Complaint Patient presents with Fall . on 07/05/22 via EMS (Emergency Medical Services) from an ECF (Extended Care Facility) after 2 falls. Per the records, pt (patient) fell while getting out of bed and then fell a second time in her room. She did hit her head. During the examination, pt is A&O x3 but is confused and answers most other questions incorrectly . only follows some commands . does not remember the second fall but when reminded of it thinks that she fell because she saw blood . The resident was admitted to the hospital and discharged back to the facility on 7/11/22.
Review of a Nursing note dated 7/11/22 at 5:00 PM, documented in part, . Resident received via stretcher accompanied by EMS (Emergency Medical Services) . A&O x1-2 able to make some needs known . Stitches and discoloration noted to forehead .
Review of the fall care plan noted no documentation of additional interventions added or modifications upon the resident readmission to the facility.
Review of a facility incident report dated 9/19/22, documented in part . writer in hall, heard a loud noise, ran to room, found resident on the floor next to bed . Resident Unable to give Description . No injuries observed at time of incident .
Review of the medical record revealed no documentation of the Interdisciplinary (IDT) team to have met to perform a root cause analysis of the 9/19/22 fall and no modification to the care plan.
On 10/19/22 at 3:15 PM, the Director of Nursing (DON) was interviewed and asked about the inadequate fall care plan interventions implemented for a confused, high fall risk resident with a history of falls. The DON was also asked about the fall risk assessment to not have been completed upon admission as directed by the facility policy and the Interdisciplinary meetings not to have been consistently conducted to find the root cause and to modify the care plan if needed. The DON stated they would look into it and follow back up.
No additional explanation or documentation was provided before the end of the survey.R28:
On 10/17/22 at 9:54 AM, Certified Nursing Assistant (CNA 'I') was observed to bring a mechanical lift into R28's room and closed the door. At 9:56 AM, CNA 'I' exited the room, closed the door and proceeded to go down the hallway out of sight.
On 10/17/22 at 9:59 AM, CNA 'I' walked past Nurse 'Y' and was about to re-enter R28's room when Nurse 'Y' asked the CNA if they were going to transfer the resident and CNA 'I' stated they were, but they were looking for someone to help. Nurse 'Y' asked CNA 'I' if they wanted help and the CNA did not respond immediately, then responded OK. Upon entering R28's room, R28 was observed to be in bed laying on top of a hoyer lift sling while in bed, with the bed positioned in a high manner. When asked about the positioning of the resident, CNA 'I' did not indicate there was any concern and reported they had placed the resident on the hoyer sling themselves just before they went to look for help with the hoyer lift. When asked about the positioning of the resident, CNA 'I' did not indicate there was any concern.
Review of the clinical record revealed R28 was admitted into the facility on 8/2/17 and readmitted on [DATE] with diagnoses which included: cerebral infarction, aphasia following cerebral infarction, cerebral edema, and unspecified convulsions.
According to the MDS assessment dated [DATE], R28 had unclear speech, was usually understood and usually able to understand orders, cognition was Not assessed/no information, required limited assistance of one person for bed mobility and was totally dependent upon one person physical assistance for transfers (which conflicted with the current plan of care).
Review of the activities of daily living (ADL) care plan initiated on 8/3/17, revised 11/22/21 read:
(R28) has an ADL self-care performance deficit r/t (related to) CVA (Cerebrovascular Accident/Stroke). S/P (Status Post) craniotomy. Hearing is adequate, with unclear speech, able to make self usually understood and usually understands others (with pictures to describe her needs, pen and paper at bedside), with impaired vision (sees only large print) and incontinent of bowel and bladder.
Interventions included:
TRANSFER: The resident requires Mechanical Lift (Hoyer) with 2 or more staff assist for transfers. This had been initiated on 8/3/17 and remained a current intervention.
Review of the safety care plan initiated 8/3/17, revised 3/27/18 read:
Safety: (Name of R28) is at risk for falls r/t loss of body control due to CVA. Hx (History) of falls prior to admission Interventions included: Low bed when not providing care. This had been initiated on 8/3/17 and remained a current intervention.
According to the most recent completed fall risk evaluation dated 11/4/2020, R28 scored an 18.0 and indicated Interventions Required.
On 10/17/22 at 10:42 AM, an interview was conducted with the Director of Nursing (DON) in the presence of the Regional Director of Clinical (Nurse 'S') and Corporate Clinical (Nurse 'O') to review the concerns observed with R28 being left positioned high in bed while unattended. The DON reported they would follow-up and acknowledged the resident should not have been left like that while unattended.
On 10/19/22 at 9:54 AM, the facility was requested to provide a facility policy for a resident's positioning while in bed. Review of the policies provided did not address this concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review the facility failed to ensure two nurses (Licensed Practical Nurse - LPN HH and Registered Nurse - RN II) followed the facility policy and maintained ...
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Based on observation, interview and record review the facility failed to ensure two nurses (Licensed Practical Nurse - LPN HH and Registered Nurse - RN II) followed the facility policy and maintained accountability of the controlled medications in the 2 East medication cart, resulting in the potential for residents being undermedicated, as well as medication loss or diversion of the controlled medications. Findings include:
On 10/18/22 at approximately 8:50 AM, Licensed Practical Nurse (LPN) HH was observed while administering the resident's morning medications. The nurse opened the first drawer of the 2 East medication cart and revealed a plastic medication cup that contained 10 small white round scored tablets. The cup was not labeled and the tablets did not have any letters or numbers on them. When LPN HH was asked what the tablets were, LPN HH replied they did not know. LPN HH was then asked if they completed a cart review and controlled medication count with the nurse going off duty and LPN HH stated they did not. When asked who did complete the cart review and controlled medication count with the off going nurse, LPN HH identified as Registered Nurse (RN) II. LPN HH was then asked if they completed a cart review and controlled medication count with RN II before taking the keys to the 2 East medication cart and LPN HH stated they did not. At 9:05 AM, an interview was conducted with RN II when asked if they completed the medication cart review and counted the controlled medication with the nurse going off duty for the 2 East Medication cart, RN II confirmed they did. When asked about the 10 pills found in the first drawer in a medication cup, RN II stated they did not see the medication in a cup when reviewing the cart with the off going nurse that morning. When asked if they completed a cart review and controlled medication count with LPN HH before providing them the keys to the 2 East medication cart, RN II confirmed they did not.
Review of a facility policy titled Controlled Substance Administration & Accountability revised 1/1/22, documented in part . It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . All keys to controlled substance containers shall be on a single key ring that is different from any other keys . The keys to this container should not be shared with other staff, including licensed staff without first conducting a complete controlled substance count . The nurse coming on duty and the nurse going off duty must make the count together .
On 10/18/22 at 3:17 PM, the Director of Nursing (DON) was interviewed and asked about RN II completing the cart review and controlled medication count with the nurse going off duty for the 2 East medication cart and then handing the keys to LPN HH without doing a cart review and controlled medication count and the DON stated if a nurse is late coming on duty the nurse that counted with the off duty nurse should have counted with the incoming nurse before providing them the keys to the cart.
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 follow a physician's order to obtain weights daily, 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 follow a physician's order to obtain weights daily, and notify within the identified parameters for one (R11) of one resident reviewed for congestive heart failure management, resulting in the increased potential for unidentified clinical changes and need for medical management.
Findings include:
According to the facility's policy titled, Weight Monitoring dated 1/1/2022, .A weight monitoring schedule will be developed upon admission for all residents .If clinically indicated - monitor weight daily .
On 10/17/22 at 10:24 AM, R11 was observed lying in bed and upon approach reported they were not feeling well today. R11 reported they were on fluid restrictions.
Review of the clinical record revealed R11 was admitted into the facility on 9/16/21 and readmitted on [DATE] with diagnoses that included: unspecified systolic (congestive) heart failure), chronic obstructive pulmonary disease, and obstructive sleep apnea.
According to the Minimum Data Set (MDS) assessment dated [DATE], R11 had no communication concerns, had moderately impaired cognition, exhibited no mood or behavior concerns.
Review of R11's physician orders included the following active orders:
Daily weights-notify Provider of weight gain of 3+ pounds in 24 hours or 5+ pounds in 1 week every day shift related to UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE). This had been ordered on 7/21/22.
2000 mL (Milliliters) FLUID RESTRICTION. Dietary to provide 1440 mL with meals, Nursing to provide 560 mL with medications-NO BEDSIDE WATER. every shift related to UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE. This had been ordered on 7/27/22.
Review of the care plans included:
The resident has (SPECIFY: fluid overload or potential fluid volume overload) r/t (related to) Disease process (UNSPECIFIED SYSTOLIC (CONGESTIVE) HEART FAILURE). This was documented as initiated and last revised on 7/20/22.
Interventions included:
Weigh at same time of day and record: (weekly times four weeks). The resident is weighed at (AM shift) using (SPECIFY: standing/WC (wheelchair) scale). Notify MD (Medical Doctor), RD (Registered Dietitian) of sudden wt (weight) changes (>5lbs in one week).
Although this care plan indicated this intervention weekly times four weeks, there was no revision to remove this intervention and the physician's order remained active as well as of this review.
Review of R11's weights since 7/20/22 included multiple missed opportunities (many blank or missing days), some were noted as refused by R11, some were marked NA (Not Applicable) with no supporting documentation, and other had weights documented that should've required follow-up with the provider as ordered, an RD per care plan.
The weight on 10/17/22 read, 222.8 pounds (lbs); the next documented weight on 10/18/22 read 216.0 lbs (a loss of 6.8 lbs).
The weight on 10/10/22 read, 200.8 lbs; the next documented weight on 10/13/22 read, 222.4 lbs (a gain of 21.6 lbs).
Review of the clinical record revealed there was no documentation that the provider or RD had been notified of the weight variances.
On 10/19/22 at 11:45 AM, an interview was conducted with the Director of Nursing (DON) in the presence of the Regional Director of Clinical (Nurse 'S') and Corporate Clinical Nurse 'O'. When asked what the facility's process was for obtaining, documenting and notifying of changes in weights, Nurse 'O' reported since the DON was new, they would assist and reported the electronic record system alerted which went to a weights and vitals board that would typically be cleared by the RD. Nurse 'S' reported they thought maybe the daily weight order should have been stopped a while ago and was included accidentally. No further explanations were provided as to the concern with lack of weight monitoring and reporting for R11's weight changes in accordance with physician orders.
On 10/19/22 at 11:55 AM, an interview was conducted with RD 'U'. When asked about the facility's alert system in their electronic medical record (EMR), and how they were notified of any weight changes, RD 'U' reported there were alerts that went to the weights and vitals sections. When asked about R11's weights and whether they had been notified of any changes within the past couple of weeks, RD 'U' reported they had not. RD 'U' further reported that the EMR system alerted if anyone had a significant weight change and the protocol to trigger the alert was a significant weight loss of 5% in 30 days or 10% in 180 days. When asked if the system was set up to alert for R11's physician orders for 3 or more lbs in 24 hours, or 5 or more lbs in one week, RD 'U' reported there was not.
When asked if they should be notified of those weight discrepancies if identified, they reported they should, but could not recall of any recent notifications. When asked if R11 should remain on daily weights, RD 'U' deferred to the physician for that decision.
On 10/19/22 at 12:22 PM, a phone interview was conducted with Physician 'J'. When asked about R11's order for daily weights and specifications of when to notify the providers, Physician 'J' deferred to their Nurse Practitioner (NP 'K') as they were in the facility frequently. Physician 'J' reported if there were concerns identified after 5:00 PM, they would be contacted, but was unable to recall anything recently about R11's weights.
