The Orchards at Harper Woods
For profit - Corporation
151 Beds
THE ORCHARDS MICHIGAN
Data: November 2025
Trust Grade
50/100
#340 of 422 in MI
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Orchards at Harper Woods has received a Trust Grade of C, meaning it is average and sits in the middle of the pack for nursing homes. With a state rank of #340 out of 422, it falls in the bottom half of facilities in Michigan, and at #54 of 63 in Wayne County, it indicates that there are only a few local options that are better. The facility is improving, having reduced its issues from 28 in 2024 to 11 in 2025. Staffing is a concern, with less RN coverage than 99% of Michigan facilities, which means residents may not receive the level of care that RNs provide. Additionally, specific incidents such as the lack of RN coverage on multiple days and CNAs not completing required training suggest that there are gaps in care and compliance that families should consider, despite no fines on record and lower than average staff turnover.
- Trust Score
- C
- In Michigan
- #340/422
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 42% turnover. Near Michigan's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Michigan facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 10 minutes of Registered Nurse (RN) attention daily — below average for Michigan. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 20%
No red flags
28 → 11 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 28 issues
2025: 11 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below Michigan average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 42%
Near Michigan avg (46%)
Typical for the industry
Chain: THE ORCHARDS MICHIGAN
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 49 deficiencies on record
Mar 2025
11 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 F0657
(Tag F0657)
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 revise care plans to accurately reflect identif...
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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 revise care plans to accurately reflect identified problems and interventions for one resident (R55) of one residents.
Findings include:
On 3/23/23 at 9:00 AM, R55 was noted in their room noted laying halfway off the bed and on the floor. R55 was noted to be in a wet brief which was hanging off. When asked about about the care, R55 appeared confused and stated they were unsure about what to do.
On 3/24/25 at 8:45 AM, R55 was observed in their room with a shirt on, no brief, no non-slip socks, looking for something to eat.
On 03/25/25 at 9:00 AM, R55 observed in their room walking barefoot.
A review of R55's electronic medical record revealed R55 was admitted on [DATE] with multiple diagnoses including Acute Respiratory Failure, Dementia, Anxiety and Macular Degeneration. A review of R55's Minimum Data Set (MDS) assessment dated on 12/26/2024 revealed a Brief Interview of Mental status (BIMS) assessment of 13 indicating resident is cognitively intact.
Further review of R55's revealed a recent fall on 3/21/25 the history of falls care plan last revised on 9/11/24, revealed several previous interventions but no subtantional most recent intervention.
On 03/25/25 at 1:45 PM, The Director of Nursing (DON) was interviewed regarding updated care plans. She indicated the expectation is care plans for falls are updated after the team reviews the fall.
A review of the facility policy titled, Comprehensive Care Plans revealed the following: The comprehensive care plan must be patient centered, be in the I care plan format and consistent with resident rights and describe that each resident is provided the necessary care and services including resident's choices to attain or maintain the highest practible physical, mental, and psychosocial well-being consistent with the residen'ts comprehensive or quarterly ; assessment. The comprehensive care plan must be consistent with resident's rights and : reflects current standards of practice
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 F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adaptive equipment for one resident (R40) out...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adaptive equipment for one resident (R40) out of three reviewed for Activities of Daily Living (ADLs). Findings include:
On 3/24/2025 at 2:18 PM, R40 was observed in their room eating lunch. R40 was observed trying to pick their water cup up and dropped the cup on themselves. R40's water cup was noted to be in a foam cup. R40 reported they usually have a smaller sippy cup that makes it easier for them to drink their water. R40 reported the cup broke about two months ago and someone stated they were ordering a new one. R40 indicated they had not heard anything else about the new cup.
A review of the medical record revealed that R40 admitted into the facility on [DATE] with the following medical diagnoses, Epilepsy and Dysphagia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment score of 10/15 indicating an impaired cognition. R40 also required staff assistance with bed mobility and transfers.
Further review of the medical record revealed the following physician orders,
Modified light weight water cup for daily use .Active.
Please ensure that resident has smaller drinking cup at bedside .Active.
On 3/25/2025 at 10:47 AM, R40 was observed in bed with no modified light weight water cup at the bedside.
On 3/25/2025 at 10:59 AM, an interview was conducted with the Registered Dietitian (RD) A. RD A stated they had spoken to the Occupational Therapist (OT) that was caring for R40, and they indicated R40 could use a regular foam cup, and the other order needed to be discontinued.
On 3/25/2025 at 11:58 AM, an interview was conducted with the Director of Nursing (DON). The DON stated there used to be a sippy cup that was easier for R40 to use, and they would have to look into reordering one.
A review of a facility policy titled, Adaptive Eating Equipment noted the following, Policy: It is the policy of this facility to assure adaptive equipment is available for those residents who would benefit from their use, based on comprehensive assessment, to assist the resident to achieve his/her highest functioning potential.
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** Based on observation, interview, and record review, the facility failed to complete and document skin treatments for one residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete and document skin treatments for one resident (R93) of one reviewed for skin treatments/documentation. Findings include:
On 3/23/25 at 9:24 AM, R93 was observed sitting on the side of their bed, right leg observed wrapped in a bandage and undated. R93 explained that they had gotten into an accident which caused the wound on their leg, but was unsure of the last date their bandage had been changed.
A review of R93's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Cellulitis of the Right Lower Limb and Peripheral Vascular Disease. Further review revealed that the resident was cognitively intact and required limited assistance with toilet use, bathing, and dressing.
Further review of the medical record revealed the following physician order dated 1/8/25, Right Lower Leg: Cleanse with Wound Cleaner, pat dry apply medihoney cover with Abd (abdominal pads) and kerlex. every day shift for WD (wound dressing) and every 24 hours as needed.
A review of the January 2025 Treatment Administration Record (TAR) revealed the following dates with missing treatments, 1/16, 1/18, 1/19, 1/21, 1/23, 1/24, 1/26, 1/29, and 1/30.
A review of the February 2025 TAR revealed the following missing treatment dates: 2/6, 2/9, 2/12, 2/16, 2/20, 2/21, 2/22, 2/23, and 2/25.
A review of March 2025 TAR revealed the following missing treatment dates: 3/2, 3/5, 3/6, 3/7, 3/12, 3/14, 3/17, 3/18, 3/19, 3/22, and 3/23.
On 3/25/25 at 1:54 PM, the Director of Nursing (DON) was interviewed regarding the missing TAR treatments, and she explained the expectation is that the treatments are completed as ordered.
A review of the facility's policy revealed the following, .3. Residents admitted with skin impairments will have appropriate interventions implemented to promote healing, a physician's order for treatment, treatment record initiated .
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** Based on observation, interview and record review, the facility failed to turn, reposition, and implement offloading interventio...
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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 turn, reposition, and implement offloading interventions to prevent further skin breakdown for one resident (R85) of three residents reviewed for pressure ulcers. Findings include:
On 3/24/25 at 2:29 PM, R85 was observed laying on their backside without pillows under either side of R85's body.
On 3/25/25 at 9:12 AM and 11:15 AM, R85 was observed laying on their backside without pillows under either side of R85's body. A pillow was observed under R85's feet.
On 3/25/25 at 12:19 PM, an observation of R85's wound was made, the wound was clean, with some slough present, and scar tissue was observed surrounding wound.
On 3/25/25 at 2:05 PM, R85 was observed laying on their backside without pillows under either side of R85's body. Three pillows were observed laying in a chair.
A review of R85 medical record revealed, R85 was admitted to the facility on [DATE] with diagnosis of Encephalopathy. A review of R85's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted R85 with a severely impaired cognition and with total dependence of staff to complete activities of daily living.
A review of R85's medical record noted, 3/7/2025 10:51 Nurses Note: CNA (Certified Nursing Assistant) notified that patient had open wound on buttock. Cleansed area with soap and water, applied barrier cream.
Further review noted, 3/11/2025 at 16:28, Skin/Wound Note Text: Resident noted with re-current open area to Sacrococcyx @ (at) 5.0x3.0x0.2 centimeters (cm) pale yellow base, scant serous drainage, irregular edges. No objective s/s (signs and symptoms) of pain noted. Attending NP (Nurse Practitioner) notified new order noted.
A note dated 3/12/2025 at 11:46, Skin/Wound Note Late Entry: Encounter Date: 03-12-2025. Chief Complaint: Follow up consult regarding sacrococcygeal . Patient examined and noted to have stage III pressure ulcer (full-thickness skin loss) sacrococcygeal treatment and offloading interventions implemented. Skin: No rash, warm and dry; Right buttocks which previously extended into sacrococcygeal resulting in stage III pressure ulcer resolved and reopened as unstageable pressure ulcer 3.0 x 4.0 x utd (Unstageable Full Thickness Depth) unable to determine 9 cm, red pink tissue and 20% eschar (dead tissue) with scant serous drainage . Assessments/Plans: Sacrococcygeal unstageable pressure ulcer . Recommended treatment Cleanse pat dry apply Medihoney cover with dry dressing change every other day and as needed Reposition Low-air-loss mattress ensure settings are appropriate and functioning for patient every shift .
A review of R85's care plan revealed, Focus: I need assistance with my ADL's. Date Initiated: 08/20/24. Goal: I will maintain my current level of functioning through the review date. Date Initiated: 08/20/24. Interventions: I require total assistance with bed mobility, transfers, toileting, personal hygiene, dressing, bathing and eating. Date initiated: 8/20/24. Focus: I have potential/actual impairment to skin integrity of the (Sacrococcyx/bilateral buttocks) r/t (related to) Stage III Pressure Injury, Per wound NP res (resident) has multiple underlying medical conditions, wound may not heal & formation of more wounds may be unavoidable: Impaired mobility, incontinent. Date initiated:11/06/2024. Goal: By allowing staff allocated interventions my risk for healing complications and further skin breakdown will be reduced. Date imitated: 11/06/24 .
Order: Coccyx/Bilat Buttocks: Cleanse w (with)/soap and water apply house barrier every shift and as needed every shift for skin and every 12 hours as needed. Start: 12/05/24.
Order: Sacrococcygeal: Cleanse w/Dakins (a cleansing solution), pat dry, apply Medihoney cover w/dry dressing every day shift for skin and every 48 hours as needed for skin. Start: 3/14/25.
A review of the March 2025, Treatment Administration Record (TAR) revealed, treatments not documented as completed on 15th,16th, 19th, 20th, and 22nd.
On 3/25/25 at 1:43 PM, the Director of Nursing (DON) was asked about R85's care planned interventions. The DON reported R85 is high risk (for skin breakdown) and should be repositioned every 2 hours with pillows.
A review of the facility's policy Facility-Acquired Pressure Ulcers undated, revealed, Anticipated Outcome: Residents will be identified for their risk of skin breakdown. Residnets admitted without pressure ulcers will have measures implemented to reduce the prevalence of acquired pressure uclers .
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 F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to apply a splint/brace for one resident (R34) out of two reviewed for limited mobility. Findings include:
On 3/24/2025 at 8:30 ...
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Based on observation, interview, and record review, the facility failed to apply a splint/brace for one resident (R34) out of two reviewed for limited mobility. Findings include:
On 3/24/2025 at 8:30 AM, R34 was observed laying in the bed, a towel was observed rolled up in their left hand. No brace/splint was observed to be in place.
A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers.
Further review of the physician orders revealed the following orders,
B/L (Bilateral) elbow splint/hand splint .Active.
On 3/25/2025 at 8:58 AM, R34 was observed laying in the bed, a towel was observed rolled up in their left hand. No brace/splint was observed to be in place.
On 3/25/2025 at 11:57 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the schedule and application of R34's B/L elbow/hand splint. The DON indicated they would have to look more into the application for the elbow/splint.
On 3/25/2025 at 12:01 PM, an interview was conducted with Restorative Nurse B. Restorative Nurse B' stated R34 is on the nurse maintenance program and is reflected on the care plan. Restorative Nurse B indicated they do not apply the splint through the restorative program and said nursing staff apply resident's splints.
An application schedule for the splint/brace was requested, but not received by end of survey.
A review of a facility policy titled, Braces and Splints noted the following, 8. Restorative staff or the licensed nurse will be responsible for application and removal of splints.
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 F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31
On 3/23/25 at 9:26 AM, R31 reported the food at the facility is bad. R31 was asked which meals. R31 reported all meals at th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31
On 3/23/25 at 9:26 AM, R31 reported the food at the facility is bad. R31 was asked which meals. R31 reported all meals at the facility are not good.
R94
On 3/23/25 at 9:57 AM, R94 reported the food doesn't look good and that when it is good, they are not given enough food.
A review of the resident council meeting minutes for February 2025, revealed multiple complaints regarding the food. The meeting minutes reflected concerns about food being cold when they receive their food trays and food carts being left on the units for long periods of time.
A review of the facility policy titled, Food Palatability-Hot Food Temperatures dated 2018, Policy: The healthcare community prepares and serves food and beverages that are palatable, attractive and at safe and appetizing temperature. Procedure: Hot foods will be held at or above135° F. Once the food is plated for serving the food temperature will begin to drop. By the time the hot food reaches the client it is expected to be less than 135°F. Variance in hot food temperatures occurs due to the ability of different foods to hold heat. For example mashed potatoes stay hot longer than rice . (3). The healthcare community makes every effort to take all factors into consideration to ensure that hot food and beverages are served at a safe and appetizing temperature.
Based on observation, interview, and record review, the facility failed to ensure meals were served at a preferred and palatable temperature for three sampled residents (R20, R31, and R94) from a total of three sampled residents reviewed for food palatability. Findings include:
R20
On 3/23/25 at 9:30 a.m., R20 was observed laying in the bed. R20 expressed several concerns pertaining to the meals. R20 saying, it is a shame that my daughter has to spend money to buy food so I can have something decent to eat. The vegetables served last week were cold and hard.
A review of R20's electronic medical record revealed R55 was admitted on [DATE] with multiple diagnoses including Chronic Obstructive Pulmonary Disease, Bilateral Osteoarthritis of the knee, Major Depressive Disorder and Alcohol Abuse. A review of R20's Minimum Data Set (MDS) assessment dated on 2/08/2025 revealed a Brief Interview of Mental status (BIMS) assessment of 15 indicating resident is cognitively intact.
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 F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for two residents (R34 and R92) out of five reviewed for imm...
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Based on interview and record review, the facility failed to obtain consent and/or declination for influenza and pneumococcal immunizations for two residents (R34 and R92) out of five reviewed for immunizations. Findings include:
On 03/25/2025 at 11:30 AM, the infection control task was completed with the Director of Nursing (DON) and acting Infection Control Preventionist (ICP) C.
R34
A request was made to review the influenza and pneumonia consents and/or declinations for R34.
ICP C stated they knew the responsible party for R34 refused all vaccinations, however they did not know where the papers were with the refusals.
A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers.
No consent or declination was received by the end of survey.
R92
A request was made to review the influenza and pneumonia consents and/or declinations for R92.
The sheet provided did not have any signatures on it. The sheet documented the words disconnected 11/11/24, 15:15 written at the bottom.
A review of the medical record revealed that R92 admitted into the facility with the following medical diagnoses, Cerebral Infarction and Sepsis. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R92 also required staff assistance with bed mobility and transfers.
ICP C stated they knew the phone line was disconnected when the previous ICP tried to get consent from the responsible party, but they were unsure what happened after that.
A review of a facility policy titled, Pneumonia noted the following, Procedure .1. Offer pneumococcal vaccine to residents on admission .2. Offer annual influenza vaccine.
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 F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to obtain consent or declination for the COVID-19 immunization for two residents (R34 and R92) out of five reviewed for immunizations. Finding...
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Based on interview and record review, the facility failed to obtain consent or declination for the COVID-19 immunization for two residents (R34 and R92) out of five reviewed for immunizations. Findings include:
On 03/25/2025 at 11:30 AM, the infection control task was completed with the Director of Nursing (DON) and acting Infection Control Preventionist (ICP) C.
R34
A request was made to review the Covid-19 consent or declination for R34.
ICP C stated they knew that the responsible party for R34 refused all vaccinations, however they did not know where the papers were with the refusal.
A review of the medical record revealed that R34 admitted into the facility with the following medical diagnoses, Dysphagia and Cerebral Infarction. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating they were unable to complete the assessment. R34 also required staff assistance with bed mobility and transfers.
No consent or declination was received by the end of survey.
R92
A request was made to review the Covid-19 consent or declination for R92.
The sheet provided did not have any signatures. The sheet documented the words disconnected 11/11/24, 15:15 written at the bottom.
A review of the medical record revealed that R92 admitted into the facility with the following medical diagnoses, Cerebral Infarction and Sepsis. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 11/15 indicating an impaired cognition. R92 also required staff assistance with bed mobility and transfers.
ICP C stated they knew the phone line was disconnected when the previous ICP tried to get consent from the responsible party, but they were unsure what happened after that.
A review of a facility policy titled, Covid noted the following, .Documenting COVID-19 .The facility will maintain documentation for all residents and staff on COVID-19 vaccination.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a tube feeding pole and floor in a sanitary ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a tube feeding pole and floor in a sanitary manner for three sampled residents (R3, R19, and R85) out of five reviewed for tube feeding. Findings include:
R3
On 3/23/25 at 10:01 AM, R3 was observed in bed with a tube feeding pole next to the bed. The pole and floor were observed with large amounts of dried formula on them.
On 3/24/25 at 9:04 AM and at 2:27 PM, the tube feeding pole and floor was observed in the same condition.
A review of R3's medical record noted, R3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Debility, Cardiorespiratory Conditions. A review of R3's annual Minimum Data Set (MDS) assessment, dated 2/2/25 noted, R3 with a severely impaired cognition and dependent of staff for activities of daily living (ADLs).
A review of R3's order noted, in the evening Jevity 1.5 @60cc/hr x 16 hrs (hours) Up at 6pm for 16 hours or until dose complete to provide 960cc (cubic centimeter) formula, 1440 kcal (Kilocalorie), 61.2g (grams) protein. Provide 35cc/hr x 16hrs water to provide 560cc. 4/5/24.
R19
On 3/23/25 at 11:21 AM, R19 was observed in bed with a tube feeding pole next to the bed. The pole and floor were observed with large amounts of dried formula on them.
On 3/24/25 at 2:24 PM, the tube feeding pole and floor was observed in the same condition.
A review of R19's medical record noted, R19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis with Hemiplegia and Hemiparesis, aphasia follow CVA (Cerebrovascular Accident). A review of R19's MDS assessment dated [DATE] noted R19 with a severely impaired cognition and dependent of staff for ADLs.
A review of R19's order revealed, one time a day Jevity 1.5 via PEG continuously via pump @ 70cc/hr x 12 hrs. Up @ 730pm until 730am dose complete to provide 840cc, 1260kcal, 53.6g pro. Provide 480cc water via auto flush over 12 hrs (40cc/hr x 12hrs).
R85
On 3/23/25 at 10:06 AM, R85 was observed in bed with a tube feeding pole next to the bed. The pole and floor were observed with large amounts of dried formula on them.
On 3/24/25 at 9:45 AM, the tube feeding pole and floor was observed in the same condition.
On 3/25/25 at 1:46 PM, the Director of Nursing (DON) was asked the facility's expectation regarding cleaning spilled formula. The DON reported the Nurses are wiped if down if they spill and housekeeping when there is a needed.
A review of the facility's policy titled, Daily Cleaning Procedures undated revealed, . 5) Disinfect. Work your way clockwise around the room (starting at the door and finishing at the door) and disinfect flat surfaces and high-touch items. This includes, but is not limited to: doorknobs, light switches, call lights, TV remotes, bed side [NAME], bed frames, footboards and headboards, bedside tables, closet handles, window sills, chairs . 9. Damp Mop. Damp mop perimeter of the room. Then stat at back of room and use a figure 8 motion to damp mop the entire floor while working your way back to the door .
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 F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week potentially affecting all 132 residents res...
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Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week potentially affecting all 132 residents residing in the facility. Findings include:
A review of the Centers for Medicare & Medicaid Services (CMS) PBJ (Payroll Based Journal) Staffing Data Report for the 1st quarter of 2025 (October 1 to December 31) revealed the facility triggered for excessively low weekend staffing.
A review of requested Daily Staffing Sheets from the 1st quarter of 2025 revealed the following dates without RN coverage: 10/15/25, 10/16/25, 10/25/25, 11/6/24, 11/13/24, 11/14/24, 11/18/24, 11/19/24, 11/20/24, 12/7/24 and 12/24/24.