On 10/19/22 at 12:25 PM, a phone interview was conducted with NP 'K'. When asked about R11's order for daily weights and specifications of when to notify, and whether they had been notified as there was no documentation this had occurred, NP 'K' reported nothing specific came to mind. When asked what the process was for monitoring residents with congestive heart failure (CHF) and NP 'K' reported usually with CHF they liked to have a weight every day. When reviewing the above weight changes, NP 'K' reported they were not able to recall being notified. NP 'K' reported they would likely talk with Physician 'J' about having R11's weights changed to every three to four days, but it has been every day.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 accurately assess, identify, implement timely treatmen...
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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 accurately assess, identify, implement timely treatments and interventions, and perform wound care treatments per physician's orders for one (R207) of four residents reviewed for pressure ulcers, resulting in the increased potential for unidentified new and/or worsening pressure injuries/ulcers.
Findings include:
According to the facility's policy titled, Pressure Injury Prevention Guidelines dated 1/1/22, .Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment .Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them .Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel floatation devices, cushions, mattresses) .Interventions will be documented in the care plan and communicated to all relevant staff .
On 10/17/22 at 9:40 AM, R207's nurse (Nurse 'Y') reported the resident was recently readmitted with hospice services and had a new pressure ulcer.
On 10/17/22 from approximately 9:40 AM to 3:40 PM, R207 was observed lying in bed on their back, slightly turned to the right with a pillow/wedge along their left side. R207 was observed laying in the same position during these observations and there was no low air loss mattress in use.
On 10/18/22 from approximately 9:35 AM to 1:20 PM, R207 was observed seated in a gerichair recliner in the main dining room leaning slightly to the right side, wearing oxygen via nasal cannula. R207 did not wake up upon approach. A urinary catheter drainage bag was observed clipped to the left side of the gerichair recliner. R207 was not observed to be repositioned by staff throughout these observations. There was no low air loss mattress in use.
On 10/18/22 at 1:25 PM, Certified Nursing Assistant (CNA 'I') confirmed they were assigned to R207. When asked when the resident had last been checked for incontinence care, CNA 'I' reported they had done it before the resident was placed in the gerichair (before 9:35 AM) and since they had a catheter, that wasn't needed. When asked about the resident's lack of repositioning, CNA 'I' offered no further response.
Review of the clinical record revealed R207 was admitted into the facility on [DATE], readmitted on [DATE] with hospice services. Diagnoses included: chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, Parkinson's disease, intellectual disabilities, Tourette's disorder, Alzheimer's disease with early onset, adult failure to thrive, and other seizures.
According to the discharge return anticipated MDS assessment dated [DATE], R207 had moderately impaired cognitive skills for daily decision making, had short term memory problem, was totally dependent for bed mobility, toilet use, and personal hygiene and had no unhealed pressure ulcers/injuries. The readmission assessment was currently in progress.
Review of R207's most recent BRADEN SCALE (tool used to measure risk for skin breakdown) score on readmission on [DATE] was a 10.0 (High Risk). The previous score on 8/7/22 was 14 (Moderate Risk).
Review of R207's nursing readmission documentation included:
On 10/11/22 at 3:40 PM, a nursing progress note read, .resident arrived via stretcher approximately 3:20 .Resident has edema on all 4 limbs. Bruising on arms and legs. Returned with existing heel and foot pressure injuries and scabs .
On 10/11/22 at 3:58 PM, a nursing progress note read, .resident has redness on left ear both front and back. bruise on left shoulder. bruising on back of left hand and first digit, right knee, bruise, right lateral knee, bruise, lower left arm, bruising. left foot, 2 PI (Pressure Injuries) on heel, left lateral foot, ankle and shin with scabs. Right medial ankle, right medial foot and right shin with scabs. scabs and PI's applied skin prep and wrapped feet with kerlix.
Review of the physician orders and corresponding Medication/Treatment Administration Records (MAR/TAR) since R207's readmission included:
On 10/14/22, Place Big Mattress on bed frame with Low Air Loss (LAL) Mattress on top of Big Mattress one time only for Pressure Ulcer Prevention. (This was noted as completed on 10/15/22 on the MAR, but as of 10/18/22 there was no LAL mattress observed.)
On 10/14/22 at 7:00 AM, Left lateral heel; apply betadine and let dry every day shift.
On 10/17/22 at 6:26 PM, additional physician order for R207's left lateral heel read, Cleanse with wound cleanser. Pat dry. Apply Bordered Foam as directed to Left Lateral Heel. Skin barrier wipe to peri wound. every day shift every 3 day(s) for Wound Care AND as needed for Loose or Soiled.
There were no wound care orders implemented upon R207's readmission on [DATE] until 10/14/22 (three days later) and as of this review on 10/18/22, there were no treatments implemented to address R207's other pressure injury areas.
Review of R207's pressure injury care plan initiated on 10/11/22 identified only a pressure injury to the left heel present on readmission. Interventions included on 10/11/22, The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested.
Review of R207's wound consultation on 10/13/22 with Wound Physician 'Z' read, .Left Heel (Lateral) .Pressure injury/ulcer - Wound Stage: Unstageable Pressure Injury (Obscured full-thickness skin and tissue loss) .LENGTH (centimeters/cm) 2.0 WIDTH (cm) 2.8 DEPTH (cm) Utd (Unable to determine) Wound Area (squared centimeters/cm2) 5.6 .The patient has a wound located on the left heel (lateral). The patient has diagnoses which include but are not limited to: Respiratory Failure, Malnutrition, Muscle Weakness, Dysphagia, Depression and Alzheimer's, etc. , that could contribute to additional deterioration or wound chronicity, retarding wound healing. The patient also has the following risk factors: Dementia, Depression, and Poor Nutritional Intake that might exacerbate the worsening of the pressure injury. The wound is stable and requires continued topical wound dressing therapy as noted above. Prognosis: I feel the prognosis for the patient is poor due to overall clinical status on hospice. High risk for development of new wounds, Discussed with hospice nurse at bedside. Follow-Up: follow up at an interval of 1 week. Offloading: continue offloading turn per facility protocol. A low air loss mattress is recommended. - discussed with hospice nurse at bedside. This evaluation only addressed the left lateral PI, and did not identify any other PI areas.
Review of R207's most recent weekly skin assessment dated [DATE] at 6:56 AM documented, .Are there any new abnormal skin areas? No .By acknowledging this box, I confirm that I conducted a full skin assessment and no new abnormal skin areas were observed. (box was check marked) .Are there any existing abnormal skin areas? Yes .List sites: Left heel pressure injury, treatment on going, other bilateral buttock no open wound, treatment on going . The comment section was left blank. There was no identification of any of the other skin concerns.
Additionally, review of the most recent wound care evaluation from Nurse 'L' on 10/17/22 at 4:15 PM documented the only wound location for R207 as an unstageable pressure injury to the left lateral heel with comments that read , .Wound is chronic, may or may not heal, and may worsen due to multiple chronic comorbidities .and chronic waxing and waning of wound. Continue to employ prescribed and/or appropriate interventions to reduce/prevent pressure wounds. Continue to monitor and to provide treatment. Although this identified the wound was chronic, R207 did not have pressure injuries/ulcers upon discharge to the hospital on 9/26/22 and were identified as new upon their readmission on [DATE].
On 10/18/22 at 9:50 AM, an interview was conducted with the Director of Social Work (SW 'Q'), Regional Director of Operations (Staff 'B') and Corporate Clinical Nurse (Nurse 'O'). When asked about the lack of LAL mattress for R207, SW 'Q' reported there was a recent change in hospice services made today and Staff 'B' reported a LAL mattress was to be delivered today with the new hospice company. When asked why there had not been a LAL mattress implemented earlier and why the MAR was noted as being completed on 10/15/22 when it was not, no further explanation was offered.
On 10/18/22 at 11:05 AM, an interview and record review were conducted with the Regional Director of Clinical Care (Nurse 'S'). When asked about the lack of wound identification, wound care treatments, and delay in wound care interventions, Nurse 'S' reported they would have to look further and would follow-up.
On 10/18/22 at 3:28 PM, wound care for R207 was completed with the Wound Nurse/Licensed Practical Nurse (Nurse 'L') who reported they had recently passed the test for wound certification. When asked about if there was a wound consultant that came to the facility, Nurse 'L' reported there was, Physician 'Z' who came to the facility every Thursday and Looked at anything that qualifies as a wound or derm issue. Nurse 'L' reported they had not seen R207's wound to the left lateral ankle since last Thursday (10/13/22) and recalled it was all necrotic (dead tissue). Upon removing R207's heel protectors, both feet were bare and there were no treatments observed to either foot. Nurse 'L' looked at the resident's left foot and stated, I'm gonna do something a little different than what's called for. Nurse 'L' proceeded to cleanse the left lateral wound and left heel with Derma Klenz and reported that was a generic wound cleanser and that the wound requires more than skin prep at this time, gonna put xeroform gauze dressing, it's a non-adhesive, it won't stick to the wound. Nurse 'L' then placed a dry dressing and wrapped with gauze. When asked about the missing treatment when they first removed the heel protector, Nurse 'L' stated, Supposed to be done every day shift. Should've had treatment on there, not sure why it wasn't.
Nurse 'L' was ready to exit the room and when asked about if there were any other treatments that needed to be done, they indicated they were only aware of the left lateral foot.
Nurse 'L' then observed R270's right foot and reported the area to the heel was scabbed over and there was also a new area on the right outer ankle on the bony prominence and would put the same xeroform gauze dressing.
When asked if they had been informed of any skin changes since last Thursday when they had seen R270, they reported, No. If it's like it is now, would've needed an order for treatment not just a dry dressing. I wasn't notified of any changes. That's another area on right heel on bony part. It's got a scab on it. When asked about the inner aspect of the ankle, Nurse 'L' reported, That's another area too.
On 10/18/22 at 5:15 PM, the Director of Nursing (DON) was asked if Nurse 'L' was available for an interview, to review concerns identified during R207's wound care earlier. The DON reported Nurse 'L' was gone for the day. At that time, the DON was informed of the concerns regarding lack of identification for all of R207's wounds that had been present on readmission, lack of inaccurate skin assessments, delayed treatment and/or missing treatments, and delayed PI interventions. The DON reported they would have to follow up with Nurse 'L'.
On 10/18/22 at 5:40 PM, an interview was conducted with the DON and Nurse 'S'. Nurse 'S' was informed of the same concerns as discussed with the DON. When asked about the conflicting skin assessment that had been completed this morning, including lack of treatment and delay in interventions, Nurse 'S' reported they would be doing a head-to-toe assessment and would follow up.
When informed of the concern that Nurse 'L' did not follow the physician ordered treatment and had not contacted the physician to obtain further guidance and/or order changes, including documentation of what treatment changes had been provided, or any other changes identified with the other wounds, Nurse 'S' reported they would have to follow up.
When asked about the concern that the skin assessment noted as completed this morning also identified only the left lateral foot, and indicated there were no other areas of concern, Nurse 'S' reported maybe those other wounds had developed since then. (The other areas had been identified upon readmission on [DATE].)
On 10/19/22 at 8:25 AM, Nurse 'S' reported they had done a head-to-toe assessment of R207 with Nurse 'O' and the DON and identified no new areas, but confirmed there were other areas that had been present on readmission and provided a copy of the same nursing admission note mentioned above on 10/22/22 at 3:58 PM. When asked to clarify, why there was only wound care treatments initiated for the left lateral foot, if these other areas had been identified on admission, and why treatment had been delayed for the left foot until 10/14/22 as well, and not identified on any of the other skin assessments since readmission, Nurse 'S' reported they were not able to answer that and would have to provide further education. When asked about the facility's protocol for how the wound nurse and/or wound physician were notified of resident's wounds, Nurse 'S' reported wounds were discussed in their daily interdisciplinary team meetings and was unable to offer any further explanation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure hand braces/splints were applied for one (R31) o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure hand braces/splints were applied for one (R31) of six residents reviewed for a limited range of motion. Findings include:
On 10/17/22 at 9:11 AM, R31 was observed lying on their back in bed with their eyes closed. Observed above their bed was a sign that documented in part . use hand splints . There were no hand splints/braces observed on R31's hands. At 2:29 PM, R31's family member was observed in R31's room and interviewed. When asked R31's family member stated the splints/braces should be applied everyday but the staff will not consistently put them on. R31's family member stated they had just applied R31's hand splints/braces because the splints/braces were not on when they came in for a visit.
On 10/18/22 at 11:40 AM, R31 was observed lying in bed their hand splints/braces were not observed on their hands.
On 10/19/22 at 1:19 PM and 3:09 PM the hand splints/braces were not observed to be applied to R31's hands.
Review of the medical record R31 was admitted to the facility on [DATE] with a readmission date of 8/10/22 and diagnoses that included: acute and chronic respiratory failure, dysphagia and quadriplegia. A MDS assessment dated [DATE] documented Severely impaired cognitive skills for daily decision making and required extensive staff assistance for all ADLs.
Review of a physician order dated 10/12/22, documented in part . Monitor bilateral hand braces for signs of swelling and correct fit every two hours and prn (as needed) .
On 10/19/22 at 12:54 PM, the Regional Director Of Clinical (RDOC) S was interviewed and asked about R31's hand splints/braces and RDOC S stated when they were in the facility, they ensured that R31's hand splints/braces were applied every day. When asked about the observations with R31's hand splints/braces to not have been applied, RDOC S stated they would follow up on it.
No further information or documentation was received by the end of survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure that three Certified Nurse Aides (CNA 'E', 'F', and 'G') whose in-service training files were reviewed, had the required 12 hours of...
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Based on interview and record review, the facility failed to ensure that three Certified Nurse Aides (CNA 'E', 'F', and 'G') whose in-service training files were reviewed, had the required 12 hours of in-service training within the required time period, resulting in the potential for unmet educational needs and unmet resident care needs.
Findings include:
According to the facility's policy titled, Training Requirements dated 1/1/22:
.It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles .The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. This person works closely with the Compliance Officer and other facility leaders in developing the program .The amount and types of training necessary are based on a facility assessment .Training content includes, at a minimum .The rights of the residents and the responsibilities of the facility to properly care for its residents .Behavioral Health .Dementia management and care of the cognitively impaired .Abuse, neglect, and exploitation prevention .Safety and emergency procedures .It is the responsibility of each employee, volunteer, or contract staff to complete required training .In-service training is provided by qualified personnel in a variety of formats .The Staff Development Coordinator maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers .
On 10/19/22 at 9:04 AM, the Administrator was requested to provide the annual 12-hour in-service education for CNA 'E' (date of hire was 7/1/14), CNA 'F' (date of hire was 6/8/04) and CNA 'G' (date of hire was 3/18/14).
On 10/19/22 at 12:50 PM, the Administrator was sent another request to provide the documentation as requested earlier.
ON 10/19/22 at 3:21 PM, the Administrator reported they had reviewed their education and was inconsistent and they were no able to provide the requested information regarding the annual 12-hour in-service education for CNA 'E', 'F', and 'G'.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure adequate pharmaceutical services to ensure provision of accurate acquiring, receiving and dispensing of controlled subs...
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Based on observation, interview and record review, the facility failed to ensure adequate pharmaceutical services to ensure provision of accurate acquiring, receiving and dispensing of controlled substance for one resident (R207) and one medication cart, resulting in the increased potential for inaccurate reconciliation and/or potential diversion of controlled medication.
Findings include:
According to the facility's policy titled, Medication Storage dated 1/1/2022:
.Narcotics and Controlled Substances .Any discrepancies which cannot be resolved must be reported immediately to the Director of Nursing and Administrator or designee .
On 10/18/22 at 11:30 AM, an observation of the first-floor medication room was conducted with Nurse 'C'. The small refrigerator was observed to contain a bottle of liquid lorazepam (a controlled substance) for R207. The bottle was opened with the plastic wrap seal broken. The bottle identified the maximum dose line was 22 ML (milliliters) but the liquid in the bottle was observed filled above this, almost to the bottle opening. The pharmacy label on the bottle indicated they had provided 30 ML. When asked how this medication was counted as the bottle had identified that the pharmacy provided 30 ML but the bottle measurement only went up to 22 ML, Nurse 'C' reported they were not sure and they thought it might have still been unopened when they counted it earlier. When asked if they did the controlled substance medication count when they started, Nurse 'C' reported the Director of Nursing (DON) and themselves had, then stated the DON counted with Nurse 'M'. When asked to clarify, Nurse 'C' reported when they took the keys from the DON, they saw the bottle in the medication room and it looked unopened.
On 10/18/22 at 11:55 AM, an interview was conducted with the DON and the Regional Director of Clinical (Nurse 'S'). The DON was asked if they had been notified of any concerns with nurses not being able to confirm the actual amount of liquid lorazepam and they reported they did not. Both were informed of the observation of the first-floor medication room and interview with Nurse 'C'. The DON was asked how the nurses were able to perform an actual account of the liquid controlled substance if the bottle was overfilled from pharmacy and they reported they were not sure how that would happen. When asked if they had done the narcotic count with the nurses this morning when they received the keys that had been then turned over to Nurse 'C', the DON reported they did not. The DON further reported they had provided Nurse 'C' with the keys and the night nurse (Nurse 'D') and the day nurse (Nurse 'M') had done the count.
On 10/18/22 at 3:19 PM, the DON reported whether a nurse was arriving, leaving or late, it should be counted off no matter what time a person comes on. When asked what their facility process was as far as what medications were counted when that occurred, the DON reported they thought they counted off only controlled meds. The DON reported they were a little concerned regarding the labeling of R207's liquid lorazepam and was unsure how anyone would be able to accurately account for the medication provided by pharmacy as it was provided and that was a concern for the safety of their nurses.
On 10/18/22 at approximately 8:50 AM, Licensed Practical Nurse (LPN) HH was observed while administering the resident's morning medications. The nurse opened the first drawer of the 2 East medication cart and revealed a plastic medication cup that contained 10 small white round scored tablets. The cup was not labeled and the tablets did not have any letters or numbers on them. When LPN HH was asked what the tablets were, LPN HH replied they did not know. LPN HH was then asked if they completed a cart review and controlled medication count with the nurse going off duty and LPN HH stated they did not. When asked who did complete the cart review and controlled medication count with the off going nurse, LPN HH identified as Registered Nurse (RN) II. LPN HH was then asked if they completed a cart review and controlled medication count with RN II before taking the keys to the 2 East medication cart and LPN HH stated they did not. At 9:05 AM, an interview was conducted with RN II when asked if they completed the medication cart review and counted the controlled medication with the nurse going off duty for the 2 East Medication cart, RN II confirmed they did. When asked about the 10 pills found in the first drawer in a medication cup, RN II stated they did not see the medication in a cup when reviewing the cart with the off going nurse that morning. When asked if they completed a cart review and controlled medication count with LPN HH before providing them the keys to the 2 East medication cart, RN II confirmed they did not.
Review of a facility policy titled Controlled Substance Administration & Accountability revised 1/1/22, documented in part . It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure . All keys to controlled substance containers shall be on a single key ring that is different from any other keys . The keys to this container should not be shared with other staff, including licensed staff without first conducting a complete controlled substance count . The nurse coming on duty and the nurse going off duty must make the count together .
On 10/18/22 at 3:17 PM, the Director of Nursing (DON) was interviewed and asked about RN II completing the cart review and controlled medication count with the nurse going off duty for the 2 East medication cart and then handing the keys to LPN HH without doing a cart review and controlled medication count and the DON stated if a nurse is late coming on duty the nurse that counted with the off duty nurse should have counted with the incoming nurse before providing them the keys to the cart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure an accurate indication for the use of psychotro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure an accurate indication for the use of psychotropic medications for one (R51) of five residents reviewed for unnecessary medications. Findings include:
On 10/17/22 at 9:44 AM, R51 was observed lying on their back in bed with their eyes closed. A grey wedge was observed in between their legs and blue inflated boots on both feet. The resident did not respond to verbal stimuli. The resident was observed to have a tracheostomy and gastrostomy.
Review of the medical record revealed R51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, dysphagia and severe protein-calorie malnutrition. A Minimum Data Set (MDS) assessment dated [DATE], documented Severely impaired cognition skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs).
Review of the physician orders documented the following:
Clonazepam 0.5 mg (milligram) tablet, give 1 mg by mouth two times a day for seizure.
Quetiapine Fumarate 100 mg tablet, give 100 mg via PEG-Tube every 12 hours for bipolar disorder.
Review of the resident medical diagnoses revealed no documentation of seizure or bipolar disorder.
Review of the R51's preadmission documents provided to the facility documented no history of a seizure of bipolar disorder.
Review of the physician notes and medical record revealed no documentation of the resident ever having the diagnoses of a seizure or bipolar disorder and no documentation of the Clonazepam or Quetiapine Fumarate having been reviewed for the correct rationale or the need of either psychotropic medication.
Review of an Initial Social Service History dated 9/4/22, documented in part . admitted on a psychoactive medication(s) . Yes . clonazepam- anxiety, QUEtiapine- bipolar . History of other behaviors or mood disorders (specify) . none . This assessment was completed by the Director Of Social Services (DOSS) Q.
On 10/19/22 at approximately 8:45 AM, the Regional Director Of Clinical (RDOC) S was interviewed and asked to verify the medical diagnoses and clinical rationale for the prescribed clonazepam and quetiapine medications, RDOC S stated they would look into it.
On 10/19/22 at 9:51 AM, DOSS Q was interviewed and asked where they obtained the diagnoses for the clonazepam and quetiapine medications. DOSS Q stated they obtained the diagnoses from the physician orders. When asked to clarify being that the physician orders documented the use of the clonazepam for a seizure disorder and they documented the use of the clonazepam for an anxiety disorder, DOSS Q stated . it must have been an oversight .
No additional explanation or documentation was provided by the end of survey.
Review of a facility policy titled, Medication - Psychotropic revised 1/1/22 documented in part, . Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident . Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform adequate hand hygiene practices during wound c...
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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 perform adequate hand hygiene practices during wound care for one (R207) of four residents reviewed for pressure injury/ulcers, resulting in the increased potential for wound infection and cross-contamination.
Findings include:
According to the facility's policy titled, Hand Hygiene dated 1/1/2022, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .Hand Hygiene Table .Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred) .After handling contaminated objects .Before and after handling clean or soiled dressings, linens, etc .
On 10/17/22 at 9:40 AM, R207's nurse (Nurse 'Y') reported the resident was recently readmitted with hospice services and had a new pressure ulcer.
Review of the clinical record revealed R207 was admitted into the facility on [DATE], readmitted on [DATE] with hospice services. Diagnoses included: chronic respiratory failure with hypoxia, severe protein-calorie malnutrition, Parkinson's disease, intellectual disabilities, Tourette's disorder, Alzheimer's disease with early onset, adult failure to thrive, and other seizures.
According to the discharge return anticipated MDS assessment dated [DATE], R207 had moderately impaired cognitive skills for daily decision making, had short term memory problem, was totally dependent for bed mobility, toilet use, and personal hygiene and had no unhealed pressure ulcers/injuries. The readmission assessment was currently in progress.