On 3/25/25 at 9:43 AM, Staff Scheduler D was interviewed regarding RN coverage and explained that it is difficult to hire and retain registered nurses, and explained that call in's occur often.
On 3/25/25 at 3:57 PM, the Director of Nursing (DON) was asked for her expectations in ensuring RN coverage was adequate, and she explained that the expectation is that there be coverage.
A review of the Staffing and Scheduling policy revealed, Staffing for acuity involve understanding the needs of residents and staffing according to assure care can be provided to address resident needs .
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 F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure certified nurse aides (CNAs) completed the required 12 hours of in-service education annually for three (E, F, and G) of five CNAs r...
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Based on interview and record review, the facility failed to ensure certified nurse aides (CNAs) completed the required 12 hours of in-service education annually for three (E, F, and G) of five CNAs reviewed for inservice education. Findings include:
A review of the following three certified nurse aide annual 12-hour nurse aide training/ in-services were reviewed:
CNA E was hired on 3/1/22. There were no 12-hour training/ in-services provided by the facility.
CNA F was hired on 3/16/22. There were no 12-hour training/ in-services provided by the facility.
CNA G was hired on 3/14/17. There were no 12-hour training/ in-services provided by the facility.
On 3/25/25 at 3:37 PM, Staff Developer B was asked about the missing 12 hours of training, and explained that she is new in the position, and acknowledged that she has been trained differently on when and how CNA's 12 hours of training annually were met.
On 3/25/25 02:00 PM, the Director of Nursing (DON) was asked about the 12 hours of CNA training not being completed, and she explained her expectation is that CNAs meet their required training.
A review of the facility's, Facility Assessment revealed the following, Required in-service training for nurse aides. In-Service training must be sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year .
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00148002.
Based on interview and record review, the facility failed to ensure the right to ma...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00148002.
Based on interview and record review, the facility failed to ensure the right to manage finances and assist with community banking services for one resident (R700) of three residents' reviewed for residents rights. Findings include:
On [DATE] at approximately 10:00 AM, an interview was conducted with R700 regarding concerns with finances. R700 stated facility was harassing them about paying their bill and issued them an involuntary discharge notice. R700 presented the involuntary discharge form that was served to resident on [DATE]. R700 said I am upset because I like it here. I have the money but have trouble getting it from bank and my drivers license had expired. I want to pay it and stay here. My debit card only let's me get $500 a day.
A review of R700's medical record revealed R700 was admitted on [DATE] with multiple diagnoses including spinal stenosis, osseous and subluxation stenosis of intervertebral foramina of the lumbar region, inflammatory spondylopathy, lumbar region. A review of R700's Minimum Data Set (MDS) assessment dated on [DATE] revealed a Brief Interview of Mental status (BIMS) assessment of 14 indicating resident is cognitively intact.
An interview was held Business Office Manager A (BOM A) on [DATE] at 10:35 AM . BOM A said R700 used his credit card regularly to pay his bill. R700 started not paying the bill in full begining [DATE]. BOM A stated she offered to assist R700 with going to a local bank and did on [DATE], however due to R700's driver's license expired the month prior, the bank could not perform any further transactions. When asked had the facility tried to assist resident with renewing the driver's license, the BOM stated, No.
A review of R700 billing statement documented the following:
-[DATE] patient pay amount was billed $1297.00;
-[DATE] patient pay amount was billed $1297.00;
-[DATE] patient pay amount was billed $1297.00.
On [DATE], R700 made a $2000.00 payment after going to the bank with BOM A.
-[DATE] patient pay amount was billed $1297.00.
On [DATE] a $500.00 payment was made and on [DATE] another $500.00 payment was made.
-[DATE] patient pay amount was billed $1297.00.
Total charges added up to $6485.00 in which R700 had paid $3500.00, leaving the balance owed as $2985.00.
Per the Electronic Medical Record (EMR) note provided by the Nursing Home Administrator (NHA), on [DATE] BOM A met with R700 and discussed using an ACH form (a credit payment that allows funds to be transferred directly from one bank account to another without the need for checks, wire transfers, or cash exchanges). R700 was told to fill out form or he would be given an involuntary discharge.
A review was made of the Resident Rights policy which documented, the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. J. The resident has the right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds.
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
This citation pertains to Intake MI00147481.
Based on interview and record review, the facility failed to permit readmission and/or provide proper notice of facility-initiated discharge for one reside...
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This citation pertains to Intake MI00147481.
Based on interview and record review, the facility failed to permit readmission and/or provide proper notice of facility-initiated discharge for one resident (R702) following a hospitalization out of one reviewed for transfers and discharges. Findings include:
A review of intake MI00147481 noted the following, Patient was seen and cleared by our behavioral health psych social worker on 10/10/24.Patient was also medically cleared to return to nursing facility on 10/10/24. [Facility name] refused to take patient back into their facility. Patient is a long-term resident at the facility and has been residing at the facility since March 2024.
A review of the medical record revealed R702 admitted into the facility on 2/28/2024 with the following diagnoses, Unspecified Dementia without Behavioral Disturbances and Anxiety. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 5/15 indicating an impaired cognition. R702 also required assistance with bed mobility and transfers.
Further review of the progress notes revealed the following, Effective Date: 10/9/2024 18:11 (6:11PM). Resident was petitioned to hospital due to becoming very aggressive with staff. Resident proceeded to hit door and use vulgar language at staff members when staff attempted to redirect pt. (patient). Staff called 911 to assist with the transfer. Sister (Guardian) was contacted and aware of the transfer and staff has explained current situation to family. Pt. escorted by police officers and EMT (Emergent Medical Transport) to (Hospital) for a psych evaluation. Physician is aware of transfer.
On 11/6/2024 at 10:46 AM, an interview was conducted with Central Intake admissions staff (CI) B. CI B stated they were informed R702 was sent to the hospital because of aggressive behaviors. CI B stated they were given the directions not to take R702 back due to the facility no longer being able to accommodate their needs.
On 11/6/2024 at 11:27 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they felt as though they could no longer accommodate R701 in the facility and they were a danger to themselves and others. The DON stated the resident refused all medications and was increasingly aggressive with staff, so they had to petition R702 out. The DON stated they did not believe R702 was treated for their condition adequately in the hospital and would not accept them back in the facility.
On 11/6/2024 at 11:52 AM, an interview was conducted with Social Worker (SW) D. SW D stated they were informed R702 was transferred to the hospital due to behaviors at the facility. SW D stated no petition was sent with R702. SW D stated R702 was evaluated by their behavioral health team in the hospital and did not appear to be manic and stated they did not want to harm themselves or anyone else. The SW D stated they were displaying signs of Dementia without behavioral disturbances. SWD stated R702 was cleared by the hospital behavioral health team for readmission back onto the facility. SW D confirmed the facility refused to take R702 back and the hospital was able to find them alternative placement.
On 11/6/2024 at 1:18PM, an interview was conducted with Ombudsman C. Ombudsman C stated they were informed by the hospital Social Worker the facility would not permit R702 to return. Ombudsman C stated they spoke to CI B, and they stated they were not able to permit R702's return to the facility. Ombudsman C stated they tried to inform the facility they had to permit R702's return and issue an Involuntary Discharge, giving R702 proper notice.
Further review of the medical record did not show documentation any communication with the hospital regarding R702's behavior at time of attempted discharge from hospital, or documentation of proper notice for facility-initiated discharge.
On 11/6/2024 at 1:31 PM, an interview was conducted with R702's Legal Guardian (LG) E. LG E stated they were informed R702 was going to the hospital because they were banging on the door and were manic. LG E stated they were informed by the hospital the facility would not accept R702 back and they did not speak to anyone at the facility explaining why they were unable to take R702 back at the facility. LG E stated R702 stated they wanted to go outside and smoke, and once the hospital gave them a nicotine patch they no longer asked to go outside. LG E stated R702 is adjusting to the new facility at this time.
On 11/6/2024 at 2:00 PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated they began to complete an Involuntary Discharge notice but did not finish it due to the emergent situation. The NHA stated they could not accommodate R702 anymore due to aggressive behaviors. The NHA was asked if they notified the ombudsman or guardian of the specific behaviors and that they would not be accepting R702 back into the facility. The NHA stated they did not because of how quickly they had to get R702 out of the facility.
A review of a facility policy titled, Transfers and Discharges noted the following, 7. Emergency Transfers/Discharges-For medical reasons, or the immediate safety and welfare of a resident, initiated by the facility (Nursing Responsibilities unless otherwise specified) .l. In case of discharge, notice requirements and procedures for facility-initiated discharges shall be followed.
Oct 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 F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00147226.
Based on observation, interview, and record review, the facility failed to ensure dignity ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to MI00147226.
Based on observation, interview, and record review, the facility failed to ensure dignity and respect was maintain for one sampled resident (R704) of two reviewed for respect and dignity. Findings include:
A review of the Intake allegations revealed, An allegation was reported the resident (R704) was verbally abused by an employee (Certified Nursing Assistant (CNA) C).
On 10/09/24 at 10:20 AM, R704 was asked about the incident with CNA C. R704 explained that during care, CNA C called them out of their name and referred to their buttocks as a rump roast. R704 further explained this was not the first time they had a problem with CNA C, and they were trying to deal with the ongoing things CNA C would say. R704 was asked if they shared the experiences they had with CNA C. R704 stated, they had conversations with the Unit Manager and the Wound Care Nurse (WC Nurse). R704 was asked how the incident affected them. R704 stated, I felt less than human. R704 continued and explained they have requested a transfer to another facility.
On 10/09/24 at 12:36 PM, the WC Nurse was asked about R704 and CNA C incident. WC Nurse explained R704 would tell her CNA C would sometimes refuse to provide care to them and say R704 could do it for themselves. WC Nurse was asked when R704 told them about CNA C's behavior. WC Nurse reported, about a couple months ago. WC Nurse was asked if they reported the behavior to the Nursing Home Administrator (NHA). The WC Nurse stated, Yes. I reported it to the team.
On 10/09/24 at 1:04 PM, Unit Manager D was called for an interview a voice message was left, a return called from Unit Manager D was not made by the end of the survey.
A review of the facility's statement from CNA C revealed, [CNA C] was suspended on Sunday, 9/22/24, after allegations of verbal abuse surfaced. This was done over the phone. [CNA C] was called many times between 9/23/24 and 9/24/24 to get terminated. [CNA C] did answer on 9/24/24 and was terminated over the phone. [CNA C] did say [they] did not do this verbal abuse at any time.
On 10/09/24 at 1:25 PM, the Director of Nursing (DON) was asked when they became aware of the problems R704 had with CNA D. The DON explained, there was a report CNA C was not helping R704 when they requested or needed care. The DON further explained, they became aware of the incident the day it happened. The DON was asked what happened after they were made aware of CNA C calling R704 buttocks a rump roast. The DON stated, [CNA C] was suspended pending investigation. [R704] did not change their story and [CNA C] was terminated.
On 1:39 PM, the NHA was asked when they were made aware of the incident with CNA C and R704. The NHA explained, the day it happened, they came in and made the 24 hour report and talked to the resident.
R704 was admitted to the facility on [DATE] with diagnosis of Multiple Fractures of Pelvis. A review of R704's medical record revealed, R704 with an intact cognition and that they required assistance with activities of daily living.
A review of R704's progress notes revealed, 9/22/2024 07:37 (AM) Nurses Note Text: Upon arrival, the resident was found comfortably situated in bed with the head of the bed elevated. [R704] was alert and oriented to person, place, time, and situation, clearly able to articulate [R704] needs. The resident expressed concerns about experiencing verbal abuse and neglect from one of [R704] caregivers (CNA). A detailed report was documented, and the resident's statement was promptly forwarded to the abuse coordinator. Both the abuse coordinator and the Director of Nursing (DON) were immediately informed of the situation. The writer took the time to reassure the resident that such treatment is unacceptable and commended [R704] for voicing [their] concerns. To further empower [R704], the writer reviewed the resident's rights (Right to Dignity, Quality of Care, and Quality of Life), emphasizing the importance of reporting any ongoing or future issues. The resident was encouraged to continue advocating for [R704] and assured of the support available to [R704].
10/3/2024 17:19 Social Services Text: Social worker met with [R704] today after [R704] requested a transfer be sent to two other nursing facilities. Social worker will gather the referral and contact the other facilities by the beginning of next week.
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 F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
This citation pertains to Intakes MI00147299 and MI00147184.
Based on observation, interview, and record review, the facility failed to ensure call lights were answered, functioning and within reach f...
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This citation pertains to Intakes MI00147299 and MI00147184.
Based on observation, interview, and record review, the facility failed to ensure call lights were answered, functioning and within reach for two residents (R702 and R704) out of three reviewed for call lights. Findings include:
R702
On 10/9/2024 at 10:51 AM, R702 was observed in bed and stated they were ready to get dressed and in the chair. R702 was asked if they had pressed (activated) their call light. R702 stated they did not know where the call light was at. An observation of the call light unit on the wall noted that there was no cord for R702 to push the call light. R702 was asked how long they have been without a call light. R702 stated they did not know.
On 10/9/2024 at 10:53 AM, Certified Nursing Assistant (CNA) B was shown the call light unit on the wall and R702 did not have a call light button. CNA B proceeded to switch the call light cord out and stated they were going to notify maintenance. CNA B stated they did not know the call light button for R702 was missing.
On 10/9/2024 at 12:05 PM, R702 was observed in their wheelchair. R702 call light button was observed tucked under their pillow. R702 stated they were unable to reach their call light from their current position in the wheelchair.
At 10:53 AM, R702's call light was observed in the same position under the pillow. R702 stated they were still unable to reach it from their current position.
A review of the medical record revealed that R702 admitted into the facility with the following diagnoses, Hypothyroidism and Diabetes. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score of 4/15 indicating an impaired cognition. R702 also required assistance from staff with activites of daily living (ADLs).
R704
On 10/9/2024 at 10:20 AM, R704's call light was observed activated. R704 stated they were waiting for some patient care.
At 10:27 AM, 10:35 AM, 10:38 AM, and 10:47 AM, R704's call light was observed to still be activated. At 10:48 AM, an unknown staff member was seen entering R704's room and turning off the call light. They were observed going into another room and informing a CNA that R704 needed patient care.
A review of the medical record revealed that R704 admitted into the facility with the following diagnoses, Multiple fractures of Pelvis and Pain in unspecified Hip. Further review of the Minimum Data Set assessment revealed a Brief Interview for Mental status score 15/15 indicating an intact cognition. R704 also required staff assistance with bed mobility and transfers.
On 10/9/2024 at 1:26 PM, an interview was conducted with the Director of Nursing (DON). The DON stated call lights should always be within reach and they complete walking rounds daily to ensure that call lights are working and in reach and if the call light is not working then they put in a request with maintenance. The DON stated they are unsure if the rounds were completed that morning. The DON stated they expect call lights to be answered within 15 to 20 minutes depending on the situation.
A review of a facility policy titled, Call Light Policy revealed the following, Policy: It is the policy of this facility to answer call lights as promptly as 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
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
This citation pertains to Intakes MI00147184 and MI00147299.
Based on observation, interview, and record review, the facility failed to provide fresh water in a timely manner for residents (R701, R702...
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This citation pertains to Intakes MI00147184 and MI00147299.
Based on observation, interview, and record review, the facility failed to provide fresh water in a timely manner for residents (R701, R702, R703, and R705) out of five reviewed for hydration. Findings include:
A review of Intake MI00147299 noted the following, Complainant states [they] are not receiving fresh water daily.
R701
On 10/9/2024 at 10:16 AM, R701's water was observed on the bedside table. The water was noted to be dated 10/9/2024 from 11PM-7AM. The water cup was noted to be warm and empty.
At 12:04 PM and 12:54 PM, R701 was observed with the same water cup dated 10/9/2024 from 11PM-7AM. R701 stated they never provide them with fresh water and it is an ongoing problem.
R702
On 10/9/2024 at 10:51 AM, R702's water was observed on the bedside table. The water was noted to be dated 10/9/2024 from 11PM-7AM. The water cup was noted to be warm and half full.
On 10/9/2024 at 12:05 PM, R702 was noted to be in their wheelchair. R702 water cup was observed to be the same cup dated 10/9/2024 from 11PM-7AM. R702 stated they wish they had some fresh water. R702 stated they would ask the Certified Nursing Assistant (CNA) when they came into the room again.
R703
On 10/9/2024 at 12:07 PM and 12:53 PM, R703's water was observed on the bedside table. The water was noted to be dated 10/9/2024 from 11PM-7AM. The water cup was noted to be warm and with a small amount in the cup. R703 said they could go for some fresh water, but they barely get fresh water.
R705
On 10/9/2024 at 12:57 PM, R705's water was observed on the bedside table. The water was noted to be dated 10/9/2024 from 11PM-7AM. The water cup was noted to be warm and half full. R705 stated they never get fresh water, and they do not know when they will receive water.
On 10/9/2024 at 12:56 PM, CNA B was observed going down the hall with the water cart. CNA B the water cart goes down on midnights and they clean it and send it back up. CNA B stated the cart is usually clean and back up to the floor by 8:00 AM. CNA B stated they try and pass water by lunch time or earlier.
On 10/9/2024 at 1:36 PM, an interview was completed with the Director of Nursing (DON). The DON stated water should be passed at a minimum of once a shift and if a resident asks for water. The DON stated they have not heard from the residents that getting fresh water was a problem.
A review of a facility policy titled, Hydration noted the following, .D. Assure fresh bedside drinking water is available at all times, unless contradicted. Assist residents to periodically take a drink throughout the day.
Sept 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citiation pertains to intake: MI00145394.
Based on observation, interview, and record review, the facility failed to provi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citiation pertains to intake: MI00145394.
Based on observation, interview, and record review, the facility failed to provide scheduled showers for one sampled resident (R903) of three residents reviewed for activities of daily living (ADL). Findings include:
R903 was admitted to the facility on [DATE] with diagnosis of Juvenile rheumatoid Polyarthrititis. A review of R903's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed, R903 with an intact cognition and dependent of staff to complete activities of daily living (ADL).
On 9/5/24 at 12:00 PM, R903 was observed lying in bed, above their bed there was a sign that noted, Shower Schedule M (Monday) & Th (Thursday) 7pm -7am. R903 was asked about the sign and explained that is to remind staff but they still don't get their showers. R903 was asked the last time they had a shower. R903 was unable to remember but did say it was in August.
A review of shower documentation revealed, N/A (not applicable) on 8/1/, 8/8, 8/15, 8/29, and 9/2/24.
On 9/5/24 at 12:19 PM, the Director of Nursing (DON) was asked about R903's showers. The DON stated, [R903] made a concern a couple of weeks ago, we change [R903] to a day shift shower (7am - 7pm). The DON was asked why the showers were changed from an afternoon shower to a day shift shower. The DON explained, R903 reported the staff were coming in too late on the afternoon shift. The DON was asked what N/A meant that was noted on R903's shower record. The DON stated they would have to contact that staff person to find out what happened on those days.
On 9/5/24 at 12:53 PM, the DON reported, the N/A documentation was completed by the same staff member on all the days. The DON explained the explanation was that the staff person thought R903 was still an afternoon shower, and the day shift was a computer error. The DON confirmed the resident did not receive a shower on the days that were marked N/A.
The DON was asked the facility's expectation for new notice of a change in the shower schedule. The DON explained the staff person should have questioned, then asked a manager or the DON about new notice of the schedule change to be sure of the schedule.
A review of R903's care plan noted, Focus: I need assistance with my ADL's r/t (related to) contractures of hand, pain in left arm, juvenile Rheumatoid Polyarthritis. Date Initiated: 09/11/2023. Goal: I will maintain my current level of functioning through the review date. Date Initiated: 09/26/2023. Interventions: of functioning through the review date. I require total assistance with bed mobility, transfers, toileting, personal hygiene, dressing, bathing and eating. Date Initiated: 09/11/2023. BATHING/SHOWERING: I require total assist by staff with bathing/showering at least weekly and whenever I prefer. I prefer shower instead bed bath. Date Initiated: 09/11/2023.
A review of the facility's policy titled, Tub Bath or Shower undated, noted Purpose: Tub baths and/or showers are used to cleanse the body, stimulate circulation, and condition & assist debriding skin. Bed linen is changed at least weekly and PRN (as needed). The policy did not address to the concern mentioned above.