On 10/18/22 at 3:28 PM, wound care for R207 was observed with the Wound Nurse/Licensed Practical Nurse (Nurse 'L') who reported they had recently passed the test for wound certification. Upon first entering the room, Nurse 'L' washed their hands and donned gloves. Nurse 'L' then exited the room by touching the door handle, removed treatment supplies (gauze, dressings and wound cleanser) and returned to the room and reported they didn't have a tray (barrier) but that would be ok and placed the treatments supplies directly on the resident's bed linens. Nurse 'L' was then observed to remove R207's heel protectors, both feet were bare and there were no treatments observed to either foot. Nurse 'L' looked lifted the resident's left foot and stated, I'm gonna do something a little different than what's called for. Nurse 'L' proceeded to cleanse the left lateral wound and left heel with Derma Klenz and reported that was a generic wound cleanser and that the wound requires more than skin prep at this time, gonna put xeroform gauze dressing, it's a non-adhesive, it won't stick to the wound. Nurse 'L' then exited the room to obtain the xeroform gauze dressing from the medication cart (while wearing the same gloves they had donned initially touching door handle and treatment cart) and returned to the room without removing gloves and washing hands/using hand sanitizer. With the same soiled gloves, Nurse 'L' placed the xeroform gauze dressing, covered with a dry dressing and wrapped with gauze. When asked about the missing treatment when they first removed the heel protector, Nurse 'L' stated, Supposed to be done every day shift. Should've had treatment on there, not sure why it wasn't.
Nurse 'L' was ready to exit the room and when asked about if there were any other treatments that needed to be done, they indicated they were only aware of the left lateral foot. Nurse 'L removed their gloves and exited the room by touching the door handle and reviewed R207's treatment orders and confirmed there was only a treatment order for the left lateral heel. Nurse 'L' was then observed to don new gloves, without washing hands or using hand sanitizer and obtain additional treatment supplies.
Nurse 'L' then observed to pick up and inspect R207's right foot and reported the area to the heel was scabbed over and there was also a new area on the right outer ankle on the bony prominence and would put the same xeroform gauze dressing. Nurse 'L' removed the glove to the right hand and left the room again to obtain additional gauze bandage. Upon returning to the room, without removing the glove on the left hand, and with an ungloved (bare) right hand (no handwashing and/or hand sanitizer was used), they began to cleanse and apply xeroform gauze bandage, dry dressing and dry gauze wrap to the resident's right foot.
On 10/18/22 at 5:15 PM, the Director of Nursing (DON) was asked if Nurse 'L' was available for an interview, to review concerns with infection control and hand hygiene identified during R207's wound care earlier. The DON reported Nurse 'L' was gone for the day. At that time, the DON was informed of the concerns regarding lack of hand hygiene and infection control practices and they reported they would have to follow up with Nurse 'L' for re-education.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to educate and offer the Influenza and pneumococcal vacci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to educate and offer the Influenza and pneumococcal vaccine for three of five residents (R53, R207 and R307) of five residents reviewed for the Influenza and pneumococcal vaccinations. Findings include:
R207
Review of the medical record revealed R207 was admitted to the facility on [DATE].
Review of the immunization tab revealed no documentation of the influenza vaccine to have been administered to R207 for the 2022-2023 season. Further review of the medical record revealed no documentation of education or consent to have been provided to R207 and/or R207's representative.
R53
Review of the medical record revealed R53 was admitted to the facility on [DATE].
Review of the immunization tab revealed no documentation of R53 to have ever received the pneumococcal vaccine. Further review of the medical record revealed no documentation of education or a consent to have been provided to R53 and/or R53's representative.
R307
Review of the medical record revealed R307 was admitted to the facility on [DATE].
Review of the immunization tab revealed no documentation of R307 to have ever received the pneumococcal vaccine. Further review of the medical record revealed no documentation of education or a consent to have been provided to R307 and/or R307's representative.
Review of a facility policy titled Influenza Vaccination revised 8/2/20, documented in part . It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza . Influenza vaccinations will be routinely offered annually from October 1st . Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed, and dated record will be filed in the individual's medical record . The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal .
Review of a facility policy titled Pneumococcal Vaccine revised 3/2022, documented in part . It is our policy to offer our residents . immunization against pneumococcal disease in accordance with current CDC (Center for Disease Control) guidelines and recommendations . Each resident will be assessed for pneumococcal immunization upon admission . Any additional efforts to obtain information shall be documented . Each resident will be offered a pneumococcal immunization . Prior to offering . each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization . A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record .
On 10/19/22 at 11:23 AM, an interview was conducted with the Regional Director Of Clinical (RDOC) S. RDOC S was asked to provide the education and consent for the Influenza vaccine that was provided to R207 and/or their representative and the education and consent for the pneumococcal vaccine provided to R53 and 307 and/or their representatives. RDOC S stated they would look into it and follow back up. At 1:08 PM, RDOC S stated they could not find any documentation of the requested documents. RDOC S stated they believed R207 received their Influenza vaccine while hospitalized . RDOC S was asked to provide that documentation.
No further explanation or documentation was provided by the end of survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to educate and offer the COVID-19 vaccination for one (R307) of five r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews the facility failed to educate and offer the COVID-19 vaccination for one (R307) of five residents reviewed for the COVID-19 immunization. Findings include:
Review of R307's medical record revealed they were admitted to the facility on [DATE].
Review of the medical record revealed no documentation of R307 ever receiving the COVID-19 vaccine. Further review of the medical record revealed no documentation of education or a consent for the COVID-19 vaccination to have been provided to the resident and/or resident representative.
On 10/19/22 at 11:23 AM, Regional Director Of Clinical (RDOC) S was interviewed and asked to provide documentation that R307 and/or representative was provided education and offered the COVID-19 vaccination by the facility. RDOC S stated they would look into it. At 1:08 PM, RDOC S returned and stated they were unable to find that education and a consent had been provided to R307 and/or to R307's representative.
Review of a facility policy titled COVID-19 Vaccination revised on 6/4/22, documented in part . It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 . by educating and offering our residents . the COVID-19 vaccine .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to address and resolve grievances brought forth by five (5) resident's attending Resident Council and resident family members. Findings include...
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Based on interview and record review the facility failed to address and resolve grievances brought forth by five (5) resident's attending Resident Council and resident family members. Findings include:
A review of the resident council meeting minutes dated 9/14/22 listed the following concerns: Issues with Certified Nursing Assistant (CNA) I ) staff person being rude and disrespectful and not addressing resident concerns, call light issues on weekends and not passing trays timely and replacing blinds for (name redacted) resident. *It should be noted that there were no resident council minutes for the months 6/22, 7/22 and 8/22.
A resident council meeting was held on 10/18/22 at 2:30 PM, six residents were present in the room and five participated in the meeting. The residents who wished to remain anonymous reported several concerns pertaining to staffing. Two residents provided specific names that include CNA I, CNA G who were rude, disrespectful and often just hung out talking to each other or were on their phones ignoring them and the call lights. A resident also noted that they were reporting concerns for themselves, but also for other residents, including one who had requested to attend group, but was not assisted out of bed timely. One resident said they just were not answering call lights and had figured out a way to avoid the call light system. Another resident noted that they had expressed these concerns on several occasions but did not always fill out a form. They also expressed a concern that last night (10/17/22) there were no CNAs on their floor, and they were told that they had to get into bed right after dinner. One resident stated that they have expressed a concern with their window blind as it was too short and noted that their room backed the parking lot and staff/visitors could look directly into their room. The resident stated that they were told the many months ago that the blind was on order but hadn't arrived. At the end of the meeting a resident's family member knocked on the door and expressed that their parent had wanted to attend the meeting earlier in the day, but staff did not get them up to attend. A meeting was held with the resident and resident's family. They both expressed concerns with staff, primarily CNAs being rude, not answering call lights or timely passing food trays. The family member also expressed that there were no CNAs working the afternoon shift on Sunday (10/16/22) and that they had to change their family member and also assist the resident's roommate with care as they were very wet. The family member noted that she had expressed her frustration to nursing staff.
On 10/18/22 at approximately 4:08 PM, Activity Directory (AD) DD was interviewed. AD DD reported that they had started employment with the facility on 9/19/22. When asked as to concerns that had been previously addressed in the resident council meetings, AD DD reported that she was currently focusing on arranging activities for all the residents and had not held a resident council meeting since her start date and had not focused on prior grievances. When asked about the two residents who wanted to attend the resident council meeting, but were not prepared by staff to attend, AD DD stated that she had told the Nurses and CNAs to get them up because she was aware they wanted to attend.
On 10/19/22 at approximately 9:44 AM, an interview was conducted with the Administrator. The Administrator was asked as to whether the concerns noted in resident council minutes dated 9/14/22 were addressed as the resident(s) were still expressing concerns as to staffing attitudes. The Administrator reported that they were present at the meeting and were aware of the resident's concerns and believed the facility had provided customer care training to all the staff. The Administrator was not sure as to whether the date of the training was prior to or after the 9/14/22 resident council meeting and noted that they would provide documentation. No documentation was provided prior to the end of the Survey. With respect to the facility's response to concerns that specified specific staff members, including, but not limited to CNA I, the Administrator indicated that direct in-service training was difficult as the staff members needed a Union Steward present during the training and they often were not available.
On 10/19/22 at approximately 10:26 AM, Maintenance Director EE was interviewed about the resident who noted they did not have a full blind covering their window. Maintenance Director EE stated that they believed one was ordered, but it had not been delivered. He was asked to provide documentation of the order. No documentation was provided by the end of the Survey.
A facility policy titled, Complaint and Grievance Process (Revised 1/1/2022) was reviewed and documented, in part, the following: Purpose: To enable any individual to file a complaint either directly to the Facility or to the Secretary of Health and Human Services. Policy: .the Facility will assist the individual with the complaint and grievance process .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dependent residents were consistently provided ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dependent residents were consistently provided with showers/bathing, removal of unwanted hair, and fingernail care for four (R3, R11, R27, R53) of six residents reviewed for Activities of Daily Living (ADL's), resulting in dissatisfaction with hygiene and grooming, omitted scheduled showers, unshaven facial hair, and long dirty fingernails. Findings Include:
R27:
On 10/17/22 at 9:25 AM, R27 was observed lying in bed, stubble was present on his face and neck. R27 was asked if he wanted a beard. R27 explained he wanted to be clean shaven, but they did not shave him every time he had a shower or bath.
Review of the clinical record revealed R27 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: amyotrophic lateral sclerosis (ALS), contractures of right and left hands, heart failure. According to the Minimum Data Set (MDS) assessment dated [DATE], R27 had intact cognition and was totally dependent on staff for all ADL's.
On 10/18/22 at 2:55 PM, R27 was observed lying in bed with the same stubble on his face. R27 explained he had been given a bed bath earlier that day, but they did not shave him.
On 10/18/22 at 3:10 PM, Certified Nursing Assistant (CNA) V, R27's assigned CNA, was asked about providing shaving and nail care to residents. CNA V explained shaving and nail care should be provided to residents at every shower or bed bath, but sometimes they did not have enough time to do all the care, so there were times shaving or nail care did not get done.
On 10/19/22 at 9:03 AM, R27 was observed lying in bed, the stubble was observed unchanged.
On 10/19/22 at 12:03 PM, the Director of Nursing (DON) was interviewed and asked about shaving residents. The DON explained it should be offered every time a resident got a shower or bed bath. When asked if residents had to ask to be shaved, the DON explained the resident should not have to ask, it should be offered every time.
R3
On 10/17/22 at approximately 9:24 AM, R3 was observed lying in bed. The resident was alert, but not able to answer questions. R3 was eating their breakfast with their hands and their nails were long, approximately one quarter inch past the nail bed. The resident's gown was not on correctly, his chest was exposed and covered with food. His room smelled of urine.
On 10/18/22 at approximately 8:45 AM, R3 was lying in bed. His nails had not been trimmed.
On 10/19/22 at approximately 9:19 AM, R3 was observed lying in bed. Again, the resident was eating breakfast and food was covering his body. His nails were still long and not trimmed.
A review of R3's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, dementia and depression. A review of the MDS indicated R3 had a BIMS score of 6/15 (cognitively impaired) and required one to two person assist for most ADLs.
A review of the resident's [NAME] for ADL care indicated the resident was to receive bathing/showers on Tuesday and Friday on midnights. A 30-day look back for bathing revealed only three bed baths were provided (10/4/22, 10/5/22 and 10/12/22). There was nothing on the [NAME] that noted if nails were trimmed.
On 10/19/22 at approximately 9:29 AM, Certified Nursing Assistant (CNA) FF was asked how about providing and documenting ADL care, specifically bathing and nail care. CNA FF reported that when a shower or bed bath is given it is placed in the electronic record and if the resident's nails need trimming it should be done at that time. CNA FF noted there is not a specific section to address nail care. CNA FF further indicated that at times there is not always enough staff to ensure showers and additional ADL care is provided.
R53:
On 10/17/21 at approximately 9:51 AM, R53 was observed lying in bed. The resident was alert and able to answer questions asked. When queried as to ADL care including showers, R53 indicated that they have only had one shower in the past month and would like another one to ensure their hair was washed. R53 indicated that they will provide a bed bath, but that is all they do.
A review of the R53's clinical record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Type II Diabetes, and stage 4 sacral wounds. Review of the MDS indicated the resident had a BIMS score of 11/15 (moderately impaired cognition) and required extensive one to two person assist for ADLs.
A review of the R53's [NAME] for ADL care indicated the resident was to receive bathing/showers on Tuesday and Friday on the day shift. A 30-day look back for showers revealed only one shower was provided on 9/23/22 and one refusal date on 10/11/22.
Review of R53's Care Plan documented, in part, the following: Focus: The resident needs activities of daily living assistance related to immobility (7/30/22) .Interventions: Resident and or RP (representative) would prefer for resident to get out of bed at least twice weekly .Resident requires 2 person care at all times .
On 10/19/22 at approximately 12:07 PM, an interview and record review were conducted with the Director of Nursing (DON) regarding resident's ADL care including R3 and R53. With respect to R3, the DON noted that nail care should during showers or as needed. The DON reported that R53 will refuse their showers. The DON was asked to provide any documentation that indicated showers were offered and refused. The DON could not locate any documentation prior to the end of the survey.
A review of the facility policy titled, Activities of Daily Living (ADLs) (Revised 1/1/2022) documented, in part: Policy: The facility will ensure a resident's abilities in ADLs do not det unless deterioration is unavoidable. This includes the residents ability to: 1. Bathe, dress and groom; Transfer and ambulate; Toilet; 4. Eat; and 5. Use speech, language or other functional communication systems .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .
R11:
On 10/17/22 at 10:24 AM, R11 was observed lying in bed and reported they weren't feeling well. The resident's nails were observed to be long with dark debris underneath some of the nail tips. Some of the nails were thick and yellow in color. When asked if staff took care of trimming their nails, R11 responded Either the staff or myself. R11 then looked at their left hand and stated, Oh that's longer, they do need to be cut.
On 10/18/22 at 11:12 AM, R11 was observed seated upright on the side of bed. They reported they felt much better today. When asked if anyone had come to trim their nails since the discussion yesterday, R11 reported, No one's cut my fingernails yet.
Review of the clinical record revealed R11 was admitted into the facility on 9/16/21 and readmitted on [DATE] with diagnoses that included: unspecified systolic (congestive) heart failure), diabetes mellitus with diabetic neuropathy, neuralgia and neuritis.
According to the MDS assessment dated [DATE], R11 had no communication concerns, had moderately impaired cognition, had no mood or behavior concerns, and required extensive assistance of one person for dressing, and personal hygiene.
Review of the activities of daily living (ADL) care plan initiated 9/16/21, revision on 9/6/22 included interventions which read, BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. This had been initiated on 9/27/21.
Review of the shower documentation as of 10/18/22 2:14 PM revealed the last documented shower was on 10/13/22 at 3:17 PM by Certified Nursing Assistant (CNA 'N'). Prior to that, the next previous shower was done on 10/7/22 by CNA 'G'.
On 10/18/22 at 1:32 PM, an interview was conducted with CNA 'G' who was currently assigned to R11. When asked about what the process was for providing nail care, CNA 'G' reported nail care was done when the residents needed it. CNA 'G' further reported they recalled giving R11 a shower on Friday (documentation showed this was on 10/7/22 and not this past Friday 10/14/22). When asked if nail care had been identified as a concern at that time, CNA 'G' reported No. CNA 'G' was asked to observe the resident's fingernails which revealed they were longer in length and extended beyond the nail tips. CNA 'G' reported, I'm not sure what you're looking at but those are not long, they're near the tip. R11 continued to report they needed their nails cut. When asked if nail care had been offered and possibly refused, where would that be documented, CNA 'G' replied, Not sure what you're looking at but can't document that in POC (a section of the electronic clinical record). When asked if that wasn't able to be documented, what was then done, CNA 'G' reported, What you mean? Just tell the nurse. When asked if they were able to recall if they had ever reported anything to the Nurse about R11 refusing care, they reported No. Nothing in POC to be able to document nail care and shaving.
On 10/18/22 at 1:40 PM, the Director of Nursing (DON), Regional Director of Clinical (Nurse 'S') and Corporate Clinical Nurse 'O' were informed of the concern with the observation of the long, dirty nails and the interview with CNA 'G'. Nurse 'S' reported they would follow-up now.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DPS #3
Based on observation, interview and record review the facility failed to ensure care, cleaning and maintenance of a femal...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DPS #3
Based on observation, interview and record review the facility failed to ensure care, cleaning and maintenance of a female external catheter was ordered and documented, and ensure staff were appropriately trained for one (R13) of one resident reviewed for external catheters. Findings include:
On 10/17/22 at 9:36 AM, R13 was observed lying in bed. An apparatus containing a suction canister and tubing running to R13's abdominal region, going under R13's blankets was observed. R13 was connected to a ventilator via a tracheostomy, R13 could not verbalize words, but could mouth words. When asked about the apparatus, R13 mouthed it was her catheter.
On 10/17/22 at 1:55 PM, Registered Nurse (RN) T, R13's assigned nurse, was asked about R13's catheter. RN T explained it was a female external catheter, it was R13's personal apparatus, she had brought it from her home because she did not qualify for an indwelling catheter.
Review of the clinical record revealed R13 was admitted into the facility on 7/22/22 with diagnoses that included: tracheostomy status, pneumonia and anxiety disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R13 had intact cognition, and required the extensive to total assistance of staff for all activities of daily living (ADL's).
Review of R13's bladder incontinence care plan revised 8/7/22 revealed no interventions for an external catheter use or care.
Review of R13's progress notes revealed no mention of an external catheter.
Review of R13's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed an order with a start date of 10/17/22 at 3:30 PM that read, Empty urinary collection system every 6 hours as needed. It should be noted this order was discontinued on 10/18/22 at 6:15 PM, with no documentation it was ever done.
On 10/18/22 at 10:31 AM, R13 was observed lying in bed. As R13 was not connected to the ventilator, R13 was able to verbally talk. When asked about the catheter apparatus, R13 explained it was her personal apparatus, she only used it at night because the facility was so short of staff, she was staying wet all the time and she did not want to stay in a wet brief all night. R13 was asked how long the apparatus had been at the facility. R13 explained she had her family bring it about two months previous. When asked who was cleaning and applying the apparatus, R13 explained her family was bringing in supplies to clean the container and staff were putting it on and taking it off her.
On 10/18/22 at 3:05 PM, Certified Nursing Assistant (CNA) V, R13's assigned CNA, was asked about R13's external catheter. CNA V explained she usually only wanted to use it at night, he would remove it in the morning after she woke up, if he was working on afternoons, he would put it on for her. When asked if he had been given any training on the apparatus by the facility, he said he had not, R13 told him how to apply it, remove it. CNA V was asked about cleaning the apparatus. CNA V explained R13's family would bring in bleach wipes to use on the canister apparatus and sometimes R13 would have him clean it with isopropyl alcohol. When asked if there was anywhere for him to document anything about the external catheter, CNA V explained there was not.
On 10/18/22 at 3:17 PM, the Director of Nursing (DON) was interviewed and asked about R13's external catheter. The DON explained it was R13's personal equipment. When informed there was no orders for care, cleaning or maintenance of the apparatus, the DON explained she was not aware there were no orders for the external catheter. The DON was asked how staff knew how or when to clean or change the catheter as there was no care plan for it. The DON explained she did not know. When asked if staff had received any training on the external catheter apparatus, the DON explained she had taught one nurse and one CNA. The DON was asked to provide the education provided. The DON explained it had been verbal education and there was no documentation of it.
Review of a facility policy titled, Incontinence revised 1/1/22 read in part, .Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .
This citation has three (3) deficient practices statements (DPS).
DPS #1
Based on observation and interview, the facility failed to provide adequate incontinence care for one resident (R52) of three residents reviewed for bowl and bladder incontinence care. Findings include:
On 10/17/22 at approximately 9:23 AM, a strong urine smell was noted outside of R52's door. Upon entry into the room, the odor worsened. R52 was alert, but not able to answer questions asked. During the observation Certified Nursing Assistant (CNA) CC entered the room. CNA CC noted the urine odor and stated that they needed to change the resident. The entire bed was soaked with urine as well as the pad. CNA CC was asked as to the last time the resident was changed. CNA CC reported that he came onto his shift at approximately 7:00 AM noticed that several of the residents assigned to him (including R52) had not been changed by the midnight staff. CNA CC reported that this happens a lot and it is either there is not enough staff, or the staff are just not performing care.
A review of R52's clinical record documented that the resident was initially admitted to the facility on [DATE] with diagnoses that included: Acute Respiratory Failure, Mood Disorder and Traumatic Brain Injury. A review of the residents Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and required extensive one to two person assistance for all Activities of Daily Living and indicated the resident was always incontinent.
On 10/19/22 at approximately 10:26AM an interview was conducted with the Administrator and Regional Director of Operations B. When queried regarding observations and interviews pertaining to R52's incontinence care, the Administrator stated that residents should not be left wet for long periods of time.
Review of the facility policy titled, Incontinence (revised 1/1/2022) documented, in part: Policy: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services .Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible .
DPS #2
Based on observation, interview, and record review, the facility failed to consistently document treatment provided and effectiveness of the treatment for one resident who did not have a bowel movement (BM) for one resident (R257) of three reviewed for bowl and bladder incontinence care. Findings include:
On 10/17/22 at approximately 10:20 AM, R R257 was observed in lying in bed and appeared very thin. The resident was alert and could answer some questions asked. The resident reported that they had lost some weight.
On 10/18/22 at approximately 1:36 AM, R257 was observed in their room sitting in a wheelchair. The resident reported that their stomach was hurting.
Review of R257's clinical record revealed the resident was originally admitted to the facility on [DATE] and the last re-admit was on 10/8/22 with diagnoses that included: Type II Diabetes, End Stage Renal Disease and Dementia. Review of the resident's MDS noted a Brief Interview for Mental Status (BIMS) score of 8/15 (moderately cognitively impaired) and was incontinent of bowl.
Continued review of R257's clinical record documented, in part the following:
Task Bowel Elimination Description: No Bowel Movement was checked on the following days: 10/11/22, 10/12/22, 10/13/22, 10/14/22, 10/15/22 and 10/16/22. A small bowel movement was noted on 10/17/22 at 11:58 AM by Certified Nursing Assistant (CNA) FF.
An Evaluation of Bowel (dated 10/15/22) contained several questions that were NOT answered, including, but not limited to: 1. Diagnoses that may impact bowl 2. Recent surgery .a. History of bowl incontinence .b. history of fecal impactions .Factor/conditions impacting bowl status .Medication .Communication . Physical Status .Elimination Status .Additional physical symptoms . Nutritional Status .Summary . The only question answered was that the resident was incontinent.