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 F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citiation pertains to Intake: MI00146442.
Based on interview, and record review, the facility failed to provide timely podi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citiation pertains to Intake: MI00146442.
Based on interview, and record review, the facility failed to provide timely podiatry care for one resident (R902) out of one reviewed for foot care. Findings include:
On 9/5/2024 at 11:40 AM, during an interview, R902 explained their toenails were very long and it was painful to put shoes on and it took a long time to get them cut.
On 9/5/2024 at 11:56 AM, Social worker (SW) A was asked to review R902's record for podiatry care. SW A then replied R902 was admitted in October (2023) and was not seen by podiatry until August (2023). Then stated It looks like she may have been seen in April (2024), but was unable to provide a treatment record. SW A said that even if R902 was seen in April they would have been due for another visit at least in June and confirmed that visit did not take place. SW A was asked if there was a written policy and procedure for podiatry care to which she responded no.
A review of R902's electronic medical record revealed that they were admitted on [DATE] with diagnoses as follows: idiopathic peripheral autonomic neuropathy; Chronic obstructive pulmonary disease, and Type 2 diabetes mellitus with diabetic neuropathy.
Further record review revealed the following:
-A request for services form for podiatry dated 2/7/24;
-A nursing note dated 7/7/24 stated the following: Family also reports that residents toenail needs to be trimmed at this time and writer will log for soc worker to review for podiatrist.;
-Physician orders: podiatry services placed 3/23/24. Podiatrist evaluation on left big toe placed 7/27/24;
-A second request for services form for podiatry dated 7/10/24;
-A podiatry visit note dated 8/2/24.
A facility policy title Foot care revealed the following: Purpose. To promote cleanliness and prevent infection. Special care for diabetic residents .2. Regularly inspect feet for cuts, cracks, blisters, corns, calluses, or red, swollen areas, Report findings to the physician. Documentations. Record any abnormal findings in the nurses' notes. In the care plan, document the need for foot care.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citiation pertains to Intake: MI00146442
Based on observation and interview, the facility failed to maintain a sanitary env...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citiation pertains to Intake: MI00146442
Based on observation and interview, the facility failed to maintain a sanitary environment potentially affecting all 129 residents whom reside in the facility. Findings include:
On 9/5/24 at 9:03AM, 10:19 AM, 11:10 AM, and at 12:20 AM, a wheelchair was observed in the hallway outside room [ROOM NUMBER] with a pile of dirty clothing on it.
On 9/5/24 at 9:18AM, 10:24 AM, and 11:10 AM, a bag of dirty linen was observed on the floor next to the wall in room [ROOM NUMBER].
On 9/5/24 at 9:21 AM, 10:23 AM, and 11:10 AM, a bag of dirty linen was observed on the counter in the anteroom outside room [ROOM NUMBER].
On 9/5/24 at 9:24 AM, 10:20 AM, and 12:20 AM, a pile of dirty linen was observed on the floor by the window in room [ROOM NUMBER].
On 9/5/24 at 10:12 AM and 11:08 AM, a dirty towel and a dirty pair of socks were observed on the windowsill in room [ROOM NUMBER].
On 9/5/24 at 10:15AM, 11:33 AM, and 1:00PM, A bag of trash and a bag of dirty linen were observed in the bathroom in room [ROOM NUMBER].
On 9/5/24 at 10:07 AM, 11:27 AM, and 1:00PM, a bag of dirty linen and a bag of trash were observed on the floor in the bathroom of room [ROOM NUMBER]. A strong foul odor was noted.
On 9/5/24 at 11:20 AM, 12:37 PM, and 1:08 PM a bag of dirty linen and a bag of trash were observed on the floor of the bathroom in room [ROOM NUMBER]. A strong foul odor was noted.
On 9/5/24 at 11:40 AM, R902 was interviewed and asked about the bags of linen and trash in their bathroom. R902 stated That happens all the time and they stay there all day.
On 9/5/24 at 12:30 PM, during an interview, Certified Nurse Assistant (CNA) B was asked who removes dirty linen and trash from residents' rooms. CNA B explained the CNA's remove the linen and will remove the trash too if it has incontinence products in it, otherwise housekeeping removes the trash.
On 9/5/24 at 12:40 PM, during an interview, the Assistant Director of Nursing (ADON) was asked who removes dirty linen and trash from residents' rooms and stated It should be removed when care is done before exiting the room.
On 9/5/24 at 1:05PM, during an interview, the Director Of Nursing (DON) was asked to describe their expectation for the removal of dirty linen and trash from residents rooms. The DON explained the CNA should remove the linen and trash when they finish performing care in the room.
A facility policy titled Housekeeping and Laundry revealed the following: 1. Pick up or collection of soiled linen. A. Collection of soiled linen. Soiled linen containers or barrels should be on each nursing unit stored in a soiled area so that nursing can deposit soiled linen. These containers should be checked at regular intervals to keep the soiled linen from overflowing, which may cause odor and infection control problems. Regularly scheduled pickups should be coordinated with nursing to get soiled linen off the units. Soiled linen must be removed from the units for two reasons: 1. Keep the area infection free. 2. The laundry needs the soiled linen picked up regularly to keep the flow of wash moving through the laundry room and clean linens properly stocked on the units. The manager should check with nursing to coordinate pickups. The timing of nursing activities such as: getting residents up. Breakfast feeding. Shoers. Changing beds. Will al have an impact on what the best ties are for soiled linen pickup.
Mar 2024
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to hold scheduled care conferences for residents and resident representatives for two residents (R34 and R81) of two residents re...
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Based on observation, interview and record review, the facility failed to hold scheduled care conferences for residents and resident representatives for two residents (R34 and R81) of two residents reviewed for care planning participation. Findings include:
R81
On 3/5/24 at 1:16 PM, R81 was observed returning to their room from a shower. Attempts to interview the resident were unsuccessful due to their cognition however, the resident's guardian, Guardian N was asked about their involvement in the resident's care, specifically the development of the president's plan of care. Guardian N explained that they haven't had any meetings regarding the resident's care since they were first admitted in 2021.
A review of R81's medical record was reviewed and revealed that they were admitted into the facility on 6/18/21 with diagnoses that included Vascular Dementia, Anxiety, and Cerebral Infarction. Further review revealed that the resident was severely cognitively impaired, and required dependence for toileting and showers.
Further review of R81's medical record revealed that one care conference was completed since admission, and was dated for 3/12/21.
R34
On 3/5/24 at 10:37 AM, resident representative I was interviewed via phone and explained that the resident has been able to express to them that they have preferences regarding care that have not been honored.
A review of R34's medical record revealed that the resident was admitted into the facility on 4/9/21 with diagnoses that include Aphasia following Cerebral Infarction, Heart Failure, Morbid Obesity, and Mood Disorder. Further review of the medical record revealed that the resident was cognitively intact and was completely dependent on two staff for transfers with a mecahnical lift.
Further review of R34's medical record revealed that the resident had not had a care conference since 7/14/21.
On 3/6/24 at 1:45 PM, Social Worker D was asked about the lack of care conferences completed for the residents identified, and she explained that when she was hired in December 2023, and audit of care conferences were completed, and identified as a concern and will be working on getting them completed.
On 3/7/24 at 3:06 PM, the Nursing Home Administrator was asked about their expectation for the completion of care conferences, and explained that care conferences should be completed within 48 hours of admission, quarterly, and annually.
A review the facility's Care Pan Conference policy revealed the following, Since the comprehensive care plan must be developed within 7 days of completion of the comprehensive assessment, care plan conferences are held: Within 7 days of the completion of the initial MDS assessment; at intervals every 90 days thereafter, with any subsequent completed assessments, and where there is a change in resident status or condition .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to honor the resident's preference regarding care for one resident (R34) of one reviewed for self-determination. Findings includ...
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Based on observation, interview, and record review, the facility failed to honor the resident's preference regarding care for one resident (R34) of one reviewed for self-determination. Findings include:
On 3/5/24 at 9:04 AM, R34 was observed lying in bed. Attempts to interview with the resident was challenging as they had a communication deficit however, the resident provided their resident representative's phone number who assisted with communication.
On 3/5/24 at 10:37 AM, resident representative I was interviewed via phone and explained that the resident has been able to express to them that they would prefer showers instead of bed baths, and that the resident is rarely gotten out of bed, and has been the last 2 years in their room.
A review of R34's medical record revealed that the resident was admitted into the facility on 4/9/21 with diagnoses that include Aphasia following Cerebral Infarction, Heart Failure, Morbid Obesity, and Mood Disorder. Further review of the medical record revealed that the resident was cognitively intact and was completely dependent on two staff for transfers with a mechanical lift.
On 3/6/24 at 8:40 AM, Certified Nursing Assistant J was asked about R34 obtaining showers. CNA J explained that they provide the resident with really good bed baths, and that the resident doesn't get up out of bed because there isn't a mechanical lift large enough for them.
A review of R34's weights revealed that they weighed 402.8 pounds on 2/8/24.
On 3/6/24 at 9:33 AM, the shower bed was observed to have a capacity of 450 pounds.
On 3/6/24 at 11:27 AM, a mechanical lift observed in hallway was observed to indicate that the capacity was 600 pounds.
On 3/6/24 at 12:20 PM, Licensed Practical Nurse (LPN) K was asked about R34 getting out of bed for showers. LPN K indicated that in the last five months, they have seen R34 out of bed maybe twice, and explained that they were unaware if the resident preferred to take showers over bed baths.
On 3/7/24 at 11:07 AM, and interview was completed with Social Worker L regarding R34's preference to have showers instead of bed baths, and the resident's desire to get up, and they explained that they are not sure why the resident hasn't gotten up for showers, and has never expressed that they wanted to get up for a shower.
A review of R34's medical record revealed that they hadn't had a care conference since 7/14/21.
Further review of R34's comprehensive level II evaluation completed by the local community health agency, and dated for 1/24/24 revealed the following, .During screening [R34] contacted [their family member] via facetime to assist [them] with answering questions. [R34's family member] reported that [R34] says [their] care is thumbs down because [they] are unable to get in the shower due to [them] being overweight which makes it difficult to lift [them] therefore, [R34] gets bathed in bed which frustrates [them] . Further review of the evaluation indicated the following, Consumer continues to report that [they] have not had a bath in some time. Staff notified of same and reports nursing home equipment is not compatible with consumer's size and may pose a safety risk .recommendations .obtain appropriate equipment to offer consumer bathes/showers without putting [them] at risk.
On 3/7/24 at 11:16 AM, Unit Manager M was asked why R34 hasn't gotten out of bed for showers per their preference. Unit Manager M explained that there are some challenges with getting the resident up due to their size, and the space of their room, but reported that they would look further into the concern.
On 3/7/24 at 2:54 PM, the Director of Nursing (DON) was asked about R34's concerns with getting out of bed, and honoring their preferences for showers instead of bed baths, and she explained that she would look further into it.
A review of the facility's Resident Rights policy revealed the following, Resident rights. The resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility .Self-Determination. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice number two.
This citation pertains to Intake MI00138528.
Based on interview and record review, the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice number two.
This citation pertains to Intake MI00138528.
Based on interview and record review, the facility failed to notify concerned family members of a change in condition for one resident (#479) out of three residents reviewed for change in condition, resulting in family members not knowing the resident went to the hospital and not having the opportunity to participate in medical decisions regarding a resident's health.
Findings include:
It was reported to the State Agency that the facility failed to notify concerned family members that the resident had been sent to the hospital.
A review of the clinical record revealed R479 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R479's diagnoses included seizure disorder, chronic drug abuse, peripheral neuropathy, panic disorder, and transient cerebral ischemic attack. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment.
During an interview on 3/6/24 at 3:35 PM with the Director of Nursing (DON) the following was revealed:
- The facility census indicated that stop billing occurred on 7/9/23 for R479 which indicated that R479 was not residing in the facility at that time.
- On 7/10/23 at 7:15 PM a nurse's note revealed, Resident returned from (local hospital), accompanied by 2 EMT's (medical transport) on a stretcher.
- Review of the clinical record failed to document the reason for R479's transfer to the hospital or that a concerned family member/emergency contact was notified. The DON acknowledged that R479's emergency contact should have been notified.
Further review of R479's clinical record documented the following:
- The local hospital's Patient Discharge Summary, dated 7/10/23 at 4:32 PM, documented patient education information provided on Trans Ischemic Attack (TIA).
- A physician's note dated 7/11/23 at 10:05 AM documented, Patient was hospitalized from [DATE] [sic] until July 10, 2023 were concerns of symptoms of CVA (cardiovascular accident). Patient was diagnosed with TIA and generalized weakness .
On 3/7/24 at 5:00 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
This citation has two deficient practices.
This citation pertains to Intake MI00135819.
Based on observation, interview, and record review the facility failed promptly notify the legal guardian after elopement of a mentally impaired legally incapacitated resident, for one resident (R179) of three residents reviewed for closed record. Findings include:
A review of the intake allegations noted, Complainant states on Friday, 04/14/23, the resident was sent on a [local hospital] transport for an appt. (appointment) The resident didn't return to the facility. The guardian, who the complainant works for, wasn't contacted until Saturday morning about his not returning to the facility.
A review of R179's medical record revealed, R179 was admitted to the facility on [DATE] and discharged [DATE]. A review of R179's form titled, Minimum Data Set (MDS) Item Set Assessment by Patient, dated 2/20/23 noted, R179 with an moderate cognitive impairment.
Further review of R179's medical record progress notes revealed, 4/14/2023 12:44 (12:44 PM) Nurses Note Text: Resident LOA (leave of absence) to [local hospital] via seat walker with 1 attendant. No issues noted upon departure. signed by Unit Manager O.
4/15/2023 06:59 (6:59 AM) Nurses Note Text: Resident went to [R179's] (outside medical) appointment and did not return back to the facility. [Local hospital] was contacted. Daughter called and was notified [R179] did not return. Will follow up with ongoing nurse.
4/15/2023 08:16 (8:16 AM) Nurses Note Text: Resident's Guardian updated on resident's status. Guardian to contact [local hospital] for more information. Guardian states Resident has eloped before.
4/15/2023 08:37 (8:37 AM) Nurses Note Text: Writer received a phone call from the [local hospital] driver who picked up Resident yesterday. Driver notes that he picked up resident and took him directly to the [local hospital] in [local city]. He mentioned the resident (R179) told him (R179) had a series of appointments and anticipated to be done by 4pm. Driver said he communicated with Resident (R179) at 4:45pm, but at the time the driver was already heading home post shift. Driver also stated that per the way [local hospital] transportation works, if resident misses scheduled pickup or it is after hours, transportation organizes alternative transportation .
On 3/06/24 at 4:34 PM, the Nursing Home Administrator (NHA) was asked for the facility's investigation regarding R179's elopement. The NHA was unable to locate the file and stated, I called the former DON and left a voice mail. The NHA provided a statement by the SW L that recounted the event that happened on 4/14/23.
The statement revealed, On the day in question, [R179] was picked up by [local hospital driver] in the morning. [R179] never returned to [the facility]. The director of social services at the time, [former director of social services-SW T]. She was calling his family, and myself (SW L), I'm a veteran, so I said I would go downtown and look for [R179] at the [local hospital]. I did stop and notify the [hospital police] about the issues. [Hospital police] did look on the camera and checked [R179's] appointments. [The hospital police] said [R179] went to one appointment out of three and left. [R179's] brother came and picked [R179] up at the [local hospital], they went to the casino and went to stay with [R179's] brother. We did get in contact with [R179's] brother, he confirmed what had happened with [R179] and himself that day with [SW T] over the phone, on speaker. This form was signed by SW L and dated for today's date 3/6/24.
On 3/06/24 at 4:50 PM, the NHA provided a folder that was reported to be a complete investigation. The folder had a summary, R179's face sheet, four sheets of progress notes/medications, and a copy of the local police card.
A review of the Summary noted, On Friday, 4/14/2023, R179 went out on an LOA (leave of absence), for 2 appointments that [R179] allegedly made at the [local hospital] . administration Medical Center one appointment was for dermatology and the other was for orthopedics. [R179] was picked up with [R179's] seat walker from the [facility] at 12:44 PM by 1 [local hospital] transport attendant, [BD Q] . No issues at this time. From 4/15/2023, per [hospital staff], patient advocate at the [local hospital] the resident went to [their] dermatology appointment but not to [their] orthopedic appointment which was supposed to be done at 4:00 PM. [R179] did call [BD Q], the [local hospital] attendant /driver at 4:45 PM whose shift was done and could not pick him up. Part of the [local hospital], in cases like this the [local hospital] organized alternate transportation if the resident misses [their] pick-up time. [R179] did not return to the facility. the [local hospital] was contacted, and the daughter called the facility to confirm that [R179] did not return. The guardian, . was updated on the resident's status. She was going to contact the [local hospital] and stated that [R179] had a elope before. The facility nurse, LPN received a call from [BD Q] the [local hospital] transport attendant who had picked [R179] that day before stating that the resident was not at the agreed upon location. The police Sergeant . the [local hospital] Medical Center were alerted to this now missing resident as were the [local university police]. The (name of local police) police were also alerted to the facility I filed a report #23-3950 by (name of officer). The [city's] police found out that [R179] had gone to the casino and collapsed there and was taken to Detroit receiving hospital, stayed overnight and was released on Sunday, 4/16/2023 at 7:00 AM and apparently found [R179's] way to [there] brother, house . [R179] was there as of this writing, 4/17/2023 at 2:00 PM.
On 3/7/24 at 8:52 AM, Local Police Officer (LPO) was asked about the police report that was made by the facility. The LPO explained that the report was made on 4/15/23 at 11:17 AM and that it noted, on 4/14/23 around 1:00pm [R179] did not return to the facility from the [local hospital], and the report was made by LPN S.
On 3/07/24 at 9:03 AM, LPN S was asked how they knew R179 was missing and stated, I got a called from the Director of Nursing (DON) on Saturday, the DON said that she got notice that R179 was at [the local hospital]. I went down to the hospital's emergency room, and they said [R179] left AMA (against medical advice). LPN S continued and explained that she called R179's family and they directed her to a local park where R179 frequents, but R179 was not located at the park. LPN S was asked what day she went out to the hospital to search for R179. LPN S stated, It was either Saturday or Sunday, because I didn't work that Friday.
On 3/07/24 at 12:43 PM, R179's Guardian was asked when they were notified that R179 was missing from the facility. The Guardian stated, The day after, that Saturday. The Guardian continued and reported that they did not know R179 had an appointment and was not made aware that R179 was leaving the facility for an appointment. The Guardian also stated, that R179 had Dementia and wouldn't know where to go without someone's assistance.
On 3/07/24 at 1:09 PM, the NHA was asked for the facility's policy that address the procedure for residents that have outside appointments. The NHA reported that the facility does not have a policy for outside appointments. The NHA was asked how they handled outside appointments for residents that have legal guardians. The NHA reported, this is a question for the Social Services department. A request was made for the LOA sign out form for R179. The NHA stated, I don't know if nursing would have record of that. I will ask SW L. The form was not provided by the end of the survey. The NHA was observed to call the Guardian on speaker phone and asked the Guardian if they were contacted about R179 missing from the facility. The Guardian reported, No. I have no notes saying we were contacted. The Guardian continued and stated that they were contacted the day after and not the day of the incident.
On 3/07/24 at 1:11 PM, the Social Services Director (SSD D) was asked the process for outside appointment with residents that have guardians. The SSD D stated, We are supposed to notify the guardian, before they go out. The SSD D was asked the process for sending a staff member out on the appointment with a resident. The SSD D explained, the facility would consider the resident's needs, their cognition, safety needs, and the guardian's request for staff escort.
On 3/07/24 at 1:59 PM, the Corporate Representative explained that R179 was a transfer of care when R179 left for their appointment. The Corporate Representative was asked the facility's process for residents with guardians that have an outside appointment. The Corporate Representative stated, Procedure that we notify the guardian.
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 MI00135819.
Based on observation, interview, and record review the facility failed to ensure e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135819.
Based on observation, interview, and record review the facility failed to ensure elopement was reported to the State Agency for one resident (R179) of three residents reviewed for closed record. Findings include:
A review of the intake allegations noted, Complainant states on Friday, 04/14/23, the resident was sent on a [local hospital] transport for an appt. (appointment) The resident didn't return to the facility .