Physician Medication Orders indicated that the resident had orders entered on 10/9/22 for the following: Senna Tablet .Give 1 tablet every 12 hours for constipation and Docusate Sodium Tablet 100 MG Give 1 tablet by mouth every 12 hours for constipation. *It should be noted that both the medications were changed on 10/15/22 to be given twice per day instead of every 12 hours. However, no change was given in the dosage.
A review of the resident's Medication Administration Record (MAR) documented that on 10/17/22 at 8:03AM, a PRN (as needed) dose of Bisacodyl Tablet Release 5 MG was administered to the resident.* It should be noted that the start date on the order was 10/8/22.
On 10/18/22 at approximately 12:01 PM, a phone interview was conducted with CNA FF. CNA FF was queried as to the description of the small bowel movement noted on 10/17/22 at 11:48 PM. CNA FF reported that the bowel movement was very hard and small and indicated it was about the size of a quarter.
On 10/19/22 at approximately 1:20 PM, an interview and record review were conducted with the Director of Nursing (DON). The DON was queried as to the facility's bowel management protocol. The DON reported that when a resident does not have a bowel movement in two day an alert should be noted and a full assessment should be completed and the physician should be contacted. In reviewing R257's clinical record the DON noted that there was an alert given, but was not able to obtain information as to a physician contact or full assessment.
The facility was asked to provide a policy pertaining to Bowel Management. No policy was provided before the end of the survey.
On 3/4/21 at 3:01 PM, the Director of Nursing (DON) was interviewed. The DON was queried about the facility's bowel management protocol. The DON reported there was no specific bowel protocol (as was the documented plan by the admitting physician), but typically if a resident did not have a bowel movement after three days, the physician would be contacted and the resident would receive milk of magnesia, if no bowel movement after that, then laxative would be ordered. The DON further reported that if after administration of laxatives, the resident still did not have a bowel movement, it could result in being transferred to the hospital. The DON reported there would be a standing order in place for the nurses to follow. At that time, the facility's policy for bowel management was requested from the DON. The DON was queried about R#228 and the lack of documented interventions, assessments, and physician notification and/or orders after they had no documentation of a bowel movement in the past four days. The DON reported they would look into it.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31
On 10/17/22 at 9:11 AM, R31 was observed lying in bed on their back. R31 was observed to have a tracheostomy and gastrostomy...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31
On 10/17/22 at 9:11 AM, R31 was observed lying in bed on their back. R31 was observed to have a tracheostomy and gastrostomy. The resident eyes were closed and did not open with verbal stimuli. An enteral feeding of Jevity 1.5 cal (calories) was infusing at 55 ml (milliters)/hr (hour) and a water flush infusing at 40 ml.
Review of the clinical record revealed R31 was admitted to the facility on [DATE] with a readmission date of 8/10/22 and diagnoses that included: acute and chronic respiratory failure, dysphagia and quadriplegia. A MDS assessment dated [DATE] documented Severely impaired cognitive skills for daily decision making and required extensive staff assistance for all ADLs.
Review of a Weight Summary documented one weight obtained from admission in February 2022 to current (October 2022). A weight obtained on 3/1/22 documented a weight of 106.4 lbs (pounds).
Review of a facility policy titled Weight Monitoring revised 1/1/22, documented in part . Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters or nutritional status, such as usual body weight or desirable body weight range . Newly admitted residents - monitor weight weekly for 4 weeks . The facility failed to weigh the resident per the facility's policy.
Review of a Nutrition Data Collection/Evaluation dated 6/1/22, documented in part . Enteral . Jevity 1.5 at 55 ml/hr via PEG (Percutaneous Endoscopic Gastrostomy) . Weight: 106.4 (lbs) Date: 3/1/2022 . no weight history to review; DON (Director Of Nursing) notified on this date to request weight . Recommendations . obtain/record body weight .
Review of a Dietary note dated 6/14/22 at 5 PM, documented in part . Weight history: unknown, only weight in chart is dated 3/1/22 . Recommendations: MONTHLY WEIGHT .
Review of a readmission Nutrition Data Collection/Evaluation dated 8/22/22, documented in part . Weight: 106.4 (Lbs) Date: 3/1/2022 .
Further review of the medical record revealed no additional documentation of the Nurse, DON or physician to have addressed the facility's failure to obtain the residents weight and the monitoring of any potential weight loss or gain.
On 10/18/22 at 4:19 PM, Registered Dietician (RD) U was interviewed and asked why the facility has failed to obtain the resident's weight since March of 2022, RD U stated it has been an ongoing problem trying to get the staff to obtain weights on the residents. When asked why, RD U smiled. When asked if the lack of staff was a factor RD U acknowledged it was. When asked if they had verbalized their concerns to the Administration and Corporate staff RD U stated they have. RD U stated It's concerning.
On 10/19/22 at approximately 4:15 PM, the weight of R31 was asked to be obtained by the facility staff. The weight was observed at 132.9 lbs. This indicated a 26.5 lb. weight gain in 7 months.
R42
On 10/17/22 at 9:25 AM, R42 was observed lying in bed sleeping and could not be awakened by verbal stimuli. R42 was observed to be pale and greyish in color. Shortly after Certified Nursing Aide (CNA) CC entered into the room to collect the resident's breakfast tray. CNA CC was asked to open the lid of the plate and CNA CC removed the lid and stated (R42) did not eat anything. CNA CC went on to say how the resident had not been themselves lately and they told the nurse days ago that the resident wasn't acting like their normal selves and was having a hard time swallowing. CNA CC stated, I don't know what's going on with her but something is wrong. CNA CC stated the resident had not been eating their meals lately.
Review of the medical record revealed R42 was admitted to the facility on [DATE] with diagnoses that included: dementia, acute kidney failure and severe sepsis with septic shock. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8 indicating moderately impaired cognition and required staff assistance for all activities of daily living (ADLs).
Review of a Weight Summary documented two weights one for 6/10/22 at 138.0 lbs. and another on 9/14/22 at 125.6 lbs. A current weight could not be obtained during the survey due to R42 being hospitalized .
On 10/18/22 at 4:15 PM, RD U was interviewed and asked about the lack of weights obtained for the resident. RD U stated it has been an ongoing issue getting the staff to obtain the weights. RD U stated they post a list of resident weights to obtain at every nurses' station every Monday and they are still not getting done. RD U stated the Administration staff is aware of the situation.
Based on observation, interview and record review, the facility failed to obtain weekly and monthly weights to ensure the identification of weight loss and/or gain in order to address potential compromised nutritional status for three residents (R16, R31 and R42) out of four sampled for nutrition. Findings include:
R16
On 10/17/22 at approximately 9:38 AM, R16 was observed lying in bed on their back. R16 was observed to have a tracheostomy and gastrostomy. The resident was alert and not able to answer all questions asked.
A review of R16's clinical record revealed the resident was initially admitted on [DATE] with diagnoses that included: Acute Respiratory Failure, Altered Mental State and Pneumonitis due to inhalation of food. Review of R16's Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 6/15 (significant cognitive impairment).
Continued review of the resident's clinical record documented, in part, the following:
Care Plan (revised 4/30/22) - Focus: R16 has potential for nutritional deficits r/t (due to) NPO (nothing by mouth) .is dependent on enternal feeding and flush order for 100% nutritional and hydration status .Interventions: Monitor/record/report to MD PRN (as needed) .significant weight loss: 3 lbs in week, >5% in month, 7.5% in 3 months, >10% in 6 months .RD (registered dietician) to evaluate and make diet change recommendations (date initiated 3/29/22).
The electronic Weight Summary documented only one weight obtained from admission in February 2022 to current (October 2022). The weight obtained was dated 2/21/2022 and documented the resident's weight as 167 pounds.
An Enteral Dietary note dated (6/28/22) documented, in part: .last current weight recorded in chart 2/21/22 .167 lbs.Current Enteral Order .Jevity 1.5 @65ml/hr via peg tube x 20 hours or until total volume 1300 ml infuses .
On 10/19/22 at approximately 12:01 PM, an interview was conducted with Registered Dietician (RD) U. When asked why the resident was weighed only once since admission, RD U noted that residents should be weighed on admission and then every week for four weeks and then monthly thereafter. When asked why R16's weight was not obtained as per facility protocol, RD U noted that staff were just not doing it.
On 10/19/22 at approximately 03:39 PM, R16 was observed being weighed using a Hoyer lift scale. The resident's weight was first observed at 153.7 lbs. After Nurse GG made some adjustments with the lift scale and noted R16's weight at 157.3 lbs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure that three Certified Nursing Assistants (CNA 'E', 'F', and 'G') of five nursing staff reviewed for nursing competencies had the requ...
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Based on interview and record review, the facility failed to ensure that three Certified Nursing Assistants (CNA 'E', 'F', and 'G') of five nursing staff reviewed for nursing competencies had the required annual competency evaluation in skills and techniques necessary to care for residents, resulting in the potential for nursing staff to lack the necessary qualifications and training to adequately care for the needs of the residents.
Findings include:
According to the facility's policy titled, Training Requirements dated 1/1/22, .It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles .The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's training program. This person works closely with the Compliance Officer and other facility leaders in developing the program .The amount and types of training necessary are based on a facility assessment .Training content includes, at a minimum .The rights of the residents and the responsibilities of the facility to properly care for its residents .Behavioral Health .Dementia management and care of the cognitively impaired .Abuse, neglect, and exploitation prevention .Safety and emergency procedures .It is the responsibility of each employee, volunteer, or contract staff to complete required training .In-service training is provided by qualified personnel in a variety of formats .The Staff Development Coordinator maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers .
Review of the documentation provided for the annual skills competency evaluations for CNA 'E', 'F', and 'G' revealed incomplete and undated evaluations. The section for the licensed nurse to sign off and/or confirm that the CNA competencies were achieved or if they needed additional training were left blank (incomplete).
On 10/19/22 at 3:04 PM, an interview and record review were conducted with the Administrator and Director of Nursing (DON). Both were informed of the concern that the skills competency evaluations for CNA 'E', 'F', and 'G' were not signed off by anyone, and there was no way to determine if anyone had actually evaluated these staff for competencies given the lack of signature and dates. Both the Administrator and DON expressed understanding and reported they would follow-up to see if there was any other information to provide. There was no further documentation provided by the end of the survey.
On 10/19/22 at 3:22 PM, the Administrator and Regional Director of Operations (Staff 'B') were requested to provide a policy for CNA skills competency evaluations.
On 10/19/22 at 3:43 PM, the Administrator reported all they had to provide was the facility policy for Training Requirements.
On 10/19/22 at 4:04 PM, the Administrator was asked who was responsible for ensuring the skills competencies were completed and they reported normally that was the Staff Development Coordinator, but they had been without since they started at the facility in July (2022). When asked in the absence of a Staff Development Coordinator, who was responsible to ensure education was being provided, they reported it would be the DON, Administrator and Human Resources.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the attending physician reviewed and acknowledged recommenda...
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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 attending physician reviewed and acknowledged recommendations and irregularities identified by the consultant pharmacist during medication regimen reviews for three (R3, R11, and R52) of five residents reviewed for Medication Regimen Review (MRR).
Findings include:
According to the facility's policy titled, Addressing Medication Regimen Review Irregularities dated 1/1/2022, .It is the policy of this facility to provide a Medication Regimen Review (MRR) for each resident in order to identify irregularities in a timely manner to prevent the occurrence of an adverse drug event .The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and the reports must be acted upon .Any irregularities noted by the pharmacist during this review must be documented on a separate, written report which may be in paper or electronic form .The report will be sent to the attending physician, the facility's medical director and director of nursing .The attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record .If documentation of the findings is not in the active record, it will be maintained within the facility and will be readily available for review.