A review of R179's medical record revealed, R179 was admitted to the facility on [DATE] and discharged [DATE].
Further review of R179's medical record progress notes revealed, 4/14/2023 12:44 (12:44 PM) Nurses Note Text: Resident LOA (leave of absence) to [local hospital] via seat walker with 1 attendant. No issues noted upon departure. signed by Unit Manager O.
4/15/2023 06:59 (6:59 AM) Nurses Note Text: Resident went to [R179's] (outside medical) appointment and did not return back to the facility. [Local hospital] was contacted. Daughter called and was notified [R179] did not return. Will follow up with ongoing nurse.
4/15/2023 08:16 (8:16 AM) Nurses Note Text: Resident's Guardian updated on resident's status. Guardian to contact [local hospital] for more information. Guardian states Resident has eloped before.
4/15/2023 08:37 (8:37 AM) Nurses Note Text: Writer received a phone call from the [local hospital] driver who picked up Resident yesterday. Driver notes that he picked up resident and took him directly to the [local hospital] in [local city]. He mentioned the resident (R179) told him (R179) had a series of appointments and anticipated to be done by 4pm. Driver said he communicated with Resident (R179) at 4:45pm, but at the time the driver was already heading home post shift. Driver also stated that per the way [local hospital] transportation works, if resident misses scheduled pickup or it is after hours, transportation organizes alternative transportation .
On 3/07/24 at 8:19 AM, an attempt to contact Unit Manager O was unsuccessful due to the phone not in service.
On 3/06/24 at 4:37 PM, Social Worker L (SW L) was asked about the incident with R179 not returning to the facility. SW L explained that the nurse came and told her that R179 had not returned to the facility, SW L was familiar with the local hospital R179 had the appointment at, SW L went to the hospital and looked for R179. The SW L stated that, I did not see [R179], it was like a ghost town there. I asked the police (hospital police) to review the cameras.
On 3/07/24 at 9:29 AM, Bus Driver Q (BD Q) was asked about transporting R179 to the medical appointment. BD Q stated, I will never forget this day because they were blowing (calling a lot) my phone up about R179 the following day. BD Q stated once they picked R179 up from the facility R179 was acting lethargic and not very alert. BD Q was asked what happened with the transportation back to the facility after the medical appointment. BD Q stated, that R179 never showed up before the end of their shift. When the residents don't show up it's not his responsibility to look for them, the resident would need to go to the travel office. BD Q was asked if they were contacted by the facility on Friday 4/14/23 and stated, I didn't speak to anyone until the next day. The next day someone from the [local hospital] kept calling me asking about [R179].
On 3/7/24 at 8:52 AM, Local Police Officer (LPO) was asked about the police report that was made by the facility. The LPO explained that the report was made on 4/15/23 at 11:17 AM and that it noted, on 4/14/23 around 1:00pm [R179] did not return to the facility from the [local hospital], and the report was made by LPN S.
On 3/07/24 at 9:03 AM, LPN S was asked how they knew R179 was missing and stated, I got a called from the Director of Nursing (DON) on Saturday, the DON said that she got notice that R179 was at [the local hospital]. I went down to the hospital's emergency room, and they said [R179] left AMA (against medical advice). LPN S continued and explained that she called R179's family and they directed her to a local park where R179 frequents, but R179 was not located at the park. LPN S was asked what day she went out to the hospital to search for R179. LPN S stated, It was either Saturday or Sunday, because I didn't work that Friday.
On 3/07/24 at 4:24 PM, the Nursing Home Administrator (NHA) was asked the reason the elopement by R179 was not reported to the State Agency. The NHA stated, Because it wasn't an elopement from the facility, and he never came back.
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 MI00135819.
Based on observation, interview, and record review the facility failed to ensure a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00135819.
Based on observation, interview, and record review the facility failed to ensure a thorough and complete investigation was conducted after an elopement for one resident (R179) of three residents reviewed for closed record. Findings include:
A review of the intake allegations noted, Complainant states on Friday, 04/14/23, the resident was sent on a [local hospital] transport for an appt. (appointment) The resident didn't return to the facility .
A review of R179's medical record revealed, R179 was admitted to the facility on [DATE] and discharged [DATE].
Further review of R179's medical record progress notes revealed, 4/14/2023 12:44 (12:44 PM) Nurses Note Text: Resident LOA (leave of absence) to [local hospital] via seat walker with 1 attendant. No issues noted upon departure. signed by Unit Manager O.
4/15/2023 06:59 (6:59 AM) Nurses Note Text: Resident went to [R179's] (outside medical) appointment and did not return back to the facility. [Local hospital] was contacted. Daughter called and was notified [R179] did not return. Will follow up with ongoing nurse.
4/15/2023 08:16 (8:16 AM) Nurses Note Text: Resident's Guardian updated on resident's status. Guardian to contact [local hospital] for more information. Guardian states Resident has eloped before.
4/15/2023 08:37 (8:37 AM) Nurses Note Text: Writer received a phone call from the [local hospital] driver who picked up Resident yesterday. Driver notes that he picked up resident and took him directly to the [local hospital] in [local city]. He mentioned the resident (R179) told him (R179) had a series of appointments and anticipated to be done by 4pm. Driver said he communicated with Resident (R179) at 4:45pm, but at the time the driver was already heading home post shift. Driver also stated that per the way [local hospital] transportation works, if resident misses scheduled pickup or it is after hours, transportation organizes alternative transportation .
On 3/06/24 at 3:02 PM, the Director of Nursing (DON) was asked if the facility had completed an investigation for this incident. The DON explained that they started working at the facility about three weeks ago and that she did not see an investigation. The DON explained that they called the Nurse and that her number is disconnected.
On 3/06/24 at 4:34 PM, the NHA was asked for the facility's investigation regarding R179's elopement. The NHA was unable to locate the file and stated, I called the former DON and left a voice mail. The NHA provided a one statement by the SW L that was dated for 3/6/24 that recounted the event that happened on 4/14/23.
The statement revealed, On the day in question, [R179] was picked up by [local hospital driver] in the morning. [R179] never returned to [the facility]. The director of social services at the time, [former director of social services SW T]. She was calling his family, and myself (SW L), I'm a veteran, so I said I would go downtown and look for [R179] at the [local hospital]. I did stop and notify the [hospital police] about the issues. [Hospital police] did look on the camera and checked [R179's] appointments. [The hospital police] said [R179] went to one appointment out of three and left. [R179's] brother came and picked [R179] up at the [local hospital], they went to the casino and went to stay with [R179's] brother. We did get in contact with [R179's] brother, he confirmed what had happened with [R179] and himself that day with [SW T] over the phone, on speaker. This form was signed by SW L and dated for today's date 3/6/24.
On 3/06/24 at 4:50 PM, the NHA provided a folder that was reported to be a complete investigation. The folder had a summary, R179's face sheet, four sheets of progress notes/medications, and a Xerox copy of the local police card.
A review of the Summary noted, On Friday, 4/14/2023, R179 went out on an LOA (leave of absence), for 2 appointments that [R179] allegedly made at the [local hospital] . administration Medical Center one appointment was for dermatology and the other was for orthopedics. [R179] was picked up with [R179's] seat [NAME] from the [facility] at 12:44 PM by 1 [local hospital] transport attendant, [BD Q] . No issues at this time. From 4/15/2023, per [hospital staff], patient advocate at the [local hospital] the resident went to [their] dermatology appointment but not to [their] orthopedic appointment which was supposed to be done at 4:00 PM. [R179] did call [BD Q], the [local hospital] attendant /driver at 4:45 PM whose shift was done and could not pick him up. Part of the [local hospital], in cases like this the [local hospital] organized alternate transportation if the resident misses [their] pick-up time. [R179] did not return to the facility. the [local hospital] was contacted, and the daughter called the facility to confirm that [R179] did not return. The guardian, . was updated on the resident's status. She was going to contact the [local hospital] and stated that [R179] had a elope before. The facility nurse, LPN received a call from [BD Q] the [local hospital] transport attendant who had picked [R179] that day before stating that the resident was not at the agreed upon location. The police Sergeant . the [local hospital] Medical Center were alerted to this now missing resident as were the [local university police]. The [NAME] woods police were also alerted to the facility I filed a report #23-3950 by S [NAME]. The [city's] police found out that [R179] had gone to the casino and collapsed there and was taken to Detroit receiving hospital, stayed overnight and was released on Sunday, 4/16/2023 at 7:00 AM and apparently found [R179's] way to [there] brother, house . [R179] was there as of this writing, 4/17/2023 at 2:00 PM.
The NHA was asked the author of this summary and stated, I wrote it. The NHA was asked for the statements by staff and a timeline what happened after the elopement. The NHA explained that was all they had for the investigation.
On 3/07/24 at 8:19 AM, an attempt to contact Unit Manager O was unsuccessful due to the phone not in service.
On 3/07/24 at 9:29 AM, Bus Driver Q (BD Q) was asked about transporting R179 to the medical appointment. BD Q stated, I will never forget this day because they were blowing (calling a lot) my phone up about R179 the following day. BD Q stated once they picked R179 up from the facility R179 was acting lethargic and not very alert. BD Q was asked what happened with the transportation back to the facility after the medical appointment. BD Q stated, that R179 never showed up before the end of their shift. When the residents don't show up it's not his responsibility to look for them, the resident would need to go to the travel office. BD Q was asked if they were contacted by the facility on Friday 4/14/23 and stated, I didn't speak to anyone until the next day. The next day someone from the [local hospital] kept calling me asking about [R179].
On 3/7/24 at 8:52 AM, Local Police Officer (LPO) was asked about the police report that was made by the facility. The LPO explained that the report was made on 4/15/23 at 11:17 AM and that it noted, on 4/14/23 around 1:00pm [R179] did not return to the facility from the [local hospital], and the report was made by LPN S.
On 3/07/24 at 9:03 AM, LPN S was asked how they knew R179 was missing and stated, I got a called from the Director of Nursing (DON) on Saturday, the DON said that she got notice that R179 was at [the local hospital]. I went down to the hospital's emergency room, and they said [R179] left AMA (against medical advice). LPN S continued and explained that she called R179's family and they directed her to a local park where R179 frequents, but R179 was not located at the park. LPN S was asked what day she went out to the hospital to search for R179. LPN S stated, It was either Saturday or Sunday, because I didn't work that Friday.
On 3/07/24 at 12:43 PM, R179's Guardian was asked when they were notified that R179 was missing from the facility. The Guardian stated, The day after, that Saturday. The Guardian continued and reported that they did not know R179 had an appointment and was not made aware that R179 was leaving the facility for an appointment. The Guardian also stated, that R179 had Dementia and wouldn't know where to go without someone.
On 3/07/24 at 1:09 PM, the NHA was asked for the facility's policy that address the procedure for residents that have outside appointments. The NHA reported that the facility does not have a policy for outside appointments. The NHA was asked how they handled outside appointments for residents that have legal guardians. The NHA reported, this is a question for the Social Services department. A request was made for the LOA sign out form for R179. The NHA stated, I don't know if nursing would have record of that. I will ask SW L. The form was not provided by the end of the survey.
On 3/07/24 at 1:11 PM, the Social Services Director (SSD D) was asked the process for outside appointment with residents that have guardians. The SSD D stated, We are supposed to notify the guardian, before they go out. The SSD D was asked the process for sending a staff member out on the appointment with a resident. The SSD D explained, the facility would consider the resident's needs, their cognition, safety needs, and the guardian's request for staff escort.
On 3/07/24 at 1:59 PM, the Corporate Representative explained that R179 was a transfer of care when R179 left for their appointment. The Corporate Representative was asked the facility's process for residents with guardians that have an outside appointment. The Corporate Representative stated, Procedure that we notify the guardian.
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
Assessment Accuracy
(Tag F0641)
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 accuracy of a Minimum Data Set (MDS) Assessment...
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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 accuracy of a Minimum Data Set (MDS) Assessment for behaviors for two residents (R56 and R6) out six sampled residents reviewed, resulting in the potential for unmet care needs and behavioral health services. Findings include:
R56
On 03/06/24 at 08:40 AM, R56 was observed sitting up in bed and eating her breakfast. R56 yelled, My sister is my guardian, and I want to go home.
On 03/06/24 at 01:55 PM, R56 was observed walking in her room. R56 had several items on the floor
and the bed was covered with items. When asked how are you today, R56 responded Why do
you want to know and laughed loudly.
On 03/07/24 at 09:08 AM, R56 observed lying bed watching television. R56 asked, Do I have an appointment today. Bye.
A review of the medical record revealed that R56 admitted into the facility on 8/30/23 with the following diagnoses of schizoaffective disorder, bipolar type, violent behavior, paranoid personality disorder, and delusion disorders. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 99 indicating an impaired cognition. Section E on the MDS assesses behaviors and R56 was coded as having none. A review of medical record progress notes revealed several behaviors which should have reflected on the assessment.
A review of the medical record revealed a progress note dated on 12/27/23, 'Resident observed hallucinating reporting that some female was trying to take something from her, then resident tells writer You want me to take my medicine because you think that im crazy dont you?.'
A review of the medical record revealed a progress note dated on 12/24/23, 'R56 sat out in the hallway and screamed singing songs. R56 was asked to lower the tone due to residents on the hallway trying to sleep and R56 lowered their voice a little and continued to sing moderately loud.'
On 03/07/2024 at 10:00 AM, an interview was conducted with Social Worker L regarding R56's behaviors and inaccuracy of assessment. Social Worker L revealed an awareness of R56 behaviors and confirmed R56 is followed by a behaviorial service provider for her behaviors.
On 03/07/2024 at 1:29 PM, an interview was conducted with Director of Nursing (DON) regarding R56's inaccurate assement on the MDS. DON stated, my expectation is that the assessment for behaviors and MDS are completed accurately.
The policy of MDS assessments was requested but not recieved.
Resident 6 (R6)
On 3/05/24 at 12:44 PM, R6 was interviewed regarding their stay at the facility. During interview R6 was unable to hear the question which required the interview to be closer to R6's ear and at a louder volume.
On 3/06/24 at 9:31 AM, R6 was observed lying in bed asleep.
A review of R6's care plan noted, Focus: I have a communication problem r/t (relate to) being HOH (hard of hearing). Date Initiated: 01/05/2022. Goal: I will be able to make basic needs known on a daily basis through the review date. Date Initiated: 01/05/2022. Interventions: Be conscious of my position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 02/20/2022. COMMUNICATION: Allow me adequate time to respond, Repeat as necessary, Do not rush, Request clarification from me to ensure understanding, Face me when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Date Initiated: 02/20/2022. Speak to me on an adult level, speaking clearly and slower than normal. Date Initiated: 02/20/2022.
On 3/07/24 at 11:28 AM, the Social Service Director D was asked if R6 had been seen by the audiology physician. SW D explained that R6 had not been seen, due to the forms not being given to R6's physician to be signed.
A review of 3/20/2023 18:37 (6:37 PM) MDS (Minimum Data Set) Note Text: Resident seen by MDS nurse this morning. Resident alert lying in bed. Resident has upper and lower dentures. Resident states [R6] is HOH but lost [R6] Hearing Aids at home and wears glasses for reading only. Denies oral pain or swallowing difficulties at mealtime. ROM (range of motion) limited upper and lower. Left side lower back pain and is receiving tramadol prn (as needed) as needed. Resident transfer from bed to w/c (wheelchair) w/o (without) assistance.
6/29/2023 16:42 (4:42 PM) [local mental health service agency] Date: Jun 29, 2023. Complaint: Review of mood and cognition . Medical history includes dysthymic d/o (disorder), GAD (Generalized anxiety disorder), Primary Insomnia, and Dementia. [R6] has been appointed a legal guardian about which [R6] is not happy. [R6] was found in [R6's] room and was cooperative and oriented to reality. [R6] could provide a coherent history and understanding of the reason for her placement though disagrees that she should remain long term. [R6] has poor vision and is hard of hearing which impeded flow of conversation at times .
Further review of R6's medical record revealed, R6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Multiple Myeloma relapse. MDS quarterly 12/09/23 noted, R6 with an impaired cognition, section titled hearing noted, Ability to hear (with hearing aid or hearing appliances if normally used). 0 adequate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 an update for a preadmission screening (PAS) and resident re...
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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 an update for a preadmission screening (PAS) and resident review (ARR) /Hospital Exempted Discharge for a Level II evaluation was completed for one (R56) of three residents reviewed for PASARR, resulting in the potential for unmet mental health services. Findings include:
A review of the medical record revealed a Preadmission Screening with a hospital exemption dated on 8/30/23. There was no change in condition for hospital discharge within 30 days and the PASSAR should have been updated after thirty days. There was no additional PASARR forms nor was a Level II screening requested due to R56 having several diagnoses of mental illness.
A review of the medical record revealed that R56 admitted into the facility on 8/30/23 with the following diagnoses of schizoaffective disorder, bipolar type, violent behavior, paranoid personality disorder, and delusion disorders. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 99 indicating an impaired cognition.
On 03/07/2024 at 10:00 AM, an interview was conducted with Social Service Assistant regarding R56's level II screening not being completed. SSA stated that the corporate social worker has been doing the 3877/3878 forms.
On 03/07/2024 at 1:27 PM, an interview was conducted with Director of Nursing (DON) regarding R56's level II screening not being completed. DON stated, my expectation is that the PASARR's and OBRA's are completed accurately and timely for the resident.
A review of a facility policy titled, PASRR reveal if a resident who was not screened due to an exception and the resident remains in the facility longer than 30 days: a) the facility must screen the individual using the state's level I screening process and refer any resident who has or may have a Mental Disorder (MD) and Intellectual Disability (ID) or related condition to the appropriate state-designated authority for Level II PASRR evaluation and determination. b) The Level II PASRR resident review must be completed within 30 days of admission.
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
This citation pertains to Intake: MI00135805
Based on observation, interview and record review, the facility failed to provide nail care for one resident (R47) out of three reviewed for Activities of ...
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This citation pertains to Intake: MI00135805
Based on observation, interview and record review, the facility failed to provide nail care for one resident (R47) out of three reviewed for Activities of Daily Living (ADL). Findings Include:
On 3/5/2024 at 9:30 AM, R47 was observed laying in bed. R47 fingernails were long with black debris underneath. R47 was noted to have a contracture of the left hand and their fingernails were digging into their hand. R47 was interviewed regarding their nails. R47 stated that they wanted their nails cut and had informed the Unit Manager that they wanted a particular certified nursing assistant (CNA) to cut them. R47 stated that they also reached out to the CNA that they wanted to cut their nails.
On 3/6/2024 at 9:25 AM, R47 nails were still noted to be long with black debris underneath them. R47 stated that they were still waiting to get them cut and that they had told the Unit Manager again.
On 3/6/2024 at 12:11 PM, the Director of Nursing (DON) was asked to come down and look at R47's nails. The DON asked R47 if they wanted their nails cut and cleaned and R47 stated yes. The DON stated that anybody could cut and clean nails, but R47 likes when a particular CNA cut them and that they would have them come and care for R47's nails.
On 3/6/2024 at 12:48 PM, Certified Nursing Assistant (CNA) C stated that they cut R47's nails and cleaned them as best they could. CNA C stated that R47 can be noncompliant and there should be a note whenever R47 refuses care.
A review of a facility policy titled, Fingernail Care noted the following, .Fingernails are checked on shower days and trimmed as needed.
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 F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137493.
Based on observation, interview, and record review, the facility failed to provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00137493.
Based on observation, interview, and record review, the facility failed to provide ancillary services related to a hearing impairment for one resident (R6) of one reviewed for hearing services. Findings include:
On 3/05/24 at 12:44 PM, R6 was interviewed regarding their stay at the facility. During interview R6 was unable to hear the question which required the interview to be closer to R6's ear and at a louder volume. R6 was asked about their hearing aides. R6 was observed to pull a tissue out of their pocket and stated, Here they are, they don't work. I have lost the case for them, so I keep them in my pocket like this.
On 3/06/24 at 9:31 AM, R6 was observed lying in bed asleep.
A review of R6's care plan noted, Focus: I have a communication problem r/t (relate to) being HOH (hard of hearing). Date Initiated: 01/05/2022. Goal: I will be able to make basic needs known on a daily basis through the review date. Date Initiated: 01/05/2022. Interventions: Be conscious of my position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 02/20/2022. COMMUNICATION: Allow me adequate time to respond, Repeat as necessary, Do not rush, Request clarification from me to ensure understanding, Face me when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Date Initiated: 02/20/2022. Speak to me on an adult level, speaking clearly and slower than normal. Date Initiated: 02/20/2022.
On 3/07/24 at 11:28 AM, the Social Service Director (SW) D was asked if R6 had been seen by the audiology physician. SW D explained that R6 had not been seen, due to the forms not being given to R6's physician to be signed.
A review of R6's progress notes revealed, 3/20/2023 18:37 (6:37 PM) MDS (Minimum Data Set) Note Text: Resident seen by MDS nurse this morning. Resident alert lying in bed. Resident has upper and lower dentures. Resident states [R6] is HOH (hard of hearing) but lost [R6] Hearing Aids at home and wears glasses for reading only. Denies oral pain or swallowing difficulties at mealtime. ROM (range of motion) limited upper and lower. Left side lower back pain and is receiving tramadol prn (as needed) as needed. Resident transfer from bed to w/c (wheelchair) w/o (without) assistance.
6/29/2023 16:42 (4:42 PM) [local mental health service agency] Date: Jun 29, 2023. Complaint: Review of mood and cognition . Medical history includes dysthymic d/o (disorder), GAD (Generalized anxiety disorder), Primary Insomnia, and Dementia. [R6] has been appointed a legal guardian about which [R6] is not happy. [R6] was found in [R6's] room and was cooperative and oriented to reality. [R6] could provide a coherent history and understanding of the reason for her placement though disagrees that she should remain long term. [R6] has poor vision and is hard of hearing which impeded flow of conversation at times .
Further review of R6's medical record revealed, R6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Multiple Myeloma relapse. MDS quarterly 12/09/23 noted, R6 with an impaired cognition, section titled hearing noted, Ability to hear (with hearing aid or hearing appliances if normally used). 0 adequate.
A policy for audiology was request by the Social Service Director and was not received by the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure timely podiatry services for one resident (R16) of one reviewed for foot care. Findings include:
On 3/5/24 at 12:24 PM,...
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Based on observation, interview and record review, the facility failed to ensure timely podiatry services for one resident (R16) of one reviewed for foot care. Findings include:
On 3/5/24 at 12:24 PM, R16 was asked about their care in the facility, and explained that they wanted to be seen by the foot doctor to have their toenails cut, as they hurt when they rub against their socks and shoes.
A review if R16's medical record revealed that they were admitted into the facility on 7/19/22 with diagnoses that included Diabetes, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. Further review revealed that the resident has a moderate impaired cognition, and is dependent on staff for bathing, bed mobility and toilet use.
Further review of the medical record revealed that the resident had not been seen for podiatry services since their admission.
On 3/6/24 at 1:02 PM, surveyor observed R16's feet with Certified Nursing Assistant (CNA) P. R16's toenails were observed as elongated and approximately a half an inch in length. Upon observation, CNA P response was woah. R16 was asked if their toenails hurt, and stated, that they hurt when they rub against socks and shoes.
On 3/6/24 at 1:45 PM, Social Worker D was asked about the lack of ancillary services specifically foot care for R16, and she explained that ancillary services have been identified as a concern since being hired in December 2023, and are working on getting residents scheduled for services.
On 3/7/24 at 2:51 PM, the Director of Nursing (DON) was asked about her expectations for residents obtaining ancillary services, and she explained that the expectation is that residents get the services that they need.
A review of the facility's Foot Care policy did not address how often foot care should be provided to a diabetic 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
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 MI00138528.
Based on interview and record review, the facility failed to ensure appropriate neu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138528.
Based on interview and record review, the facility failed to ensure appropriate neurological assessments were completed after an unwitnessed fall for one resident (#479) out of five residents reviewed for falls, resulting in the potential delay to provide resident care needs following an unwitnessed fall.
Finding include:
It was reported to the State Agency that staff failed to provide timely medical evaluation.
A review of the clinical record revealed R479 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R479's diagnoses included seizure disorder, chronic drug abuse, peripheral neuropathy, panic disorder, and transient cerebral ischemic attack. A Minimum Data Set assessment dated [DATE] documented moderate cognitive impairment, extensive one-person physical assistance for bed mobility, and extensive two-person physical assistance for transfers.
On 3/6/24 at 3:35 PM with the Director of Nursing (DON), R479's Incident Note of 7/4/23 was reviewed: At approximately 4:20am, resident is observed on the floor, besides her bed, laying on her back, CNA (certified nurse assistant), writer & supervisor transferred her from floor to bed, ROM (range of motion) is limited d/t (due to) her baseline muscle weakness/spasms, when asked how she fell, she stated picking her shoes then changed statement that somebody was putting shoes on her, she also claims that she was under the bed, but she is actually besides her bed, No injury is noted, 0 bruising, 0 redness, 0 open skin, V/S 114/60, P104, R20, T97.4, SpO2 99%, Made her feel comfortable, pillows & wedges tucked in both sides of her bed under fitted sheet, bed placed in lowest position, call light w/in reach, Neuro check started for an unwitnessed fall, MD (medical doctor) & family notified, MD orders to continue to closely monitor & report for any changes of condition.
Further review of R479's clinical record revealed a neuro assessment was documented on 7/4/23 at 4:20 AM which revealed R479's level of consciousness as confused. The DON acknowledged there were no additional neuro assessment documentation provided, such as level of consciousness, lethargy, and changes in mentation, and there should have been.
The Falls Management Policy was reviewed. Under the subtitle Definition, it stated when a resident is observed on the floor, the facility is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring. Under the subtitle Practice Guidelines, number five requires the licensed nurse to document the incident on a Post- Fall Assessment (if incident is a fall), and Charting in the nurses notes over the next 72 hours. There is not charting from any discipline until 7/6/2023 regarding discharge planning.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2.
Based on observation, interview, and record review, the facility failed to provide nutritional ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2.
Based on observation, interview, and record review, the facility failed to provide nutritional supplements per physician orders for one resident (R65) out of one reviewed for nutrition. Findings include:
A review of the medical record revealed that R65 admitted into the facility on 5/31/2022 with the following diagnoses, Severe Protein Calorie Malnutrition and Anorexia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status assessment of 99, indicating that R65 was unable to complete the assessment. R65 also required assistance with bed mobility and transfers.
A review of the physician orders revealed the following orders, Ensure three times a day and Health Shake with meals.
On 3/5/2024 at 12:45 PM, R65 was observed laying in bed and asking for a pillowcase. R65's tray was observed off to the side. No supplements were noted on the meal tray.
On 3/7/2024 at 8:30 AM, R65 was observed sitting in a chair eating their food. No supplements were observed on the meal tray.
A review of the progress notes revealed the following note by Registered Dietitian (RD) F, Resident is on regular diet with thin liquids. Receives Ensure + 1 can TID, Health shakes with meals, Liquid Protein 30ml Q a day This writer talked to the CNA and charge nurse, unit manager - per them resident is with variable intake, loves to drink her supplements, friend also visits often and brings food for her .Per Unit manager and charge nurse resident is hard to be redirected or encouraged to eat more or to be assisted but likes to drink her supplements .Will continue with diet and supplements as ordered as further weight gain is planned and desirable to gain weight
On 3/7/2024 at 10:59 AM, an interview was conducted with RD F. RD F was informed that there were observations of R65 not having supplements on their tray during mealtime. RD F stated that they will have to look at the meal ticket and see what it says.
No other information was provided prior to the end of survey.
A review of a facility policy titled, Supplements noted the following, .4. Dietary will deliver the appropriate product to the nurse's station, properly labeled with the resident's name, room number, date, and time of delivery. 5. The nursing staff will deliver the supplement and assist the resident if necessary.
This citation has two deficient practices.
Deficient practice #1.
Based on observation, interview, and record review, the facility failed to consistently assess and implement nutrition interventions for one resident (R63) of seven residents reviewed for maintenance or improvement in nutritional status, resulting in a delay in the identification of continued significant weight loss and the potential for further decline in nutritional status.
Findings include:
On 3/5/24 at 11:10 AM, during the initial tour of the facility, Resident #63 (R63) was observed asleep and lying in bed. R63 appeared very thin in appearance.
A review of the clinical record for R63 documented an admission date of 2/2/22 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, cirrhosis of liver, and type 2 diabetes mellitus. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment.
A review of R63's care plans documented in part the following:
Focus: I am at nutritional risk related to partial intestinal obstruction, hemiplegia/hemiparesis, type 2 diabetes mellitus, muscle weakness, symbolic dysfunctions, cirrhosis of liver, contractures, hydronephrosis with renal/ureteral calculous obstruction, kidney/ureter disease, .dementia, calculus of gallbladder with acute cholecystitis. I receive a mechanically altered diet, however, I may choose to consume regular textured items at my discretion that I purchase/have brought in for me. I use a 3-compartment plate. I do not like built-up silverware & prefer to use my hands to eat with regular silverware, however, I now require total assistance with my meals. I receive nutritional supplements. I am on meds that may affect my nutritional status. I benefit from total assistance with meals. I recently triggered for significant weight loss; the RD (Registered Dietitian) is monitoring me. My BMI (body mass index) is WNL (within normal limits). 3/5/24: 137# as of 2/8/24. Intake is variable, need assist with meals. Date initiated: 02/25/2022. Revised on 03/05/2024.
Review of R63's documented body weight revealed the following:
10/9/23: 154.8#
11/9/23: 148.8#
12/5/23: 147.8#
1/10/24: 145.0#
2/8/24: 137.4#
2/9/24: 137.4#
R63's body weight was 135.9# on 3/7/24 at 11:32 AM.
A review of R63's nutrition notes documented in part the following:
1. RD October 27, 2023 weight change note. WEIGHT WARNING: Value: 154.8#. Resident was reviewed r/t (related to) significant weight loss x 180 days. BMI: 22.9 - WNL. Resident continues to experience gradual weight loss likely r/t some fluctuations in PO (oral) intake. Currently receiving Liquid Protein TID (3 x day) for wound healing. Recommend Magic Cup BID (twice a day) with lunch and dinner to help maintain CBW (current body weight) and avoid further weight loss. Current diet with recommended supplement regimen will likely meet estimated nutritional needs. Usually good appetite and PO intake. Recommendation above, otherwise, continue with current plan of care and will adjust as needed. Will continue to monitor for any changes, weights, PO intake, skin, nutrition-related labs, and f/u (follow up) as needed.
2. RD November 16, 2023 weight change note. WEIGHT WARNING: Value: 148.8#. Resident was reviewed r/t significant weight loss x 180 days. BMI: 22.0 - WNL. Resident continues to experience gradual weight loss likely r/t some fluctuations in PO intake. Currently receiving Liquid Protein TID for wound healing and Magic Cup BID. Current diet with supplement regimen is likely meeting estimated nutritional needs. Usually good appetite and PO intake. Recommend increase protein portion sizes. Recommendation above, otherwise, continue with current plan of care and will adjust as needed. Will continue to monitor for any changes, weights, PO intake, skin, nutrition-related labs, and f/u as needed.
3. RD December 26, 2023 weight change note. WEIGHT WARNING: Value: 147.8#. Resident was reviewed r/t significant weight loss x 180 days. BMI: 21.8 - WNL. Resident continues to experience gradual weight loss likely r/t some difficulty . and need for increased assistance with meals. Orders updated to provide resident with pureed meats and total assistance at meal times. Continues to receive Liquid Protein TID for wound healing and Magic Cup BID. Current diet with supplement regimen is likely meeting estimated nutritional needs. Usually good appetite and PO intake. Recent adjustments above, otherwise, continue with current plan of care and will adjust as needed. Will continue to monitor for any changes in weight, PO intake, skin, nutrition-related labs and f/u as needed.
5. RD nutrition note of 3/5/24. Resident is on mechanical soft with thin liquids. Receives Liquid Protein 30 ml TID, Juven 1 pack for wound healing and Magic Cup BID, one-to-one assistance with all meals. Weights: 137# x 2, 8# loss in 30 days, 11.4# loss, significant loss of 7.6% in 90 days. Resident is with fair intake. Intake variable. Resident is his own responsible party. Physician notified of weight loss. Physician notified to evaluate for appetite stimulant. Per skin note of 2/28/24: Wound #1 left lateral ankle chronic diabetic ulcer 7.5 x 8.0 cm (centimeter). Will start resident on weekly weights, request (labs): next lab draw to rule out weight loss. Will add Ensure 1 can BID to provide extra calorie and protein for weight maintenance and wound healing.
On 3/7/24 at 8:13 AM, the Certified Dietary Manager said the facility does not presently have a full-time Registered Dietitian.
On 3/7/24 at 9:50 AM, RD F said the facility has not had a RD for a couple of months. RD F indicated she usually comes once a week to cover the facility.
On 3/7/24 at 11:07 AM, RD F said residents that experience significant weight loss are high risk and should be seen monthly and as needed. When a resident experiences significant weight loss, RD F said they should be evaluated as soon as possible, normally within two to three business days. RD F acknowledged that R63 experienced a significant weight loss of 5.24% between 1/10/24 and 2/8/24. RD F indicated there was a delay in identifying R63's continued significant weight loss, addressing risk factors, and modifying interventions as needed. RD F indicated the delay in providing nutrition recommendations can put a resident's health at risk.
A review of the facility document titled, Weight Management, undated but provided during the survey, revealed in part the following:
- Residents will be monitored for significant weight change on a regular basis.
- Ensure that each resident identified with significant weight change is on a weekly schedule.
- Ensure that each resident with significant weight change has a current assessment by the RD.
On 3/7/24 at 11:57 AM, the Director of Nursing indicated that when a resident experiences significant weight loss, the RD should have reviewed the resident, the resident should be on weekly weights, and the physician notified.
On 3/7/24 at 5:00 PM during the exit conference, NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label a bag of Intravenous (IV) fluids, an Intravenou...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label a bag of Intravenous (IV) fluids, an Intravenous (IV) line, and IV dressing for one resident (R52) out of six reviewed for IV fluids. Findings Include:
On 3/5/2024 at 9:21 AM, an interview was conducted with R52. R52 stated that they had been receiving fluids for the last day or so. R52 was observed to be receiving fluids. R52 stated that IV was infusing on the side of their stomach.
On 3/5/2024 at 9:24 AM, certified nursing assistant (CNA) G turned R52 over and no date was observed on the bag of fluids, IV line, and/or the dressing at the insertion site.
A review of the medical record revealed that R52 admitted into the facility on [DATE] with the following diagnoses, Sepsis and Urinary Tract Infection. A review of Minimum Data Set assessment revealed a Brief Interview for Mental status score of 15/15 indicating an intact cognition. R52 also required assistance with bed mobility and transfers.
On 3/7/2024 at 9:38 AM, an interview was conducted with the Director of Nursing (DON). The DON state that they expect IV bags, lines, and dressings to be dated.
On 3/7/2024 at 11:30 AM, an interview was conducted with the Infection Preventionist (IP) H. IP H stated that they round each morning to ensure that all IV's are dated and have a name. IP H was informed that R52 did not have their IV bag, line, and/or dressing dated. IP H stated that it should have been dated.
A review of a facility policy titled, IV drug administration policy and procedure did not address the labeling of IV fluids, line, and/or dressing.
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice number two.
Based on interview and record review, the facility failed to prevent unnecessary use of Psychotro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice number two.
Based on interview and record review, the facility failed to prevent unnecessary use of Psychotropics for two (Resident #8, and Resident #56,) of five residents reviewed who had an order for Ativan without a stop date of 14 days, potentially resulting in serious side effects and adverse reactions. Findings include:
R8
On 03/06/24 at 9:30 AM, the physician entered an order for R8 on 7/30/2023 for Ativan Gel 1 mg (milligram)/ml (milliliter), apply to arm topically as needed for anxiety, PRN (as needed). There was not an end date. The Ativan order, appeared on the Medication Administration Record (MAR) 7/30/2023 thru the present.
The pertinent diagnoses for R8 are: A history of transient ischemic attack, cerebral Infarction, unspecified psychosis major depressive disorder, chronic kidney disease, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, adjustment disorder with mixed disturbance, and metabolic encephalopathy.
R56
A review of the medical record revealed that R56 admitted into the facility on 8/30/23 with the following diagnoses of schizoaffective disorder, bipolar type, violent behavior, paranoid personality disorder, and delusion disorders. A review of the most recent Minimum Data Set assessment dated [DATE] was completed with a Brief Interview for Mental Status (BIMS) score of 99 indicating an impaired cognition.
Further record review revealed a physician order for Ativan (Lorazepam-antianxiety) Oral Tablet 0.5 MG (milligrams)to give 1 tablet by mouth every 4 hours as needed for anxiety and agitation. R56 is also prescribed Lithium Carbonate, Trazadone, Risperdal and Aripiprazole (medications to treat mental health disorders).
On 03/07/24 at 1:27 PM, the identified concern regarding the Ativan PRN order without a stop date was reviewed with the Director of Nursing (DON). The DON stated,My expectation would be that the order would have a stop date.
A review of the facility's policy/procedure titled, Psychotropic Medcation Assessment and Monitoring, dated June 2018, revealed PRN psychotropic medications will be time limited to 14 days unless documented by the physician regarding the rationale for extending the PRN past 14 days.
This citation has two deficient practice statements.
Deficient Practice Statement number one.
Based on interview and record review, the facility failed to properly monitor an antipsychotic (AP) medication for one resident (R123) out of three reviewed for antipsychotic use. Findings Include:
A review of the medical record revealed that R123 admitted into the facility on 1/15/2024 with the following diagnoses, Repeated Falls and Metabolic Encephalopathy. A review of the Minimum Data Set assessment revealed a Brief Interview Mental status score of 5/15 indicating an impaired cognition. R123 also required staff assistance with bed mobility and transfer.
Further review of the physician orders revealed that R123 was currently prescribed Zyprexa (AP) two times a day for Dementia.
Further review of the medical record revealed no Abnormal Involuntary Movement (AIMS) testing or psychiatric notes.
On 3/6/2024 at 12:38 PM, an interview was conducted with Social Worker (SW) D. SW D stated that R123 has not been seen by psychiatry yet. SW D stated that they were working on getting everyone seen, however they have been having some problems with the psychiatry group they use. SW D was queried as to if R123 had any AIMS testing completed. SW D stated that psychiatry usually does them, but since R123 had not seen them, that one was not completed. SW D stated that they would have the nursing department complete the AIMS testing.
On 3/7/2024 at 9:39 AM, the Director of Nursing (DON) stated that they had just completed the AIMS testing for R123.
A review of a facility policy titled, Psychotropic Medication Assessment and Monitoring did not address AIMS testing.
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 properly store medication for two residents (R47 and R94) out of two reviewed for medication storage. Findings Include:
On 3/...
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Based on observation, interview, and record review, the facility failed to properly store medication for two residents (R47 and R94) out of two reviewed for medication storage. Findings Include:
On 3/5/2024 at 1:17 PM, R47 was observed in their room. R47 was noted to be laying in bed. A nebulizer machine was observed in the corner, unplugged. Under the television stand, 4 vials of albuterol inhalation liquid were observed sitting on a shelf.
A review of the medical record revealed that R47 admitted into the facility on 9/25/2021 with the following diagnoses, Hemiplegia and Contracture, Left Hand. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R47 was also dependent on staff for bed mobility and transfers.
A review of the physician orders revealed the following, Order: Albuterol Sulfate Nebulization Solution 0.63 milligrams (MG)/3 milliter (ML). Directions: 1 vial inhale orally via nebulizer every 6 hours as needed for SOB AND 1 vial inhale orally via nebulizer every 6 hours for SOB . Status: Active.
On 3/6/2024 at 8:58 AM, the four vials were observed sitting on the television stand on the shelf.
On 3/6/2024 at 9:21 AM, Licensed Practical Nurse (LPN) E was shown the albuterol vials and asked if R47 was supposed to have medication at the bedside. LPN E stated that they were not supposed to have them and proceeded to take the medication out the room.
On 3/6/2024 at 12:11 PM, the Director of Nursing (DON) was informed that there was medication found at the bedside. The DON stated that the medication should not have been there.