R3:
Review of the clinical record revealed R3 was admitted into the facility on [DATE] under hospice care with diagnoses that included: Alzheimer's disease, dementia in other diseases classified elsewhere with behavioral disturbance, major depressive disorder recurrent, restlessness and agitation.
According to the Minimum Data Set (MDS) assessment dated [DATE] R3 had unclear speech, had severely impaired cognition, had no mood or behavioral concerns, no hallucinations, or delusions, received antipsychotic medication for six of the seven days during this review period, received antidepressant medication for seven of the seven days, and had no gradual dose reduction (GDR) attempted, or physician clinical rationale.
Review of the pharmacy recommendations revealed irregularities were identified on: 11/3/21, 2/4/22, 3/5/22, and 8/3/22. There was no documentation available in the clinical record of what the specific irregularities/recommendations were and whether they had been addressed.
R11:
Review of the clinical record revealed R11 was admitted into the facility on 9/16/21 and readmitted on [DATE] with diagnoses that included: unspecified systolic (congestive) heart failure), COPD, Type 2 DM with diabetic neuropathy, morbid obesity due to excess calories, dysphagia, neuralgia and neuritis, anxiety disorder, MDD, obstructive sleep apnea, bipolar disorder, and cardiomyopathy.
According to the MDS assessment dated [DATE], R11 had moderately impaired cognition.
Review of the pharmacy recommendations revealed irregularities were identified on: 2/4/22, 4/6/22, 6/7/22, and 9/6/22, however there was no documentation available in the clinical record of what the specific irregularities/recommendations were and whether they had been addressed.
R52
A review of R52's clinical record revealed the resident was initially admitted to the facility on 12.28.18 with diagnoses that included: Acute Respiratory Failure, Mood Disorder and Traumatic Brain Injury. Review of the most recent completed MDS indicated the resident was severely cognitively impaired.
A review of Pharmacy Medications Review Progress Notes for R52 revealed, in part, the following:
1/5/22: .Medications and chart reviewed. 3 new pharmacy recommendations made. (2 MD (doctor) and one RN).
3/4/22: Medications and chart reviewed, 3 new pharmacy recommendations mad (2 MD and one RN).
4/6/22: Medications and chart reviewed, one new pharmacy recommendation made to Nursing.
6/6/22: Medications and chart reviewed, one new pharmacy recommendation made to Nursing.
On 10/19/22 at 12:55 PM, Regional Director of Clinical Director (Nurse 'S') was requested to provide the above pharmacy recommendations for R3, R11 and R52 as they were not available for review in the clinical record.
On 10/19/22 at 2:22 PM, Nurse 'S' was asked what the facility's process was for receiving and following up on identified irregularities and they reported the Director of Nursing (DON) and Medical Director received pharmacy recommendations directly and then the Medical Director would send the completed recommendations back to the facility.
10/19/22 at 3:34 PM, review of the additional documentation provided by Nurse 'S' revealed no further documentation for the identified irregularities/recommendations for R3, R11 and R52.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
On 10/18/22 at 8:42 AM, an observation was made of the 2 East medication cart to have been unlocked. The medication drawers were opened to verify that the cart was unlocked. There was no staff observe...
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On 10/18/22 at 8:42 AM, an observation was made of the 2 East medication cart to have been unlocked. The medication drawers were opened to verify that the cart was unlocked. There was no staff observed in the hallway. At 8:44 AM, Licensed Practical Nurse (LPN) HH was observed walking to the cart. When asked, LPN HH stated they should have locked their computer screen and medication cart when they left to give a resident their medications.
Review of a facility policy titled Medication Storage revised 1/1/22, documented in part, . All drugs and biologicals will be stored in locked compartments (i.e., medications carts, cabinets, drawers .) . During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart .
On 10/18/22 at 3:17 PM, the Director Of Nursing (DON) was interviewed and asked when the nurses are supposed to lock the medication carts when the nurse leaves the cart to administer medications and the DON stated if the cart is unattended the screen and medication cart should be locked.
Based on observation, interview, and record review the facility failed to ensure appropriate medication storage, labeling and discarding in two of three medication carts, resulting in the potential for misuse, contamination, and medication administration errors.
Findings include:
According to the facility's policy titled, Medication Storage dated 1/1/2022, .All drugs and biologicals will be stored in locked compartments (i.e., medication carts .) .Only authorized personnel will have access to the keys to locked compartments .Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels .
On 10/18/22 at 11:21 AM, an observation of one of two medication carts on the first floor was conducted with Nurse 'C'. The following concerns were identified:
A container of glucose strips was opened, undated and only seven strips remained. When asked when the container had been opened, Nurse 'C' reported they weren't sure as there was no date, but the container should've been labeled with the date when opened. Nurse 'C' was requested to provide the manufacturer's insert for labeling/dating, but was not provided by the end of the survey.
An insulin pen (Humalog Kwik Pen) was observed opened and undated for a resident that Nurse 'C' reported was no longer at the facility remained stored in the cart. Nurse 'C' reported that should've been removed and returned to pharmacy as the resident was no longer at the facility.
On 10/18/22 at 11:55 AM, an interview was conducted with the Director of Nursing (DON) and Regional Director of Clinical (Nurse 'S'). When asked about labeling and dating medication and biologicals, the DON reported that should've been labeled when opened. The DON was asked what should occur with medication when a resident was discharged from the facility and they reported the medication should be removed and put in a return to pharmacy area in the medication room. When asked how often pharmacy was usually at the facility, the DON reported usually two times a day when they deliver medications and when they're here they will usually ask if there's anything to go back. The DON was unable to explain why that had not occurred.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure timely completion and timely notification to th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure timely completion and timely notification to the physician of abnormal STAT (as soon as possible) labs for one (R42) of one resident reviewed for a change of condition, resulting in a delayed transfer to the hospital for a higher level of care. Findings include:
On 10/17/22 at 9:25 AM, R42 was observed lying in bed sleeping and could not be awakened by verbal stimuli. R42 was observed to be pale and greyish in color. Shortly after Certified Nursing Aide (CNA) CC entered into the room to collect the resident's breakfast tray. CNA CC was asked to open the lid of the plate and CNA CC removed the lid and stated (R42) did not eat anything. CNA CC went on to say how the resident had not been themselves lately and they told the nurse days ago that the resident wasn't acting like their normal selves and was having a hard time swallowing. CNA CC stated, I don't know what's going on with her but something is wrong. CNA CC stated the resident had not been eating their meals lately.
Review of the medical record revealed R42 was admitted to the facility on [DATE] with diagnoses that included: dementia, acute kidney failure and severe sepsis with septic shock. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8 indicating moderately impaired cognition and required staff assistance for all activities of daily living (ADLs).
Review of a Nursing note date 10/14/22 at 11:23 AM, documented in part . (Physician name) notified of resident change color pale/jaundice lethargic and lab work BUN (blood urea nitrogen)/Cr (Creatinine) elevated .
Review of the physician orders documented on 10/14/22 at 11:38 AM, a CBC w/Diff (complete blood count with differential), CMP (comprehensive metabolic panel), MAG (magnesium), PHOS (phosphate), ALBUMIN, PREABLUMIN, PROTEIN, TOTAL PROTEIN was ordered as STAT (as soon as possible) for electrolyte imbalance.
Review of the lab results with a documented a Collected date of 10/15/22 at 6:59 AM, and a reported (to the facility) date of 10/15/22 at 5:12 PM, documented a critical hemoglobin level of 4.2 (normal 12.0-15.0) and a critical Hematocrit of 14.0 (normal 37.2-46.3).
Review of a Nursing note dated 10/16/22 at 7:41 AM, documented in part . Writer spoke with physician concerning lab received. Order of stat CBC. Ordered <sic> implemented. This physician was informed of the STAT results the next day after the facility received the lab results.
Review of a physician order dated 10/16/22 at 7:36 AM, documented in part Repeat CBC STAT ordered . STAT for decrease hemoglobin.
Review of the clinical record revealed no documentation or test results of any labs to have been completed on 10/16/22.
Review of a Nursing note dated 10/17/22 at 7:22 PM, documented in part . Resident alert, appears weak. Provider (Nurse Practitioner name) ordered STAT CBC and CMP .
Review of a physician order dated 10/17/22, documented in part . STAT CBC STAT CMP . STAT for low hemoglobin .
Review of lab results dated 10/17/22, documented a [NAME] Blood Cell Count of 15.44 H (normal 4.50-10.00), Hemoglobin 4.8 CL (Critical Low) and Hematocrit 16.0 CL (normal 37.2-46.3).
Review of the medical record revealed no documentation of the physician being notified of the results on 10/17/22.
A Nursing note documented a day later on 10/18/22, documented in part . resident went to hospital via stretcher approximately 8 am. Sent out for low hemoglobin. NP and guardian notified.
The resident was sent to the hospital on [DATE] for a low hemoglobin that was initially identified three days before on 10/15/22 and four days after the reported change of condition with the resident.
Review of a hospital Internal Medicine History and Physical, documented in part . complaints of severe anemia, hemoglobin initially 4.9. Improved to 9.1 today post 2 units PRBC (Packed Red Blood Cells) . labs reveal mild leukocytosis .
On 10/19/22 at 2:21 PM, the Director of Nursing (DON) was interviewed and asked what the expected time frame is for a STAT lab, the DON was unsure but stated they would find out and follow back up. The DON was then asked if a STAT lab is ordered, how does the facility obtain the results to report to the physician if necessary. The DON stated they were unsure but would find out and follow back up. The DON was then asked about the delay in ordering and reporting to the physician of the STAT labs for R42 on 10/15/22 and 10/17/22. The DON was also asked about the STAT labs ordered for R42 on 10/16/22 that was never completed. Lastly the DON was asked about the change of condition with R42 identified on 10/14/22, delay of STAT labs which resulted in the delay to transfer the resident to a higher level of care for additional treatment that could not be provided at the facility and the DON stated they would look into all of the questions asked and follow back up. At 2:37 PM, the DON returned and stated STAT labs are usually drawn within four to six hours at the facility and if there are any critical labs identified the laboratory will call the facility and fax over the results. The DON stated the nurses are expected to call the physician to inform them of any critical results. The DON stated they were still looking into the additional questions asked at the initial interview.
No further explanation or documentation was provided by the end of survey.
Review of a facility policy titled Laboratory and Diagnostic Guidelines revised 1/1/22, documented in part . This guideline is set up to track the timely completion, reporting and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status . STAT labs may be obtained per physician order 7 days per week . The physician should be notified of all lab/diagnostic test results based on the below parameters . Critical lab results or urgent diagnostic should be called to the physician upon receipt . All notifications, attempts at notifications, and response should be noted in the resident's medical record . STAT orders . Upon receipt of a STAT lab/diagnostic test, the nurse should contact the appropriate vender to obtain the ordered test or . If unable to obtain the STAT test within facility established time frames, the physician should be notified for further orders or resident sent to a provider who can perform such test . Documentation of the above should be completed in the resident's medical record as explained in the documentation section of this procedure .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to operationalize an antibiotic stewardship program which consistently ensured appropriate clinical indication for us of antibiotic medications...
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Based on interview and record review the facility failed to operationalize an antibiotic stewardship program which consistently ensured appropriate clinical indication for us of antibiotic medications. This deficient practice affected multiple residents at the facility when residents who were deemed as not meeting criteria were prescribed on antibiotic therapy, resulting in the potential for increased antibiotic resistance. Findings include:
Review of the Center for Disease Control's (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes dated 2015, documented in part, .Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year .studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic- resistant organisms . Infection prevention coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections .Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacterial or urinary tract infection prophylaxis and implement specific interventions to improve use .
Review of the facility's September 2022 infection control log book documented of 28 antibiotic line listings, 18 of them did not meet criteria for antibiotic use.