A review of a facility policy titled, Medication Storage in The Facility noted the following, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff member lawfully authorized to administer medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00135865
Based on interview and record review, the facility failed to ensure nursing standar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00135865
Based on interview and record review, the facility failed to ensure nursing standards of practice for medication administration documentation were followed for three residents (#70, #74, #121) of three residents reviewed for maintenance of medical records, resulting in the potential for medication errors and compromise and complications in health.
Findings include:
A resident group meeting was held on 3/6/24 at 10:00 AM with six residents, all of whom were alert, oriented, and able to express themselves without difficulty. Resident #74 (R74) and Resident #121 (R121) indicated the following when queried if staff were available to assist them when needed:
R74 verbalized a concern about getting medications in a timely manner.
R121 said their pain meds were not provided for two days, multiple times.
During an interview on 3/7/24 at 11:44 AM, R74 said they would be in pain when medications are late or not received.
During an interview on 3/7/24 at 11:46 AM, R121 stated, I feel sick when I don't get my meds.
A review of the clinical record revealed R74 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Their diagnoses included type 2 diabetes mellitus, psoriasis, anxiety disorder, and pain in the right shoulder. A Minimum Data Set assessment (MDS) dated [DATE] documented intact cognition.
Record review of R74's cardiovascular status care plan revised on 12/18/23 documented, Provide me with my medications as ordered. R74's potential for pain/discomfort) care plan revised on 12/18/23 documented, Administer my analgesic per orders.
A review of the clinical record revealed R121 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), cancer of the cervix, iron deficiency anemia, and cancer related pain. A MDS assessment dated [DATE] documented intact cognition.
Record review of R121's cardiovascular status care plan revised 12/12/23 documented, Provide me with my medications as ordered. R121's pain/discomfort related to pelvic pain, cancer of cervix care plan revised 12/12/23 documented, Anticipate my need for pain relief and respond as soon as possible to any complaint/signs of pain.
A review of the clinical record revealed Resident #70 (R70) was admitted to the facility on [DATE] with diagnosis that included cancer of the pharynx, chronic pancreatitis, and COPD. A MDS assessment dated [DATE] documented severe cognitive impairment.
Record review of R70's fluid imbalance and nutritional risk care plans revised on 6/29/23 and 3/5/24 respectively documented to administer medications as ordered.
The Director of Nursing (DON) was interviewed on 3/7/24 at 12:00 PM. Reviews of the February 2024 Medication Administration Records (MARs) for R70, R74, and R121 were conducted with the DON. The administration of the following medications, at the dates and times specified, were not documented on the MARs:
R70-
1. 6:00 AM Amlodipine besylate 5 milligrams (mg) (for elevated blood pressure): 2/2/24, 2/15/24, 2/18/24, 2/19/24.
2. Prior to bedtime Atorvastatin 40 mg (for high blood cholesterol): 2/14/24, 2/17/24, 2/18/24.
3. 6:00 AM Flomax 0.4 mg (for benign prostatic hyperplasia): 2/2/24, 2/15/24, 2/18/24, 2/19/24.
4. Prior to bedtime Latanoprost (eye drop for glaucoma): 2/14/24, 2/17/24, 2/18/24.
5. 6:00 AM Levothyroxine 25 mcg (microgram) (for hypothyroidism): 2/2/24, 2/15/24, 2/18/24, 2/19/24.
6. Zenpep oral capsule (pancreatic enzymes):
-6:00 AM: 2/2/24, 2/15/24, 2/18/24, 2/19/24.
-10:00 PM: 2/14/24, 2/17/24, 2/18/24.
R74-
1. 9:00 PM Atorvastatin 40 mg (for hyperlipidemia): 2/14/24, 2/17/24, 2/18/24.
2. 5:00 PM Hydroxyzine 10 mg (for itching): 2/15/24.
3. Prior to bedtime Metoprolol 12.5 mg (for hypertension): 2/14/24, 2/17/24, 2/18/24.
4. 9:00 PM Norco (pain management): 2/14/24, 2/17/24, 2/18/24.
5. Prior to bedtime Gabapentin 300 mg (pain management): 2/14/24, 2/17/24, 2/18/24.
R121-
1. 6:00 AM Miralax 17 gm (for constipation): 2/15/24, 2/18/24, 2/19/24.
2. 6:00 AM Tamsulosin 0.4 mg (for urinary retention): 2/15/24, 2/18/24, 2/19/24.
3. 6:00 AM Ferrous sulfate 325 mg (dietary supplement): 2/15/24, 2/18/24, 2/19/24.
4. 6:00 AM Lactulose 20 ml (milliliters) (for liver disease): 2/15/24, 2/18/24, 2/19/24.
5. 6:00 AM Morphine sulfate 30 mg (for pain management): 2/15/24, 2/18/24, 2/19/24.
6. 10:00 PM Morphine sulfate 30 mg: 2/14/24, 2/17/24, 2/18/24.
After reviewing the MARs, the DON said that it was expected that medications are given as ordered and if the medications are not given the physician should be contacted. The DON was requested to provide nursing notes regarding the missing medication administration documentation or that the physician was contacted, and none was provided by the end of the survey.
On 3/7/24 at 5:00 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe and functional environment for the facilities census of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe and functional environment for the facilities census of 131 residents and its staff resulting in an increased potential for harm. Findings include:
On 3/6/24 between 10:02 AM, and 11:18 AM, during an environmental tour of the facility the following observations were made:
Privacy curtains were observed missing in resident rooms 12A and 11.
A heat deflector was observed detached from the radiator in resident room [ROOM NUMBER].
Drywall was observed heavily damaged in resident room [ROOM NUMBER], and to the left of bed one in resident room [ROOM NUMBER].
A six inch by six inch square was observed missing in the vinyl flooring in resident room [ROOM NUMBER].
On 3/6/24 at 11:20 AM, upon interview with Maintenance Director, staff B, on how work orders are submitted to the maintenance department to be completed they stated, it is all electronic, and we check it three times a day. Once in the morning, around lunchtime, and before we leave for the day. At this time the surveyor inquired with staff B on if they were aware of the conditions in the above mentioned resident rooms to which they stated, No. As soon as they are entered, we get on them, but if they are not entered we don't know about them. I'll get on these items today.
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
On 3/5/24 at 8:40 AM, during the initial tour of the kitchen with the Certified Dietary Manager (CDM) the following was observed:
-The caulking around both the handwashing sink near the three-compartm...
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On 3/5/24 at 8:40 AM, during the initial tour of the kitchen with the Certified Dietary Manager (CDM) the following was observed:
-The caulking around both the handwashing sink near the three-compartment sink and the walk-in cooler were observed cracked and separated.
-The paint on the wall above and around the handwashing sink near the walk-in cooler was peeling and chipping.
-The fire suppression agent storage cylinder located in the cook's prep area was soiled with dust and grime.
On 3/5/24 at 9:10 AM, the ice machine used by kitchen staff, located in the employee breakroom, was observed. The area behind the ice machine surrounding the ice machine drain was observed soiled with dirt, grime, and various pieces of debris such as a mask, plastic knife, paper towel, and used condiment packages. The CDM stated, (This) is a mess that needs to be cleaned up.
A review of the 2013 FDA Food Code documented the following:
-Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
-Section 6-201.11 Floors, Walls, and Ceilings. Except as specified under § 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable.
On 3/7/24 at 5:00 PM during the exit conference, the Nursing Home Administrator and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
Based on observation and interview, the facility failed to maintain sanitary conditions in the kitchen and employee breakroom resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 127 residents who receive meal services (4 nothing by mouth residents, or NPO) out of the facility's total census of 131 residents. Findings include:
On 3/5/24 at 10:05 AM, the kitchen's steamer was observed in use and outside of the cooking lines exhaust hood. Further inspection of the area revealed an accumulation of condensation and water droplets on the ceiling above the unit and above the clean equipment storage rack containing cutting boards, plastic containers, and lids. On 3/5/24 at 10:25 AM, upon interview with Certified Dietary Manager, staff A, the surveyor inquired if the steamer had always been in its current location, to which they stated, since I started working here about two years ago. At this time staff A acknowledged the additional moisture in this area.
Review of 2017 U.S. Public Health Service Food Code, Chapter 6-304.11 Mechanical, directs that:
If necessary to keep rooms free of excessive heat, steam, condensation, vapors, obnoxious odors, smoke, and fumes, mechanical ventilation of sufficient capacity shall be provided.
2. On 3/5/24 at 10:11 AM, the two-door reach in vegetable freezer's left door handle was observed damaged and with missing pieces resulting in a sharp metal outer edge. On 3/5/24 at 10:27 AM, upon interview with Certified Dietary Manager, staff A, the surveyor inquired if a work order has been placed for the door's handle to which they stated, not yet.
Review of 2017 U.S. Public Health Service Food Code, Chapter 4-501.11 Good Repair and Proper Adjustment, directs that:
(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.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in this ...
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Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in this food equipment not being protected against contamination from sewage or other sources of contamination, potentially affecting all residents consuming food from the kitchen.
Findings include:
On 3/5/24 at 8:40 AM, during the initial tour of the kitchen with the Certified Dietary Manager (CDM), the drain line from the two-compartment sink was observed to not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). The CDM said the two-compartment sink was used for thawing frozen food and that there was not enough of an air gap.
On 3/7/24 at 3:22 PM, the Nursing Home Administrator (NHA) said someone should have detected that the two-compartment sink was not properly air gapped and alerted the maintenance director right away.
The 2013 FDA Food Code was reviewed and revealed the following in Section 5-202.13 Backflow Prevention, Air Gap: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch.
On 3/7/24 at 5:00 PM during the exit conference, the NHA and Director of Nursing (DON) were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to maintain an effective pest control program, resulting in multiple resident complaints regarding pests, and the presence of live pests (gnats)...
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Based on observation and interview, the facility failed to maintain an effective pest control program, resulting in multiple resident complaints regarding pests, and the presence of live pests (gnats) in multiple areas of the facility.
Findings include:
On 3/5/24 at 8:50 AM, multiple gnats (too many to count) were observed swarming around the trash can located in the lower-level staff break room.
During an interview with Resident #8 on 3/6/24 at 9:23 AM, gnats were observed flying around the resident's head.
A resident group meeting was held on 3/6/24 at 10:00 AM with six residents, all of whom were alert, oriented, and able to express themselves without difficulty. A gnat was observed in the dining room during the group meeting. The following resident responses were given to the question, Do you have a concern with gnats in the building?
- I have gnats in my room. Gnats are around the garbage, and they fly in your face.
- I have seen them in my room and hallway.
- I saw a gnat in my room.
- I saw gnats in the dining room and in my room.
- They're around you when you're eating.
On 3/7/24 at 3:22 PM, the Nursing Home Administrator (NHA) said a pest control company comes out every two weeks or as needed. The NHA said the facility will do room searches of a resident's room if food hoarding/inappropriate storage of food is identified as a concern. The NHA said they did a room search last week. The NHA provided no other answer regarding the continued presents of gnats in the building.
On 3/7/24 at 5:00 PM during the exit conference, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00133917.
Based on interview and record review, the facility failed to notify the resident's...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00133917.
Based on interview and record review, the facility failed to notify the resident's representative of a fall for one resident (R901) of one reviewed for notification of changes, resulting in the resident's representative being unaware of the fall, and a delay in the opportunity to participate in medical decisions regarding care and treatment. Findings include:
A review of MI00133917 revealed the following, On December 7th I was called regarding a fall [R901] had that resulted in no injury. The nurse mentioned that it was nothing like the fall [R901] had 2 days prior that had split [their] eyebrow open. I was shocked because they had never called to report this injury to me. When I arrived to check on [R901] on December 8th I observed a severe wound on [their] eyebrow and side of [their] eye. I questioned why I was never called about this injury as it is required by state law and they told me that it was a new nurse who was unaware of the requirement to report a residents fall to their legal guardian. I was worried that [their] injury could have possibly been severe or had not been treated properly so I asked for them to send [R901] to the hospital for observation .
A review of R901's medical record revealed that they were admitted to the facility on [DATE] with diagnoses that included, Stroke, Dementia, and Heart Failure. Further review of the medical record revealed that the resident was severely cognitively impaired, and required extensive assistance with Activities of Daily Living.
Further review of the medical record revealed the following progress notes:
12/6/2022 17:24 (5:24pm) Nurses Notes: Client recently had a fall. Injury noted to the upper right eyebrow. Skin has been cleaned and dried. Nursing provided Steri-Strips to site. Neurochecks q15 minutes (every 15 minutes). Will continue to monitor.
12/7/2022 17:17 (5:17pm) Nurses Note: Resident assess r/t (related to) post-fall. Resident alert to name, confusion noted r/t dementia .6 steri strips in place to right eyebrow .
12/8/2022 17:07 (5:07pm) Move out/discharge note: Resident had a fall on 12/8/22 and family requested [R901] be sent out for further evaluation of right eye. [Physician] contacted the facility and agreed to send resident to hospital .
A review of R901's Incident and Accident report dated 12/6/22 revealed the following, .Nursing Description: Client was asleep in bed. Per CNA (certified nursing assistant) heard a loud noise coming from the hall. When nursing arrived client was laying on the floor c/o (complain of) pain .Immediate Action Taken. Description: Physician and Nurse unit Manager notified. Physician stated to apply steri-strips. Neuro-checks q15 minutes along with skin assessment. Client received Tylenol for pain. Will continue to monitor .
Further review of the Incident and Accident reports and progress notes revealed that R901's resident's representative was not notified of the fall.
On 10/2/23 at 3:07 PM, the Director of Nursing (DON) was asked for her expectation regarding a resident's representative being contacted following a fall. The DON explained that the responsible party should be contacted following a fall.
A review of the facility's Fall Management Guidelines revealed the following, .6. As soon as practicable, communicate the fall to the attending physician and the resident's responsible party/legal representative and document in the medical record .
Dec 2022
9 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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide clothing protectors and serve meals in an appropriate manner in one dining room (the long term care dining room) of t...
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Based on observation, interview, and record review, the facility failed to provide clothing protectors and serve meals in an appropriate manner in one dining room (the long term care dining room) of two dining rooms, resulting in an unpleasant and potentially undignified dining experience. Findings include:
On 12/01/2022 at 12:30 PM, the lunch meal was observed in the dining room for the long term care residents. There were two staff members present in the dining room and six tables set up with either one or two residents at each table.
On 12/01/2022 at 12:34 PM, a lunch caddy was observed to be delivered to the dining room. The two staff members removed a few food trays from the caddy and began to serve some of the residents. Unit Manager A made a comment to the other staff member in the room that they needed clothing protectors for the residents. The other staff member left the room on several occasions, but did not return with any clothing protectors. Unit Manager A placed a white hand towel on the chest of one of the Residents that was eating. Unit Manager A then sat down and began feeding a Resident. There were two tables that had two residents at each table, with only one resident served a meal.
On 12/01/2022 at 12:53 PM, there were a total of ten residents in the dining room, only five had been served. The residents that were eating did not have any clothing protectors on. Unit Manager A was queried on how the residents are served. According to Unit Manager A, all the residents were not served at the same time because they had to wait for each bay (the units the residents live on) to be served, then the food caddy would be delivered to the dining room for the staff to serve those trays. Unit Manager A stated the nurse aides from the units serve those residents first, then bring down the left over trays to the dining room.
On 12/01/2022 at 1:00 PM, the last food tray was served to the last resident waiting for their lunch. There were still no clothing protectors on the residents.
On 12/02/2022 at 12:28 PM, lunch was observed in the long term care dining room. There were two staff members in the dining room, including Unit Manager A.
On 12/02/2022 at 12:34 PM, the first resident was served. There were eight residents in the dining room. There were no clothing protectors on the residents.
On 12/02/2022 at 12:52 PM, two more residents were served. An Unsampled Resident asked Unit Manager A where their food was. Unit Manager A explained that the food trays were coming to the dining room and would be served once they arrived. The Resident wheeled their wheelchair back to their table with a frown on their face. The Resident continued to pace around the dining room in their wheelchair until they finally got served their meal (around 1:00 PM).
On 12/02/2022 at 1:05 PM, the last resident left without getting served their meal tray.
On 12/02/2022 at 1:10 PM, Unit Manager A was interviewed in regard to serving meals to the residents at the same time. According to Unit Manager A, each bay or unit, gets served differently each day so that the same residents do not get served last daily. Unit Manager A was asked where the clothing protectors were and if they utilize them for meals. Unit Manager A explained that they do have clothing protectors and they are usually kept in the cupboard in the dining room. During this time, Unit Manager A walked over to the cupboard with this Surveyor and opened the cupboard to reveal no clothing protectors.
On 12/02/2022 at 2:10 PM, an interview was completed with the Director of Nursing (DON). The DON was asked if meals were served together and explained that prior to the pandemic, they had fine dining and would serve the residents at the same time. The DON further explained that they used to use the steam table to serve meals and that she planned to open fine dining back up. The DON was asked about serving with clothing protectors on the residents and stated that the staff should be offering clothing protectors to those residents who want to wear them.
A review of the facility policy titled Meal Distribution dated 09/01/2021 revealed the following: Guidelines .All food items will be transported promptly for appropriate temperature maintenance . There was no reference to meal serving at the same time or clothing protector use.
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 ciation pertains to intakes MI00129931 and MI00130619.
Based on interview and record review, the facility failed to include...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This ciation pertains to intakes MI00129931 and MI00130619.
Based on interview and record review, the facility failed to include urostomy care and monitoring in the comprehensive care plan for one resident (R336) of seven reviewed for activities of daily living (ADLs), resulting in the potential for inadequate assessment and unmet care needs. Findings include:
A review of R336's record revealed that the resident was most recently admitted into the facility on 7/18/22 and discharged from the facility to the hospital on 8/8/22. R336's diagnoses included Encephalopathy, Hypertensive Heart And Chronic Kidney Disease With Heart Failure, Anemia, Chronic Viral Hepatitis, Acquired Absence Of Other Parts Of Urinary Tract, Osteoarthritis, Fistula Of Vagina To Large Intestine, and Colostomy Status. A review of R336's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was moderately cognitively impaired and required extensive assistance from staff for ADLs.
A review of R336's referral documentation sent to the facility from the hospital prior to their admission on [DATE] revealed that the resident was going to be admitted with both a colostomy (surgical diversion of the colon to the abdomen to drain stool) as well as a RLQ (right lower abdominal quadrant) urostomy (surgical diversion to drain urine out of an open area in the abdomen).
A review of R336's progress notes revealed:
-7/19/2022 11:35 (AM) Skin/Wound Note Note Text: admission skin assessment findings: urostomy draining bag noted to RLQ remains patent draining yellow urine, colostomy bag noted to LUQ (left upper quadrant) draining brownish liquid stool .
-7/24/2022 20:03 (8:03 PM) Nurses Note Note Text: remains alert and verbal no acute distress has colotomy (sic) bag on and ileostomy in place note bag was of (sic) after replacing it and noted that it was empty and had small amount of stool bag was change again . R336's pre-admission information from the hospital did not indicate that the resident had an ileostomy, only a RLQ urostomy and newly created left abdominal colostomy.
-8/8/2022 15:45 (4:45 PM) Nurses Note Note Text: Resident [family] came to visit with resident and noticed the change in resident's condition. Writer observed resident more alert than in the AM but still confused, not eating, swelling in bilateral hands, and a yellowish green discharge in urostomy bag .Resident's [other family] called writer and requested that resident be transferred to hospital .
No additional progress note nor skilled charting dated 8/8/22 were found to detail that the resident had been observed as confused and not eating prior to being transferred out of the facility. Additionally, the resident's urostomy on various skilled nursing assessments was charted inconsistently - at times it was marked as an ileostomy (assessment dated [DATE] 11:12), at others, the resident was marked as wearing pads/briefs with no assessment of the urostomy or colostomy (assessment dated [DATE] 23:12).
A review of R336's care plan revealed the following:
-I have a Colostomy/Ileostomy r/t (related to): inflammatory disease Date Initiated: 07/18/2022.
-I have a colostomy - observe my stoma sight (sic) and report unusual drainage, irritation, etc. to my nurse. Date Initiated: 07/18/2022.
-Observe my bowel movements and report any abnormalities such as, color, presence of blood, consistency changes. Date Initiated: 07/18/2022.
R336's care plan did not mention the resident's urostomy, nor care or monitoring of the urostomy/urine output.
A review of R336's physician orders revealed no orders related to urostomy care nor urostomy monitoring. Additionally, per the resident's pre-admission information from the hospital, R336's colostomy was not created due to an inflammatory disease but was created due to a colovaginal/enterovaginal fistula.
On 12/2/22 at 2:18 PM, the Director of Nursing (DON) was interviewed and queried regarding R336's urostomy. When queried, the DON indicated that she would have expected R336's urostomy to be part of the comprehensive care plan, to include interventions for care and monitoring.
A review of the facility's policy/procedure titled, Comprehensive Plan of Care, undated, revealed, .Each resident will have a comprehensive care plan developed within 7 days after the completion of a comprehensive or quarterly assessment .must be patient centered .each resident is provided the necessary care and services including resident's choices to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment .must .address the resident's individual needs .include interventions to prevent avoided decline in function or functional level .
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 has two deficient practice statements.
Deficient practice statement number 1.
Based on observation, interview and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation has two deficient practice statements.
Deficient practice statement number 1.
Based on observation, interview and record review, the facility failed to provide care planned seizure precautions for one resident (R38) of one reviewed for seizure care, resulting in unnecessary prolonged seizure activity and discomfort utilizing the reasonable person concept. Findings include:
On 11/30/2022 at 11:44 AM, R38 was observed in a low bed, flat on their back. The Resident appeared to be sleeping and had no helmet on. Their was a tan colored soft helmet observed on top of the dresser in a washing basin. There were no floor mats on the floor.
During a record review, it was noted that R38 was wearing a soft blue helmet on the profile picture of the electronic medical record.
On 12/01/2022 at 10:03 AM, R38 was in bed awake. The head of the bed was up 75 degrees. The Resident made eye contact when spoken to, but did not speak or answer questions appropriately. The resident did not have a helmet on. The helmet was located on top of the dresser in the basin. Upon further inspection of the helmet, there was a broken black Velcro chin strap.
A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was readmitted to the facility on [DATE] with the diagnoses of Intellectual Disability and Localized Related (focal) (partial) Symptomatic Epilepsy and Epileptic Syndromes with Complex Partial Seizures, Intractable without Status Epilepticus. R38 was dependent on staff for all activities of daily living (ADL) care and had a severely impaired cognition.
A record review of the Progress Notes for R38 revealed the following:
10/30/2022 15:30 (3:30 PM) Social Services Note Text: [R38] guardian call back. She said she doesn't buy helmets, and it isn't her job.
11/9/2022 02:09 (AM) NURSE PRACTIONER NOTES Late Entry: Note Text: Patient seen for breakthrough seizure, prn (as needed) ativen (sic-medication utilized to treat seizure activity) given seen post ictal (following seizure), sleeping easy to awaken no further seizures activity. Valproic level ordered.
11/8/2022 22:30 (10:30 PM) Alert Note Note Text: Resident received in bed and resident observed w/ (with) blank stare r/t (related to) sz (seizure) activity that started at approx (approximately) 22:15 pm (10:15 PM) and was administered sz meds via peg (percutaneous endoscopic gastrostomy tube-tube inserted into the stomach for food, water and medication) approx 1 min (minute) after sz was observed, then eval (evaluated) w/ min (minimal) effectiveness and sz activity continued another 26 mins continuously and vs (vital signs) obtained and MD (Medical Doctor) was notified w/orders to give ativan 1 mg (milligrams) im (intramuscularly) q (every) 1 hr (hour) .
A record review of the care plan for R38 revealed the following:
Focus-I have a Potential for Injury: Seizure Disorder: R/T (related to): Hx (history) of Seizures
Date Initiated: 01/24/2016 .
Goal-Seizures will be controlled and anti-convulsant levels will be monitored and maintain within a
normal range. Date Initiated: 02/15/2015 .
Interventions- .Mats X2-while in bed. Date Initiated: 11/12/2015 . Wear helmet at all times in case of seizure activity. Date Initiated: 05/07/2019.
On 12/02/2022 at 8:27 AM, R38 was observed lying in bed awake. They had no helmet on. Certified Nurse Assistant (CNA) B was in the hallway and stated that she was in charge of the direct care of R38. CNA B was asked about R38's helmet not being on and explained that the helmet was removed because because R38 get sweaty underneath it. CNA B was asked the reason for the helmet and stated, It (the helmet) is for safety because they have seizures. CNA B was asked how often the resident should wear the helmet and stated, As needed.
On 12/02/2022 at 1:33 PM, the Director of Nursing (DON) was interviewed in regards to the seizure activity of R38 on 11/08/2022. The DON was asked if it was appropriate for R38 to have 26 minutes of continuous seizure activity and remain in the building. The DON stated, We normally wouldn't wait that long, let me look at the charting. The DON reviewed the charting and stated, (This is) Not usually what we do (allow seizure activity to continue that long). The DON explained that normally when a nurse puts this type of note in the medical record they are supposed to check a box that would populate to the 24 hour nursing report which would alert her to the specific incident for follow up. The DON stated, I would have followed up on this had I known. The DON was asked about the Resident not wearing a helmet during the survey observations and stated, I know (R38) gets break periods. Most of the time, it (the helmet) is on. The Unit Manager told me something about it (the helmet being broke) yesterday, I told her to run up to a hardware store and get a strap for it.
A review of the facility policy titled Seizure (undated) revealed the following: .11. If a prolonged seizure or cardio-respiratory failure occurs post seizure, activate EMS (emergency medical services) .
Deficient practice number 2.
Based on observation, interview and record review, the facility failed to follow physician recommendations for one resident (R99) of one resident reviewed for follow up care, resulting in the delay of treatment and unnecessary discomfort. Findings include:
On 11/29/2022 at 2:27 PM, R99 was observed in their bed awake. The Resident had clear speech and was alert and oriented. R99 was interviewed in regard to the care received at the facility and stated, I do have a problem with the follow up care. When asked to elaborate, R99 explained that they were seen by the doctor at the facility and had discussed with them problems they had been having with their Gastro Esophageal Reflux Disease (GERD). R99 stated, I have a different form of GERD. I had a procedure done before that helped me. I am having issues again and I think I may need that procedure again. I need to see my GERD Doctor. R99 further explained that they had discussed this in detail with the facility doctor and that the doctor had said they would order a consult. R99 stated, I also was told I possibly need a suprapubic catheter (tube inserted in through the abdomen into the bladder) because this one (indwelling catheter-tube inserted in through the penis) leaks constantly. This was all discussed back in September (2022). I have not heard anything back from the doctor.
A review of the Progress Notes for R99 revealed the following:
9/21/2022 07:21 (AM) .please schedule appointment with [GERD Doctor] .Writer did ask resident if .wanted to f/u (follow up) with speech therapy at this time . Resident reports that problem is the same as in 2012 .resident reports that .is having gerd episodes w/ (with) mild cough and reports that .will need to f/u w/ MD (Medical Doctor) at this time for possible [NAME] tx (treatment) at this time. Plz (please) and [NAME] (thank you).
A record review of the Minimum Data Set Assessment (MDS) dated [DATE] revealed R99 was readmitted to the facility on [DATE] with the diagnoses of Anemia and Chronic Obstructive Pulmonary Disease. R99 needed extensive assistance with most Activites of Daily Living (ADLs) and had a BIMS (brief interview for mental status) score of 15, indicating an intact cognition.
On 12/02/2022 at 01:49 PM, the Director of Nursing (DON) was interviewed in regard to the follow up care for R99's GERD problems. The DON reviewed the note from 09/21/2022 and explained that she was not aware of the need for a follow up visit for R99 because the nurse that wrote the note did not check off the box for the information to flow on to the 24 hour report. The DON stated, If she (the nurse) would have checked off the box, I would have reviewed the information in morning report and made sure the consult was scheduled. The DON was unable to provide an explanation of why the nurse did not follow up with the Doctor recommendations.
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 F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2
Based upon observation, interview and record review, the facility failed to provide and apply a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice Statement #2
Based upon observation, interview and record review, the facility failed to provide and apply a left hand palm protector for one resident (R56) from a total sample of 29, resulting in a potential loss of range of motion (ROM) and progression of hand contracture. Findings include:
Review of the facility record for R56 revealed an admission date of 9/23/19 with diagnoses that included CVA with left hemiplegia, muscle weakness and depression. Minimum Data Set (MDS) assessment indicated R56 required total assistance with transfers and mobility and maximum/total assistance for most self care tasks. R56 is able to complete some self feeding and grooming tasks with set up and minimal assistance.
On 11/30/22 at 8:56 AM, R56 reported not having a palm protector anymore. The left hand is severely contracted. R56 reported having a palm protector in the past but not having it applied in recent weeks or months. No type of hand splint is observed in the room.
On 12/01/22 at 9:53 AM, R56 did not have a splint in place on the left hand. R56 gave permission to check the drawers and storage adjacent to the bed and no splint was located.
On 12/02/22 at 9:13 AM, R56 had no left hand palm protector in place. R56 reported not having palm protector application offered today.
On 12/02/22 at 9:35 AM, the facility Director of Rehab (DOR) stated that they were not aware of R56's current status regarding left hand splint application and agreed to obtain the most recent therapy documentation for R56.
On 12/02/22 at 10:08 AM, Review of the most recent occupational therapy (OT) evaluation dated 2/25/22 indicated splint/orthotic recommendation: left upper extremity palm protector and elbow extension orthotic. OT recertification and discharge both dated 3/25/22 regarding left palm protector and elbow extension orthosis indicated resident is not in possession of a left palm protector splint or elbow extension orthosis.
On 12/02/22 at 1:28 PM, Review of R56 Therapy to Restorative nursing transfer form dated 5/17/22 is unsigned in the RNA signature box. The Contracture Management section states Left: palm protector and daily range of motion exercises during ADL care to prevent further contractures. Towel roll can be used (on) left palm and elbow. R56 reported they do not recall a washcloth/towel roll being applied to the left hand in recent weeks or months.
On 12/02/22 at 3:02 PM, the facility Director of Nursing (DON) reported that if the care plan for splint use is current the expectation is that the splint will be applied. The DON reported that the facility currently does not have a restorative aide.
Deficient Practice Statement #1.
Based on observation, interview, and record review, the facility failed to provide restorative nursing services to one sampled resident (R127) of four reviewed for limited range of motion, resulting in the potential for functional decline. Findings include:
On 11/29/22 at 1:14 PM, Confidential Witness I was interviewed regarding R127's care at the facility. Witness I and R127 both indicated they had a concern regarding the resident's functional status. Witness I stated the resident received therapy for a couple of weeks but has received no services for maintaining/improving function since. Witness I also indicated that R127 is left-handed with left-sided impairment after having a stroke and requires a hoyer lift to get up out of bed. Witness I and R127 did indicate that the resident had improvement in mobility after finishing therapy but that they would like for the resident to still receive some kind of functional service.
A review of R127's record revealed that the resident was admitted into the facility on 8/16/22 with medical diagnoses of Hemiplegia And Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, Syndrome Of Inappropriate Secretion Of Antidiuretic Hormone, Morbid (Severe) Obesity With Alveolar Hypoventilation, Iron Deficiency Anemia, Hypertensive Heart Disease With Heart Failure, Essential (Primary) Hypertension, Mixed Hyperlipidemia, and Long Term (Current) Use Of Anticoagulants. Review of R127's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident is severely cognitively impaired and requires extensive assistance from staff for activities of daily living (ADLs). R127 was discharged from therapy services on 10/4/22.
Additional review of R127's record revealed the following, Therapy to Restorative Nursing Transfer Form, signed and dated by therapy on 10/5/2022:
-Transfer Type: a. Therapy to Restorative .
1. Reason for Transfer: Discharge from skilled OT (Occupational Therapy) and PT (Physical Therapy) .
2. Recommended Program:
3 times a week for 12 weeks:
1. LUE (left upper extremity) PROM (passive range of motion)/RUE (right upper extremity) AROM (active range of motion) all planes and joints 1-3 sets of 10 reps as tolerated
2. LUE resting hand splint application up to 5-6 hrs as tolerated
3. AAROM (active assisted range of motion) LLE (left lower extremity) & Active RLE (right lower extremity) exercise 15 rep to improve strength .
3. Program Goals: Maintenance of ROM and Strength .
4. Specific Resident Needs and Interventions: LUE Shoulder pain management prior to participation, LUE Shoulder sling application in sitting, Left sided weakness .
The nursing portion of the above transfer form was not completed/signed.
On 12/2/22 at 10:45 AM, R127 was observed lying in bed. When queried regarding receiving restorative services, R127 stated that they were supposed to receive it but never did. The resident replied that they remembered restorative being mentioned to them, and added that they had been asking staff about therapy/restorative but no one ever got back to them about it.
On 12/2/2022 at 10:39 AM, the facility was asked to provide documentation that R127 was receiving the restorative therapy that had been ordered. Documentation of such was not provided prior to survey exit.
On 12/2/22 at 1:04 PM and 2:18 PM, the Director of Nursing was queried regarding the facility's restorative nursing program (RNP). The DON stated that the facility just lost their nurse in charge of the program. When queried regarding R127 receiving RNP services, the DON provided the order from therapy dated 10/5/2022 and nothing further. When queried, the DON confirmed that R127 never received RNP services as indicated.
A review of the facility's policy/procedure titled, Establishing a Nursing Restorative Care Program, undated, revealed, .Prompt and clear communication makes it easier for the nurses and other clinicians to identify residents who may benefit from Nursing Restorative Care program services .Residents who could benefit from receiving Nursing Restorative Care program services include: Those who are ready to finish a skilled rehabilitation therapy program .Those who should continue to practice or be assisted with doing something they were taught by the rehabilitation therapists .Those who are willing to participate and can physically participate .Plan of Care: .Develop a plan of care .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow its smoking policy (periodic smoking assessment...
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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 its smoking policy (periodic smoking assessments and securing of smoking paraphernalia) for one sampled resident (R8) of one reviewed for smoking, resulting in the resident keeping smoking item on their person and the potential for accidental burns.
Findings include:
On 11/30/22 at 10:11 AM, R8 was observed to ambulate in the hallway, during that time R8 dropped a pack of cigarettes and asked for assistance with picking the pack up. R8 was then observed with a lighter in their hand heading outside to smoke.
On 12/01/22 at 9:38 AM, the Director of Nursing (DON) was asked the facility's smoking policy and explained, once covid-19 started we became smoke free, but now if they are alert and oriented, they can sign out to go and smoke. The DON was asked if the residents had an assessment completed in the medical record regarding the safe smoking. The DON stated, No. Each smoker has a smoking agreement.
A review of R8's medical record noted, R8 was admitted to the facility on [DATE] with a diagnosis of Effusion Right Knee. A review of R8's Minimum Data Set (MDS) assessment noted, an intact cognition and required assistance with activities of daily living by staff.
Care plan. Focus: I am a smoker. Date Initiated: 10/25/2022. Goal: I will not have an injury from unsafe smoking practices through the next review date Date Initiated: 10/25/2022. Intervention: I am aware of the no smoking policy; I was informed to sign out for independent smoking. Date Initiated: 10/25/2022. Instruct me on the facility's policy on smoking, i.e., location, time, etc. Date Initiated: 10/25/2022. Observe my clothes and skin for signs of cigarette burns Date Initiated: 10/25/2022. Talk to me about smoking risks and hazards, in addition to the smoking cessation aids that are available. Date Initiated: 10/25/2022.
Continued review of R8's medical record did not reveal any initial assessment or ongoing monitoring for smoking.
On 12/02/22 at 1:47 PM, the staff at the Nurses station was asked where they kept the cigarettes and lighters for the residents that go out to smoke and stated, We don't have any smokers on this unit.
On 12/02/22 at 1:48 PM, R8 was observed in their room sitting in their wheelchair and was asked if they kept their cigarettes and lighter on them and stated, Yes. A request was made to observe the items and R8 pulled a pack of cigarettes and a lighter out of their fanny pack that was around their waist. R8 was asked if the facility made them turn those items in and stated, No. I keep them.
A review of R8's Resident agreement noted, .2. I agree that all smoking material or paraphernalia must remain with facility staff and will be secured in a designated location .
On 12/02/22 at 1:56 PM, the Nursing Home Administrator (NHA) was asked if the facility had a location where the resident's smoking items are kept and explained, that the facility is supposed to have it, but he didn't think they had a spot. The NHA was told about the observations and stated, They (residents) are not supposed to have that.
On 12/02/22 at 2:13 PM, the Nurses at the station where R8 room is located was asked if they had a secured location where resident's smoking material is kept and stated, No. We don't keep it. They sign out to go smoke.
A review of the facility's policy titled Smoking Policy undated, noted, Policy: It is the policy of this facility to provide a safe smoking environment for residents who can't smoke independently and are deemed a Safe Smoker based on a comprehensive smoking safety assessment. The facility maintains It's status of providing a non-smoking environment and smoking may be in designating outdoor areas . Procedure: Residents who express a desire to smoke will be assessed by the admitting licensed nurse with input from the interdisciplinary team. 1. Residents who smoke will be assessed upon admission, quarterly, new request to smoke and as needed to assure ongoing safety . 7. Residents are not permitted to maintain on their person any smoking tools (i.e cigarettes, lighters, cigars) and are required to return the items to the designated staff person or nurse . Documentation: Complete the smoking assessment in PCC (electronic medical record software).
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 F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains in part to intakes MI00129931 and MI00130619.
Based on 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 in part to intakes MI00129931 and MI00130619.
Based on interview and record review, the facility failed to consistently and accurately monitor and care for a urostomy for one resident (R336) of seven reviewed for activities of daily living (ADLs), resulting in the delayed identification of an infection. Findings include:
A review of R336's record revealed that the resident was most recently admitted into the facility on 7/18/22 and discharged from the facility to the hospital on 8/8/22. R336's diagnoses included Encephalopathy, Hypertensive Heart And Chronic Kidney Disease With Heart Failure, Chronic Kidney Disease, Anemia, Chronic Viral Hepatitis, Acquired Absence Of Other Parts Of Urinary Tract, Osteoarthritis, Fistula Of Vagina To Large Intestine, and Colostomy Status. A review of R336's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was moderately cognitively impaired and required extensive assistance from staff for activities of daily living (ADLs).
A review of R336's referral documentation sent to the facility from the hospital prior to their admission on [DATE] revealed that the resident was going to be admitted with both a colostomy (surgical diversion of the colon to the abdomen to drain stool) as well as a RLQ (right lower abdominal quadrant) urostomy (surgical diversion to drain urine out of an open area in the abdomen).
A review of R336's physician orders revealed no orders related to urostomy care nor urostomy monitoring. R336's care plan was also reviewed and did not mention the resident's urostomy, nor care or monitoring of the urostomy/urine output.
The skilled charting nursing assessments for R336 were reviewed and included areas for observation of urine color, clarity, and odor, however these areas were not filled out consistently (left blank on the assessment dated [DATE]). Additionally, the resident's urostomy on various skilled nursing assessments was charted inconsistently - at times it was marked as an ileostomy (assessment dated [DATE] 11:12), at others, the resident was marked as wearing pads/briefs with no assessment of the urostomy or colostomy (assessment dated [DATE] 23:12).
A review of R336's progress notes revealed:
-7/19/2022 11:35 (AM) Skin/Wound Note Note Text: admission skin assessment findings: urostomy draining bag noted to RLQ remains patent draining yellow urine, colostomy bag noted to LUQ (left upper quadrant) draining brownish liquid stool .
-7/22/2022 16:08 (4:08 PM) Physician Progress Notes Note Text: .diverting colostomy creation on 7/1/22 .Colostomy and Urostomy in place. Soft stool and clear urine in bags .Assessment and Plan: Colostomy care .Urostomy care .
-7/24/2022 20:03 (8:03 PM) Nurses Note Note Text: remains alert and verbal no acute distress has colotomy (sic) bag on and ileostomy in place note bag was of (sic) after replacing it and noted that it was empty and had small amount of stool bag was change again . R336's pre-admission information from the hospital did not indicate that the resident had an ileostomy, only a RLQ urostomy and newly created left abdominal colostomy.
[No nursing progress notes found during the timeframe between above note and below note].
-8/8/2022 15:45 (4:45 PM) Nurses Note Note Text: Resident [family] came to visit with resident and noticed the change in resident's condition. Writer observed resident more alert than in the AM but still confused, not eating, swelling in bilateral hands, and a yellowish green discharge in urostomy bag .Resident's [other family] called writer and requested that resident be transferred to hospital .