Review of the facility's August 2022 infection control log book documented of 26 antibiotic line listings, 15 of them did not meet criteria for antibiotic use.
Review of the facility's July 2022 infection control log book documented of 21 antibiotic line listings, 13 of them did not meet criteria for antibiotic use.
On 10/12/22 at 12:31 PM, the Regional Director of Clinical (RDC) S, who served as the Infection Preventionist, was interviewed and confirmed the facility utilized the McGeers criteria for antibiotic use system. RDC S was asked about the administration of inappropriate antibiotics to residents. RDC S explained the resident could become resistant to antibiotics. When asked about the antibiotic usage for the residents that did not meet criteria. RDC S explained she usually did not find out about a resident prescribed an antibiotic until she got the report from the pharmacy. When asked if she ever questioned the doctors, or informed them that they did not meet criteria for antibiotics, RDC S explained she did occasionally. RDC S was asked if she had ever brought up the issue of antibiotic usage to the Medical Director. RDC S explained usually she would only talk to the Medical Director about her own residents.
Detailed review, with RDC S, of the 18-line listings for September 2022 that did not meet criteria revealed in part:
R207 was given Cephalexin for period of lethargy and 1 day of fever on 9/18/22, the line listing indicated criteria was not met.
Review of R207's UA/C&S collected 9/20/22 revealed only a trace number of bacteria was found. The culture results were apparent skin and/or genital flora, indicating no infection.
Review of R207's September 2022 Medication Administration Record (MAR) revealed Cephalexin 500 mg (milligrams) was given every 12 hours from 9/20/22 to 9/25/22.
R23 was given Macrobid for dysuria (painful urination) and foul urine, the line listing indicated criteria was not met.
Review of R23's lab results revealed no UA or C&S collected.
Review of a Nurse Practitioner (NP) progress note dated 9/2/22 at 2:55 PM read in part, .UTI (urinary tract infection) + dipstick . Start macrobid 100mg bid (two times a day) x 7 days .
Review of R23's September 2022 MAR revealed Macrobid 100 mg was given every 12 hours from 9/3/22 until 9/9/22.
RDC S was asked why R207 was given antibiotics when the UA/C&S did not indicate an infection. RDC S had no answer. RDC S was asked why R23 did not have a UA/C&S collected to determine if there was an infection. RDC S explained the facility did not have urine dipsticks, and did not know why a UA/C&S was not collected before antibiotics were ordered.
Review of a facility policy titled, Antibiotic Prescribing Practices revised 1/1/22, read in part, .The facility will utilize a '5 D's approach' to antibiotic prescribing: .Diagnosis . Drug . Dose .Duration . De-escalation: Reassessment of empiric precautions will be conducted for appropriateness and necessity, factoring in results of diagnostic tests, laboratory results, and/or changes in the clinical status of the resident .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff to meet resident needs for two (R13 and R52) residents reviewed for staffing, and five residen...
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Based on observation, interview, and record review the facility failed to ensure sufficient nursing staff to meet resident needs for two (R13 and R52) residents reviewed for staffing, and five residents that participated in the confidential resident council interview, resulting in complaints of prolonged response to activated call lights, and inadequate care for activities of daily living related to insufficient staffing.
Findings include:
R52
On 10/17/22 at approximately 9:23 AM, a strong urine smell was noted outside of R52's door. Upon entry into the room, the odor worsened. R52 was alert, but not able to answer questions asked. During the observation Certified Nursing Assistant (CNA) CC entered the room. CNA CC noted the urine odor and stated I need to change the resident. The entire bed was soaked with urine as well as the pad. CNA CC was asked as to the last time the resident was changed. CNA CC reported that he came onto his shift and noticed that several of the residents assigned to him had not been changed by the midnight staff and R52 was one of the last residents that he needed to address. CNA CC reported that this happens a lot and it is either there is not enough staff, or the staff are just not performing care.
On 10/18/22 at 10:31 AM, R13 was observed lying in bed. A female external catheter apparatus was observed. When asked about the catheter apparatus, R13 explained it was her personal apparatus, she had her family bring it two months previously because the facility was so short of staff, she was staying wet all the time and she did not want to stay in a wet brief all night.
A resident council meeting was held on 10/18/22 at 2:30 PM, six residents were present in the room and five participated in the meeting. The residents who wished to remain anonymous reported several concerns pertaining to staffing. Two residents provided specific names of staff that include CNA I and CNA G who were rude, disrespectful and often just hung out talking to each other or were on their phones ignoring them and the call lights. One resident said they just were not answering call lights and had figured out a way to avoid the call light system. They also expressed a concern that last night (10/17/22) there were no CNAs on their floor, and they were told that they had to get into bed right after dinner. At the end of the meeting a resident's family member knocked on the door and expressed that their parent had wanted to attend the meeting earlier in the day, but staff did not get them up to attend. A meeting was held with the resident and resident's family. They both expressed concerns with staff, primarily CNAs being rude, not answering call lights or timely passing food trays. The family member also expressed that there were no CNAs working the afternoon shift on Sunday (10/16/22) and that they had to change their family member and also had to assist the resident's roommate with care as they were very wet. The family member noted that she had expressed her frustration to nursing staff.
On 10/18/22 at 3:10 PM, CNA V was asked about providing shaving and nail care to residents. CNA V explained shaving and nail care should be provided to residents at every shower or bed bath, but sometimes they did not have enough time to do all the care because of staffing, so there were times shaving or nail care did not get done.
A request was made for the nursing staff schedule for 10/16/22 and 10/17/22 as well as the time punch cards. Review of the documentation provided noted that on 10/16/22 no CNA's worked on the 1st floor hallway on the afternoon shift (3PM to 11PM). There were two nurses that worked from 7AM until 7PM and both left at or about 7PM and were replaced with one nurse. The 10/17/22 schedule noted that there were no CNAs that worked on the 1st floor hallway from 7:30 PM to 11:30 PM and one Nurse was on the floor from 7AM to 7PM and replaced by another nurse at 7PM.
On 10/19/22 at approximately 10:26AM an interview was conducted with the Administrator and Regional Director of Operations B. When asked as to staffing including the lack of CNAs on the afternoon shift on 10/16/22 and 10/17/22, the Administrator indicated that when CNAs are not working, the facility will have Nursing staff act as CNAs. When asked how one Nurse could do both CNA services along with Nursing care, the Administrator indicated they are in the process of hiring nursing staff.
On 10/19/22 at approximately 4:00 PM, an interview was conducted with Nurse GG was asked if they had ever been asked to work in a CNA role due to short staffing. Nurse GG stated that there have been many times when there are no CNAs and while she would assist with some resident's care that included changing briefs, she rarely had the time to do additional resident care such as showering and/or weighing residents as they needed to provide medications.
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 ensure food items were labeled, dated and discarded when expired, failed to maintain the kitchen and equipment in a sanitary ...
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Based on observation, interview, and record review, the facility failed to ensure food items were labeled, dated and discarded when expired, failed to maintain the kitchen and equipment in a sanitary manner, and failed to ensure dishware was properly sanitized. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include:
During an initial tour of the kitchen from 8:45 AM-9:30 AM, the following items were observed:
There was a personal cell phone on the food preparation table across from the oven. On 10/17/22 at 12:15 PM, Dietary Director AA was queried about staff personal cell phones in the kitchen, and confirmed that they should not be placing their phones on the counters, and that staff should wash their hands after handling their phones.
According to the 2013 FDA food code, Section 7-209.11 Storage, Except as specified under §§ 7-207.12 and 7-208.11, Employees shall store their personal care items in facilities as specified under 6-305.11(B), and Section 6-403.11 Designated Areas, .(B) Lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, linens, and single-service and single use articles cannot occur.
In the walk-in cooler, there was a package of deli turkey that was opened and dated 10/11-10/25, a plastic container of cooked green beans dated 10/15-10/25, a 6-quart container of pineapple slices dated 10/15- 10/22, a 2-quart container of mandarin oranges dated 10/11-11/30, an opened package of deli roast beef dated 10/6-10/12, and a plastic storage bag with sliced ham that was undated. On 10/17/22 at 9:30 AM, Dietary Director AA stated that food items are good for 7 days after opening, with the first day counting as day 1.
According to the 2013 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.
The True reach-in cooler was observed with a shredded gasket on the left side door.
According to the 2013 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.
There were dusty ceiling vent covers located in the main kitchen above the clean cutting boards and in the dry storage room.
According to the 2013 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials.
In the dry storage room, there was food debris and crumbs on the floor in the corners and underneath the racks. In addition, there were cobwebs underneath the racks, and spotty black stains on the tile floor under the racks.
According to the 2013 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean.
The quaternary ammonia test strips located by the 3-compartment sink were observed to be wet and discolored from water damage. On 10/17/22 at 9:25 AM, Dietary Director AA confirmed that the test strips needed to be replaced.
According to the 2013 FDA Food Code section 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration, Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device.
There was a red sanitizer bucket observed with liquid and rags inside. The solution was tested with a quaternary ammonia test strip, and did not change color to detect the presence of sanitizer. On 10/17/22 at 9:20 AM, Dietary Director AA confirmed that the bucket was supposed to contain sanitizer.
There was a dusty wall mounted fan blowing onto the clean side of the dish machine.
According to the 2013 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
On 10/17/22 at 12:00 PM, Dietary Staff BB was observed preparing to serve the lunch meal. Dietary Staff BB retrieved some soiled scoops and tongs, washed them in the 3-compartment sink wash basin, dipped them in approximately 1 inch of cold water in the rinse compartment, and then put them at the steam table for use. Dietary Staff BB did not sanitize the utensils, as the sanitizer bin at the 3-compartment sink was empty. On 10/17/22 at 12:20 PM, Dietary Manager AA was queried and stated that the soiled dishware should always be washed, rinsed and sanitized before re-use.
According to the 2013 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: .(C) Chemical manual or mechanical operations, including the application of SANITIZING chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under § 4-501.114. Contact times shall be consistent with those on EPA-registered label use instructions by providing: .
(3) A contact time of at least 30 seconds for other chemical SANITIZING solutions, or(4) A contact time used in relationship with a combination of temperature, concentration, and pH that, when evaluated for efficacy, yields SANITIZATION as defined in Subparagraph 1-201.10(B).
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 37% turnover. Below Michigan's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 2 life-threatening violation(s), Special Focus Facility, 4 harm violation(s), $296,114 in fines, Payment denial on record. Review inspection reports carefully.
- • 97 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $296,114 in fines. Extremely high, among the most fined facilities in Michigan. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Medilodge Of Farmington's CMS Rating?
CMS assigns Medilodge of Farmington 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 Medilodge Of Farmington Staffed?
CMS rates Medilodge of Farmington's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 37%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Medilodge Of Farmington?
State health inspectors documented 97 deficiencies at Medilodge of Farmington during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 91 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Medilodge Of Farmington?
Medilodge of Farmington is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MEDILODGE, a chain that manages multiple nursing homes. With 117 certified beds and approximately 78 residents (about 67% occupancy), it is a mid-sized facility located in Farmington, Michigan.
How Does Medilodge Of Farmington Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Medilodge of Farmington's overall rating (1 stars) is below the state average of 3.1, staff turnover (37%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Medilodge Of Farmington?
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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Medilodge Of Farmington Safe?
Based on CMS inspection data, Medilodge of Farmington has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). 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 Medilodge Of Farmington Stick Around?
Medilodge of Farmington has a staff turnover rate of 37%, which is about average for Michigan nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Medilodge Of Farmington Ever Fined?
Medilodge of Farmington has been fined $296,114 across 6 penalty actions. This is 8.2x the Michigan average of $36,040. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Medilodge Of Farmington on Any Federal Watch List?
Medilodge of Farmington is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.