No additional progress note nor skilled charting dated 8/8/22 were found to detail that the resident had been observed as confused and not eating prior to being transferred out of the facility.
Furthermore, no nursing progress notes were found for the month of August for R336 prior to the one dated 8/8/22.
On 12/1/22 at 1:47 PM, Confidential Witness O was interviewed via phone. Witness O indicated that they had visited R336 every other day to daily while they were in the facility. Witness O stated that they had been the family member present at the facility on 8/8/22 and had brought the resident's status to staff's attention. Witness O stated that they were, The person who made them send [R336] to the hospital. Witness O indicated that they had also seen the resident on 8/6/22, and while the resident seemed fine (acting like themselves) at that time, Witness O said they knew R336 had an infection because of what they observed in the resident's urostomy bag. Witness O explained that they had noticed pus in the resident's urostomy bag on 8/6/22 and had tried to tell the resident's nurse that something was wrong. Witness O indicated they had taken photos which were provided for review. Witness O confirmed that R336 had a urostomy on the right side of their abdomen and a colostomy on the left side.
Witness O continued and indicated that on multiple occasions, they had witnessed the resident without ostomy bags in place at both sites for hours at a time, and on one occasion, they found the resident sitting in their own stool from their colostomy because there was no bag present. Witness O concluded, When I went to go visit on 8/8 you could tell [R336] was going septic .I knew something was off, [R336] was confused and had pus in [their] urine. [R336] could barely talk. I believe they were just being negligent, and just ignoring doing it.
On 12/1/22 at 2:01 PM, a photo of R336's urostomy dated 8/6/22 and time stamped at 11:25 AM was reviewed and revealed a urostomy bag which contained a significant amount of greenish pus at and around the stoma site along with a small amount of cloudy green/yellow urine present in the bag.
R336's hospital records were obtained after transferring out of the facility on 8/8/22. A review of the records revealed the following:
-History of Present Illness: .Patient was very altered, so author reviewed the charts .recently discharged 3 weeks ago after a 25 day admission for sepsis requiring pressors .a diverting colostomy was made. Patient's [family member] visited .yesterday in the nursing home, noted that the patient was not eating, has swelling in the bilateral hands, yellowish-green discharge in the ostomy bag, and decided to bring [them] to the hospital. On getting to the hospital, urine bag was also noted to be cloudy. admission vitals were stable, labs concerning for leukocytosis .Patient was placed on [antibiotic] for multidrug-resistant UTI (urinary tract infection) and admitted to the hospital .family made the decision to change patient to comfort care .arrangements were made for patient to go home with hospice care and .was subsequently discharged and transported home via ambulance . R336 was admitted to the hospital on [DATE] from the facility and discharged home with hospice on 8/13/22.
A review of the schedule revealed that on 8/6/22 day shift, Licensed Practical Nurse (LPN) K was assigned to care for R336.
The skilled charting assessment for R336 completed by LPN K on 8/6/22 at 11:12 AM indicated that the resident wore pads/briefs, and had a colostomy and ileostomy (incorrect information). Urostomy was not checked, and an assessment of the resident's urine was not present. There was nothing noted on the assessment to indicate that the resident's ostomies were assessed and noted to be normal, patent, and draining.
On 12/1/22 at 2:45 PM, the facility's wound care nurse, LPN J was noted to be speaking with LPN K. LPN J was queried if wound care was responsible for caring for and monitoring ostomies in the facility to which she said she was not. LPN K then indicated that she had not received training from the facility on caring for ostomies, although the facility does admit residents with them. When shown the photo of R336's urostomy and drainage from 8/6/22, LPN K indicated that she did not remember being alerted to an issue with the resident's urostomy. LPN K mentioned that she did recall R336's family visiting often. LPN K further indicated that R336 may have been one of the first residents she had ever encountered with a urostomy, but that the pus draining from it did not appear normal. LPN K further indicated that if there was just an assessment written by her and no progress note that, Things were probably fine .I don't remember anything off with that resident that weekend, I'm not saying there wasn't, but I just don't remember. LPN K further indicated that in relation to monitoring and caring for a urostomy, she would expect there to be a physician order that would populate on the medication administration record/treatment administration record (MAR/TAR). Additionally, LPN K stated that she does not feel that the facility has a systemic process in place for nurses when admitting a resident who has an ostomy.
On 12/2/22 at 11:35 AM, LPN M, the nurse assigned to R336 on 8/8/22 and who sent the resident to the hospital, was interviewed via phone. LPN M indicated that she had seen the resident early in the day to give them their medication and that R336's family member (Witness O) came in a couple of hours later and brought a problem with the resident's urine to her attention. LPN M stated, [R336] was sluggish and I sent [them] out. LPN M was asked if Witness O informed her about R336's abnormal urine and telling staff about it days prior. LPN M indicated she could not recall.
When queried if the facility had provided her training on how to care for ostomies, LPN M indicated she had not received any and felt inexperienced when caring for residents with them, but felt she could go to the Director of Nursing (DON) or Unit Manager with questions. LPN M admitted that she had not yet assessed R336's ostomies on her 8/8/22 shift prior to sending the resident out to the hospital. When queried where care/monitoring of ostomies was documented in the medical record, LPN M stated, Normally they would have it pop up on the MARs, but I can't remember if that particular one (R336's) was.
On 12/2/22 at 2:18 PM, the Director of Nursing (DON) was interviewed. When queried regarding R336's urostomy, the DON indicated she would have expected the urostomy to be a part of the resident's comprehensive care plan, as well as for there to have been physician orders related to the monitoring and care of the urostomy. Additionally, the DON stated she would expect nurses would be monitoring and documenting the output from the ostomies. The DON indicated that there is likely a need for further ostomy training for staff, and that the nurses at the facility may not be used to as high of acuity of patients as R336 was.
A review of the facility's policy/procedure titled, Colostomy & Ileostomy Care, undated, revealed, .In the treatment record, record: Date and time of pouching system change. The policy did not address urostomies.
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
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete and/or document monthly medication reviews (M...
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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 complete and/or document monthly medication reviews (MMR) in the electronic medical record (EMR) for three of five residents (R2, R9, and R62) reviewed for unnecessary medications, resulting in the potential for missed pharmacy recommendations and adverse reactions from medications. Findings include:
Resident 2
On 11/29/2022 at 01:42 PM, R2 was dressed and groomed up in their wheelchair. The resident had clear speech and was alert and oriented. R2 was asked about the care received at the facility and was very pleasant with conversation.
A record review of the Physician Orders revealed the following psychotropic medication orders for R2:
Zoloft
Depakote
Tetrabenazine
A record review of the Minimal Data Set (MDS) assessment dated [DATE] revealed that R2 was readmitted to the facility on [DATE] with the diagnoses of Depression and Chronic Obstructive Pulmonary Disease (COPD). R2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition.
A record review of the EMR for R2 revealed no completed monthly MMRs.
On 12/02/2022 at 10:02 AM and 11:41 AM, A request was made to the Nursing Home Administrator (NHA) for the MMRs for R2. There were no MMRs received by the end of the survey.
R62
On 11/30/2022 at 10:37 AM, R62 was observed up in their wheelchair in their room. The Resident appeared disheveled and was unable to answer questions appropriately.
A review of the Physician Orders for R62 revealed the following ordered psychotropic medications:
Xanax
Trazodone
A review of the MDS dated [DATE] revealed that R62 was readmitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus, Anxiety, Depression and Parkinson's Disease. Resident #62 had no behaviors, had a BIMS of 03 (indicating a severely impaired cognition), and needed extensive assistance with most activities of daily living.
A record review of the EMR for R62 revealed no completed monthly MMR.
On 12/02/2022 at 12:20 PM, a request was made to the NHA for the MMRs for R62. No documents were received by the end of the survey.
A review of the facility policy titled Monthly Pharmacy Consultant Recommendations (undated) revealed the following: Procedure .1. The Pharmacy Consultant should submit the DRRs (Drug Regimen Review) to the Director of Nursing (DON) after each monthly visit .After the DDRs are reviewed and completed by the physician, the form should be scanned into [EMR].
Based on interview and record review the facility failed to ensure MRRs were documented in the electronic medical record
Resident #9
Unnecessary Meds, Psychotropic Meds, and Med Regimen Review
12/01/22 11:08 AM RR
BusPIRone HCl Tablet 5 MG Give 1 tablet by mouth three times a day for anxiety related to GENERALIZED ANXIETY DISORDER
DULoxetine HCl Capsule Delayed Release Particles 60 MG
Give 1 capsule by mouth one time a day for depression
Medication Review not found in PCC.
12/01/22 11:17 AM asked DON for the mthly med reviews.
12/02/22 01:15 PM DON provided the Rx medication review report.
[DATE] - 11/29. R9's 11/28/2022
In PCC 2/25/2021 - 4/25/2022. no others found in resident's chart.
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** Based on observation, interview, and record review, the facility failed to maintain a comfortable/homelike room environment affe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a comfortable/homelike room environment affecting two residents (R127 and R130) and the residents residing in room [ROOM NUMBER], and failed to maintain wall mounted fans in the hallways throughout the facility in a sanitary manner. This deficient practice resulted in actual and potential resident dissatisfaction with their living environment. Findings include:
On 11/29/22 at 1:14 PM, Confidential Witness I was interviewed regarding R127's care at the facility. Witness I pointed out a clear covering taped over the window in R127's room and explained that it was a clear shower curtain liner. Witness I stated that they had informed the facility about a draft from the window and cold temperatures felt in the room, affecting both R127 and their roommate, R130. Witness I stated, [R127 and their roommate] were freezing to death .And in the summer the room was too hot because of the air coming through . Witness I stated they had most recently informed the Nursing Home Administrator (NHA) of the cold temperatures and drafty window on 11/18. Witness I produced a photo dated 11/19 of the window covered with a sheet and towels on the window ledge. Witness I stated that cold air was still felt coming through despite the towels and sheet. Witness I further explained that the facility had also put a foil strip at the bottom of the window but that it did not fix the draft. Witness I indicated that no further action was taken by the facility to remedy the situation, which prompted them to tape up the clear shower liner themselves. R127 and R130 confirmed the unstable temperatures they had experienced over past months in the room. Per CustomWeather.com, the average outdoor temperature in [NAME] Woods, MI in November 2022 was 45 degrees Fahrenheit (F), with a low outdoor temperature of 18 degrees F recorded the night of 11/20/22.
On 11/30/22 at 9:10 AM, 12/1/22 at 8:51 AM, and 12/1/22 at 3:34 PM, the clear shower liner was observed to still be taped over R127/R130's window.
On 12/2/22 at 9:02 AM, Maintenance Director H was interviewed in R127/R130's room regarding the drafty window and presence of a clear shower curtain liner. Director H indicated he was unaware that there was plastic over the window and that he hadn't received a work order for any issues in the room. Director H further indicated that the facility could use new windows. Director H then inspected the window area and indicated that the draft issue was coming from two places. Director H indicated that a piece of wood was missing from the window frame and that the foil had been placed over that area, however, a draft was still noted upon review. Director H also noted that the heater located directly under the window had a gap between the unit and the hot water coil and therefore, cool air was blowing through the gap.
On 12/2/22 at 10:13 AM, the NHA acknowledged that the window in R127/R130's room was currently, Under construction, but stated he had been unaware of the presence of the shower curtain liner.
On 11/29/22 at 2:23 PM, room [ROOM NUMBER] was observed with deep grooves of plaster gone from the wall behind bed 1.
The wall remained in the same condition during the entire survey which ended 12/2/22.
A review of the facility's policy/procedure titled, Resident Rights, undated, revealed, .9. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
On 11/30/22 at 11:00 AM, the wall mounted fans in the South Oak Street, North Pine Street, South Pine Street, and South Maple Tree hallways were observed to be soiled and dusty.
On 12/2/22 at 9:02 AM, Maintenance Director H was queried regarding the soiled fans in the hallways, and stated that they are cleaned by environmental services at least monthly or as needed.
On 11/30/22 at approximately 3:30 PM, a policy for the cleaning of the wall mounted hallway fans was requested. On 12/1/22 at approximately 7:00 AM, the Administrator stated that the facility does not have a policy for cleaning wall fans.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 69 (R69)
On 12/01/2022 at 01:09 PM, R69 was observed lying in bed awake. The Resident had clear speech and was alert an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 69 (R69)
On 12/01/2022 at 01:09 PM, R69 was observed lying in bed awake. The Resident had clear speech and was alert and oriented. R69 had long fingernails (extended out approximately five millimeters past their finger tips). Some of the nails had dark black debris underneath them. R69 was interviewed regarding their fingernails and explained that they did not like having long nails. When asked the reason for the long nails, R69 shrugged and stated, They (staff) said they are out of nail clippers.
A record review of the care plan for R69 revealed the following:
Focus-I need ext.(extensive) to total assistance with my ADL's (activities of daily living) r/t (related to) spinal cord compression, neurogenic bladder, paraplegia, DM II (Diabetes Mellitus Type 2) Reviewed 11/12/2020.
Goals-I will be well groomed and dressed daily with assisting as much as able. Date Initiated: 01/03/2016.
Intervention-bathing and showering: Check my nail length - file and clean them on my bath day and as necessary. Report any changes to the nurse. Date Initiated: 01/03/2016.
On 12/02/22 01:10 PM, Certified Nurse Assistant/CNA C (R69's CNA) was queried on where the nail clippers were kept. CNA C went into a storage room. CNA C opened an empty drawer and stated, Usually they would be in here. CNA C went with another staff member to the basement of the facility and after approximately twenty minutes, brought up a small clear plastic container that held about six nail clippers.
A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R69 was readmitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus and Anemia. R69 had a Brief Interview for Mental Status (BIMS) score of 15, indicating an intact cognition, and needed extensive assistance with personal hygiene.
A review of the facility policy titled Fingernail Care (undated) revealed the following: Purpose .fingernails are checked on shower days and trimmed as needed .
Based on observation, interview and record review the facility failed to provide timely activities of daily living (ADLs) for four sampled residents (R34, R60, R124, and R77), resulting in unmet care needs. Findings include:
Resident #34 (R34)
On 11/29/22 at 1:44 PM R34 was observed laying in bed and asked about the care at the facility. R34 stated that they are not getting their showers as scheduled. During the interview R34 was observed with their hair uncombed, and nails that were long, uneven, and dirty. R34 was asked if the staff washed their hair and cut their nails and stated, No.
On 11/30/22, 12/1/22, and 12/2/22 R34 fingernails remain in the same conditions as observed on 11/29/22.
Resident #60 (R60)
On 11/29/22 at 2:23 PM, R60 was observed laying in bed with their hair unkept. R60 was asked if their hair was getting washed and comb daily and stated, No. I need my hair washed and comb, I have thick and tight hair. R60 further explained that if their hair was not maintained that it will get matted and would need to be cut to untangle it.
On 11/30/22 and on 12/01/22 at 10:18 AM, R60's hair was in the same condition as observed on 11/29/22.
On 12/02/22 at 8:36 AM, R60 was observed in bed with their hair comb, R60 was asked if they got their hair washed and stated, No, but it was comb today.
On 12/02/22 at 2:39 PM, the Director of Nursing (DON) was asked how residents that prefer a bed bath get their hair washed and stated, We have dry shampoo.
Resident #77 (R77)
On 11/29/22 at 1:45 PM, R77 was observed with thick chin hairs that covered the bottom of the chin. R77 was asked if they prefer the hair on their chin or if they would like it to be removed and stated, I would like for someone to do that.
On 11/30/22 R77 chin was in the same condition as on 11/29/22.
On 12/01/22 at 4:21 PM, R77 was observed in their room smiling and stated, I got a shower today. R77's chin was observed without the chin hair.
On 12/02/22 at 2:43 PM, the DON was asked if it's the facility's policy that the resident must ask for nail care, or facial hair to be remove and stated, No. The DON explained that ADL care is important, and expects that if staff sees it that they will take care of it.
R124
On 12/02/22 at 11:57 AM, R124 was observed to be laying in bed in a hospital style gown and without socks on their feet. Scrapes and scabs were visible on the lower legs. A high back wheelchair was observe on the left side of the bed at the head of the bed. The TV was on the menu screen and a remote control for the TV was not visible in the area of R124.
R124 reported they had gray sweat pants go to the laundry and not come back. A check of the closet noted a few pairs of black socks, a pair of shorts with a coffee like stain and a hooded sweat jacket. R124 was able to move all extremities independently. R124 reported they had fallen upon an attempt to stand up as their legs were weaker than they thought and had not walked in months. R124 reported they were walking prior to entry into the facility.
R124 then reported they had asked the aide to get them up into there wheelchair a few hours earlier and was upset that they had not been assisted out of bed. R124 asked would you want to lay in bed all day? R124 spoke in a loud angry tone of voice at times while they voiced concerns. R124 was asked about call light response and reported it was not timely. The call light was activated at 12:02 PM. Three staff walked by the room and did not enter the room to ask if R124 needed help. At 12:15 PM the call light was answered by a certified nursing assistant. The aide asked what R124 needed and stated nothing at they had put it on the check response time.
R124 continued and reported that showers were supposed to scheduled and they had not had a shower in months and preferred that over any bed bath. R124 further comment that they had not refused any showers. A review of the shower task in the electronic medical record for the last thirty days documented showers were on Monday and Thursday on the 7 PM to 7 AM shift. There were eight opportunities for showers with six documented, of the six one was documented as refused, two as given and three as not applicable. A shower sheet dated 12/01/22 documented a bed bath was given. This bath was not documented in the electronic medical record. R124 denied receiving a bed bath. R124's hair appeared flat and greasy.
On 12/02/22 at 12:29 PM, Certified Nursing Assistant (CNA)was asked about caring for R24 and reported R124 keeps to themselves, was able to move about in their wheelchair, would say when wants to get up and has not had any issues with other residents.
On 12/02/22 at 12:34 PM, CNA E was asked about R124 and reported, R124 can be cranky at times, but can be more agreeable and does not refuse care.
On 12/02/22 at 12:37 PM, CNA F was asked about R124 and reported R124 needs total care and has always been the same. R124 may have some gripes about certain aides or care but will calm down when given time. CNA F commented they may not always chart the different behaviors as it was just the way R124 has always been. CNA F was asked about showers and reported R124 does not refuse showers. CNA F reported that R124 had asked to get out of bed earlier in the morning but as they had a busy set they had not been able to get R124 out of bed yet.
A review of the clinical record for R124 revealed R124 was admitted into the facility on [DATE]. Diagnoses included Malnutrition, Quadriplegia and Muscle Contracture. The Minimum Data Set (MDS) assessment dated [DATE] indicated moderately impaired to intact cognition with a 12/15 Brief Interview for Mental Status (BIMS) score. Bed Mobility was limited assist of one person, transfer and locomotion occurred only once in the look back period and required one or two persons, dressing, toilet use and personal hygiene was extensive assistance of one person and bathing was total assistance of one person.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Michigan facilities.
- • 42% turnover. Below Michigan's 48% average. Good staff retention means consistent care.
Concerns
- • 49 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is The Orchards At Harper Woods's CMS Rating?
CMS assigns The Orchards at Harper Woods an overall rating of 2 out of 5 stars, which is considered 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 The Orchards At Harper Woods Staffed?
CMS rates The Orchards at Harper Woods's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 42%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Orchards At Harper Woods?
State health inspectors documented 49 deficiencies at The Orchards at Harper Woods during 2022 to 2025. These included: 49 with potential for harm.
Who Owns and Operates The Orchards At Harper Woods?
The Orchards at Harper Woods 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 THE ORCHARDS MICHIGAN, a chain that manages multiple nursing homes. With 151 certified beds and approximately 126 residents (about 83% occupancy), it is a mid-sized facility located in Harper Woods, Michigan.
How Does The Orchards At Harper Woods Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, The Orchards at Harper Woods's overall rating (2 stars) is below the state average of 3.1, staff turnover (42%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Orchards At Harper Woods?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is The Orchards At Harper Woods Safe?
Based on CMS inspection data, The Orchards at Harper Woods has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Michigan. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Orchards At Harper Woods Stick Around?
The Orchards at Harper Woods has a staff turnover rate of 42%, 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 The Orchards At Harper Woods Ever Fined?
The Orchards at Harper Woods has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Orchards At Harper Woods on Any Federal Watch List?
The Orchards at Harper Woods is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.